Organizational Virtue Ethics and Moral Distress among Healthcare Workers.

AbstractMoral distress is traditionally defined as situations where one knows the right thing to do but external constraints make it nearly impossible to pursue the right course of action. Many interventions to mitigate moral distress focus on making healthcare workers more resilient or courageous in the face of adverse circumstances. While these "virtue cultivation" responses might be valuable traits for individuals, I want to argue that cultivating virtue is at best an incomplete strategy for dealing with moral distress in an organizational setting. The individualistic character of these approaches ignores how an organization's policies may be contributing to many morally distressing situations. I will argue that resources from the virtue tradition can still play a valuable theoretical role in addressing moral distress in healthcare settings if we transpose them to the organizational level. The policies of a hospital or healthcare institution can be seen as virtuous to the degree that they further the organization's goals of medicine. Organizational virtue ethics can then illuminate the issue of moral distress in healthcare organizations. If an organization's policies contribute to its members suffering from moral distress, then that policy may well inhibit the organization from carrying out its mission of providing excellent healthcare. Organizations should respond to moral distress and seek ways to mitigate if not eliminate it.

Characterization of patients requiring inpatient hospital ethics consults- A single center study.

INTRODUCTION: Ethics consultations are often needed at difficult junctures of medical care. However, data on the nature of how patient characteristics, including race/ethnicity, language, and diagnosis, affect ethics consult outcomes are lacking. METHODS: We performed a retrospective cohort study of all patients who were seen by the Ethics Consult Service between 2017 and 2021 at a large tertiary academic center with the aim of determining whether patient demographic and clinical factors were associated with the timing of ethics consult requests and recommendations of the ethics team. RESULTS: We found that patients admitted for COVID-19 had significantly longer median times to consult from admission compared with other primary diagnoses (19 vs 8 days respectively, p = 0.015). Spanish-speaking patients had longer median times to consult from admission compared to English speaking patients (20 vs 7 days respectively, p = 0.008), indicating that language barriers may play a role in the timing of ethics consultation. CONCLUSIONS: This study demonstrates the need to consider clinical and demographic features when planning and prioritizing ethics consultations at large institutions to enhance consult efficiency, resource utilization, and patient experience and autonomy.

Racism, early psychosis, and institutional contact: A qualitative study of Indigenous experiences.

BACKGROUND: There is evidence of Indigenous and ethnic minority inequities in the incidence and outcomes of early psychosis. Racism has been implicated as having an important role. AIM: To use Indigenous experiences to develop a more detailed understanding of how racism operates to impact early psychosis outcomes. METHODS: Critical Race Theory informed the methodology used. Twenty-three Indigenous participants participated in four family focus group interviews and thirteen individual interviews, comprising of 9 Maori youth with early psychosis, 10 family members and 4 Maori mental health professionals. An analysis of the data was undertaken using deductive structural coding to identify descriptions of racism, followed by inductive descriptive and pattern coding. RESULTS: Participant experiences revealed how racism operates as a socio-cultural phenomenon that interacts with institutional policy and culture across systems pertaining to social responsiveness, risk discourse, and mental health service structures. This is described across three major themes: 1) selective responses based on racial stereotypes, 2) race related risk assessment bias and 3) institutional racism in the mental health workforce. The impacts of racism were reported as inaction in the face of social need, increased use of coercive practices and an under resourced Indigenous mental health workforce. CONCLUSION: The study illustrated the inter-related nature of interpersonal, institutional and structural racism with examples of interpersonal racism in the form of negative stereotypes interacting with organizational, socio-cultural and political priorities. These findings indicate that organizational cultures may differentially impact Indigenous and minority people and that social responsiveness, risk discourse and the distribution of workforce expenditure are important targets for anti-racism efforts.

Organizational ethics in urgent transfers of severely disabled people to intensive care units - a qualitative study.

PURPOSE: Urgent transfers of severely impaired patients with chronic neurological disability (PwND) from a neurological physical and rehabilitation medicine (nPRM) to an intensive care unit (ICU) or an emergency room (ER) served as the basis for this study. We hypothesized that human and structural factors interfered with but were not directly related to the acute context. METHODS: We decided to use a qualitative methodology, based on in-depth interviews with 16 ICU/ER physicians. We used mixed bottom-up and top-down methods. We interpreted our data using a thematic approach based on the key principles of grounded theory, which were modified with consideration of the literature. RESULTS: Three main domains emerged. The impact of the clinical setting notably implied the patient's clinical typology between the acute event and the chronic background, but also bed availability. Key elements of the telephone negotiation were confidence and perceived usefulness of the transfer. Finally, the otherness of some categories of patients, transferred with more difficulty, involved those with cognitive impairment. CONCLUSIONS: The existence of healthcare pathways for many years has created an organizational culture between departments of nPRM and ICUs. But urgent transfers also imply organizational ethics, as a balance should be struck between utility and equity. IMPLICATIONS FOR REHABILITATIONStructural and human factors interfere in urgent transfers, involving the settings within health pathways, the key elements of negotiation to get confidence and a perceived utility of transfer, and certain categories of people, especially those with cognitive impairment.Transfers that imply negotiation between practitioners from physical and rehabilitation medicine and intensive care unit departments, lead to a need of organizational ethics, as a balance should be struck between the principles of utility and equity.The development of facilitating tools such as a commitment charter is of paramount importance as it can support ethical decision-making.

Implementation of Medical Assistance in Dying as Organizational Ethics Challenge: A Method of Engagement for Building Trust, Keeping Peace and Transforming Practice.

This paper focuses on the ethics of how to approach the introduction of MAiD as an organizational ethics challenge, a focus that diverges from the traditional focus in healthcare ethics on the ethics of why MAiD is right or wrong. It describes a method co-designed and implemented by ethics and medical leadership at a tertiary hospital to develop a values-based, grassroots response to the decriminalization of assisted dying in Canada. This organizational ethics engagement method embodied core tenants that drew inspiration from a variety of sources, including poetic ones. These tenants are: make the problem bigger; focus on values; cultivate open moral spaces; and trust emergence. The paper describes how these tenants were put into practice in order to create a rigorous and sustainable MAiD program that delivers high-quality care to patients and families while honoring the moral diversity of the hospital workforce. One of the goals in sharing this method is to provide a roadmap for healthcare organizations in Canada and other jurisdictions around the world that are facing the challenge of responding to patient requests for MAiD following the decriminalization of this care option.

Grateful Patient Philanthropy: A Challenge to Organizational Ethics.

An examination of organization development in health care reveals a pattern of increasing reliance of academic medical centers toward new sources of revenue in support of operations. This trend is partly in response to the reduction of traditional funding sources such as public appropriations and tuition. Clinical income from faculty earnings and hospital transfer payments have supplanted heritage funding sources and are now predominantly institutional transactions rather than physician-patient interactions. Grateful patient philanthropy can be viewed as moving toward transactional status, with challenging ethical questions for the involved physician and patient as institutional control increases.

Is there a role for ethics in addressing healthcare incivility?

In a healthcare setting, a multitude of ethical and moral challenges are often present when patients and families direct uncivil behavior toward clinicians and staff. These negative interactions may elicit strong social and emotional reactions among staff, other patients, and visitors; and they may impede the normal functioning of an institution. Ethics Committees and Clinical Ethics Consultation Services (CECSs) can meaningfully contribute to organizational efforts to effectively manage incivility through two distinct, yet inter-related channels. First, given their responsibility to promote a humane, respectful, and professional climate, many CECSs and Ethics Committees may assist institutional leadership in evaluating and monitoring incivility policies and procedures. Second, when confronted with individual incidents of patient/family incivility, Ethics Consultants can and often do work with all stakeholders to address and mitigate potentially deleterious impacts. This manuscript presents an overview of the multifaceted ethical implications of incivility in the healthcare environment, discusses the inherent qualifications of Ethics Consultants for assisting in the management of incivility, and proposes specific mitigating actions within the purview of CECSs and Ethics Committees. We also invite healthcare organizations to harness the skills and reputation of their CECSs and Ethics Committees in confronting incivility through comprehensive policies, procedures, and training.

'Value, values and valued': a tripod for organisational ethics.

Public benefit corporations are National Health Service, that is, state, entities whose function to provide healthcare in discharge of public duties. If we regard value as the output of such organisations, it seems logical to connect the values of the organisation to the value produced by such organisations. But, on closer examination there are competing underlying logics in play: (1) those based on promoting organisational efficiency and efficacy; and (2) those based on the idea of building service provision around the clinician-patient relationship. Underlying these logics are differing value sets. These clash. Because of the clashing of underlying moral frameworks the connection between values and value becomes hard, if not impossible. This paper argues that (1) the clash in these moral frameworks must be addressed by the organisation rather than between individuals or groups of individuals within the organisation; (2) alloying duties within hybrid professionals submerges but does not resolve these conflicts; (3) one approach could be to impose on the organisation itself an ethical imperative to promote, enhance and protect from deterioration the welfare of the patients; (4) a board ethics committee is a possible organisational structure that could transparently and fairly balance clashes within the competing moral frameworks in a way that could reconcile the competing logics and (5) if such conflicts can be better resolved at the organisational level what the organisation must do to achieve its objectives will become clearer because what needs to be valued would naturally emerge connecting values, value and what is valued.

A world away and here at home: a prioritisation framework for US international patient programmes.

Programmes serving international patients are increasingly common throughout the USA. These programmes aim to expand access to resources and clinical expertise not readily available in the requesting patients' home country. However, they exist within the US healthcare system where domestic healthcare needs are unmet for many children. Focusing our analysis on US children's hospitals that have a societal mandate to provide medical care to a defined geographic population while simultaneously offering highly specialised healthcare services for the general population, we assume that, given their mandate, priority will be given to patients within their catchment area over other patients. We argue that beyond prioritising patients within their region and addressing inequities within US healthcare, US institutions should also provide care to children from countries where access to vital medical services is unavailable or deficient. In the paper, we raise and attempt to answer the following: (1) Do paediatric healthcare institutions have a duty to care for all children in need irrespective of their place of residence, including international patients? (2) If there is such a duty, how should this general duty be balanced against the special duty to serve children within a defined geographical area to which an institution is committed, when resources are strained? (3) Finally, how are institutional obligations manifest in paradigm cases involving international patients? We start with cases, evaluating clinical and contextual features as they inform the strength of ethical claim and priority for access. We then proceed to develop a general prioritisation framework based on them.

The effectiveness of the Ethics Quarter intervention on the ethical activity profile of nurse managers: A randomized controlled trial.

AIM: To test the effectiveness of a new ethics educational e-learning intervention, Ethics Quarter, in supporting nurse managers' ethical activity profile. BACKGROUND: Health care organisations need evidence-based ethics interventions to support nurse managers' ethical activity profile. METHODS: A parallel-group, individually randomized controlled trial was conducted in 2020. Finnish nurse managers nationwide [members of the Union of Health and Social Care Professionals in Finland (Tehy) trade union] were randomly allocated to intervention (n = 169) or control group (n = 172). The intervention group participated in the Ethics Quarter comprising twelve 15-min evidence-based educational 'quarters' spread over 6 weeks. The control group had standard organisational ethics structures. The primary and secondary outcomes were ethical activity profile and ethics knowledge, respectively. The Consolidated Standards of Reporting Trials (CONSORT) statement for study design and reporting was adopted. RESULTS: Ethical activity profile showed statistically significant differences in mean changes between the groups from baseline to 10 weeks: all five dimensions were statistically significantly higher in the intervention group compared with the control group (p = <.0001). CONCLUSION: The Ethics Quarter was effective in increasing nurse managers' ethical activity profile. IMPLICATIONS FOR NURSING MANAGEMENT: Applying this ethics educational e-learning intervention would benefit nursing management education and health care organisations. TRIAL REGISTRATION: clinicaltrials.gov: NCT04234503.

Institutional betrayal in nursing: A concept analysis.

BACKGROUND: Ethical relationships are important among many participants in healthcare, including the ethical relationship between nurse and employer. One aspect of organizational behavior that can impact ethical culture and moral well-being is institutional betrayal. RESEARCH AIM: The purpose of this concept analysis is to develop a conceptual understanding of institutional betrayal in nursing by defining the concept and differentiating it from other forms of betrayal. DESIGN: This analysis uses the method developed by Walker and Avant. RESEARCH CONTEXT: Studies were reviewed using health literature databases with no date restrictions. ETHICAL CONSIDERATIONS: Analysis was conducted using established guidelines for ethical research. FINDINGS: Although institutional betrayal is a concept applied in the literature, there was a paucity of studies exploring the concept within nursing. Examples of the concept in the literature include violation of trust between organization (i.e. employer) and nurse, such as provision of inadequate workplace protections, ineffective or hostile management, and gaslighting of those who experience negative events. Examples of institutional betrayal have become more visible during the COVID-19 pandemic. DISCUSSION: A conceptual definition of institutional betrayal is a deep violation of trust or confidence or violation of moral standards committed by an institution toward a nurse. This definition incorporates experiences and issues suggested by the literature. Outcomes are likely negative, including impacts on nurse psychological and workplace well-being. This concept likely fits within a framework of ethical workplaces and has conceptual relationships with moral distress and moral resilience. Further studies can help qualitatively explore and empirically measure this concept. CONCLUSION: In the pursuit of improving the ethical culture of healthcare workplaces, this concept can provide meaningful insight into organizational behavior and its consequences. Naming and describing the concept can promote conceptual clarity and equip researchers, nurses, and leaders to identify and mitigate the issue.

Commentary on "Pandemics and Beyond: Considerations When Personal Risk and Professional Obligations Converge".

The excellent article by Daniel J. Benedetti, Mithya Lewis-Newby, Joan S. Roberts, and Douglas S. Diekema draws strength by dealing both with micro ethical (personal) and macro ethical (institutional policies and structures) considerations. One should further note that often, the macro factors are even stronger than the article implies, although individuals can affect the macro context. A particularly important macro factor for all matters concerning healthcare, indeed all human services, is the tension between the profit motive and ethical decisions.

The Resident and the Spouse and the Lover and the Ethicist: Considerations and Challenges in Nursing Home Romance.

The level of impairment shown by the 1.3 million residents of nursing homes in the United States varies significantly, and this raises considerable challenges for how to address the sexual and romantic interests and needs of these diverse individuals. Unfortunately, bright-line rules and a one-size-fits-all approach are often taken when addressing these challenges. This article proposes a novel taxonomy for classifying the potential sexual and romantic relationships of cognitively impaired nursing home residents that includes relationships between unmarried residents, relationships between residents and their own spouses, and adulterous relationships. We explore the ethical and logistical challenges distinctive to each category of relationship.

Incorporating Stakeholder Perspectives on Scarce Resource Allocation: Lessons Learned from Policymaking in a Time of Crisis.

The coronavirus disease (COVID-19) crisis provoked an organizational ethics dilemma: how to develop ethical pandemic policy while upholding our organizational mission to deliver relationship- and patient-centered care. Tasked with producing a recommendation about whether healthcare workers and essential personnel should receive priority access to limited medical resources during the pandemic, the bioethics department and survey and interview methodologists at our institution implemented a deliberative approach that included the perspectives of healthcare professionals and patient stakeholders in the policy development process. Involving the community more, not less, during a crisis required balancing the need to act quickly to garner stakeholder perspectives, uncertainty about the extent and duration of the pandemic, and disagreement among ethicists about the most ethically supportable way to allocate scarce resources. This article explains the process undertaken to garner stakeholder input as it relates to organizational ethics, recounts the stakeholder perspectives shared and how they informed the triage policy developed, and offers suggestions for how other organizations may integrate stakeholder involvement in ethical decision-making as well as directions for future research and public health work.

Ethical conflict during COVID-19 pandemic: the case of Spanish and Italian intensive care units.

AIM: To identify factors underlying ethical conflict occurring during the current COVID-19 pandemic in the critical care setting. BACKGROUND: During the first wave of the COVID-19 outbreak, Spanish and Italian intensive care units were overwhelmed by the demand for admissions. This fact revealed a crucial problem of shortage of health resources and rendered that decision-making was highly complex. SOURCES OF EVIDENCE: Applying a nominal group technique this manuscript identifies a series of factors that may have played a role in the emergence of the ethical conflicts in critical care units during the COVID-19 pandemic, considering ethical principles and responsibilities included in the International Council of Nurses Code of Ethics. The five factors identified were the availability of resources; the protection of healthcare workers; the circumstances surrounding decision-making, end-of-life care, and communication. DISCUSSION: The impact of COVID-19 on health care will be long-lasting and nurses are playing a central role in overcoming this crisis. Identifying these five factors and the conflicts that have arisen during the COVID-19 pandemic can help to guide future policies and research. CONCLUSIONS: Understanding these five factors and recognizing the conflicts, they may create can help to focus our efforts on minimizing the impact of the ethical consequences of a crisis of this magnitude and on developing new plans and guidelines for future pandemics. IMPLICATIONS FOR NURSING PRACTICE AND POLICY: Learning more about these factors can help nurses, other health professionals, and policymakers to focus their efforts on minimizing the impact of the ethical consequences of a crisis of this scale. This will enable changes in organizational policies, improvement in clinical competencies, and development of the scope of practice.