1. Doucette, Jeffrey N. MS, RN, CEN, NEA-BC, FACHE

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A key responsibility of the nurse leader is to ensure that the highest ethical standards are maintained and discussed during the decision-making process. Why should ethics be a front-of-mind consideration when dealing with conflict, a hostile work environment, or even physical violence in the workplace? Here we'll consider a case study and examine the possible outcomes through an ethics lens.


Components of ethical decision making

Six principles of ethical behavior in the nurse leader's role have been identified: respect for person, beneficence, nonmaleficence, justice, veracity, and fidelity.1 Each of these principles is a consideration when balancing the needs of patient safety and employee rights during workplace conflict.


Respect for the person might include involving direct care nurses in the decision-making process of how policies, procedures, and training programs related to workplace conflict are developed and implemented.

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Beneficence may include creating a practice setting in which all employees can provide safe, high-quality care in a workplace free from violence where conflict is dealt with in a constructive way.


Nonmaleficence as an ethical consideration means ensuring that processes are in place to prevent violence and minimize conflict.


Justice should be considered when evaluating new programs or possible solutions. The use of mandatory overtime for specific nurses and not all nurses is an example of how distributive justice can be misused.2 Ensure that all policies and standards of behavior are upheld and that each provider, regardless of role, is held to the same performance standards.


Veracity and fidelity mean telling the truth and remaining faithful to commitments. Doing so will maintain your credibility within the context of difficult decision making, as well as within the organizational structure as a whole.


The surgeon and the scrub nurse: A case study

As a nurse leader, dealing with workplace conflict is something that frequently causes anxiety and trepidation. Often these complex human resource issues involve hearsay, hurt feelings, and highly charged emotions, making uncovering and addressing the core issues difficult. Let's consider the following case study to illustrate how incorporating ethical principles into decision making can improve the outcome of these challenging situations.


Early in the course of a complex surgical case, a surgeon and a scrub nurse get into an argument when the surgeon perceives the nurse "isn't doing her job." The exchange between the two is less than complimentary and quickly becomes heated, with the physician calling the scrub nurse "stupid" and demanding that she not be allowed in "his" OR in the future. Tensions are high in the room for the remainder of the procedure and, at the end of the case, the surgeon "tosses" the instruments in his hand on to the Mayo stand and storms out of the room.


The scrub nurse has a very different take on the situation and indicates that the surgeon berated her. She says that she felt threatened but couldn't leave the patient during the case to get help from a supervisor. Furthermore, she tells you that the surgeon expects her to "read his mind" and asserts that she's perfectly competent to perform her duties. She shares that she felt physically threatened as she was standing at the Mayo stand when the instruments were "thrown" at her. The scrub nurse threatens to file a complaint based on you facility's workplace violence policy and sue the hospital and the surgeon for harassment. You anticipate she might follow through with her threat.


Your role

Managing conflict is a fundamental nurse leader competency. Sadly, the dynamics of our case study can be applied in almost any clinical setting on any given day. Lateral violence and abuse among healthcare workers is commonly known to be on the rise. In working with the nurse and the surgeon involved, your first responsibility is to listen actively to both party's concerns. Recognize and understand that one of the essential components of managing the conflict resolution process is the role of facilitator. This inherently creates a challenge from the beginning because the goal of any conflict resolution process should be true collaboration where each party feels "heard and whole" at the end of the process.


Understanding the various conflict resolution strategies is important for effectively managing this situation. Five potential conflict management strategies related to nurse leaders have been identified: avoiding, compromising, collaborating, accommodating, and competing.3 In all but one of these strategies, each party "gives up" something in the process. The only true win-win strategy is collaboration.


In addition to understanding the various approaches to conflict resolution, you need to understand the roles of culture, age, hierarchy, gender, and workplace factors.4 One author noted that "surgeons frequently do not call this type of behavior conflict, rather they see it as the means to advocate and take a stand for their patient in the operative setting."5 These are a few of the key issues and potential challenges when managing a situation such as this.


Another important aspect of this particular situation is the early involvement of risk management and human resources in the investigation process. Any time an employee threatens legal action against the employer, you have a responsibility to protect not only the affected individuals, but also the patient and the organization.


Your response

Begin by first meeting with the parties involved and understanding the problem from multiple perspectives. Gather information about past patterns of behaviors of both parties, as well as any conflict resolution strategies that may have been beneficial in the past. Further assess what role others in the organization may play in helping to resolve the situation. Many leaders have a false belief that it's their responsibility to solve every problem that's brought before them when, in fact, the role of the leader is often to simply listen and offer counsel. As in most conflict situations, you must acknowledge that each party will have his or her own perspective on the source, severity, and expected outcomes of the conflict situation.


Partner with your physician leader counterpart to conduct one-on-one meetings with the scrub nurse and the surgeon to get their perspectives on the conflict. Based on these interviews, as well as interviews with others in the room at the time of the event, you can create a plan of action for dealing with the specific issues of the situation. The Joint Commission requires organizations to have policies and procedures in place to address disruptive behavior and harassment in the workplace. Utilize these policies as a guide to managing the process.


In addition to the disruptive behavior policy, the medical staff peer review and nursing peer review processes can be very helpful in dealing directly with these types of behaviors. The ethical construct of beneficence means mitigating the current situation, as well as clearly setting expectations for future behavior and performance. To that end, you may facilitate a meeting between all parties to address the situation and define expectations.


Although this behavior should be of serious concern and raise several red flags, of greater concern is the overall culture in the OR. Typically, these incidents don't happen in isolation and are generally a symptom of deeper issues within the overall culture of a clinical area. Your next steps should be to focus on this aspect of the issue by conducting a culture and safety survey, examining the perceptions of professional conduct, safety, teamwork, and conflict resolution in the OR. The results of this survey will provide a broader perspective of the day-to-day issues in this environment and, after being compiled, the results should be shared with the team. Engaging the team in developing an action plan to address any of the identified issues within the culture that aren't aligned with the basic principles of a healthy work environment meets the ethical obligation of respect.


This case illustrates many key opportunities for nurse leaders. One study indicated that 91% of surveyed nurses reported they had experienced verbal abuse in the workplace in the previous month, with physicians being the primary source of the abuse.6 In the same study, 50% of nurses surveyed on workplace violence didn't feel adequately prepared to deal with verbal abuse.


Ethics as a basis for cultural change

One of the most challenging aspects of dealing with situations such as the one in this case study is finding a common ground to begin the problem-solving process. Using an ethical framework allows you to build consensus from a vantage point that makes the conflict less about the people involved and more about doing what's right for the patient and the organization. In addition to using an ethics lens to solve problems, the organization also benefits by meeting the numerous expectations placed on nurse leaders regarding ethical practice by professional organizations. (See Ethics and succession planning.) These examples can be used for education, training, and case presentations, as well as in applications for national accreditation and recognition programs.


Nurse leaders are in a strategic position to support staff and patients who may be confronted with difficult situations in the workplace. To be unwilling to enter into these experiences renders you ineffective and abandons the staff, the patient, and the organization when they're, at times, most vulnerable. Have the courage to address issues head on and evaluate the effectiveness of decisions, actions, and outcomes in a timely and critical manner. The use of an ethics-based decision-making model will help you lead in a way that protects the dignity of those involved, advocate for those who may not feel they're in a position to advocate for themselves, and often arrive at a more collaborative solution.


Ethics and succession planning

As organizations continue to grow more complex and the role of the nurse leader continues to become more diverse, succession planning is more important than ever before. Organizational learning and succession planning consist of assessing and forecasting for future leadership needs, developing leadership competencies, identifying candidates with high leadership potential, and implementing plans for cultivating that talent.1 One strategy for sustained organizational learning is the early identification of staff members with leadership potential and the development of career maps.


The use of career maps allows a structured approach to assist with goal setting and remove personal barriers to growth and development. Typical career maps include some type of personality and/or leadership assessment and action items to aid the nurse in reaching the established goals.2 Incorporating personal aspects of a leader's growth plan can create several ethical challenges.


For example, you have a leader who has great potential, but who's recognized as having a "wild" lifestyle outside of work, which is widely known to staff via extensive posts on social media. You've heard concerns voiced about photographs that have surfaced showing the leader acting in a way that's "irresponsible" and "could cast the organization in a negative light." As a leader, you wouldn't normally be addressing these issues unless there was a performance problem; however, in the case of succession planning, this is a game changer.


Using an ethics framework is very helpful in this situation. You can coach the up-and-coming leader about his or her ethical obligations to the organization, the profession, and his or her role as a leader. This obligation can be framed in the constructs of veracity and fidelity, whereby the nurse leader creates and maintains credibility with key stakeholders, both inside and outside of the work setting.


The active engagement in setting expectations around organizational learning, holding both mentors and mentees accountable, and sharing the plan for organizational learning with the appropriate audiences are all key aspects of the nurse leader's role that are enhanced when viewed through an ethics lens.


Sources: 1. Redman R. Leadership succession planning: an evidenced-based approach for managing the future. J Nurs Adm. 2006;36(6):292-297.


2. Shermont H, Krepcio D, Murphy J. Career mapping: developing nurse leaders, reinvigorating careers. J Nurs Adm. 2009;39(10):432-437.




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