- Email: [email protected]
Organizational ethics: No longer the elephant in the room
Reflections on healthcare leadership ethics
Organizational ethics: No longer the elephant in the room Jennifer L. Gibson, PhD Organizational ethics is concerned with the ethical issues encountered in the management and governance of health organizations; the ethical implications of organizational decision making on key stakeholders (eg, patients, staff, and the community); and the ethical complexities of balancing the goal of quality patient care with other important goals such as financial sustainability, staff well-being, learning and innovation, and public accountability.1–3 Mission and value statements are sometimes described as the organization’s “moral compass”4 for it is through its mission and value statements that an organization articulates the core standards according to which its decisions and actions are to be judged.3,4 However, ethical issues arise when missionbased commitments or espoused values are in tension or conflict. Thus, the goals of organizational ethics are not only to achieve a strong alignment between the organization’s stated mission and values and the decisions and actions taken by individuals on behalf of the organization5,6 but also to create an organizational climate in which organizational ethics issues can be constructively addressed.3 In other words, organizational ethics calls on health institutions “to define their core values and mission, identify areas in which important values come into conflict, seek the best possible resolution of these conflicts, and manage their own performance to ensure that it acts in accord with espoused values.”4 Over the last 10 years, there has been a dramatic increase in attention paid to ethics in Canadian health institutions. The Canadian College of Health Leaders has defined a Code of Ethics and identified ethics explicitly among the professional competencies of health leaders, most notably in its LEADS in a Caring Environment leadership capability framework.7,8 Accreditation Canada and its US counterpart, the Joint Commission on Accreditation
Corresponding Author: Jennifer L. Gibson, PhD e-mail: [email protected] Healthcare Management Forum 2012 25:37–39 0840-4704/$ - see front matter © 2012 Canadian College of Health Leaders. Published by Elsevier Inc. All rights reserved. doi:10.1016/j.hcmf.2012.01.003
of Health Organizations, are developing robust ethics standards related to the governance and effective leadership of health organizations.9,10 Many healthcare organizations are investing resources in building comprehensive ethics programs to address the myriad of ethical issues arising in clinical, research, and organizational decision making. A recent Canadian survey found that, in 2008, 85% of acute care hospitals have an ethics committee (compared with 58% in 1989), and 59% of these were created in the last 10 years.11 For their part, ethicists and ethics committees are reporting an increased demand for their expertise in addressing organizational ethics issues.12,13 Meanwhile, research in organizational ethics is growing, although to date it has been primarily focused on acute hospital settings and the perspective of clinicians.14 In the spring of 2007, Healthcare Management Forum introduced a new section called “Your Ethics Questions Answered.” In the inaugural article, I reported on a qualitative study of the organizational ethics issues in hospitals.15 The ethical issues fell into three main categories: (1) ethical issues emerging in clinical care because of decisions taken elsewhere in the organization, (2) ethical issues in clinical care with wider-reaching organizational implications, and (3) ethical issues related specifically to the business aspects of healthcare organizations. In this study and elsewhere in the literature, the most commonly cited ethical issues are related to resource management.15–21 Failure to resolve the tension between managing economic constraints, on the one hand, and providing high-quality service on the other, has been identified by nurse executives as the most pressing organizational ethics issue in their institutions.21 Research and lived experience has shown that “how” an organization makes decisions can have a profound impact on staff perceptions of and trust in organizational leadership.22–25 A recent study of priority setting in Ontario’s Local Health Integration Networks found that the perceived fairness of a funding allocation process was linked closely to the transparency of the rationales for allocation decisions.26 Perceptions of organizational fairness are correlated with increased quality of care ratings, job satisfaction, and trust of management as well as decreased emotional exhaustion among nurses,26 –29 whereas
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Gibson
perceptions of organizational unfairness are correlated with increased psychological distress among physicians30 and increased absenteeism among hospital staff generally.31 Unresolved moral distress accounts for as much as 25% of nurses’ decisions to leave an organization or the nursing profession entirely.32,33 Inadequate staffing levels are a major contributor to moral distress among nurses because of the impact of staffing levels on the quality of care and patient safety.28 Thus, as health leaders look for ways to manage resource pressures, they need to be as attentive to the impact of such decisions on staff as they are attentive to their impact on the bottom line.34 Another issue is related to the health leader’s experience when faced with managing a difficult organizational ethics issue. Mitton et al35 reported moral distress among health leaders who were compelled to “sell” budget allocation decisions they did not believe in or felt were wrong. Tough decisions are justified to staff as “strategically aligned,” as “consistent with our values,” or as “good for patients” when in fact many health leaders are worrying if they have made the right decision and feeling constrained to express their concerns without being perceived to not be a team player. Notwithstanding this experience, health leaders are often perceived by frontline staff to be out of touch with the ethical impact of their organizational decisions.17 Yet, when the University of Toronto Joint Centre for Bioethics has asked health leaders and frontline staff to identify what ethical issues are most pressing in their organization as part of an overall ethics needs assessment, their responses have been remarkably similar (unpublished data). Health leaders are often very aware of the ethical issues frontline staff are struggling with and will express concern for staff and patient well-being. Unfortunately, this shared experience of moral uncertainty and distress is rarely discussed explicitly with frontline staff. A related problem is that the values component of organizational decision making may be influential but unacknowledged. In their recent article, Nelson et al36,37 describe the relationship between common ethics principles (eg, autonomy and beneficence) and the goals of improving the quality and safety of patient care. Recurring issues related to quality of care, they argue, may often reflect an underlying values conflict or an erosion of ethics standards. Thus, addressing the quality issues will entail dealing with the precipitating or exacerbating ethical issues. As they argue elsewhere, the organizational costs of not addressing ethical conflicts (ie, operational, legal, and reputational) can be considerable.38 It is time to name the elephant in the room. Ethics is not just about investing in ethics programs, complying with Accreditation Canada’s ethics standards, or managing the organizational costs of ethical conflict. It is about grappling explicitly with the values and values-based challenges inherent in the day-to-day practice of organizational decision making. This presents a unique challenge and critical opportunity for health leaders. On the one hand, it means 38
that health leaders must be willing and equipped to identify the values component of organizational decisions, particularly where values may conflict, and to give voice to the moral uncertainty they may be experiencing. On the other hand, it means linking the rationale for organizational decisions to these underlying values, including where they may have been in conflict and how these conflicts were resolved, and communicating this effectively to affected stakeholders.39 Giving voice to the ethical challenges of organizational decision making may not only alleviate some of the moral distress experienced by health leaders in making difficult decisions, it may also bridge the perceptual gap between health leaders and frontline staff by creating conditions for shared understanding and, hence, trust. Where might we go from here? First, ethics needs to be acknowledged by health leaders as a constitutive component of good governance and effective leadership. Like quality and patient safety, ethics cannot be treated as an add-on or a “nice to have” investment. Rather, it must be treated as part of an uncompromising commitment to strategic and operational excellence. Second, there remain important knowledge gaps about how organizational ethics is experienced within Canadian health organizations, particularly those outside the acute hospital sector and from the perspective of health leaders. To shore up these gaps, colleagues and I are undertaking a national survey of health executives, managers, and ethicists to get a better understanding of the organizational ethics issues health organizations are facing, the strategies they are using to address these issues, and the perceived effectiveness of these strategies. The study, which is funded by the Canadian Institutes of Health Research, is being conducted in collaboration with the Canadian College of Health Leaders, Accreditation Canada, the Canadian Bioethics Society, and other leadership organizations. Finally, the ethics conversation must be extended beyond the walls of health institutions to include the communities served by them. In Canada, there are a number of examples of health ministries and institutions engaging citizens in addressing the ethics and values of health policy and organizational decision making.40 – 42 Now, more than ever, when health systems and institutions are under strain, ethics must be addressed explicitly. As a chief executive officer commented once, “in times of crisis, we need more ethics rather than less.” When ethics are made explicit, people have a language to articulate their hopes, worries, and commitments in a way that can create understanding, sustain relationships, and build trust during times of tremendous transformation and change.
REFERENCES 1. Gibson JL, Connolly E, Sibbald R, et al. Organizational ethics. In: Singer PA, Viens A, eds. The Cambridge Textbook of Bioethics. Cambridge: Cambridge University Press; 2008:243–250.
Healthcare Management Forum ● Forum Gestion des soins de sante´ – Spring/Printemps 2012
ORGANIZATIONAL ETHICS: NO LONGER THE ELEPHANT IN THE ROOM
2. Hall RT. An Introduction to Health Care Organizational Ethics. Oxford: Oxford University Press; 2000. 3. Spencer EM, Mills AE, Rorty MV, et al. Organization Ethics in Health Care. New York, New York: Oxford University Press; 2000. 4. Pearson SD, Sabin JE, Emanuel E. No Margin, No Mission: Health Care Organizations and the Quest for Ethical Excellence. Oxford: Oxford University Press; 2003. 5. Boyle PJ, DuBose ER, Ellingson SJ, et al. Organizational Ethics in Health Care: Principles, Cases, and Practical Solutions. San Francisco: Jossey-Bass; 2001. 6. Silverman HJ. Organizational ethics in health care organizations: proactively managing the ethical climate to ensure organizational integrity. HEC Forum. 2000;12:202–215. 7. Canadian College of Health Leaders. Code of ethics. Available at: http://www.cchl-ccls.ca/assets/ethics/CodeEthics.pdf. Accessed January 10, 2012. 8. Canadian College of Health Leaders. LEADS in a caring environment. Available at: http://www.cchl-ccls.ca/default_ conferences.asp?active_page_id⫽6492. Accessed January 10, 2012. 9. Accreditation. Canada: Qmentum Program: Leadership Standards, v. 6. Available at: http://www.accreditation.ca. Accessed January 10, 2012. 10. Accreditation Canada: Qmentum Program: Governance Standards, v. 6. Available at: http://www.accreditation.ca. Accessed January 10, 2012. 11. Gaudine A, Thorne L, LeFort SM, et al. Evolution of hospital clinical ethics committees in Canada. J Med Ethics. 2010;36: 132–137. 12. Silva DS, Gibson JL, Sibbald R, et al. Clinical ethicists’ perspectives on organisational ethics in health care organisations. J Med Ethics. 2008;34:320 –323. 13. Foglia MB, Pearlman RA, Bottrell M, et al. Ethical challenges within Veterans Administration healthcare facilities: perspectives of managers, clinicians, patients, and ethics committee chairpersons. Am J Bioeth. 2009;9:28 –36. 14. Suhonen R, Stolt M, Virtanan H, et al. Organizational ethics: a literature review. Nurs Ethics. 2011;18:285–303. 15. Gibson JL. Organizational ethics and the management of health care organizations. Healthc Manage Forum. 2007;20: 32–34. 16. Lemieux-Charles L, Meslin EM, Aird C, et al. Ethical issues faced by clinician/managers in resource allocation decisions. Hosp Health Serv Adm. 1993;38:267–285. 17. Foglia MB, Pearlman RA, Bottrell MM, et al. Priority setting and the ethics of resource allocation in VA healthcare facilities: results of a survey. Organ Ethic. 2007;4:83–96. 18. Daniels N, Sabin JE. Setting Limits Fairly: Can We Learn to Share Medical Resources? Oxford: Oxford University Press; 2002. 19. Gibson JL, Martin DK, Singer PA. Evidence, economics, and ethics: resource allocation in health services organizations. Healthc Q. 2005;8:50 –59. 20. Peacock S, Ruta D, Mitton C, et al. Using economics to set pragmatic and ethical priorities. BMJ. 2006;332:482– 485. 21. Cooper RW, Frank GL, Gouty CA, et al. Key ethical issues encountered in healthcare organizations: perceptions of nurse executives. J Nurs Adm. 2002;32:331–337.
22. Hall LM, Doran D. Nurses’ perceptions of hospital work environments. J Nurs Manag. 2007;15:264 –273. 23. Gelsen TI, Van Der Dorf M, Maes S, et al. A longitudinal study of job stress in the nursing profession: causes and consequences. J Nurs Manag. 2006;14:289 –299. 24. Wall S. Organizational ethics, change, and stakeholder involvement. HEC Forum. 2007;19:227–243. 25. Gibson JL, Mitton C, Dubois-Wing G. Priority setting in the LHINs: ethics and economics in action. Healthc Q. 2011;14: 35– 46. 26. Hart SE. Hospital ethical climates and registered nurses’ turnover intentions. J Nurs Scholarsh. 2005;37:173–177. 27. Corley MC. Moral distress of critical care nurses. Am J Crit Care. 1995;4:280 –285. 28. Corley MC, Minick P, Elswich RK, et al. Nurse moral distress and ethical work environment. Nurs Ethics. 2005;12:381–390. 29. Severinsson E. Moral stress and burnout: qualitative content analysis. Nurs Health Sci. 2003;5:59 – 66. 30. Sutinen R, Kivimäki M, Elovainio M, et al. Organizational fairness and psychological distress in hospital physicians. Scand J Public Health. 2002;30:209 –215. 31. Kivimäki M, Elovainio M, Vahtera J, et al. Organizational justice and health of employees: prospective cohort study. Occup Environ Med. 2003;60:27–33. 32. Corley MC. Nurse moral distress: a proposed theory and research agenda. Nurs Ethics. 2002;9:636 – 650. 33. Aiken L, Clarke S, Sloane D, et al. Nurses’ reports on hospital care in five countries. Health Aff (Millwood). 2001;20:43–53. 34. Bell JAH, Breslin J. Healthcare provider moral distress as a leadership challenge. JONAS Healthc Law Ethics Regul. 2008; 10:94 –97. 35. Mitton C, Peacock S, Storch J, et al. Moral distress among health system managers: exploratory research in two British Columbia health authorities. Health Care Anal. 2011;19:107– 121. 36. Nelson WA, Gardent PB, Shulman E, et al. Preventing ethics conflicts and improving healthcare quality through system redesign. Qual Saf Health Care. 2010;19:526 –530. 37. Nelson WA. Ethics: a foundation for quality. Healthc Exec. 2011;26:48 – 49. 38. Self G. Put values up front: new discernment tool makes sure values aren’t left to chance. Health Prog. 2010 (NovDec):10 –14. 39. Nelson WA, Weeks WB, Campfield JM, et al. The organizational costs of ethical conflicts. J Healthc Manag. 2008;53: 41–53. 40. Laupacis A, Born K. Citizens participate in hospital restructuring processes. Available at: http://healthydebate.ca/2011/01/ topic/cost-of-care/citizen-participation-hospital-restructuring. Accessed January 11, 2012. 41. Government of Ontario: Ontario Citizens Council. Available at: http://www.health.gov.on.ca/en/public/programs/drugs/ councils/citizens_council.aspx. Accessed January 11, 2012. 42. Menon D, Stafinski T. Setting priorities for health technology assessment: public participation using a citizens’ jury. Health Expect. 2008;11:282–293.
Healthcare Management Forum ● Forum Gestion des soins de sante´ – Spring/Printemps 2012
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Organizational ethics: No longer the elephant in the room Jennifer L. Gibson, PhD Organizational ethics is concerned with the ethical issues encountered in the management and governance of health organizations; the ethical implications of organizational decision making on key stakeholders (eg, patients, staff, and the community); and the ethical complexities of balancing the goal of quality patient care with other important goals such as financial sustainability, staff well-being, learning and innovation, and public accountability.1–3 Mission and value statements are sometimes described as the organization’s “moral compass”4 for it is through its mission and value statements that an organization articulates the core standards according to which its decisions and actions are to be judged.3,4 However, ethical issues arise when missionbased commitments or espoused values are in tension or conflict. Thus, the goals of organizational ethics are not only to achieve a strong alignment between the organization’s stated mission and values and the decisions and actions taken by individuals on behalf of the organization5,6 but also to create an organizational climate in which organizational ethics issues can be constructively addressed.3 In other words, organizational ethics calls on health institutions “to define their core values and mission, identify areas in which important values come into conflict, seek the best possible resolution of these conflicts, and manage their own performance to ensure that it acts in accord with espoused values.”4 Over the last 10 years, there has been a dramatic increase in attention paid to ethics in Canadian health institutions. The Canadian College of Health Leaders has defined a Code of Ethics and identified ethics explicitly among the professional competencies of health leaders, most notably in its LEADS in a Caring Environment leadership capability framework.7,8 Accreditation Canada and its US counterpart, the Joint Commission on Accreditation
Corresponding Author: Jennifer L. Gibson, PhD e-mail: [email protected] Healthcare Management Forum 2012 25:37–39 0840-4704/$ - see front matter © 2012 Canadian College of Health Leaders. Published by Elsevier Inc. All rights reserved. doi:10.1016/j.hcmf.2012.01.003
of Health Organizations, are developing robust ethics standards related to the governance and effective leadership of health organizations.9,10 Many healthcare organizations are investing resources in building comprehensive ethics programs to address the myriad of ethical issues arising in clinical, research, and organizational decision making. A recent Canadian survey found that, in 2008, 85% of acute care hospitals have an ethics committee (compared with 58% in 1989), and 59% of these were created in the last 10 years.11 For their part, ethicists and ethics committees are reporting an increased demand for their expertise in addressing organizational ethics issues.12,13 Meanwhile, research in organizational ethics is growing, although to date it has been primarily focused on acute hospital settings and the perspective of clinicians.14 In the spring of 2007, Healthcare Management Forum introduced a new section called “Your Ethics Questions Answered.” In the inaugural article, I reported on a qualitative study of the organizational ethics issues in hospitals.15 The ethical issues fell into three main categories: (1) ethical issues emerging in clinical care because of decisions taken elsewhere in the organization, (2) ethical issues in clinical care with wider-reaching organizational implications, and (3) ethical issues related specifically to the business aspects of healthcare organizations. In this study and elsewhere in the literature, the most commonly cited ethical issues are related to resource management.15–21 Failure to resolve the tension between managing economic constraints, on the one hand, and providing high-quality service on the other, has been identified by nurse executives as the most pressing organizational ethics issue in their institutions.21 Research and lived experience has shown that “how” an organization makes decisions can have a profound impact on staff perceptions of and trust in organizational leadership.22–25 A recent study of priority setting in Ontario’s Local Health Integration Networks found that the perceived fairness of a funding allocation process was linked closely to the transparency of the rationales for allocation decisions.26 Perceptions of organizational fairness are correlated with increased quality of care ratings, job satisfaction, and trust of management as well as decreased emotional exhaustion among nurses,26 –29 whereas
Healthcare Management Forum ● Forum Gestion des soins de sante´ – Spring/Printemps 2012
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Gibson
perceptions of organizational unfairness are correlated with increased psychological distress among physicians30 and increased absenteeism among hospital staff generally.31 Unresolved moral distress accounts for as much as 25% of nurses’ decisions to leave an organization or the nursing profession entirely.32,33 Inadequate staffing levels are a major contributor to moral distress among nurses because of the impact of staffing levels on the quality of care and patient safety.28 Thus, as health leaders look for ways to manage resource pressures, they need to be as attentive to the impact of such decisions on staff as they are attentive to their impact on the bottom line.34 Another issue is related to the health leader’s experience when faced with managing a difficult organizational ethics issue. Mitton et al35 reported moral distress among health leaders who were compelled to “sell” budget allocation decisions they did not believe in or felt were wrong. Tough decisions are justified to staff as “strategically aligned,” as “consistent with our values,” or as “good for patients” when in fact many health leaders are worrying if they have made the right decision and feeling constrained to express their concerns without being perceived to not be a team player. Notwithstanding this experience, health leaders are often perceived by frontline staff to be out of touch with the ethical impact of their organizational decisions.17 Yet, when the University of Toronto Joint Centre for Bioethics has asked health leaders and frontline staff to identify what ethical issues are most pressing in their organization as part of an overall ethics needs assessment, their responses have been remarkably similar (unpublished data). Health leaders are often very aware of the ethical issues frontline staff are struggling with and will express concern for staff and patient well-being. Unfortunately, this shared experience of moral uncertainty and distress is rarely discussed explicitly with frontline staff. A related problem is that the values component of organizational decision making may be influential but unacknowledged. In their recent article, Nelson et al36,37 describe the relationship between common ethics principles (eg, autonomy and beneficence) and the goals of improving the quality and safety of patient care. Recurring issues related to quality of care, they argue, may often reflect an underlying values conflict or an erosion of ethics standards. Thus, addressing the quality issues will entail dealing with the precipitating or exacerbating ethical issues. As they argue elsewhere, the organizational costs of not addressing ethical conflicts (ie, operational, legal, and reputational) can be considerable.38 It is time to name the elephant in the room. Ethics is not just about investing in ethics programs, complying with Accreditation Canada’s ethics standards, or managing the organizational costs of ethical conflict. It is about grappling explicitly with the values and values-based challenges inherent in the day-to-day practice of organizational decision making. This presents a unique challenge and critical opportunity for health leaders. On the one hand, it means 38
that health leaders must be willing and equipped to identify the values component of organizational decisions, particularly where values may conflict, and to give voice to the moral uncertainty they may be experiencing. On the other hand, it means linking the rationale for organizational decisions to these underlying values, including where they may have been in conflict and how these conflicts were resolved, and communicating this effectively to affected stakeholders.39 Giving voice to the ethical challenges of organizational decision making may not only alleviate some of the moral distress experienced by health leaders in making difficult decisions, it may also bridge the perceptual gap between health leaders and frontline staff by creating conditions for shared understanding and, hence, trust. Where might we go from here? First, ethics needs to be acknowledged by health leaders as a constitutive component of good governance and effective leadership. Like quality and patient safety, ethics cannot be treated as an add-on or a “nice to have” investment. Rather, it must be treated as part of an uncompromising commitment to strategic and operational excellence. Second, there remain important knowledge gaps about how organizational ethics is experienced within Canadian health organizations, particularly those outside the acute hospital sector and from the perspective of health leaders. To shore up these gaps, colleagues and I are undertaking a national survey of health executives, managers, and ethicists to get a better understanding of the organizational ethics issues health organizations are facing, the strategies they are using to address these issues, and the perceived effectiveness of these strategies. The study, which is funded by the Canadian Institutes of Health Research, is being conducted in collaboration with the Canadian College of Health Leaders, Accreditation Canada, the Canadian Bioethics Society, and other leadership organizations. Finally, the ethics conversation must be extended beyond the walls of health institutions to include the communities served by them. In Canada, there are a number of examples of health ministries and institutions engaging citizens in addressing the ethics and values of health policy and organizational decision making.40 – 42 Now, more than ever, when health systems and institutions are under strain, ethics must be addressed explicitly. As a chief executive officer commented once, “in times of crisis, we need more ethics rather than less.” When ethics are made explicit, people have a language to articulate their hopes, worries, and commitments in a way that can create understanding, sustain relationships, and build trust during times of tremendous transformation and change.
REFERENCES 1. Gibson JL, Connolly E, Sibbald R, et al. Organizational ethics. In: Singer PA, Viens A, eds. The Cambridge Textbook of Bioethics. Cambridge: Cambridge University Press; 2008:243–250.
Healthcare Management Forum ● Forum Gestion des soins de sante´ – Spring/Printemps 2012
ORGANIZATIONAL ETHICS: NO LONGER THE ELEPHANT IN THE ROOM
2. Hall RT. An Introduction to Health Care Organizational Ethics. Oxford: Oxford University Press; 2000. 3. Spencer EM, Mills AE, Rorty MV, et al. Organization Ethics in Health Care. New York, New York: Oxford University Press; 2000. 4. Pearson SD, Sabin JE, Emanuel E. No Margin, No Mission: Health Care Organizations and the Quest for Ethical Excellence. Oxford: Oxford University Press; 2003. 5. Boyle PJ, DuBose ER, Ellingson SJ, et al. Organizational Ethics in Health Care: Principles, Cases, and Practical Solutions. San Francisco: Jossey-Bass; 2001. 6. Silverman HJ. Organizational ethics in health care organizations: proactively managing the ethical climate to ensure organizational integrity. HEC Forum. 2000;12:202–215. 7. Canadian College of Health Leaders. Code of ethics. Available at: http://www.cchl-ccls.ca/assets/ethics/CodeEthics.pdf. Accessed January 10, 2012. 8. Canadian College of Health Leaders. LEADS in a caring environment. Available at: http://www.cchl-ccls.ca/default_ conferences.asp?active_page_id⫽6492. Accessed January 10, 2012. 9. Accreditation. Canada: Qmentum Program: Leadership Standards, v. 6. Available at: http://www.accreditation.ca. Accessed January 10, 2012. 10. Accreditation Canada: Qmentum Program: Governance Standards, v. 6. Available at: http://www.accreditation.ca. Accessed January 10, 2012. 11. Gaudine A, Thorne L, LeFort SM, et al. Evolution of hospital clinical ethics committees in Canada. J Med Ethics. 2010;36: 132–137. 12. Silva DS, Gibson JL, Sibbald R, et al. Clinical ethicists’ perspectives on organisational ethics in health care organisations. J Med Ethics. 2008;34:320 –323. 13. Foglia MB, Pearlman RA, Bottrell M, et al. Ethical challenges within Veterans Administration healthcare facilities: perspectives of managers, clinicians, patients, and ethics committee chairpersons. Am J Bioeth. 2009;9:28 –36. 14. Suhonen R, Stolt M, Virtanan H, et al. Organizational ethics: a literature review. Nurs Ethics. 2011;18:285–303. 15. Gibson JL. Organizational ethics and the management of health care organizations. Healthc Manage Forum. 2007;20: 32–34. 16. Lemieux-Charles L, Meslin EM, Aird C, et al. Ethical issues faced by clinician/managers in resource allocation decisions. Hosp Health Serv Adm. 1993;38:267–285. 17. Foglia MB, Pearlman RA, Bottrell MM, et al. Priority setting and the ethics of resource allocation in VA healthcare facilities: results of a survey. Organ Ethic. 2007;4:83–96. 18. Daniels N, Sabin JE. Setting Limits Fairly: Can We Learn to Share Medical Resources? Oxford: Oxford University Press; 2002. 19. Gibson JL, Martin DK, Singer PA. Evidence, economics, and ethics: resource allocation in health services organizations. Healthc Q. 2005;8:50 –59. 20. Peacock S, Ruta D, Mitton C, et al. Using economics to set pragmatic and ethical priorities. BMJ. 2006;332:482– 485. 21. Cooper RW, Frank GL, Gouty CA, et al. Key ethical issues encountered in healthcare organizations: perceptions of nurse executives. J Nurs Adm. 2002;32:331–337.
22. Hall LM, Doran D. Nurses’ perceptions of hospital work environments. J Nurs Manag. 2007;15:264 –273. 23. Gelsen TI, Van Der Dorf M, Maes S, et al. A longitudinal study of job stress in the nursing profession: causes and consequences. J Nurs Manag. 2006;14:289 –299. 24. Wall S. Organizational ethics, change, and stakeholder involvement. HEC Forum. 2007;19:227–243. 25. Gibson JL, Mitton C, Dubois-Wing G. Priority setting in the LHINs: ethics and economics in action. Healthc Q. 2011;14: 35– 46. 26. Hart SE. Hospital ethical climates and registered nurses’ turnover intentions. J Nurs Scholarsh. 2005;37:173–177. 27. Corley MC. Moral distress of critical care nurses. Am J Crit Care. 1995;4:280 –285. 28. Corley MC, Minick P, Elswich RK, et al. Nurse moral distress and ethical work environment. Nurs Ethics. 2005;12:381–390. 29. Severinsson E. Moral stress and burnout: qualitative content analysis. Nurs Health Sci. 2003;5:59 – 66. 30. Sutinen R, Kivimäki M, Elovainio M, et al. Organizational fairness and psychological distress in hospital physicians. Scand J Public Health. 2002;30:209 –215. 31. Kivimäki M, Elovainio M, Vahtera J, et al. Organizational justice and health of employees: prospective cohort study. Occup Environ Med. 2003;60:27–33. 32. Corley MC. Nurse moral distress: a proposed theory and research agenda. Nurs Ethics. 2002;9:636 – 650. 33. Aiken L, Clarke S, Sloane D, et al. Nurses’ reports on hospital care in five countries. Health Aff (Millwood). 2001;20:43–53. 34. Bell JAH, Breslin J. Healthcare provider moral distress as a leadership challenge. JONAS Healthc Law Ethics Regul. 2008; 10:94 –97. 35. Mitton C, Peacock S, Storch J, et al. Moral distress among health system managers: exploratory research in two British Columbia health authorities. Health Care Anal. 2011;19:107– 121. 36. Nelson WA, Gardent PB, Shulman E, et al. Preventing ethics conflicts and improving healthcare quality through system redesign. Qual Saf Health Care. 2010;19:526 –530. 37. Nelson WA. Ethics: a foundation for quality. Healthc Exec. 2011;26:48 – 49. 38. Self G. Put values up front: new discernment tool makes sure values aren’t left to chance. Health Prog. 2010 (NovDec):10 –14. 39. Nelson WA, Weeks WB, Campfield JM, et al. The organizational costs of ethical conflicts. J Healthc Manag. 2008;53: 41–53. 40. Laupacis A, Born K. Citizens participate in hospital restructuring processes. Available at: http://healthydebate.ca/2011/01/ topic/cost-of-care/citizen-participation-hospital-restructuring. Accessed January 11, 2012. 41. Government of Ontario: Ontario Citizens Council. Available at: http://www.health.gov.on.ca/en/public/programs/drugs/ councils/citizens_council.aspx. Accessed January 11, 2012. 42. Menon D, Stafinski T. Setting priorities for health technology assessment: public participation using a citizens’ jury. Health Expect. 2008;11:282–293.
Healthcare Management Forum ● Forum Gestion des soins de sante´ – Spring/Printemps 2012
39