Ethical behavior in organizational contexts

Ethics and Nursing

One of the complexities of 21st century medicine is the evolution of nursing care theories in combination with a changing need and expectation of the stakeholder population. Nurses must be advocates and communicators, but must balance these along with an overall philosophy of ethics while still remaining mindful of budgets and the need for the medical institution to be profitable. It seems as if these issues comprise a three-part template for nursing: respect for patient value & individuality, education of patients, and cognition and respect for the realities of contemporary medicine. When there are issues surrounding unethical behavior, the standard view is that the issue is one of ignorance (unaware of the issue or policy), failure (sloppy medical work), or intent (purposeful negativity). Instead, Christopher Meyers (2004) believes that it is more the culture of the institution that frames ethical behavior than it is anything more purposeful. Indeed, in some ways Meyers' views take on a social-psychology role. Like Skinner's condition model, he believes that "culture plays a powerful and sometimes detrimental role in establishing the nature of the ethical debate…. Which is the organization's genuine mission, and what behaviors will be rewarded or criticized."

This view is echoed by Gaudine, et.al. (2011) in that medical staff may experience ethical conflicts when there are differing views between their own values and the values of the organization. Thematically, there are five major ethical conflicts within organizations that vary over the geographical spread of the research. Within each of these conflicts, however, the major theme echoes Myers -- different institutions, like different organizations, set the corporate culture of that organization. This might be due to a religious affiliation or sponsorship, the political or cultural orientation of the community or Board, or even the predominant viewpoint of the majority of the physicians who allow the flow of culture into their practice and with staff. Thus, the nurses' focus to be an advocate in that they will encourage, advocate, and enable the patient to take on part of the responsibility for their own care. This is not always a black and white issue -- for instance, sometimes medications can be painful and have uncomfortable side effects, which in the long-term, may have beneficial effects, but in the short-term may seem potentially harmful -- again, a utilitarian concept. However, while the nursing code of ethics echoes the Hippocratic Oath of "do no harm," the greater or long-term benefit to the patient may, at times, override brief discomfort in order to heal.

These five broad conflicts can be understood better if one looks at the thematic relationship they have to staff and/or the institution in question.

1. Lack of respect for professionals -- In particular in some of the larger HMO and Corporate Hospitals, medical professionals do not feel valued, but only "producers." Their salary, promotion and even quality of work are dependent on towing the administrative line in a profit and loss manner -- sometimes at the cost of patient care.

2. Insufficient resources for adequate patient care -- This issue is particularly relevant for modern nursing. While nurses are expected to take a more active role in patient care, there are serious staffing shortages that cause care to be mediocre through no fault of the individual nurse -- there are only so many things one person can do within a given shift. Nurses are the front line, but in struggling to meet the demand of the patients, ethical lapses sometimes occur due to understaffing.

3. Disagreement with organizational policies -- For most medical professionals, advocacy and the ethics of patient information and disclosure are paramount. In some cases, medical professionals feel that the administration is circumventing certain basic ethical rules for cost savings or economies of scale.

4. Lack of administration's support -- There seems to be a wide gulf between the administrative paradigm and that of the healthcare professional. Physicians and nurses feel that their expertise should overcome administrative issues, but administration sees clinical issues as costs -- resulting in poor communication and care.

5. Lack of organizational transparency -- Many professionals feel that information about issues, patients, care, and even ethical dilemmas remains hidden by the administration, likely due to either legal or managerial decisions. This may range from staff cuts or layoffs to a promise that consent forms were on file (Gaudine, et.al., pp. 758-63).

The two articles under review, then, essentially have the same basic premise -- it is the organizational culture that sets the tone for ethical behavior in the healthcare industry. The Gaudine, et.al. material, though, uses a mixed-method approach: a total of 75 healthcare professionals in four Canadian hospitals were interviewed. These subjects worked in a variety of clinical areas from acute care, surgery, ICU, to psychiatry and gerontology. The study used snowball sampling, then took the qualitative data and transposed it into thematic quantitative materials, using the qualitative explanations to buttress the themes. Content analysis was used to identify some of the thematic material, and then the data was transcribed. The Meyers material is more of a follow-up and generalized account to the findings in Gaudine. Meyers uses a utilitarian concept (greatest good for the greatest number), while providing a philosophical basis for changes in healthcare policy at the institutional level. In Meyers' opinion, organizations should not rely on an in-house ethicist to determine policy, but instead, find a basis in transparent and ethical behavior that speak to the foundations of medical ethics: autonomy, justice, fidelity, beneficence, veracity, non-maleficence, and paternalism. In this way, the foundation of behaviors will be written into policy and more applicably distributed to all -- regardless of fiscal or personal opinion or policy. Second, the role of ethics is becoming increasingly important within the modern healthcare organization, even as technology increases the toolbox for the medical professional. Just because we "can" do something does not mean we should, and medicine must be seen as an art and a science. It is the art of advocacy, communication and care while using the science of disease prevention and eradication in the most effective way based on sound ethical principles (Meyers, p. 275-6).