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  • BIOETHICS FORUM ESSAY

The Words on the Wall: Nurse Leaders’ Perspectives on Organizational Ethics in Health Care

When nurses have an opportunity to step away from the “real world” of clinical leadership and back into academia, they gain a fresh perspective they see in their organizations every day. We five career nurses have had this opportunity: for the past 18 months: while continuing our typical 60-hour work weeks, we have also been graduate students at the Yale School of Nursing, studying health management, policy, and leadership.  Our combined nursing experience adds up to 124 years.  We come from New England, the Great Plains, and British Columbia.   We work in institutions ranging from a 25-bed critical access rural hospital to a 966-bed Level 1 trauma center in a multi-hospital health care system.  We are all “nurse leaders” in our institutions, although our titles differ: Chief Nursing Officer; Program Manager; Quality Improvement Coordinator; Vice President of Patient Services; and Nurse Manager.

In our health care ethics course at Yale this semester, we discussed a article by Carol Bayley, an organizational ethicist who works for a multi-state health care system,  entitled “Turning the Titanic: Changing the Way We Handle Mistakes.” Bayley argues that the “words on the wall” of a hospital – those core values you find on the wall of the lobby (or on the home page of the website) – can and should be a guide to ethical action inside and outside of those walls. Bayley’s observations rang true to each of us. Our experiences and perspectives on the role of nurse leaders in helping the words on our own walls to speak through the actions of our organizations follow.

Leslie: Since its founding in 1976, my once 40-bed, now 25-bed critical access hospital has been dedicated to service in the community.  The hospital serves a rural population of approximately 17,000 in three counties, where the economy is driven by agriculture and the meat packing industry. The mission statement of this hospital is “to support and improve the health of the community and provide high-quality health care in a cost effective manner, recognizing the psychosocial, spiritual, physical and cultural values of the individual.”  The words on our wall reflect our continuing commitment to meeting the needs of an increasingly diverse community, which now includes Latino packinghouse workers, Somali Muslim refugees, Caucasians of German and Swedish descent, and a small number of Vietnamese and Chinese residents.

Such diversity  introduces new ethical issues and presents new challenges and rewards in delivering excellent quality care in a small hospital.  For example, our Muslim population’s values and preferences in end of life care are different from the values and preferences of our Hispanic population, while individuals in both populations have their personal values and preferences.   Language barriers impede discussions about quality of life, suffering, and dying with dignity, at a time when clear communication between patients, families, and health care providers is essential to meeting all those “physical, psychosocial and spiritual and cultural needs.”  The words on our wall guide us, but practical problems remain as we integrate technology, research, and clinical advances into our practice.   In the words of philosopher Margaret Urban Walker, we need to create “moral space” to identify and discuss the ethical components of these advances as they play out inside our own walls.

Beverly The words on the wall of this 305-bed community teaching hospital appear on 12 foot long banners: “teamwork,” “compassion,” “integrity,” “respect,” “accountability.”  Also on the banners are photographs, illustrating each of the values. Words and images reflect the hospital’s commitment to providing quality services “focused on the needs of [its] communities.”  There are two distinct communities served by this hospital: wealthy suburbanites, and poor and working class urban residents. Major donors to the hospital receive what is termed a “higher level of service” when they are admitted to or interact with the hospital. A patient representative is assigned to them 24/7, to handle requests for better rooms, more staff attention or anything else they may need or want.    The hospital argues that the ends justify the means: diverting staff and other resources to wealthy patients leads to bigger gifts, which benefit all patients. Many clinical staff members struggle with the two-tiered care system resulting from this practice. Some nurses choose to leave.  I was one of them.

As I look back on this experience, I see an opportunity for that hospital’s nurse leader to initiate a dialogue about the two-tiered system.  The nurses, after all, are the ones who are expected to provide that extra attention to certain patients.  Can a nurse leader help to create an environment where those words on the wall are applied to everyone, mindful of the continuing need – no margin, no mission – for those donations?

Dana:: “Compassion for People; Passion for Excellence; Freedom to Innovate; Spirit of Teamwork” are the words on the walls of the hospital where I work as the quality improvement coordinator for adult and pediatric emergency medicine.  During my nursing career I have worked in other leadership positions and in different institutions, so as I read Carol Bayley’s article, I thought about whether I could discern the impact of organizational values on patient outcomes.  Most of my current colleagues already come equipped with a strong sense of compassion for people and a passion for excellence.  Few of us come through the hospital doors each morning thinking, “I want to provide average care today.”

However, individual commitment is not enough to keep patients safe and their care effective.  We now know that there is a direct correlation between staff collaboration and patient outcomes. Responsibility for fostering an environment of teamwork rests on the shoulders of leadership: staff take their cues from us.  Do we, as leaders, measure up to our institutional values during periods of stress, during crises and sentinel events?  How do we handle damage control?  Do we stay behind closed doors, fostering an environment of secrecy, perpetuating a hidden agenda, or do we face our mistakes and shortcomings in the open, in a way that includes patients and all members of the health care team and creates opportunities for reflective dialogue?

The well publicized wrong side procedure events at my hospital tested how well we live up to our institutional values.  And this brings us to the freedom to innovate.  Post event questionnaires and staff interviews would be innovations that allowed us to collect internal perspectives on how well our system responds to such events.  They would signal our openness to staff and provide valuable system feedback on how to recover from and prevent errors.  Choosing the path of openness during crises is difficult and may create short-term hassles – we would have to spend more time explaining what went wrong and what is being done about it. But this is what leaders should do.

Diane: Hospitals have become complex and at times chaotic havens for the sick.  The environment in which we work is battered by a perfect storm of revenue production, expense control, regulatory oversight, consumer expectations and the everyday challenges of providing efficient and effective care. “Getting back to basics” through service excellence and patient centered care is part of every top hospital’s business plan.  For health care workers, whether entry level or seasoned professionals, the words on the wall should provide clear direct to staff – and patients — as we navigate the storm. In the 21st century, providing health care requires all hands on deck.

The words on my hospital’s wall are our Pledge to Service Excellence: “I will take action because I am the organization.”  Our wall also includes Patient Rights, to “safe, high quality care; information; participation in care; confidentiality; prompt response to concerns and complaints and management of pain.” (If we fulfilled these rights, our patient satisfaction scores would be above 90 percent.)

Patient Responsibilities are also posted on the wall: “respect hospital policy; ask questions; participate in your plan of care; tell us how we can provide better care.” But do we welcome this feedback, or do the words we speak differ from the words on our wall?  As we evaluate our successes each year, measured in terms of targets met in our business plans, we should also evaluate the words on our walls, and model those values we believe are central to the care of all our patients and their families.

Liz:  I have worked for the same faith-based health care organization for my entire nursing career.  For most of those years, my own values have been aligned with the words on our wall. Seeing those words every day nurtured a level of trust I might not otherwise have developed. The first letters of each word on our wall spell “SISTER,” in reference to the four founding groups of missionary sisters who created our organization. The words are: “spirituality,” “integrity,” “stewardship,” “trust,” “excellence,” and “respect.”

Like all health care organizations, we are constantly changing. A recent decision, based on a review by external consultants, to cut some leadership positions while expanding the portfolios of the remaining, already overloaded leaders, challenged my values deeply.  I believed that the consultants did not properly assess the impact that reduced leadership would have on patient care, nor treat the remaining leaders as true stakeholders in a decision in which fiscal concerns appeared to take precedence over other concerns.

My own continuing challenge has been to respond to this decision in a way that incorporated the words on the wall, when faced with a situation that I didn’t believe reflected the values of stewardship and trust.  “Spirituality” reminds me to be compassionate towards those who make unpalatable decisions. “Integrity” reminds me to look such decision from other perspectives.  “Stewardship” means more than finances: it also reminds me that we are accountable to our work place community and we must evaluate the impact of our actions on that community. Demonstrating my own “trustworthiness” in situations where I may not witness it in others is more than difficult – but worth the effort. “Excellence” is achieved only through learning and continuous improvement.  The key to my ability to believe in these values is “respect.”  My organization has supported and encouraged me for 22 years, and it has earned my respect.  The value of respect allows us to disagree strongly on certain issues, but value long-term relationships.

Health care organizations are composed of individuals, who do the best we can, every day, under difficult circumstances.  It is essential that the care we provide reflects the words on our walls. It is also essential that when it is necessary to defend those values, we do so with grace.

The writers are students in the Master’s Program in Nursing Management, Policy and Leadership at Yale University School of Nursing.

Published on: November 20, 2008
Published in: Health and Health Care

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