Cultivating ethical leadership in the recovery of COVID-19.

AIM: To propose the necessity of fostering ethical leadership in the recovery of COVID-19. BACKGROUND: Supporting physically and emotionally exhausted nurses, whilst ensuring quality standards of care delivery in the recovery phase of COVID-19, requires careful, considerate and proactive planning. EVALUATION: Drawing on literature and utilizing Lawton and Paez Gabriunas' (2015) integrated ethical leadership framework (purpose, practices, virtues), possible practical suggestions for the operationalization of ethical leadership are proposed. DISCUSSION: Nurse managers must maintain ethical vigilance in order to nurture value-driven behaviour, demonstrating empathy and compassion for nurses experiencing physical and emotional exhaustion because of COVID-19. It is important that open dialogue, active listening and self-care interventions exist. Nurse managers have an essential role in inspiring and empowering nurses, and building morale and a collective commitment to safe and quality care. CONCLUSION: Nurse managers need to consider ways of empowering, supporting and enabling nurses to apply ethical standards in everyday practice. IMPLICATIONS FOR NURSING MANAGEMENT: Fostering ethical nurse leadership requires careful and sensitive planning, as well as charismatic, compassionate and inspirational leaders. Supporting staff through respect, empathy, role modelling and genuine conscientiousness is essential for increasing job performance and sustaining an ethical work environment.

Relationship between ethical leadership and organisational commitment of nurses with perception of patient safety culture.

AIM: To determine the relationship between ethical leadership, organisational commitment of nurses and their perception of patient safety culture. BACKGROUND: Patient safety, organisational commitment and ethical leadership styles are very important for improving the quality of nursing care. METHODS: In this descriptive-correlational study, 340 nurses were selected using random sampling from the hospitals in Tehran in 2016. Data were analysed using descriptive and inferential statistics in SPSS v.20. RESULTS: There was a significant positive relationship between the ethical leadership of nursing managers, perception of patient safety culture and organisational commitment. The regression analysis showed that nursing managers' ethical leadership and nurses' organisational commitment is a predictor of patient safety culture and confirms the relationship between the variables. CONCLUSION: Regarding the relationship between the nurses' safety performance, ethical leadership and organisational commitment, it seems that the optimisation of the organisational commitment and adherence to ethical leadership by administrators and managers in hospitals could improve the nurses' performance in terms of patient safety. IMPLICATIONS FOR NURSING MANAGEMENT: Implementing ethical leadership seems to be one feasible strategy to improve nurses' organisational commitment and perception of patient safety culture. Efforts by nurse managers to develop ethical leadership reinforce organisational commitment to improve patient outcomes. Nurse managers' engagement and performance in this process is vital for a successful result.

The Business, Ethics, and Quality Cases for Consumer Engagement in Nursing.

OBJECTIVE: The aims of this study were to illustrate the quality, safety, cost-effectiveness, and ethics of consumer engagement initiatives and identify promising practices and leadership strategies used by nursing leaders. METHODS: A literature review was performed with supplementary interviews conducted with 25 key nursing informants including nursing executives and chief nursing officers at acute care hospitals, community health centers, policy institutions, and quality and safety organizations. A narrative synthesis approach was used to identify and compare existing measures of consumer engagement and compassionate care in acute care settings. One-hour semistructured interviews were performed, and information was gathered by notes and audio recordings. RESULTS: Consumer engagement activities focusing on compassionate patient and provider interactions involving patients and family as partners on the care team are associated with increases in treatment savings and patient safety in terms of length of stay and reduced medication errors. Engagement initiatives support employee health and reduce compassion fatigue. CONCLUSION: Findings illustrate the impact of patients and family engagement in decision making and promising organizational practices that reinforce engagement.

An ethical leadership program for nursing unit managers.

PURPOSE: The aims of this study were to evaluate the effect of an ethical leadership program (ELP) on ethical leadership, organizational citizenship behavior (OCB), and job outcomes of nursing unit managers (UMs) and to examine changes in staff nurses' perception about UMs' EL, OCB, job outcomes, and ethical work environments (EWEs) post-ELP. DESIGN: A quasi-experimental (pre- and post-test design) study conducted six-month intervention (ELP) using self-reported UM survey (n=44), and staff nurses (n=158) were randomly extracted by two steps. METHODS: The Korean version of Ethical Leadership at Work for UMs' self-ethical leadership, the Ethical Leadership Scale for staff nurses' perceived ethical leadership, a 19-item OCB scale, and six dimensions of the medium-sized Copenhagen Psychosocial Questionnaire II for job outcomes and EWEs were administered at baseline and post-intervention. FINDINGS: UMs' ethical leadership scores differed significantly over time in people orientation (p=0.041) and concern for ethical leadership sustainability (p=0.002) adjusting for UM experience duration and nursing unit type. Total mean and level of power-sharing of ethical leadership among UMs with <5years of UM experience improved significantly over time. Of staff nurses' perception changes about UMs' ethical leadership, OCB, job outcomes, and EWEs, significant improvement over time appeared only in EWEs' work influence level (p=0.007). CONCLUSIONS: This study provides useful information for clinical ELP development and examining the program's effect on leadership skills and followers' outcomes. Program facilitation relies on practical training methods, participant motivation, and assessment outcome designs by controlling clinical confounding factors. Findings have implications as an attempt for intervention to promote competencies related to ethical leadership of nursing unit managers.

[The ethical leadership of the nursing ward managers as a key determinant of nurses' organisational behaviours in the healthcare settings]. / La leadership etica del coordinatore come fattore determinante i comportamenti organizzativi degli infermieri, nei luoghi di cura.

AIM: The main aim of this study is to examine the influence of the coordinator's ethical leadership on nurses' emotions (i.e., positive and negative) and work behaviours. METHOD: A questionnaire was administered in paper format, including well-validated scales reported in literature, to a sample of 347 nurses working in a university hospital. A structural equation model has been tested after examining Pearson's correlations among study variables. RESULTS: The coordinator's ethical leadership is strongly related to the implementation of nurses' organisational citizenship behaviour and counterproductive work behaviour, which are influenced by their emotions. Positive emotions fully mediate the relationship between ethical leadership and organisational citizenship behaviour, while negative emotions partially mediate the relationship between ethical leadership and counterproductive work behaviour. CONCLUSIONS: Ethical leadership acts on nurses' organisational behaviour, as described in the modelling process. The nurses' organisational behaviour is crucial to the outcome of the health care service. Therefore, the ethical leadership indirectly affects the quality of the care and the cure offered to the patients.

Nurse leaders as managers of ethically sustainable caring cultures.

AIMS: The aim of this study was to identify the distinctive foundations of the care culture and how nurse leaders (NL) can manage and strengthen these in a quest for ethically sustainable caring cultures. BACKGROUND: Sustainability presupposes an ethical leadership, a management of the good care and a well-educated staff, but research on NLs as managers of ethically sustainable caring cultures is not available. DESIGN: The study has a quantitative design with elements of a qualitative research approach. METHOD: Data were collected through a web-based questionnaire sent to staff at eight selected units at a hospital in western Finland during September 2013; the reply rate was 32%. The data material was comprised of opinion questions, the ranking of values and two open-ended questions on lodestars in care and ethical principles in care work. RESULTS: NLs manage a care culture that rests on a solid foundation, where staff are co-creators of an ethically sustainable caring culture that includes good traditions for the praxis of care. NLs as managers are therefore responsible for realizing and passing on ethically sustainable caring cultures and creating prerequisites for staff's growth and development. CONCLUSION: The basis of good care, patient safety and sustainability is comprised of ethics with a respectful and dignified care that is evidence-based and economically stable. Through their management NLs have a responsibility to nurture and protect the core of caring and create contextual, professional and cultural prerequisites to maintain the core and art of caring as well as care staff's ethical and professional competence.

Between meaning and duty - leaders' uses and misuses of ethical arguments in generating engagement.

AIM: To identify, record and determine from the perspective of an argumentation theory whether and how nurse leaders use or possibly misuse ethical arguments to motivate and engage their staff when daily practice is affected by reforms. BACKGROUND: In some cases, health reforms based on New Public Management theories have met resistance, especially when perceived as contrary to nurses' professional and personal ethical values, creating a motivational challenge for nurse leaders. METHODS: Qualitative thematic analysis and argumentation analysis based on personal interviews, focus group interviews and observations of nurse leaders and nurses in two different wards in a Danish hospital that has undergone structural and management reforms. CONCLUSION: Nurse leaders use ethical arguments to engage their staff, either by trying to make the reforms ethically meaningful or by appealing to duty when no meaning can be found. Occasionally, these ethical arguments are fallacious and inconclusive from an argumentation theory perspective. IMPLICATIONS FOR NURSING MANAGEMENT: Using ethical arguments can motivate and engage staff, but it may also escalate conflicts. Managers and leaders must be aware that, if the argument is flawed, appealing to higher ethical values is not always beneficial.

Ethical activity profile of nurse managers.

AIM: To describe the ethical activity profile of nurse managers (NM). BACKGROUND: Ethical responsibilities require nurse managers to perform certain ethical activities. In this study, these activities are referred to as an ethical activity profile and are divided into five dimensions: (1) developing one's own ethics knowledge, (2) influencing ethical issues, (3) conducting or implementing ethics research, (4) identifying and (5) solving ethical problems. This paper focuses on the first four dimensions. METHODS: Survey data were collected in 2011 using a questionnaire (mainly open questions) amongst managers at the ward, middle and strategic levels (n = 122). The data were analysed using inductive content analysis and quantification. RESULTS: The ethical activity profile of nurse managers was high, referring to the identification of various work-related ethical problems [related to staff (31%), the nurse managers themselves (29%), resources (17%), patients (12%), superiors (7%) and organisations (4%)]. However, developing one's own ethics knowledge, influencing ethical issues and conducting or implementing research dimensions of the ethical activity profile were low. CONCLUSIONS: There is room to improve the ethical activity profile of nurse managers. IMPLICATIONS FOR NURSING MANAGEMENT: Organisations have to demand that nurse managers meet all their ethical responsibilities and support this via organisational structures.

How nurse managers in Japanese hospital wards manage patient violence toward their staff.

AIM: This study explores nurse managers' experiences in dealing with patient/family violence toward their staff. BACKGROUND: Studies and guidelines have emphasised the responsibility of nurse managers to manage violence directed at their staff. Although studies on nursing staff have highlighted the ineffectiveness of strategies used by nurse managers, few have explored their perspectives on dealing with violence. METHODS: This qualitative study adopted a grounded theory approach to explore the experiences of 26 Japanese nurse managers. RESULTS: The nurse managers made decisions using internalised ethical values, which included maintaining organisational functioning, keeping staff safe, advocating for the patient/family and avoiding moral transgressions. They resolved internal conflicts among their ethical values by repeating a holistic assessment and simultaneous approach consisting of damage control and dialogue. They facilitated the involved persons' understanding, acceptance and sensemaking of the incident, which contributed to a resolution of the internal conflicts among their ethical values. CONCLUSIONS: Nurse managers adhere to their ethical values when dealing with patient violence toward nurses. Their ethical decision-making process should be acknowledged as an effective strategy to manage violence. IMPLICATIONS FOR NURSING MANAGEMENT: Organisational strategies that support and incorporate managers' ethical decision-making are needed to prevent and manage violence toward nurses.

Nurses' adherence to ethical codes: The viewpoints of patients, nurses, and managers.

BACKGROUND: Ethical codes are guidelines that orient nurses and ensure that their decisions are in accordance with the values of the professional system. These codes show that there is a connection among values, patients' rights, and nurses' duties. OBJECTIVES: This study aimed to compare the viewpoints of patients, nurses, and nurse managers regarding the extent to which clinical ethical codes are observed. RESEARCH DESIGN: In this descriptive-comparative study, data were collected using three questionnaires based on Iranian nurses' ethical codes with a focus on clinical care. The reliability of the questionnaire was verified by test-retest method (r = 0.9). The patients were interviewed by the researcher, but nurses and managers completed the questionnaires themselves. After all, the data were analyzed using the SPSS statistical software (v 15). PARTICIPANTS AND RESEARCH CONTEXT: In all, 100 patients, 100 nurses, and 30 managers from internal and surgical wards of two major hospitals in Shiraz, Iran, participated in 2014. ETHICAL CONSIDERATIONS: This research was approved by the Ethics Committee of Shiraz University of Medical Sciences. All the participants signed written informed consents. FINDINGS: According to the results, 70% of the patients, 86% of the nurses, and 53.3% of the nurse managers rated nurses' adherence to ethical codes as satisfactory. The mean scores (standard deviation) of the level of adherence to ethical codes were 38.44 (6.91) in the patients, 41.08 (4.82) in the nurses, and 37.83 (6.98) in the nurse managers. The results of analysis of variance revealed a significant difference between the attitudes of the nurses and the other two groups (p = 0.001). DISCUSSION: Nurses' adherence to ethical codes was satisfactory in all three groups. Accordingly, our findings agree with the results of some national and international studies, although there are still controversies in this regard. CONCLUSION: Although the nurses rated their performance in certain fields more satisfactory compared to the patients and managers, all the three groups agreed that clinical ethical codes were properly observed in the internal and surgical wards. Nurses can improve the quality of care by considering the viewpoints of patients and managers about their ethical performance.

Solving work-related ethical problems.

BACKGROUND: Nurse managers are responsible for solving work-related ethical problems to promote a positive ethical culture in healthcare organizations. OBJECTIVES: The aim of this study was to describe the activities that nurse managers use to solve work-related ethical problems. The ultimate aim was to enhance the ethical awareness of all nurse managers. RESEARCH DESIGN: The data for this descriptive cross-sectional survey were analyzed through inductive content analysis and quantification. Participants and research context: The data were collected in 2011 using a questionnaire that included an open-ended question and background factors. Participants were nurse managers working in Finnish healthcare organizations (n = 122). Ethical considerations: Permission for the study was given by the Finnish Association of Academic Managers and Experts of Health Sciences. FINDINGS: Nurse managers identified a variety of activities they use to solve work-related ethical problems: discussion (30%), cooperation (25%), work organization (17%), intervention (10%), personal values (9%), operational models (4%), statistics and feedback (4%), and personal examples (1%). However, these activities did not follow any common or systematic model. DISCUSSION AND CONCLUSION: In the future, nurse managers need a more systematic approach to solve ethical problems. It is important to establish new kinds of ethics structures in organizations, such as a common, systematic ethical decision-making model and an ethics club for nurse manager problems, to support nurse managers in solving work-related ethical problems.

Ethical dilemmas facing chief nurses in Japan: A Pilot study.

BACKGROUND: Chief nurses are most likely to take the lead in discussing and working to resolve ethical dilemmas, creating an ethical culture within their organization that results in effective ethics training. As the first step in this process, there is a need to define the kinds of ethical dilemmas that chief nurses grapple with on a regular basis as a target for future study. RESEARCH DESIGN: Anonymous written questionnaires and semi-structured interviews. ETHICAL CONSIDERATIONS: All research procedures were approved by the Chubu University Ethics Review Board, the research institution to which the authors belong (authorization no. 250016). FINDINGS AND DISCUSSION: Responses from four chief nurses indicated that ethical dilemmas could be categorized as either those related to patient dignity or those related to management (unique to their roles as administrators). It was also learned that chief nurses struggle with the fact that although they consult with their superiors and others, these efforts do not lead to resolution. The expectation is that going forward, chief nurses will play a central role in acting as coordinators with physicians to promote better communication as well as lead group discussions aimed at providing care that respects patient dignity.

Ethical problems in nursing management: The views of nurse managers.

BACKGROUND: Nurse managers have responsibilities relating to the quality of care, the welfare of the staff and running of the organization. Ethics plays significant role in these responsibilities. Ethical problems are part of daily management, but research in this area is limited. OBJECTIVE: The aim of this study was to identify and describe ethical problems nurse managers encounter in their work to get more detailed and extensive view of these problems. METHODS: The data consisted of nine interviews with nurse managers at different management levels in primary healthcare and specialized healthcare organizations, and it was analysed by inductive content analysis. ETHICAL CONSIDERATIONS: Permission to conduct the interviews including ethical approval was given at all participating organizations according to national standards. The respondents were informed about the aim of the study, and voluntary participation, anonymous response and confidentiality were explained to them. FINDINGS: Four main categories were found: conflicts in practical situations, lack of appreciation, disregard of problems and experienced inadequacy. Problems could also be divided to patient-related, staff-related, organization-related and other problems. DISCUSSION: The findings correspond with results from earlier studies but add knowledge of the nature and details of nurse managers' ethical problems. New information is produced related to the ethical problems with nurse managers' own courage, motivation and values. CONCLUSION: Nurse managers identified a variety of different ethical problems in their work. This information is useful in the development of ethics in nursing management. Further research about the frequency and intensity of nurse managers' ethical problems is needed as well as possible differences in different levels of management.

[A Validation Study of the Modified Korean Version of Ethical Leadership at Work Questionnaire (K-ELW)].

PURPOSE: The purpose of this study was to validate the Korean version of the Ethical Leadership at Work questionnaire (K-ELW) that measures RNs' perceived ethical leadership of their nurse managers. METHODS: The strong validation process suggested by Benson (1998), including translation and cultural adaptation stage, structural stage, and external stage, was used. Participants were 241 RNs who reported their perceived ethical leadership using both the pre-version of K-ELW and a previously known Ethical Leadership Scale, and interactional justice of their managers, as well as their own demographics, organizational commitment and organizational citizenship behavior. Data analyses included descriptive statistics, Pearson correlation coefficients, reliability coefficients, exploratory factor analysis, and confirmatory factor analysis. SPSS 19.0 and Amos 18.0 versions were used. RESULTS: A modified K-ELW was developed from construct validity evidence and included 31 items in 7 domains: People orientation, task responsibility fairness, relationship fairness, power sharing, concern for sustainability, ethical guidance, and integrity. Convergent validity, discriminant validity, and concurrent validity were supported according to the correlation coefficients of the 7 domains with other measures. CONCLUSION: The results of this study provide preliminary evidence that the modified K-ELW can be adopted in Korean nursing organizations, and reliable and valid ethical leadership scores can be expected.

Quality, efficiency and integrity: value squeezes in management of hospital wards.

AIM: The aim of this study was to explore and describe the value squeezes experienced by ward managers in connection with quality management in hospital wards. The study focused on integrity pressure and coping strategies to deal with such pressure. BACKGROUND: Nurses in the role of ward managers have a key function in the field of quality improvement. These managers are also responsible for the efficient running of their wards and thus face tensions between demands for both quality and efficiency. METHOD: Data were collected through interviews conducted with 10 ward managers from six Norwegian hospitals. The data were analysed using both content and template analysis. RESULTS: Ward managers felt squeezed between conflicting values associated with demands for both quality and efficiency. These tensions resulted in pressure on integrity for the managers as well as their nursing colleagues. Three different management strategies were used to cope with such pressure: quality conscious, efficiency adjusting and hybrid. CONCLUSION: A hybrid strategy appeared to be the best, both for the ward managers and the hospital organisations, despite the fragmentation associated with this strategy. IMPLICATIONS FOR NURSING MANAGEMENT: Hybrid management may be beneficial for coping with pressure on integrity, although more empirical research is needed.

A Validation Study of the Modified Korean Version of Ethical Leadership at Work Questionnaire (K-ELW)

PURPOSE: The purpose of this study was to validate the Korean version of the Ethical Leadership at Work questionnaire (K-ELW) that measures RNs' perceived ethical leadership of their nurse managers. METHODS: The strong validation process suggested by Benson (1998), including translation and cultural adaptation stage, structural stage, and external stage, was used. Participants were 241 RNs who reported their perceived ethical leadership using both the pre-version of K-ELW and a previously known Ethical Leadership Scale, and interactional justice of their managers, as well as their own demographics, organizational commitment and organizational citizenship behavior. Data analyses included descriptive statistics, Pearson correlation coefficients, reliability coefficients, exploratory factor analysis, and confirmatory factor analysis. SPSS 19.0 and Amos 18.0 versions were used. RESULTS: A modified K-ELW was developed from construct validity evidence and included 31 items in 7 domains: People orientation, task responsibility fairness, relationship fairness, power sharing, concern for sustainability, ethical guidance, and integrity. Convergent validity, discriminant validity, and concurrent validity were supported according to the correlation coefficients of the 7 domains with other measures. CONCLUSION: The results of this study provide preliminary evidence that the modified K-ELW can be adopted in Korean nursing organizations, and reliable and valid ethical leadership scores can be expected.

Philanthropic dilemmas and the nurse administrator role.

Nurse administrators are in a position to encounter ethical dilemmas when evaluating philanthropic proposals. Nurses may have little formal training in ethics, or they may be most experienced with ethical frameworks that apply primarily to clinical patient encounters. Gifts of goods, services, education, or other benefits to nurses may create ethical dilemmas. Philanthropic ethics and potential dilemmas are discussed in nonnursing professions such as medicine and nonprofit administration but rarely explored in the nursing administration context. Nurse administrators in a position to evaluate generous offers of philanthropy should identify key components to fully assess the ethics of their receipt. A survey of several resources is done to provide nurse administrators with the foundation to develop policies related to philanthropy if they are absent, preferably in advance of the offer. Recommendations for assessment and evaluation of philanthropic proposals are provided to aid nurse administrators in their synthesis and application of ethical principles from multiple sources.

The nature of ethical conflicts and the meaning of moral community in oncology practice.

PURPOSE/OBJECTIVES: To explore ethical conflicts in oncology practice and the nature of healthcare contexts in which ethical conflicts can be averted or mitigated. RESEARCH APPROACH: Ethnography. SETTING: Medical centers and community hospitals with inpatient and outpatient oncology units in southern California and Minnesota. PARTICIPANTS: 30 oncology nurses, 6 ethicists, 4 nurse administrators, and 2 oncologists. METHODOLOGIC APPROACH: 30 nurses participated in six focus groups that were conducted using a semistructured interview guide. Twelve key informants were individually interviewed. Coding, sorting, and constant comparison were used to reveal themes. FINDINGS: Most ethical conflicts pertained to complex end-of-life situations. Three factors were associated with ethical conflicts: delaying or avoiding difficult conversations, feeling torn between competing obligations, and the silencing of different moral perspectives. Moral communities were characterized by respectful team relationships, timely communication, ethics-minded leadership, readily available ethics resources, and provider awareness and willingness to use ethics resources. CONCLUSIONS: Moral disagreements are expected to occur in complex clinical practice. However, when they progress to ethical conflicts, care becomes more complicated and often places seriously ill patients at the epicenter. INTERPRETATION: Practice environments as moral communities could foster comfortable dialogue about moral differences and prevent or mitigate ethical conflicts and the moral distress that frequently follows.