Authors

  1. Smith, Mary Atkinson DNP, FNP-BC, ONP-C, CNOR, RNFA

Abstract

What are the ethical leadership qualities of nurses, and how do these traits contribute to competent, safe patient care?

 

Article Content

Working on the frontline of care delivery and patient communication, nurses inevitably encounter ethical dilemmas. That said, all nurses have an ethical obligation to advocate for patients in a way that protects them from harm, regardless of the nurse's environment or title in their organization. A nurse's education and license serve as the basis for the expected standards of competent nursing practice. When patient care practices become substandard and lack competency, the nurse increases the risk of patient harm. Every nurse must cultivate ethical leadership qualities to build his or her own moral compass in a way that guides the delivery of ethical and competent nursing care, and provide a model for other nurses to follow.

  
Figure. No caption a... - Click to enlarge in new windowFigure. No caption available.

Building a moral compass

In 2015, the American Nurses Association (ANA) introduced a revision of the Code of Ethics for Nurses with Interpretive Statements to guide nurses in all areas of practice.1 Daily, nurses are vital leaders in the delivery and design of life-saving care. The ethical leadership of nursing covers more than just the delivery of direct patient care; it also applies to the development and design of systemwide models of nursing care delivery that impact indirect patient care. Ethical leadership is critical in both direct and indirect delivery of optimal nursing care. This code revision may serve to guide nurses in recognizing and developing ethical leadership qualities.

 

The ANA Code of Ethics for Nurses with Interpretive Statements contains nine provisions that have been revised from the 2001 version.1 The nine provisions contain a centralized relative theme-the nurse-and focus on his or her national and global convergence with patients, other nurses, other individuals, the nursing profession, and society. These provisions assist nurses with identifying basic values and commitments, highlighting the limits of loyalty and duty, and recognizing the facets of responsibilities that extend beyond the singular encounter with a patient. The revision of these provisions also addresses the current environment of nursing in a way that encourages nurses to realize the global scope of nursing significance on health.1

 

To better understand the ANA's Code of Ethics for Nurses with Interpretive Statements and how it correlates with ethical leadership qualities, it's important to know the standard ethical principles of nursing, which are respect for autonomy, beneficence, fidelity, justice, nonmaleficence, and veracity.2,3 Becoming more familiar with these individual principles may also help nurses identify and develop qualities needed to promote ethical leadership within the nursing profession. (See Table 1.)

  
Table 1: The six pri... - Click to enlarge in new windowTable 1: The six principles of ethical leadership in nursing

Morals vs. ethics

Nurses may have difficulty comprehending the difference between morals and ethics. Although they're often used interchangeably, the two terms have separate meanings, and it's vital for clinicians to know the difference. Morals are "good" or "bad" thoughts and actions derived from ethical reasoning. Ethics, a broader term, is the study of moral values and the principles of humanitarian duty as they relate to a set of rules that a group or society follows.4 Ethics refers to the ideals of a group, organization, or society. Morals are based on a more personal and individualized set of values that guide the nurse's beliefs or ideas.4

 

It's also vital for nurses to understand how morality relates to ethical leadership. A nurse's morality may serve to influence his or her thoughts and actions regarding patient advocacy, so it's crucial for nurses to develop a level of moral maturity that influences sound ethical decision making during challenging dilemmas in nursing practice.5 Ethical leadership in nursing that's morally mature involves committing to a career-long learning process of developing ethical reasoning that promotes integrity in problem solving of ethical dilemmas on the behalf of patients and their family members. Regarding ethical dilemmas, nurses have a moral and ethical obligation to intentionally make patient safety a priority for themselves, their patients, and the organization and institutions they represent.

 

The complex and heavy demands on nurses place them at high risk for experiencing moral distress-feelings of anger, frustration, and dissatisfaction, along with poor performance that results from the inability to follow moral values and do the "right thing" due to external constraints.4 To successfully promote ethics-driven patient advocacy among frontline nurses, leadership support must lack this distress.6

 

Characteristics of ethical leaders

The individual qualities that constitute ethical nursing leadership and promote a systemwide culture of it within organizations can be viewed as the eight C's: courage, competency, compassion, commitment, candor, consistency, communication, and the conviction of intuition.

 

* Courage: Possessing moral courage refers to the nurse directly confronting an issue that doesn't reflect his or her beliefs or values, or standing up for what's right by speaking out, even when faced with potential consequences.4,7 A recent study revealed that support from organizational administrators is essential for fostering nurses' moral courage to speak up. This study also revealed the need for highlighting the code of ethics in nursing and applying it to patient safety in nursing school curricula-specifically by using moral courage in simulation scenarios. These findings highlight the importance of moral courage in academic and clinical practice settings regarding advocating for patient safety.8

 

 

Moral courage involves ethical nurse leaders being bold and having a moral compass with ethical boundaries that promote patient advocacy. Ethical leaders don't stand in silence because it may be viewed as agreement. They boldly and courageously speak out against anything that undermines the delivery of safe, high-quality care because they know that silence could be fatal to their patient.

 

* Competency: Patients have a right to competent nursing care, and nurses are responsible for the promotion, maintenance, and practice of individual professional competency, which is a major quality of ethical nurse leaders.9 Nurses may promote competency individually by committing to lifelong learning that supports evidence-based practice (EBP), high-quality care, and positive patient outcomes. Competency may also be promoted by individual nurses through reflecting on practice, translating the best evidence into practice, and pursuing knowledge and skills current and related to their specialty practice area. It's important for nurses to promote competency within their respective institutions, organizations, professional associations, and regulatory agencies.

 

* Compassion: A universal definition of compassion is lacking in evidence-based literature. The most commonly cited definition is the Aristotle-based merit of suffering described as "a deep awareness of the suffering of another coupled with the wish to relieve it."10 Compassion is considered a fundamental aspect of the nursing profession.11 As healthcare continues to advance and grow more complex, nurses must not lose the fundamental aspects of compassion. The nursing profession should promote a culture of compassion throughout all levels, including academia and clinical practice.12

 

 

A recent study found that patients view compassion as the nurse taking time to get to know them, displaying empathy, and possessing effective communication skills.11 Compassion is an integral quality of ethical leaders when it comes to promoting patient advocacy in nursing. Ethical leaders show compassion in their actions and their attitudes while serving as role models and mentors for other nurses to follow suit.

 

* Commitment: This trait is often viewed as a pledge, promise, or obligation related to a particular cause.13 In ethical leadership, an excellent description of commitment is dedication. An ethical leader is dedicated to displaying actions that are fair, humane, just, honest, and respectful. A commitment to promoting patient advocacy may present as an awareness of approaching challenges and active planning to overcome those challenges in a way that's in the best interest of patients. Another example of commitment to patient advocacy includes continuously striving to improve the quality and safety of nursing care while possessing a willingness to listen and focus on feedback from both patients and nurses.13

 

* Candor: The quality of sincerity and honesty, candor refers to being open and truthful in your communication and actions with others. Ethical leaders who display candor also have a strong sense of humility. Transparency is also a form of candor, which is beneficial when leading change that promotes patient advocacy. For nursing staff to be fully supported in the role of patient advocacy, nurse leaders must display candor that develops trusting relationships among an organization's administration, staff, and the patients they serve. Trust is one of the necessary components needed to promote a culture of candor in nursing that encourages compassion, competency, and morality to support patient advocacy.14

 

* Consistency: This quality can be viewed as steady, reliable, and unwavering adherence to ethical principles. Successful qualities among ethical leaders don't waver. Effective ethical leadership to promote patient advocacy involves consistency of words, actions, and responses. Consistency for ethical leaders isn't born from implementing models or concepts, but from personal discipline. As an ethical leader, inconsistencies in mood or behavioral reactions may prevent other nursing staff members from seeking support when dealing with issues that are ethically and morally challenging, which may lead to less effective patient advocacy. When ethical nurse leaders are consistent in their communication and behaviors, nursing staff members know what to expect, everyone's stress level is lower, and everyone benefits, including patients.

 

* Communication: An integral facet of leadership in general, effective and clear communication is a necessary component of ethically leading other nurses and advocating for patients. Ethical leaders communicate in ways that build trust, widely disseminate vital information, and promote internal and external organizational transparency to develop collaboration within and outside of the organization. Ethical leaders who possess highly effective communication skills will further foster staff morale that can be a springboard for promoting wellness, reducing stress, preventing burnout, enhancing patient safety, increasing patient satisfaction, and improving quality of life for nurses and patients.15

 

 

Nurses must be mindful that interpersonal communication includes verbal and nonverbal cues. Examples of effective and transparent communication in ethical leadership include listening to others with the intent to understand; responding in an empathetic and positive fashion; and being open and clear regarding roles, expectations, and goals. Competent ethical leaders realize that interpersonal communication is an integral part of enhancing patient safety and improving outcomes in complex and morally challenging situations.15

 

* Conviction of intuition: Recent research defines intuition as a state of knowing that isn't conscious or analytical.16 Conviction of intuition involves being mindful of feelings that point to something being unsound or unsafe without the need for conscious reasoning. An example includes nurses sharing experiences related to the feeling that something "wasn't right" with a patient; in these cases, when the nurse acted on these feelings, patients were saved from a potentially life-threatening outcome.

 

 

Developed intuition contributes to responses from nurses that assist with beneficial decisions regarding patient care.16 With research that supports intuition's role in nursing regarding the promotion of patient safety and minimization of adverse events, the profession of nursing must remain mindful of intuition's impact. Ethical leaders should promote the development of intuition among nurses in the venues of education and clinical practice through encouraging the desire for an increased knowledge base related to EBP that supports safe patient handling. Simulation may also be used to develop skills and critical thinking that promote intuition in nursing, especially in new graduate and less experienced nurses.17

 

Nursing implications

There are many ways that ethical leaders can promote patient advocacy in nursing. One example includes creating or revising protocols, policies, or procedures to reflect EBP in a way that encourages positive patient outcomes and promotes patient safety by minimizing errors and confronting negligent practices. Ethical leaders in nursing can also lead changes in organizations that support an ethical culture of patient advocacy that promotes exemplary nursing care. The development of care delivery models that go beyond the standard of care may serve to minimize errors and sentinel events.

 

Staff members must remember that they aren't infallible; perfection doesn't exist when it comes to competency, performance, and outcomes. However, nurses must remember that excellence does exist. Nurses should strive for ethical excellence when it comes to advocating for the safety and well-being of patients. Nurses who want to promote patient advocacy must follow their intentions with actions. Ethical leadership has a global impact when it comes to influencing and encouraging nurses to advocate for patient safety.

 

Nurses can cultivate ethical leadership and patient advocacy within the profession by mentoring and leading by example. Nurses will face ethical challenges when delivering patient care that are unavoidable and can't be ignored. For ethical nursing leadership and patient advocacy to be effective, there must be corresponding actions that display courage, compassion, and competency. Nurses play a major role in promoting positive patient outcomes through ethics and advocacy. Every nurse owes this to themselves, their patients, and the profession.

 

INSTRUCTIONS The ethics/advocacy connection

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REFERENCES

 

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2. American Nurses Association. Short definitions of ethical principles and theories, familiar words, what do they mean? http://www.nursingworld.org/MainMenuCategories/EthicsStandards/Resources/Ethics-Definitions.pdf. [Context Link]

 

3. Butts J. Ethics in professional nursing practice. In: Butts J, Rich K, eds. Nursing Ethics Across the Curriculum and into Practice. Burlington, MA: Jones and Bartlett Learning; 2013:69-98. [Context Link]

 

4. Rich K. Introduction to bioethics and ethical decision making. In: Butts J, Rich K, eds. Nursing Ethics Across the Curriculum and into Practice. Burlington, MA: Jones and Bartlett Learning; 2013:31-68. [Context Link]

 

5. Sanderson C. Ethical and bioethical issues in nursing and health care. In: Cherry B, Jacob S, eds. Contemporary Nursing: Issues, Trends, & Management. St. Louis, MO: Elsevier; 2014:166-182. [Context Link]

 

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8. Dinndorf-Hogenson GA. Moral courage in practice: implications for patient safety. J Nurs Regul. 2015;6(2):10-16. [Context Link]

 

9. American Nurses Association. Professional role competence. http://www.nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/NursingStandards/Professional-Role-Competence.html. [Context Link]

 

10. Chochinov HM. Dignity and the essence of medicine: the A, B, C, and D of dignity conserving care. BMJ. 2007;335(7612):184-187. [Context Link]

 

11. Bramley L, Matiti M. How does it really feel to be in my shoes? Patients' experiences of compassion within nursing care and their perceptions of developing compassionate nurses. J Clin Nurs. 2014;23(19-20):2790-2799. [Context Link]

 

12. Francis R. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. https://http://www.gov.uk/government/uploads/system/uploads/attachment_data/file/279124/0947.pdf. [Context Link]

 

13. O'Connor S. The leadership academy: commitment is essential every day. http://www.nursingtimes.net/commitment-is-essential-everday/5064554.fullarticle. [Context Link]

 

14. Rutherford MM. The value of trust to nursing. Nurs Econ. 2014;32(6):283-288. [Context Link]

 

15. Vertino KA. Effective interpersonal communication: a practical guide to improve your life. Online J Issues Nurs. 2014;19(3):1. [Context Link]

 

16. Payne LK. Toward a theory of intuitive decision-making in nursing. Nurs Sci Q. 2015;28(3):223-228. [Context Link]

 

17. Green C. Nursing intuition: a valid form of knowledge. Nurs Philos. 2012;13(2):98-111. [Context Link]