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Moral Leadership in Nursing
Moral Leadership in Nursing j Dana Bjarnason, PhD, RN, NE-BC; and Cynthia Ann LaSala, MS, RN ABSTRACT: In order for the moral activity of nursing to occur, all nursesdfrom the board room to the patient roomdmust embrace the ideal of their duties and obligations related to moral leadership in nursing. Understanding the issues that affect the environment of care is a responsibility regardless of the nurses’ roled educators, administrators, clinicians, and scholars must join together to address the myriad opportunities that exist. Moral leaders embrace key concepts that promote ethical environments, creating a nursing milieu that enhances the quality and safety of patient care. (J Radiol Nurs 2011;30:18-24.) KEYWORDS: Nursing; Moral; Ethical; Leadership.
INTRODUCTION What is our needful thing? To have high principles at the bottom of all. Without this, without having laid our foundation, there is small use in building up our details. This is as if you were to try to nurse without eyes or hands.If your foundation is laid in shifting sand, you may build your house, but it will tumble down (Nightingale, 1915). The past two decades have produced remarkable changes in the health care environment. As the acuity and complexity of patient care have increased, creating environments that foster safe, high-quality patient care has become increasingly challenging. In addition to sicker patients who require highly skilled, knowledgebased assessment and intervention is the growing need to possess expert skills to operate increasingly complex technology. Further factors that complicate the care environment include fiscal pressures, nursing shortages, reliance on supplemental staffing, and changing patterns of ethnic, generational, and gender diversity that affect the workplace.
Dana Bjarnason, PhD, RN, NE-BC, is an Associate Administrator & Chief Nursing Officer in Ben Taub General Hospital/Quentin Mease Community Hospital at Houston, TX. Cynthia Ann LaSala, MS, RN, is a Clinical Nurse Specialist for Patient Care Services in the Department of Nursing, Massachusetts General Hospital at Boston, MA. Corresponding author: Dana Bjarnason, Ben Taub General Hospital/ Quentin Mease Community Hospital, 1504 Taub Loop, Houston, TX 77030. E-mail: [email protected] 1546-0843/$36.00 Copyright Ó 2011 by the Association for Radiologic & Imaging Nursing. doi: 10.1016/j.jradnu.2011.01.002
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It is clear that certain traits and values impact an organization’s ability to create environments where nurses’ coalesce around a vision for nursing, communicate transparently about difficult issues, and create an environment that nurtures and supports the moral activity of nursing. Given the looming nursing shortage (Buerhaus, 2008; JCAHO, 2002; U.S. Department of Health and Human Services, 2010) coupled with the unknown ramifications of health care reform, the urgency with which hospitals and other health care organizations must examine and initiate strategies to create work environments predicated on moral leadership, ethical practice, and moral courage in the workplace cannot be understated. This article provides a historical perspective of the development of professional nursing that creates the context for moral leadership, as well; it explores the traits and values that are in inherent in workplace environments where moral leadership predominates. PROFESSIONAL COMPETENCE Modern nursing includes prevalent and traditionally agreed on characteristics of a profession such as education and training, skill based on theoretical knowledge, a code of ethics, professional organizations, and service to society (Miller, Adams, & Beck, 1993). In 1859, when Florence Nightingale published Notes on Nursing, she informed her reader that the notes were not a rule of thought or a manual to teach nurses (Nightingale, 1859). Countering Nightingale’s modest assertion is commentary provided by 1996 American Nurses Association Hall of Fame inductee Martha E. Rogers who, in observations published about Notes on Nursing, states that the thoughtful reader can find the underpinnings for much of
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what is going on in nursing today within that historic book (Rogers, 1992). Even more striking given the contemporary practice environment are the goals of nursing articulated by Nightingale, including autonomous nursing practice, a framework for preparation, and standards for ethical conduct and character (Maraldo, 1992). These enduring traits persist, and indeed are considered the hallmarks of professionalism. The historic nature of nursing professionalism is mirrored in The Florence Nightingale Pledge. Despite the fact that it was written in 1893, it is, within the historical context, quite progressive. The Florence Nightingale Pledge not only articulates nursing as a profession but is also directive, objective, and rational, calling on nurses to create care environments through collaboration, education, and high moral standards. Rogers elaborates by saying that although Nightingale was oriented in the era in which she lived, her vision was obvious related to the concepts of human compassion, knowledge base, reasoning, and understandingdvalues that resonate as the basis for nursing professionalism today (Rogers, 1992). NURSINGS’ CODE OF ETHICS Today, the Code of Ethics for Nurses (herein referred to as the Code) serves as nursing’s moral compass in articulating the ethical obligations, duties, standards, and principles to which all nurses are both accountable and responsible irrespective of role, position, or practice setting (ANA, 2001). The Code’s nine provisions and corresponding interpretive statements speak to nursing’s fundamental values and commitments, boundaries of duty and loyalty, and the nurse’s obligations that reach beyond an individual patient to the health care needs of the global community and advancement of professional nursing (ANA, 2001). The Code defines what it means to be professionally accountable to oneself and others and instructs that nurses demonstrate ethical behavior in their actions based on “the moral principles of fidelity and respect for the dignity, worth, and selfdetermination of patients” (p. 4). The Code describes the nurse’s duty to oneself and others as being equally important and expected. Nurses practice with “wholeness of character,” and “personal integrity,” (ANA, 2001, p. 18) and must be committed to professional development and maintaining competence. Nurses “wholeness of character” includes “an authentic expression of one’s own moral point of view in practice” and “the nurse has a responsibility to express moral perspectives, even when they differ from those of others, and even when they might not prevail” (p. 19). “Wholeness of character” also alludes to nurses’ relationships with patients in maintaining “appropriate professional and moral boundaries” (p. 10). The Code VOLUME 30 ISSUE 1
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is nonnegotiablednurses are bound by the values and ethical conduct inherent to the professiondeven when their integrity is threatened. Nurses may engage in compromise as long as it is “integrity preserving” (ANA, 2001, p. 19), that is to say, the compromise will not endanger personal wellbeing or the well-being of others. Nurses never abandon patients, however, nurses may conscientiously object to any situation or circumstance that limits or prevents them from acting morally and upholding moral standards of the profession. In cases where the nurse conscientiously objects to participating in care, nurses fulfill their obligation to the patient by ensuring the appropriate transfer of care, thus ensuring the patient’s safety (ANA, 2001). The Code describes the “morally good person” as someone who possesses “wisdom, honesty, and courage” (ANA, 2001, p. 20). The “morally good nurse” demonstrates “excellences” (compassion, patience, and skill) that exemplify good character (p. 20). Further, the Code speaks to nurses’ “responsibility to create, maintain, and contribute to environments that support the growth of virtues and excellences and enable nurses to fulfill their ethical obligations” (p. 21). NURSING, PRINCIPLE-BASED ETHICS, AND THE ETHIC OF CARE Although the ethic of care represents an ethos that is congruent with nursing, awareness of the utility of principle-based ethics is also essential. In fact, nurses’ responsibility to advocate for patients and the profession produces an obligation to know and use ethical principles as a basis for providing compassionate and competent care. Four fundamental principles are manifested in the ethic of care and have been embedded in nursing since the time of the Florence Nightingale Pledge. Beneficence Beneficence is the ethical duty of bringing about good (Purtilo & Cassel, 1981). For nurses to do “good,” they must consider the values of individual patients. Nurses must be constantly vigilant to the wishes and desires of patients, valuing and respecting autonomy and choice. The Code clearly directs nurses to provide services with respect for human dignity and the uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems (ANA, 2001). Further support of this principle is found in the Code’s tenet directing nurses to collaborate with members of the health professions and other citizens in promoting community and national efforts to meet the health needs of the public.
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Nonmaleficence Nonmaleficence is the principle that holds that the caretaker “do no harm” (Beauchamp & Childress, 1994). Again, upholding this principle while caring for and treating patients requires knowing and understanding the patient’s beliefs and circumstances. The principle of nonmaleficence also necessitates that nurses be cognizant of actions or interventions that may seem innocuous, but that could be justifiably seen as harmful in the eyes of patients and families (Purtilo & Cassel, 1981). The Code lends strength to nurses’ role in upholding this principle by providing direction to “take appropriate action regarding any instances of incompetent, unethical, illegal, or impaired practice of any member of the health care team or health care system” (ANA, 2001, p. 14). The ethical principles of both beneficence and nonmaleficence are also strengthened by state nursing practice acts, which mandate that nurses are legally obligated to safeguard patients and the profession. Autonomy Invoking the principle of autonomy upholds respect for the decision-making capacity of patients (Beauchamp & Childress, 1994). All too often, families, significant others, and even the health care team make care decisions without involving the patient. At times, the health care team may defer to patients’ families when it is inappropriate to do so. This action is improper without the full knowledge, consent, and direction of capacitated patients. Nurses provide an essential link to patients, thus ensuring that the right to make autonomous decisions is maintained. At times, upholding the principle of autonomy, even with patients who are fully competent, is difficult because of barriers to communication such as language differences, hearing deficits, or limited knowledge. In these cases, nurses should direct their efforts toward facilitating clear and directed communication. The principle of autonomy is implemented through the legal and ethical doctrine of informed consent (Lo, 1990). This doctrine requires that patients receive information regarding the risks and benefits of proposed treatments. Nurses have a fundamental duty to protect and promote patient autonomy. Their role related to informed consent is to ensure that patients have a clear understanding of planned procedures, treatments, or interventions. Nurses can achieve this fundamental duty through collaborating with other health care providers and educating and counseling patients and families. Justice Justice in the health care environment has to do with the equitable distribution of benefits and services, and with fairness, which is understood as giving to 20
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each person that to which they have a legitimate right. (May & Sharratt, 1994). Nurses are instrumental in ensuring that a consistent standard of care is upheld for all patients and that unfair or unwarranted paternalistic actions or decision making are questioned. The overarching standard of nursing practice that supports the principle of justice is the requirement that nurses provide services without discrimination.
The ethic of care Beyond principles and more resonant for nursing is the ethic of care, which is not a set of rules and principles. The ethic of care is a practice requiring specific moral qualities that focus on characteristics that connect to the right action (Tronto, 1994). Elements of the ethic of care include such traits as attentiveness, responsibility, competence, and responsiveness (Tronto, 1994). These elements of the ethic of care are further defined as that which refers to care for, emotional commitment to, and willingness to act on behalf of persons with whom one has a significant relationship (Beauchamp & Childress, 1994). These attributes are clearly associated with nurses not only in their relationships with patients, but also in their relationships with other nurses and members of the health care team. MORAL REASONING Moral reasoning (moral judgment or moral development) is a process related to moral choice that one gains over time through personal development and knowledge acquisition (Kelefan & Ormond, 1988). An individual’s level of moral development may be influenced by one’s stage of intellectual development and concurrent social and educational climates. Individuals are thought to develop a higher level of moral judgment in environments characterized by shared decision making, taking responsibility for the consequences of their actions, and where opportunities for collective participation exist (Kelefan & Ormond, 1988). In their discussion on the moral foundation of nursing, Packard and Ferrara (1988) propose that nursing is composed of the following components: (a) taking the right actions to effect health promotion and quality of life, (b) possessing the knowledge and skills necessary to discern when and when not to respond, (c) knowing what the appropriate action(s) should be, and (d) a willingness to act that supports the ethical principle of beneficence. Nurses are at their best when the work they do allows them to “act authentically” (Packard & Ferrara, 1988, p. 69), and to be empathetic, sympathetic, intuitive, and patient centered.
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MORAL COURAGE The implications of moral courage as a sacred value at the clinical, operational, administrative, and executive levels of nursing practice that must be protected and nurtured cannot be overstated. In their commitment to an ethic of care, nurses practice with moral courage when they confront situations that pose a direct threat to care. The nature of their response is predicated on a commitment to serve and advocate for patients and the profession. Attributes of moral courage include faithfulness to one’s moral foundation and the ability to focus on the full significance of a situation (Purtilo, 2000). Practicing with moral courage is a call to act with moral conviction. CULTURAL COMPETENCE To serve the unique and diverse needs of patients in the United States, it is imperative that nurses understand cultural differences by valuing, incorporating, and examining their own health-related values and beliefs, and those of their health care organizationsdfor it is only then can they support the principle of respect for persons and the ideal of transcultural care (Bjarnason, Mick, Thompson, & Cloyd, 2009). Relevant to the culture of nursing is that nurses need to understand and appreciate inherent differences and similarities not only locally, but regionally, nationally, and worldwide (Leininger, 1991). In the United States, nursing’s culture and its commitment to cultural competence are defined through its foundational documents. The Code articulates the value of diversity in its first provision which states “the nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems” (ANA, 2001, p. 7). Nursing’s Social Policy Statement is a fundamental document that describes the articulation of nursing and its social framework and obligations. The statement articulates values and assumptions which characterize the value of diversity, including that human experience is contextually and culturally defined and that the interaction between the nurse and the patient occurs within the context of the values and beliefs of both (ANA, 2010b). In addition to the code of ethics and the social policy statement, the ANA publication Nursing Scope and Standard of Practice outlines standards of practice that describe a competent level of nursing care. Dominant themes essential to the practice of professional nursing include providing culturally and ethnically sensitive care and communicating effectively (ANA, 2010c). The standards reflect nursing’s values VOLUME 30 ISSUE 1
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and priorities and are the authoritative statements for which nurses are accountable. POSITIVE, ETHICAL WORK ENVIRONMENTS The complexity, fluidity, and dynamic nature of health care both now and in the future will pose new challenges as the United States addresses the outcomes of newly enacted health care reform, an unprecedented shortage of registered nurses, ongoing budgetary constraints, introduction of new technologies, and escalating health care needs among its citizens. It is imperative that leadership within health care organizations embrace these challenges as opportunities for creative innovation, employee empowerment, and workplace redesign. Organizations embodying these characteristics have shown positive correlations relative to vacancy rates, turnover, patient satisfaction, and staff satisfaction. In addition, lower morbidity and mortality rates have been associated with “magnet” hospitals, a designation that was established following research that showed certain organizations were able to develop environments where nurses thrived and patient outcomes were unparalleled (Aiken & Salmon, 1994; Aiken, Smith, & Lake, 1994). Shared governance A high degree of formal power is associated with jobs that are flexible, essential to organizational vision, mission, and goals, and encourage employee creativity and prudent decision making. Institutional collaboration and communication through effective partnerships internal and external to the organization bestow informal power (Ning, Zhong, Wang, & Qiujie, 2009). As health care organizations redesign care delivery models to address the needs of patients and families, leadership must promote autonomous decision making among frontline staff. Registered nurses must acquire new skills in delegation and leadership with administrative support, which promotes the development of care and professional practice models that facilitate autonomy in practice, maximize efficiency, and effect quality patient care outcomes (Laschinger, Sabiston, & Kutzscher, 1997). Research has demonstrated several positive outcomes associated with the shared governance model, including increased nurse satisfaction, increased nursing recruitment and retention, and a more motivated, engaged nursing staff (Bretschneider, Glenn-West, Green-Smolenski, & Richardson, 2010). In her theory of structural power in organizations, Rosabeth Moss Kanter (1977) describes four structural factors within organizations that lead to empowerment, which include (a) access to information, (b) support from organizational leadership, subordinates, and peers, (c) adequate resources to do the work, and (d) opportunities for
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personal and professional development. According to Kanter, formal and informal power facilitates access to structural factors that promote empowerment, thereby contributing to the achievement of organizational goals. Mission, vision, values, and philosophy Creating the foundation for an ethical work environment that fosters nursing empowerment is enhanced by ensuring that all stakeholders have a clear understanding of organizational goals and the process through which achieving those goals occurs. In nursing, this can be accomplished by articulating nursing’s mission, vision, and values, and the philosophy of nursing that drives outcomes (Lachman, 2009). Articulating and agreeing to the mission, vision, and values sets the tone for the work of nursing in the organization, creates a future state that implies a commitment to organizational improvement, and suggests the types of activities that will ensure that the organization reaches those goals. Adopting a nursing philosophy allows the organization to define itself to its internal and external communities, and provides examples of professional comportment that hold nurses responsible and accountable for taking action to achieve its mission and vision. Model of care Ethical work environments are enhanced by embracing a model of care that articulates the nursing organization’s commitment to professional and scientific precepts that express nursing’s promise to patients, to peers, and to colleagues. The American Nurses Credentialing Center (2008) defines a professional practice model as “the driving force of nursing care; a schematic description of a theory, phenomenon, or system that depicts how nurses practice, collaborate, communicate, and develop professionally to provide the highest quality of care for those served by the organization (e.g., patients, families, community). Professional practice models illustrate the alignment and integration of nursing practice with the mission, vision, and values that nursing has adopted” (p. 64). Autonomy, accountability, professional development, and emphasis on high-quality care provide a framework for professional practice models in nursing (Fasoli, 2010). Professional practice models are further guided by delivery models that are patient centered, adaptable, and flexible. Teamwork fosters collaboration, consultation, consensus building, and effective interpersonal relationships. Participatory management encourages shared decision making, shared responsibility, and taking ownership of one’s practice at the point of care. An example of participatory management is 22
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shared governance, which requires the design and implementation of supportive structures, and a process for reinforcing and sustaining them. As part of a professional practice model, a reward and recognition system acknowledges performance improvement and nurses’ commitment to uphold high standards of practice predicated on a strong value system and quality professional relationships (Fasoli, 2010). According to Fasoli, “professional practice environments create empowerment and engagement in the workplace that lead to optimal care” (p. 28). EFFECTIVE COMMUNICATION, CHAIN OF COMMAND, AND JUST CULTURE Communication is a critical element of patient safety and quality care and as such, the Joint Commission directs organizations to take action to address communication needs (The Joint Commission, 2009). This directive is based on evidence from the Joint Commission’s sentinel event database that shows that communication is cited as a root cause in nearly 70% of reported sentinel events, surpassing other commonly identified issues such as staff orientation and training, patient assessment, and staffing (Joint Commission Resources, n.d.). Although essential to safe and effective care, communicating effectively can be extremely challenging. Skill with assertive communication, which includes stating a position with assurance, is an honest, direct, and appropriate means of communicating that focuses on solving a problem (Lachman, 2009). Additionally, using the chain of command is critical when a problem has escalated beyond the problem-solving ability and/ or scope of those involved. Engaging the chain of command ensures that individuals with appropriate responsibility and/or authority are aware of potentially grave or threatening situations and helps to avert serious outcomes. A position paper recently published by the ANA supports both the notion of effective communication and chain of command. Embracing the just culture model incentivizes error reporting by recognizing that individuals are not accountable for system problems over which they have no control. A just culture distinguishes a care environment based on the premise that patient care safety and quality are based on teamwork, communication, and a collaborative work environment (ANA, 2010a). MORAL LEADERSHIP IN NURSING There has long been confusion between the terms moral and ethical. The term ethics is derived from the Greek word “ethikos,” which pertains to custom, and “ethos,” which refers to character, whereas morality is associated with the Latin word “mores,” which is associated
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with character, or custom and habit (Rhode, 2006). Ethical generally refers to reasons for decisions about how one ought to act, for example using ethical theories (e.g., humanist, feminist, or social), adhering to principles (e.g., beneficence or justice), or cultivating virtue. Moral overlaps with ethical but is more aligned with personal beliefs and cultural values. Regardless, in popular usage, moral or ethical are understood to be a commitment to the right action, and involve honesty, fair dealing, and social responsibility. The common core of the meaning of “to lead” comes from the Old English “leden” or “loedan,” which means to make go, to guide, or to show the way, and from the Latin “ducere,” which means to draw, drag, pull, or conduct (Rost, 1991). Four leadership styles that exemplify ideals associated with moral leadership include transformational leadership, which demonstrates “idealized influence/charisma” (Nielsen, Yarker, Brenner, Randall, & Borg, 2008, p. 467) and whose followers serve as role models who inspire autonomy and desired behavior. Transformational leaders motivate employees to engage in problem solving, shared decision making, and their own professional development through coaching, mentoring, and being present. They are successful in communicating organizational mission, vision, and goals and incorporate shared values in their actions and institutional policies (Leach, 2005). Similarly, authentic leaders are committed to personal core values, self-discipline, leading with compassion, forming lasting relationships, and understanding their own sense of purpose (Shirey, 2006). Authentic leaders are perceived as real, trustworthy, sincere, dependable, and possessing integrity. It is the authentic nature of this leadership style characterized by a profound sense of self and personal conviction related to personal values and beliefs and the issues at hand that distinguishes authentic leadership from other leadership styles (Shirey, 2006). Listening, awareness, persuasion, stewardship, commitment to developing others, and building community have been identified as necessary attributes for servant leadership (Thorne, 2006). Leaders who practice servant leadership think in terms of team success and recognition as opposed to their own. Their vision is to serve team members to enable them to complete their work and become stronger individually and collectively in the process (Thorne, 2006). Thorne notes “servant leadership advocates a group-oriented approach to analysis and decision making as a means of strengthening institutions and of improving society” (p. 104). Finally, evidence-based leadership requires developing work environments to replace compartmentalization and fragmentation with new ways of collaborating and
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reaching consensus on a common agenda among stakeholders (Porter-O’Grady & Malloch, 2008). Evidencebased leaders direct their efforts to building both the infrastructure and behavior that support implementation of mutually agreed on goals to advance clinical care and professional practice that are managed by clinical providers at the point of care. Characteristics associated with this style of leadership include innovation thinking, planning, and implementation. CONCLUSION Ethical practices, values, and principles are the foundation on which moral action and moral decision making in professional practice are based. Respect for persons embraces the notion that one’s values, beliefs, and human dignity are acknowledged and preserved. Nurses have obligations to patients, one another, and the global community to assure optimal health, personal well-being, and quality of life for all with whom they come in contact. Nurse leaders in management roles who practice fidelity promote work environments that are grounded in ethical principles, supportive of the needs of staff, and sustain an ethic of care. The accountability and responsibility for creating moral environments and transforming the workplace does not exclusively rest with nurse administrators. This obligation is shared by all nurses, in every role, in every specialty, in every setting. All nurses are leaders in their roles as patient advocates, role models, and health care providers, meeting the needs of patients either directly or indirectly at the bedside, in the classroom, at the executive board meeting, or when conducting research. Embracing the concept of moral leadership in nursing is about raising the bar for accountability, responsibility, and professionalism. Moral leadership is about raising expectations, not only individually, but also collectively. It is about communicating openly and honestly, about being fair and trustworthy, and being proactive, not reactive. Last but not least, moral leadership in nursing is about putting patients first. References Aiken, L., & Salmon, M. (1994). Health care workforce priorities: What nursing should do now. Inquiry, 31, 318-329. Aiken, L., Smith, H., & Lake, E. (1994). Lower Medicare mortality among a set of hospitals known for good nursing care. Medical Care, 32(8), 771-787. American Nurses Association (2001). Code of ethics for nurses with interpretive statements. Silver Spring, MD: Nursebooks.org. American Nurses Association (2010a). Just culture. American Nurses Association. Retrieved from, http://www.nursingworld. org/FunctionalMenuCategories/MediaResources/PressReleases/ 2010-PR/ANA-Statements-Affecting-Nursing-Practice.aspx. March 31, 2010.
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American Nurses Association (2010b). Nursing’s social policy statement: The essence of the profession. Silver Spring, MD: Nursebooks.org. American Nurses Association (2010c). Nursing scope and standards of practice (2nd ed.). Silver Spring, MD: Nursebooks.org. American Nurses Credentialing Center (2008). A new model for ANCC’s magnet recognition program, Retrieved from, www. nursecredentialing.org. March 17, 2010. Beauchamp, T.L., & Childress, J.F. (1994). Principles of biomedical ethics (4th ed.). New York: Oxford University Press. Bjarnason, D., Mick, J., Thompson, J.A., & Cloyd, E. (2009). Perspectives on transcultural care. In Bjarnason, D., Carter, M.A. (Eds.), Nursing clinics of North America: Legal and ethical issues: To know, to reason, to act. Philadelphia, PA: W.B. Saunders, pp. 495-503. Bretschneider, J., Glenn-West, R., Green-Smolenski, J., & Richardson, C. (2010). Strengthening the voice of the clinical nurse: The design and implementation of a shared governance model. Nursing Administration Quarterly, 34(1), 41-48. Buerhaus, P.I. (2008). Current and future state of the U.S. nursing workforce. Journal of the American Medical Association, 300(20), 2422-2424. Fasoli, D.R. (2010). The culture of nursing engagement: A historical perspective. Nursing Administration Quarterly, 34(1), 18-29. Joint Commission on Accreditation of Healthcare Organizations (2002). Health care at the crossroads: Strategies for addressing the evolving nursing crisis, Retrieved from, http://www. aacn.nche.edu/media/pdf/JCAHO8-02.pdf. March 17, 2010. Joint Commission Resources (n.d.). Robert Wood Johnson Foundation, Retrieved from, http://dev.icps.jcrinc.com/ Products-and-Services/Conferences-and-Seminars/RobertWood-Johnson-Foundation-Communication/. March 31, 2010. Kanter, R.M. (1977). Men and women of the corporation. New York: Basic Books. Kelefan, S., & Ormond, I. (1988). Moral reasoning and ethical practice in nursing: An integrative review. New York: National League for Nursing. Publication Number 15-2250. Lachman, V.D. (2009). Developing your moral compass. New York: Springer Publishing. Laschinger, H.K.S., Sabiston, J.A., & Kutzscher, L. (1997). Empowerment and staff nurse decision involvement in nursing work environments: Testing Kanter’s theory of structural power in organizations. Research in Nursing & Health, 20, 341-352. Leach, L.S. (2005). Nurse executive transformational leadership and organizational commitment. Journal of Nursing Administration, 35(5), 228-237. Leininger, M. (1991). Transcultural nursing: The study and practice field. Imprint, 38, 55-66. Lo, B. (1990). Assessing decision-making capacity. Law, Medicine & Health Care, 18(3), 193-201. Maraldo, P.J. (1992). NLN’s first century. Nursing & Health Care, 13(5), 227-228.
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May, L., & Sharratt, S.C. (1994). Applied ethics: A multicultural approach. Englewood Cliffs, NJ: Prentice Hall. Miller, B.K., Adams, D., & Beck, L. (1993). A behavioral inventory for professionalism in nursing. Journal of Professional Nursing, 9(5), 290-295. Nielsen, K., Yarker, J., Brenner, S.O., Randall, R., & Borg, V. (2008). The importance of transformational leadership style for the well-being of employees working with older people. Journal of Advanced Nursing, 63(5), 465-475. doi: 10.1111/ j.13652648.2008.04701.x. Nightingale, F. (1859). Notes on nursing: What it is, and what it is not. London: Harrison. Nightingale, F. (1915). Florence Nightingale to her nurses. London: MacMillan & Co. Ning, S., Zhong, Z., Wang, L., & Qiujie, L. (2009). The impact of nurse empowerment on job satisfaction. Journal of Advanced Nursing, 65(12), 2642-2648. doi: 10.1111/j.1365-2648.2009. 05133x. Packard, J.S., & Ferrara, M. (1988). In search of the moral foundation of nursing. Advances in Nursing Science, 10(4), 60-71. Porter-O’Grady, T., & Malloch, K. (2008). Beyond myth and magic: The future of evidence-based leadership. Nursing Administration Quarterly, 32(3), 176-187. Purtilo, R.B. (2000). Moral courage in times of change: Visions for the future. Journal of Physical Therapy Education, 14(3), 4-6. Purtilo, R.B., & Cassel, C.K. (1981). Ethical dimensions in the health professions. Philadelphia, PA: W.B. Saunders. Rhode, D.L. (2006). Introduction: Where is the leadership in moral leadership? In Rhode, D.L. (Ed.) Moral leadership: The theory and practice of power, judgment, and policy. San Francisco, CA: John Wiley & Sons, pp. 4. Rogers, M.E. (1992). Nightingale’s notes on nursing: Prelude to the 21st century in notes on nursing. Carroll, D.P. Notes on nursing (Commemorative ed.). Philadelphia, PA: J.B. Lippincott, pp. 58-62. Rost, J.C. (1991). Leadership for the 21st century. Westport, CT: Quorum Books. Shirey, M.R. (2006). Authentic leaders creating health work environments for nursing practice. American Journal of Critical Care, 15(3), 256-267. The Joint Commission (2009). The Joint Commission 2009 requirements that support effective communication, Retrieved from, http://www.jointcommission.org/NR/rdonlyres/B48B39E3-107D495A-9032-24C3EBD96176/0/PDF32009HAPSupportingStds. pdf. March 31, 2010. Thorne, M. (2006). What kind of leader are you? Topics in Emergency Medicine, 28(2), 104-109. Tronto, J.C. (1994). Moral boundaries: A political argument for the ethic of care. New York: Routledge, Chapman, and Hall. U.S. Department of Health and Human Services, Health Resources and Services Administration (2010). The registered nurse population: Initial findings from the 2008 national sample of survey of registered nurses, Retrieved from, http:// bhpr.hrsa.gov/healthworkforce/rnsurvey. March 17, 2010.
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INTRODUCTION What is our needful thing? To have high principles at the bottom of all. Without this, without having laid our foundation, there is small use in building up our details. This is as if you were to try to nurse without eyes or hands.If your foundation is laid in shifting sand, you may build your house, but it will tumble down (Nightingale, 1915). The past two decades have produced remarkable changes in the health care environment. As the acuity and complexity of patient care have increased, creating environments that foster safe, high-quality patient care has become increasingly challenging. In addition to sicker patients who require highly skilled, knowledgebased assessment and intervention is the growing need to possess expert skills to operate increasingly complex technology. Further factors that complicate the care environment include fiscal pressures, nursing shortages, reliance on supplemental staffing, and changing patterns of ethnic, generational, and gender diversity that affect the workplace.
Dana Bjarnason, PhD, RN, NE-BC, is an Associate Administrator & Chief Nursing Officer in Ben Taub General Hospital/Quentin Mease Community Hospital at Houston, TX. Cynthia Ann LaSala, MS, RN, is a Clinical Nurse Specialist for Patient Care Services in the Department of Nursing, Massachusetts General Hospital at Boston, MA. Corresponding author: Dana Bjarnason, Ben Taub General Hospital/ Quentin Mease Community Hospital, 1504 Taub Loop, Houston, TX 77030. E-mail: [email protected] 1546-0843/$36.00 Copyright Ó 2011 by the Association for Radiologic & Imaging Nursing. doi: 10.1016/j.jradnu.2011.01.002
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It is clear that certain traits and values impact an organization’s ability to create environments where nurses’ coalesce around a vision for nursing, communicate transparently about difficult issues, and create an environment that nurtures and supports the moral activity of nursing. Given the looming nursing shortage (Buerhaus, 2008; JCAHO, 2002; U.S. Department of Health and Human Services, 2010) coupled with the unknown ramifications of health care reform, the urgency with which hospitals and other health care organizations must examine and initiate strategies to create work environments predicated on moral leadership, ethical practice, and moral courage in the workplace cannot be understated. This article provides a historical perspective of the development of professional nursing that creates the context for moral leadership, as well; it explores the traits and values that are in inherent in workplace environments where moral leadership predominates. PROFESSIONAL COMPETENCE Modern nursing includes prevalent and traditionally agreed on characteristics of a profession such as education and training, skill based on theoretical knowledge, a code of ethics, professional organizations, and service to society (Miller, Adams, & Beck, 1993). In 1859, when Florence Nightingale published Notes on Nursing, she informed her reader that the notes were not a rule of thought or a manual to teach nurses (Nightingale, 1859). Countering Nightingale’s modest assertion is commentary provided by 1996 American Nurses Association Hall of Fame inductee Martha E. Rogers who, in observations published about Notes on Nursing, states that the thoughtful reader can find the underpinnings for much of
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what is going on in nursing today within that historic book (Rogers, 1992). Even more striking given the contemporary practice environment are the goals of nursing articulated by Nightingale, including autonomous nursing practice, a framework for preparation, and standards for ethical conduct and character (Maraldo, 1992). These enduring traits persist, and indeed are considered the hallmarks of professionalism. The historic nature of nursing professionalism is mirrored in The Florence Nightingale Pledge. Despite the fact that it was written in 1893, it is, within the historical context, quite progressive. The Florence Nightingale Pledge not only articulates nursing as a profession but is also directive, objective, and rational, calling on nurses to create care environments through collaboration, education, and high moral standards. Rogers elaborates by saying that although Nightingale was oriented in the era in which she lived, her vision was obvious related to the concepts of human compassion, knowledge base, reasoning, and understandingdvalues that resonate as the basis for nursing professionalism today (Rogers, 1992). NURSINGS’ CODE OF ETHICS Today, the Code of Ethics for Nurses (herein referred to as the Code) serves as nursing’s moral compass in articulating the ethical obligations, duties, standards, and principles to which all nurses are both accountable and responsible irrespective of role, position, or practice setting (ANA, 2001). The Code’s nine provisions and corresponding interpretive statements speak to nursing’s fundamental values and commitments, boundaries of duty and loyalty, and the nurse’s obligations that reach beyond an individual patient to the health care needs of the global community and advancement of professional nursing (ANA, 2001). The Code defines what it means to be professionally accountable to oneself and others and instructs that nurses demonstrate ethical behavior in their actions based on “the moral principles of fidelity and respect for the dignity, worth, and selfdetermination of patients” (p. 4). The Code describes the nurse’s duty to oneself and others as being equally important and expected. Nurses practice with “wholeness of character,” and “personal integrity,” (ANA, 2001, p. 18) and must be committed to professional development and maintaining competence. Nurses “wholeness of character” includes “an authentic expression of one’s own moral point of view in practice” and “the nurse has a responsibility to express moral perspectives, even when they differ from those of others, and even when they might not prevail” (p. 19). “Wholeness of character” also alludes to nurses’ relationships with patients in maintaining “appropriate professional and moral boundaries” (p. 10). The Code VOLUME 30 ISSUE 1
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is nonnegotiablednurses are bound by the values and ethical conduct inherent to the professiondeven when their integrity is threatened. Nurses may engage in compromise as long as it is “integrity preserving” (ANA, 2001, p. 19), that is to say, the compromise will not endanger personal wellbeing or the well-being of others. Nurses never abandon patients, however, nurses may conscientiously object to any situation or circumstance that limits or prevents them from acting morally and upholding moral standards of the profession. In cases where the nurse conscientiously objects to participating in care, nurses fulfill their obligation to the patient by ensuring the appropriate transfer of care, thus ensuring the patient’s safety (ANA, 2001). The Code describes the “morally good person” as someone who possesses “wisdom, honesty, and courage” (ANA, 2001, p. 20). The “morally good nurse” demonstrates “excellences” (compassion, patience, and skill) that exemplify good character (p. 20). Further, the Code speaks to nurses’ “responsibility to create, maintain, and contribute to environments that support the growth of virtues and excellences and enable nurses to fulfill their ethical obligations” (p. 21). NURSING, PRINCIPLE-BASED ETHICS, AND THE ETHIC OF CARE Although the ethic of care represents an ethos that is congruent with nursing, awareness of the utility of principle-based ethics is also essential. In fact, nurses’ responsibility to advocate for patients and the profession produces an obligation to know and use ethical principles as a basis for providing compassionate and competent care. Four fundamental principles are manifested in the ethic of care and have been embedded in nursing since the time of the Florence Nightingale Pledge. Beneficence Beneficence is the ethical duty of bringing about good (Purtilo & Cassel, 1981). For nurses to do “good,” they must consider the values of individual patients. Nurses must be constantly vigilant to the wishes and desires of patients, valuing and respecting autonomy and choice. The Code clearly directs nurses to provide services with respect for human dignity and the uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems (ANA, 2001). Further support of this principle is found in the Code’s tenet directing nurses to collaborate with members of the health professions and other citizens in promoting community and national efforts to meet the health needs of the public.
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Nonmaleficence Nonmaleficence is the principle that holds that the caretaker “do no harm” (Beauchamp & Childress, 1994). Again, upholding this principle while caring for and treating patients requires knowing and understanding the patient’s beliefs and circumstances. The principle of nonmaleficence also necessitates that nurses be cognizant of actions or interventions that may seem innocuous, but that could be justifiably seen as harmful in the eyes of patients and families (Purtilo & Cassel, 1981). The Code lends strength to nurses’ role in upholding this principle by providing direction to “take appropriate action regarding any instances of incompetent, unethical, illegal, or impaired practice of any member of the health care team or health care system” (ANA, 2001, p. 14). The ethical principles of both beneficence and nonmaleficence are also strengthened by state nursing practice acts, which mandate that nurses are legally obligated to safeguard patients and the profession. Autonomy Invoking the principle of autonomy upholds respect for the decision-making capacity of patients (Beauchamp & Childress, 1994). All too often, families, significant others, and even the health care team make care decisions without involving the patient. At times, the health care team may defer to patients’ families when it is inappropriate to do so. This action is improper without the full knowledge, consent, and direction of capacitated patients. Nurses provide an essential link to patients, thus ensuring that the right to make autonomous decisions is maintained. At times, upholding the principle of autonomy, even with patients who are fully competent, is difficult because of barriers to communication such as language differences, hearing deficits, or limited knowledge. In these cases, nurses should direct their efforts toward facilitating clear and directed communication. The principle of autonomy is implemented through the legal and ethical doctrine of informed consent (Lo, 1990). This doctrine requires that patients receive information regarding the risks and benefits of proposed treatments. Nurses have a fundamental duty to protect and promote patient autonomy. Their role related to informed consent is to ensure that patients have a clear understanding of planned procedures, treatments, or interventions. Nurses can achieve this fundamental duty through collaborating with other health care providers and educating and counseling patients and families. Justice Justice in the health care environment has to do with the equitable distribution of benefits and services, and with fairness, which is understood as giving to 20
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each person that to which they have a legitimate right. (May & Sharratt, 1994). Nurses are instrumental in ensuring that a consistent standard of care is upheld for all patients and that unfair or unwarranted paternalistic actions or decision making are questioned. The overarching standard of nursing practice that supports the principle of justice is the requirement that nurses provide services without discrimination.
The ethic of care Beyond principles and more resonant for nursing is the ethic of care, which is not a set of rules and principles. The ethic of care is a practice requiring specific moral qualities that focus on characteristics that connect to the right action (Tronto, 1994). Elements of the ethic of care include such traits as attentiveness, responsibility, competence, and responsiveness (Tronto, 1994). These elements of the ethic of care are further defined as that which refers to care for, emotional commitment to, and willingness to act on behalf of persons with whom one has a significant relationship (Beauchamp & Childress, 1994). These attributes are clearly associated with nurses not only in their relationships with patients, but also in their relationships with other nurses and members of the health care team. MORAL REASONING Moral reasoning (moral judgment or moral development) is a process related to moral choice that one gains over time through personal development and knowledge acquisition (Kelefan & Ormond, 1988). An individual’s level of moral development may be influenced by one’s stage of intellectual development and concurrent social and educational climates. Individuals are thought to develop a higher level of moral judgment in environments characterized by shared decision making, taking responsibility for the consequences of their actions, and where opportunities for collective participation exist (Kelefan & Ormond, 1988). In their discussion on the moral foundation of nursing, Packard and Ferrara (1988) propose that nursing is composed of the following components: (a) taking the right actions to effect health promotion and quality of life, (b) possessing the knowledge and skills necessary to discern when and when not to respond, (c) knowing what the appropriate action(s) should be, and (d) a willingness to act that supports the ethical principle of beneficence. Nurses are at their best when the work they do allows them to “act authentically” (Packard & Ferrara, 1988, p. 69), and to be empathetic, sympathetic, intuitive, and patient centered.
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MORAL COURAGE The implications of moral courage as a sacred value at the clinical, operational, administrative, and executive levels of nursing practice that must be protected and nurtured cannot be overstated. In their commitment to an ethic of care, nurses practice with moral courage when they confront situations that pose a direct threat to care. The nature of their response is predicated on a commitment to serve and advocate for patients and the profession. Attributes of moral courage include faithfulness to one’s moral foundation and the ability to focus on the full significance of a situation (Purtilo, 2000). Practicing with moral courage is a call to act with moral conviction. CULTURAL COMPETENCE To serve the unique and diverse needs of patients in the United States, it is imperative that nurses understand cultural differences by valuing, incorporating, and examining their own health-related values and beliefs, and those of their health care organizationsdfor it is only then can they support the principle of respect for persons and the ideal of transcultural care (Bjarnason, Mick, Thompson, & Cloyd, 2009). Relevant to the culture of nursing is that nurses need to understand and appreciate inherent differences and similarities not only locally, but regionally, nationally, and worldwide (Leininger, 1991). In the United States, nursing’s culture and its commitment to cultural competence are defined through its foundational documents. The Code articulates the value of diversity in its first provision which states “the nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems” (ANA, 2001, p. 7). Nursing’s Social Policy Statement is a fundamental document that describes the articulation of nursing and its social framework and obligations. The statement articulates values and assumptions which characterize the value of diversity, including that human experience is contextually and culturally defined and that the interaction between the nurse and the patient occurs within the context of the values and beliefs of both (ANA, 2010b). In addition to the code of ethics and the social policy statement, the ANA publication Nursing Scope and Standard of Practice outlines standards of practice that describe a competent level of nursing care. Dominant themes essential to the practice of professional nursing include providing culturally and ethnically sensitive care and communicating effectively (ANA, 2010c). The standards reflect nursing’s values VOLUME 30 ISSUE 1
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and priorities and are the authoritative statements for which nurses are accountable. POSITIVE, ETHICAL WORK ENVIRONMENTS The complexity, fluidity, and dynamic nature of health care both now and in the future will pose new challenges as the United States addresses the outcomes of newly enacted health care reform, an unprecedented shortage of registered nurses, ongoing budgetary constraints, introduction of new technologies, and escalating health care needs among its citizens. It is imperative that leadership within health care organizations embrace these challenges as opportunities for creative innovation, employee empowerment, and workplace redesign. Organizations embodying these characteristics have shown positive correlations relative to vacancy rates, turnover, patient satisfaction, and staff satisfaction. In addition, lower morbidity and mortality rates have been associated with “magnet” hospitals, a designation that was established following research that showed certain organizations were able to develop environments where nurses thrived and patient outcomes were unparalleled (Aiken & Salmon, 1994; Aiken, Smith, & Lake, 1994). Shared governance A high degree of formal power is associated with jobs that are flexible, essential to organizational vision, mission, and goals, and encourage employee creativity and prudent decision making. Institutional collaboration and communication through effective partnerships internal and external to the organization bestow informal power (Ning, Zhong, Wang, & Qiujie, 2009). As health care organizations redesign care delivery models to address the needs of patients and families, leadership must promote autonomous decision making among frontline staff. Registered nurses must acquire new skills in delegation and leadership with administrative support, which promotes the development of care and professional practice models that facilitate autonomy in practice, maximize efficiency, and effect quality patient care outcomes (Laschinger, Sabiston, & Kutzscher, 1997). Research has demonstrated several positive outcomes associated with the shared governance model, including increased nurse satisfaction, increased nursing recruitment and retention, and a more motivated, engaged nursing staff (Bretschneider, Glenn-West, Green-Smolenski, & Richardson, 2010). In her theory of structural power in organizations, Rosabeth Moss Kanter (1977) describes four structural factors within organizations that lead to empowerment, which include (a) access to information, (b) support from organizational leadership, subordinates, and peers, (c) adequate resources to do the work, and (d) opportunities for
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personal and professional development. According to Kanter, formal and informal power facilitates access to structural factors that promote empowerment, thereby contributing to the achievement of organizational goals. Mission, vision, values, and philosophy Creating the foundation for an ethical work environment that fosters nursing empowerment is enhanced by ensuring that all stakeholders have a clear understanding of organizational goals and the process through which achieving those goals occurs. In nursing, this can be accomplished by articulating nursing’s mission, vision, and values, and the philosophy of nursing that drives outcomes (Lachman, 2009). Articulating and agreeing to the mission, vision, and values sets the tone for the work of nursing in the organization, creates a future state that implies a commitment to organizational improvement, and suggests the types of activities that will ensure that the organization reaches those goals. Adopting a nursing philosophy allows the organization to define itself to its internal and external communities, and provides examples of professional comportment that hold nurses responsible and accountable for taking action to achieve its mission and vision. Model of care Ethical work environments are enhanced by embracing a model of care that articulates the nursing organization’s commitment to professional and scientific precepts that express nursing’s promise to patients, to peers, and to colleagues. The American Nurses Credentialing Center (2008) defines a professional practice model as “the driving force of nursing care; a schematic description of a theory, phenomenon, or system that depicts how nurses practice, collaborate, communicate, and develop professionally to provide the highest quality of care for those served by the organization (e.g., patients, families, community). Professional practice models illustrate the alignment and integration of nursing practice with the mission, vision, and values that nursing has adopted” (p. 64). Autonomy, accountability, professional development, and emphasis on high-quality care provide a framework for professional practice models in nursing (Fasoli, 2010). Professional practice models are further guided by delivery models that are patient centered, adaptable, and flexible. Teamwork fosters collaboration, consultation, consensus building, and effective interpersonal relationships. Participatory management encourages shared decision making, shared responsibility, and taking ownership of one’s practice at the point of care. An example of participatory management is 22
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shared governance, which requires the design and implementation of supportive structures, and a process for reinforcing and sustaining them. As part of a professional practice model, a reward and recognition system acknowledges performance improvement and nurses’ commitment to uphold high standards of practice predicated on a strong value system and quality professional relationships (Fasoli, 2010). According to Fasoli, “professional practice environments create empowerment and engagement in the workplace that lead to optimal care” (p. 28). EFFECTIVE COMMUNICATION, CHAIN OF COMMAND, AND JUST CULTURE Communication is a critical element of patient safety and quality care and as such, the Joint Commission directs organizations to take action to address communication needs (The Joint Commission, 2009). This directive is based on evidence from the Joint Commission’s sentinel event database that shows that communication is cited as a root cause in nearly 70% of reported sentinel events, surpassing other commonly identified issues such as staff orientation and training, patient assessment, and staffing (Joint Commission Resources, n.d.). Although essential to safe and effective care, communicating effectively can be extremely challenging. Skill with assertive communication, which includes stating a position with assurance, is an honest, direct, and appropriate means of communicating that focuses on solving a problem (Lachman, 2009). Additionally, using the chain of command is critical when a problem has escalated beyond the problem-solving ability and/ or scope of those involved. Engaging the chain of command ensures that individuals with appropriate responsibility and/or authority are aware of potentially grave or threatening situations and helps to avert serious outcomes. A position paper recently published by the ANA supports both the notion of effective communication and chain of command. Embracing the just culture model incentivizes error reporting by recognizing that individuals are not accountable for system problems over which they have no control. A just culture distinguishes a care environment based on the premise that patient care safety and quality are based on teamwork, communication, and a collaborative work environment (ANA, 2010a). MORAL LEADERSHIP IN NURSING There has long been confusion between the terms moral and ethical. The term ethics is derived from the Greek word “ethikos,” which pertains to custom, and “ethos,” which refers to character, whereas morality is associated with the Latin word “mores,” which is associated
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with character, or custom and habit (Rhode, 2006). Ethical generally refers to reasons for decisions about how one ought to act, for example using ethical theories (e.g., humanist, feminist, or social), adhering to principles (e.g., beneficence or justice), or cultivating virtue. Moral overlaps with ethical but is more aligned with personal beliefs and cultural values. Regardless, in popular usage, moral or ethical are understood to be a commitment to the right action, and involve honesty, fair dealing, and social responsibility. The common core of the meaning of “to lead” comes from the Old English “leden” or “loedan,” which means to make go, to guide, or to show the way, and from the Latin “ducere,” which means to draw, drag, pull, or conduct (Rost, 1991). Four leadership styles that exemplify ideals associated with moral leadership include transformational leadership, which demonstrates “idealized influence/charisma” (Nielsen, Yarker, Brenner, Randall, & Borg, 2008, p. 467) and whose followers serve as role models who inspire autonomy and desired behavior. Transformational leaders motivate employees to engage in problem solving, shared decision making, and their own professional development through coaching, mentoring, and being present. They are successful in communicating organizational mission, vision, and goals and incorporate shared values in their actions and institutional policies (Leach, 2005). Similarly, authentic leaders are committed to personal core values, self-discipline, leading with compassion, forming lasting relationships, and understanding their own sense of purpose (Shirey, 2006). Authentic leaders are perceived as real, trustworthy, sincere, dependable, and possessing integrity. It is the authentic nature of this leadership style characterized by a profound sense of self and personal conviction related to personal values and beliefs and the issues at hand that distinguishes authentic leadership from other leadership styles (Shirey, 2006). Listening, awareness, persuasion, stewardship, commitment to developing others, and building community have been identified as necessary attributes for servant leadership (Thorne, 2006). Leaders who practice servant leadership think in terms of team success and recognition as opposed to their own. Their vision is to serve team members to enable them to complete their work and become stronger individually and collectively in the process (Thorne, 2006). Thorne notes “servant leadership advocates a group-oriented approach to analysis and decision making as a means of strengthening institutions and of improving society” (p. 104). Finally, evidence-based leadership requires developing work environments to replace compartmentalization and fragmentation with new ways of collaborating and
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reaching consensus on a common agenda among stakeholders (Porter-O’Grady & Malloch, 2008). Evidencebased leaders direct their efforts to building both the infrastructure and behavior that support implementation of mutually agreed on goals to advance clinical care and professional practice that are managed by clinical providers at the point of care. Characteristics associated with this style of leadership include innovation thinking, planning, and implementation. CONCLUSION Ethical practices, values, and principles are the foundation on which moral action and moral decision making in professional practice are based. Respect for persons embraces the notion that one’s values, beliefs, and human dignity are acknowledged and preserved. Nurses have obligations to patients, one another, and the global community to assure optimal health, personal well-being, and quality of life for all with whom they come in contact. Nurse leaders in management roles who practice fidelity promote work environments that are grounded in ethical principles, supportive of the needs of staff, and sustain an ethic of care. The accountability and responsibility for creating moral environments and transforming the workplace does not exclusively rest with nurse administrators. This obligation is shared by all nurses, in every role, in every specialty, in every setting. All nurses are leaders in their roles as patient advocates, role models, and health care providers, meeting the needs of patients either directly or indirectly at the bedside, in the classroom, at the executive board meeting, or when conducting research. Embracing the concept of moral leadership in nursing is about raising the bar for accountability, responsibility, and professionalism. Moral leadership is about raising expectations, not only individually, but also collectively. It is about communicating openly and honestly, about being fair and trustworthy, and being proactive, not reactive. Last but not least, moral leadership in nursing is about putting patients first. References Aiken, L., & Salmon, M. (1994). Health care workforce priorities: What nursing should do now. Inquiry, 31, 318-329. Aiken, L., Smith, H., & Lake, E. (1994). Lower Medicare mortality among a set of hospitals known for good nursing care. Medical Care, 32(8), 771-787. American Nurses Association (2001). Code of ethics for nurses with interpretive statements. Silver Spring, MD: Nursebooks.org. American Nurses Association (2010a). Just culture. American Nurses Association. Retrieved from, http://www.nursingworld. org/FunctionalMenuCategories/MediaResources/PressReleases/ 2010-PR/ANA-Statements-Affecting-Nursing-Practice.aspx. March 31, 2010.
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American Nurses Association (2010b). Nursing’s social policy statement: The essence of the profession. Silver Spring, MD: Nursebooks.org. American Nurses Association (2010c). Nursing scope and standards of practice (2nd ed.). Silver Spring, MD: Nursebooks.org. American Nurses Credentialing Center (2008). A new model for ANCC’s magnet recognition program, Retrieved from, www. nursecredentialing.org. March 17, 2010. Beauchamp, T.L., & Childress, J.F. (1994). Principles of biomedical ethics (4th ed.). New York: Oxford University Press. Bjarnason, D., Mick, J., Thompson, J.A., & Cloyd, E. (2009). Perspectives on transcultural care. In Bjarnason, D., Carter, M.A. (Eds.), Nursing clinics of North America: Legal and ethical issues: To know, to reason, to act. Philadelphia, PA: W.B. Saunders, pp. 495-503. Bretschneider, J., Glenn-West, R., Green-Smolenski, J., & Richardson, C. (2010). Strengthening the voice of the clinical nurse: The design and implementation of a shared governance model. Nursing Administration Quarterly, 34(1), 41-48. Buerhaus, P.I. (2008). Current and future state of the U.S. nursing workforce. Journal of the American Medical Association, 300(20), 2422-2424. Fasoli, D.R. (2010). The culture of nursing engagement: A historical perspective. Nursing Administration Quarterly, 34(1), 18-29. Joint Commission on Accreditation of Healthcare Organizations (2002). Health care at the crossroads: Strategies for addressing the evolving nursing crisis, Retrieved from, http://www. aacn.nche.edu/media/pdf/JCAHO8-02.pdf. March 17, 2010. Joint Commission Resources (n.d.). Robert Wood Johnson Foundation, Retrieved from, http://dev.icps.jcrinc.com/ Products-and-Services/Conferences-and-Seminars/RobertWood-Johnson-Foundation-Communication/. March 31, 2010. Kanter, R.M. (1977). Men and women of the corporation. New York: Basic Books. Kelefan, S., & Ormond, I. (1988). Moral reasoning and ethical practice in nursing: An integrative review. New York: National League for Nursing. Publication Number 15-2250. Lachman, V.D. (2009). Developing your moral compass. New York: Springer Publishing. Laschinger, H.K.S., Sabiston, J.A., & Kutzscher, L. (1997). Empowerment and staff nurse decision involvement in nursing work environments: Testing Kanter’s theory of structural power in organizations. Research in Nursing & Health, 20, 341-352. Leach, L.S. (2005). Nurse executive transformational leadership and organizational commitment. Journal of Nursing Administration, 35(5), 228-237. Leininger, M. (1991). Transcultural nursing: The study and practice field. Imprint, 38, 55-66. Lo, B. (1990). Assessing decision-making capacity. Law, Medicine & Health Care, 18(3), 193-201. Maraldo, P.J. (1992). NLN’s first century. Nursing & Health Care, 13(5), 227-228.
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May, L., & Sharratt, S.C. (1994). Applied ethics: A multicultural approach. Englewood Cliffs, NJ: Prentice Hall. Miller, B.K., Adams, D., & Beck, L. (1993). A behavioral inventory for professionalism in nursing. Journal of Professional Nursing, 9(5), 290-295. Nielsen, K., Yarker, J., Brenner, S.O., Randall, R., & Borg, V. (2008). The importance of transformational leadership style for the well-being of employees working with older people. Journal of Advanced Nursing, 63(5), 465-475. doi: 10.1111/ j.13652648.2008.04701.x. Nightingale, F. (1859). Notes on nursing: What it is, and what it is not. London: Harrison. Nightingale, F. (1915). Florence Nightingale to her nurses. London: MacMillan & Co. Ning, S., Zhong, Z., Wang, L., & Qiujie, L. (2009). The impact of nurse empowerment on job satisfaction. Journal of Advanced Nursing, 65(12), 2642-2648. doi: 10.1111/j.1365-2648.2009. 05133x. Packard, J.S., & Ferrara, M. (1988). In search of the moral foundation of nursing. Advances in Nursing Science, 10(4), 60-71. Porter-O’Grady, T., & Malloch, K. (2008). Beyond myth and magic: The future of evidence-based leadership. Nursing Administration Quarterly, 32(3), 176-187. Purtilo, R.B. (2000). Moral courage in times of change: Visions for the future. Journal of Physical Therapy Education, 14(3), 4-6. Purtilo, R.B., & Cassel, C.K. (1981). Ethical dimensions in the health professions. Philadelphia, PA: W.B. Saunders. Rhode, D.L. (2006). Introduction: Where is the leadership in moral leadership? In Rhode, D.L. (Ed.) Moral leadership: The theory and practice of power, judgment, and policy. San Francisco, CA: John Wiley & Sons, pp. 4. Rogers, M.E. (1992). Nightingale’s notes on nursing: Prelude to the 21st century in notes on nursing. Carroll, D.P. Notes on nursing (Commemorative ed.). Philadelphia, PA: J.B. Lippincott, pp. 58-62. Rost, J.C. (1991). Leadership for the 21st century. Westport, CT: Quorum Books. Shirey, M.R. (2006). Authentic leaders creating health work environments for nursing practice. American Journal of Critical Care, 15(3), 256-267. The Joint Commission (2009). The Joint Commission 2009 requirements that support effective communication, Retrieved from, http://www.jointcommission.org/NR/rdonlyres/B48B39E3-107D495A-9032-24C3EBD96176/0/PDF32009HAPSupportingStds. pdf. March 31, 2010. Thorne, M. (2006). What kind of leader are you? Topics in Emergency Medicine, 28(2), 104-109. Tronto, J.C. (1994). Moral boundaries: A political argument for the ethic of care. New York: Routledge, Chapman, and Hall. U.S. Department of Health and Human Services, Health Resources and Services Administration (2010). The registered nurse population: Initial findings from the 2008 national sample of survey of registered nurses, Retrieved from, http:// bhpr.hrsa.gov/healthworkforce/rnsurvey. March 17, 2010.
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