Universidad de Sta.
Isabel Vincentian Learning Module
College of Health Sciences HEALTH CARE ETHICS
Nursing Program Abbie Mae SJ. Panday, RN
Chapter 6: Ethical Considerations in Nursing Leadership
and Management
OVERVIEW
Ethical considerations are fundamental to nursing leadership and management, shaping the quality of
care and the ethical climate within healthcare organizations. This chapter delves into the essential
aspects of ethical leadership in nursing, emphasizing the importance of creating an environment
conducive to high-quality, cost-effective healthcare.
Key Themes
Ethical Leadership: The chapter begins by defining ethical leadership in nursing,
highlighting the role of nurse leaders in fostering ethical behavior among staff and ensuring
adherence to established ethical codes.
Moral Decision-Making: It explores the process of moral decision-making, emphasizing
the need for ethical judgment and the ability to navigate complex dilemmas that arise in
clinical settings.
Principles of Moral Discernment and Well-Formed Conscience: The text outlines
critical principles that guide ethical decision-making, including the importance of a well-
formed conscience and the ability to discern moral actions based on a commitment to ethical
standards.
Ethical Issues: The chapter identifies various ethical issues faced by nursing leaders, such
as moral distress, resource allocation, and access to care. It also discusses the impact of
these issues on nurse morale and patient outcomes.
Ethical Competence: Attributes of ethical competence in nursing leaders are examined,
including empathetic interactions, ethical behavior, and exalted manners. Barriers to
implementing ethical leadership are also discussed.
At the end of this lesson, you will be able to:
1. Understand the importance of ethics in nursing leadership and management.
2. Analyze the principles of moral discernment and well-formed conscience.
3. Identify common ethical issues in nursing leadership and management.
4. Apply ethical decision-making frameworks to real-world scenarios.
Introduction to Ethical Leadership in Nursing
In the last decade of the 20th century, there was a growing emphasis on ethical leadership
within nursing, aimed at fostering a supportive environment for high-quality and cost-effective
healthcare. Ethical leadership is characterized by three main aspects: character, conduct, and
institutional practices.
• Character involves the ability to recognize ethical issues and model ethical behavior.
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Universidad de Sta. Isabel Vincentian Learning Module
College of Health Sciences HEALTH CARE ETHICS
Nursing Program Abbie Mae SJ. Panday, RN
• Conduct relates to maintaining high ethical standards and implementing consequences
for violations.
• Institutional practices focus on creating an ethical climate that upholds dignity,
safety, and patient rights.
Ethical leaders in nursing are portrayed as altruistic and fair, equipped to handle moral distress
effectively while serving as role models. They utilize both positional and personal power to
cultivate an ethical workplace. The legacy of Florence Nightingale highlights the importance of
ethical guidelines, which continue to govern nursing practices today. Current nursing leaders are
crucial in ensuring adherence to these ethical codes, thereby sustaining the profession's ethical
standards.
Ethical Considerations in Nursing Leadership and Management
Ethical considerations are vital in nursing leadership and management, significantly
impacting workforce activation and organizational goals. The ethical behavior of nurse
leaders enhances care quality by positively influencing nurse performance and fostering
beneficial outcomes for the organization. Creating an ethical climate facilitates
professional development and effective results within the nursing profession.
Moral distress shapes the ethical climate, which, in turn, affects ethical decision-making,
moral courage, and overall ethical behavior. Research shows a strong correlation
between a positive ethical work environment and increased moral courage and
organizational citizenship. Additionally, moral sensitivity is closely linked to ethical
decision-making, indicating that both are essential for navigating ethical dilemmas.
Moral courage is crucial for making ethical decisions that balance moral principles and
legal considerations, highlighting the need to maintain this courage while addressing
challenging situations in practice.
A. ON MORAL DECISION- MAKING
Moral decision making is imperative to arrive at an ethical action or intervention. It would require
an ethical judgment and such judgment needs a basis- a specific reference point, a criterion or
condition so we can examine, evaluate then judge and consequently act ethically.
Ethical decision-making confidence develops from clinical expertise and is a core competency for
nurse leaders. No tool exists to measure confidence levels in nurse leaders based upon an ethical
decision- making framework. (Birkholz et al., 2022)
Using the Phases of Development of Core Competency for Ethical Decision-Making by Hamric
and Delgado (2013), the ethical decision-making confidence scale was developed
The phases of competency are:
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Universidad de Sta. Isabel Vincentian Learning Module
College of Health Sciences HEALTH CARE ETHICS
Nursing Program Abbie Mae SJ. Panday, RN
Phases of Competency Development
1. Phase 1: Knowledge Development - Moral Sensitivity
This phase focuses on fostering an awareness of ethical issues and moral sensitivities.
Nurse leaders must be trained to recognize ethical dilemmas and understand the
implications of their decisions on patient care and team dynamics.
2. Phase 2: Knowledge Application
In this phase, the emphasis shifts to applying ethical knowledge in real-world situations.
Nurse leaders learn to use ethical frameworks and models to analyze scenarios, ensuring
their decisions are informed by ethical principles.
3. Phase 3: Creating an Ethical Environment
This phase involves actively fostering an ethical climate within the healthcare setting.
Nurse leaders work to establish policies and practices that promote ethical behavior
among staff, encouraging open discussions about ethical dilemmas and supporting one
another in ethical decision-making.
4. Phase 4: Promoting Social Justice Within the Health Care System
The final phase emphasizes the broader implications of ethical decision-making,
encouraging nurse leaders to advocate for social justice in healthcare. This includes
addressing inequalities and ensuring that all patients receive fair and equitable care.
18 indicators are identified in the development of ethical decision-making
confidence scale: (Birkholz et al., 2022)
1. Recognize a genuine ethical dilemma in practice
2. Make a sound ethical decision
3. Explain ethical decisions using correct ethical terminology and language
4. Provide a clear statement of the personal values that guide your ethical decision-
making and practice
5. Articulate legal guidelines related to complex ethical issues in patient care i.e.,
assisted suicide, informed consent, research involving minors)
6. Articulate the difference between ethical dilemmas, moral distress, issues related
to interprofessional collaboration and communication, difficult patients, etc.
7. Articulate the definition of moral distress and provide an example of your
experience of moral distress in your practice
8. Identify ethical issues in complex patient care i.e., identify scenarios requiring
ethical decision-making and/or ethical consult team guidance
9. Apply ethical decision-making models or structured processes to complex clinical
problems
10. Participate in and/or guide mediation related to complex clinical problems
involving ethical dilemmas or moral distress
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Universidad de Sta. Isabel Vincentian Learning Module
College of Health Sciences HEALTH CARE ETHICS
Nursing Program Abbie Mae SJ. Panday, RN
11. Recognize and manage moral distress in self and others
12. Role model collaborative problem solving in complex clinical problems involving
ethical dilemmas or moral distress
13. Engage in preventative ethics initiatives to address the ethical environment in
your practice area
14. Mentor others to develop ethical practice behaviors
15. Address barriers to ethical practice through systems changes
16. Use preventative ethics to decrease unit level moral distress
17. Engage in health policy initiatives supporting social justice
18. Provide leadership at the unit, organizational, local, state and federal level for
policy change initiatives to address social justice issues in health care.
Nurses employ ETHICAL DECISION MAKING whenever there are Ethical Dilemma. An
ethical dilemma or ethical paradox is a decision-making problem between two possible
moral imperatives, neither of which is unambiguously acceptable or preferable .
Ethical dilemmas arise from conflicts where adhering to one moral imperative may
violate another, often challenging existing ethical systems. These dilemmas are
prevalent in everyday decisions, highlighting the need for ethics at all levels of life,
including personal conduct, organizational responsibility, and societal norms.
An ethical decision fosters trust and reflects values such as responsibility, fairness, and
caring. The decision-making process involves reviewing options, discarding unethical
choices, and selecting the best ethical alternative based on conscience. According to
Lawrence Kohlberg, conscience is just one aspect of moral development, which occurs
in three stages.
The process of making ethical decisions requires:
Commitment: The desire to do the right thing regardless of the cost
Consciousness: The awareness to act consistently and apply moral convictions to daily
behavior
Competency: The ability to collect and evaluate information, develop alternatives, and
foresee potential consequences and risks
Good decisions are both ethical and effective:
Ethical decisions generate and sustain trust; demonstrate respect, responsibility, fairness
and caring; and are consistent with good citizenship. These behaviors provide a
foundation for making better decisions by setting the ground rules for our behavior.
Effective decisions are effective if they accomplish what we want accomplished and if they
advance our purposes. A choice that produces unintended and undesirable results is
ineffective. The key to making effective decisions is to think about choices in terms of their
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Universidad de Sta. Isabel Vincentian Learning Module
College of Health Sciences HEALTH CARE ETHICS
Nursing Program Abbie Mae SJ. Panday, RN
ability to accomplish our most important goals. This means we have to understand the
difference between immediate and short-term goals and longer-range goals.
B. Principle of Moral Discernment
To make a conscientious ethical decision one must do the following:
▪ Proceed on the basis of a fundamental commitment to God and to human persons
(including oneself) according to their God-given and graced human nature
▪ Among possible actions that might seem to be means of fulfilling that commitment,
exclude any that are contradictory to it (or those that are intrinsically evil)
▪ Consider how one's own motives and other circumstances may contribute to or nullify
the effectiveness of these other possible actions as means to fulfill one's fundamental
commitment.
▪ Among the possible means not excluded or nullified, select one by which one is most
likely to fulfill that commitment and act on it.
C. Principle of Well-Formed Conscience
To attain the true goals of human life by responsible actions, in every free decision
involving an ethical question, people are morally obliged to do the following:
▪ Informed themselves as fully as practically possible about the facts and the
ethical norms
▪ Form a morally certain judgment of conscience on the basis of this information
▪ Act according to this well-formed conscience
▪ Accept responsibility for their actions
CONSCIENCE FORMATION
Conscience, derived from the Latin "conscientia" and French "conciense," is defined as
an internal sense of right and wrong, guiding individuals in decision-making and action.
In nursing, conscience is broadly perceived as an authority, a warning signal, demanding
sensitivity, an asset, a burden, inherent in nursing, and culturally dependent.
Key points include:
• Authority and Sensitivity: Conscience is viewed as an authority and a warning signal
that demands sensitivity, varying in perception based on cultural context.
• Quality of Care: When nurses follow their conscience, they are likely to provide high-
quality care and experience fewer conflicts. Conversely, those unable to do so often face
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Universidad de Sta. Isabel Vincentian Learning Module
College of Health Sciences HEALTH CARE ETHICS
Nursing Program Abbie Mae SJ. Panday, RN
a troubled conscience, leading to feelings of guilt, especially when personal beliefs clash
with professional obligations.
• Stress of Conscience: Repeated exposure to stressful situations can result in a "stress
of conscience," negatively impacting a nurse's practice and personal life. This stress is
linked to burnout, as some nurses may suppress their conscience to cope with
overwhelming demands.
• Practical Judgment: Conscience involves practical reasoning about ethical issues,
requiring a foundation in reality and truth, rather than mere desire or blind choice. A
well-formed conscience develops from personal experiences, education, and moral
teachings.
• Error and Accountability: While conscience can guide moral decision-making, it is not
infallible. Misunderstandings or misguided beliefs can lead to errors, for which individuals
are accountable only to the extent of their ability to avoid them.
Ethical Issues in Nursing Leadership and Management
Nurses frequently encounter difficult situations involving decisions about the best course of
action. Nurses are expected to provide not only expanding nursing care but also ethical and legal
client care that demonstrates respect for others. Consequently, nurses confront not only the
expanding role and ever-changing clinical environment but also various ethical or moral
problems and concerns.
Nurses have the right to work in an organization where they are considered, understood, and
respected where there is mutual trust, honesty, integrity, and where they feel a sense of
belongingness and participation in realizing the organization's vision and mission. The nursing
leader who is able to ensure that nurses under her supervision experience such ethical climate,
who pays attention to the ethical dimension of the leader's role is a leader who reflects
trustworthiness and ethical competence.
Attributes of Ethical competence of Nursing Leaders were identified under three (3) main
categories. (Barkhordari-Sharifabad et al., 2018) These are:
1. Empathetic interactions - Solution of problems and wishes; Establishing confidence and
assurance; Mutual liking and respect; Establishing the human and ethical interaction
Empathy; Cooperation
2. Ethical behavior - Supportive behavior; Contributory behavior; Fair behavior; Ethical
behavior toward wrongdoers; Ethical behavior toward patients
3. Exalted manners - Honesty; Humility; Sincerity; Decisiveness and determination Good-
temperedness; Patience and tolerance
Ethics is an essential component of leadership qualifications and the ethical leader can help
create an ethical atmosphere, offer ethical guidance, and ensure the occupational satisfaction of
personnel through prioritizing moralities. However, some issues prevent the implementation of
this type of leadership by nursing leaders.
3 main obstacles were identified: ethical, cultural and managerial problems. (Barkhordari-
Sharifabad & Atashzadeh-Shoorideh, 2017)
1. Ethical problems -pertain to doubt in ethical actions, ethical conflicts and ethical distress;
2. Cultural problems - include organizational and social culture;
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Universidad de Sta. Isabel Vincentian Learning Module
College of Health Sciences HEALTH CARE ETHICS
Nursing Program Abbie Mae SJ. Panday, RN
3. Managerial problems- are connected to organizational and staff-related issues.
In 1984, Andrew Jameton introduced the term "MORAL DISTRESS" (Jameton, 2017). He
described moral distress as the emotional or physical pain experienced when individuals are
unable to act according to their beliefs about what is right . Nurses may encounter barriers that
prevent them from doing what they believe is ethical due to facility policies, patient or family
influences, supervisory directives, or time constraints. This distress arises when nurses
compromise their personal moral values and fail to meet their perceived responsibilities,
especially when faced with two or more conflicting moral obligations that seem equally valid.
Moral uncertainty occurs when a nurse recognizes a moral issue but is unsure about the right
course of action. In contrast, moral outrage arises when a nurse knows the correct ethical action
but finds institutional or other limitations make it nearly impossible to take appropriate steps.
This feeling can also manifest when a colleague performs an act that the nurse considers to be
immoral.
Nurse managers have identified a range of ethical issues in their work, which encompass
patient-related, staff-related, and organization-related problems. Additionally, some challenges
are linked directly to the managers themselves (Aitamaa et al., 2016).
The main categories of ethical problems identified by nurse managers are:
1. Conflicts in practical situations - Conflicts in practical situations included situations
where there were at least two different opinions as to what was the right way to act.
Situations where conflicts exist are obvious and conflicting values are easily found, and there
usually is open discussion between two or more parties.
▪Patient Care Conflicts: Disagreements can occur between patients and staff, nurses
and physicians, or patients and their relatives. Key values in these conflicts include
patient autonomy and self-determination versus the professional or familial perspective
on what constitutes the patient's best interests.
▪ Between patient and staff, these conflicts included refusal of care, coercion and power.
For some reason, staff's understanding of necessary care differed from the patients'
opinion. Differences of opinion on patient care also appeared between nurses and
physicians, especially when the patient was not strong enough to make his or her own
decisions. Acting as an advocate to patients was thought to be nurses'
responsibility.
▪ Relatives may also disagree about patient care with staff or the patient. Sometimes
disagreements were related to treatment, which the patient or relatives had perceived as
unfair or inappropriate. In the case of complains on treatment, NMs' problem is to find
out what actually happened.
2. Lack of appreciation - Nurse managers have perceived some participants being
undervalued or not taken into account when making decisions. The values included are
equality, respect and - regarding to patients - human dignity.
▪ Related to patients, lack of appreciation finds expression in paternalistic culture,
inequality of patients and indiscreet treatment of patients. The culture of paternalism
was still more or less in evidence in hospitals. Nurses and physicians thought that they
knew what was best for patients better than the patients themselves.
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Universidad de Sta. Isabel Vincentian Learning Module
College of Health Sciences HEALTH CARE ETHICS
Nursing Program Abbie Mae SJ. Panday, RN
▪ Related to staff, lack of appreciation was expressed as lack of collegial behavior and
problems with collaboration with other professionals. Lack of collegial behavior appeared
as lack of collaboration, criticizing colleagues without good reason, denying help to a
colleague, not trusting colleagues' work, and not committing to group decisions.
Problems with collaboration with other professionals mean unsatisfactory
multiprofessional teamwork. Especially, physicians were seen to be acting based on
medicine, not taking account of nursing perspective.
3. Disregard of problems - Disregard of problems consisted of matters that nurse managers
considered wrong but somehow accepted as existing in the organization culture, or at least
there was nothing active going on to correct them. According to NMs, these problems are
perceived commonly in the organization also by other professionals.
▪ Related to patients, there were accounts of not patient-oriented routines and habits as
an expression of a caring culture that has developed for historical reasons, so that
routines are more inclined to serve professionals or organization than patients. There are
not necessarily any conflicts, but the patient's role is not as participative as it should be.
▪ Related to staff, there are two problems in this category: not listening to staff and
excessive collegiality on the part of physicians. According to NMs, they get messages
from the staff that they are not sufficiently listened to. This could have to do with
organization culture where management is more about giving orders than interacting.
4. Experienced inadequacy - Nurse managers described situations where they did not have
enough ways to do the best possible thing. There were many kinds of obstacles which are
very difficult to impact: legislative, financial and cultural. NMs experienced inadequacy in
these situations.
▪ Patient-related problems in the category of experienced inadequacy were prioritization of
patient care, limited power and limited circumstances.
Prioritization in patient care was described as situations where it was not possible to car
Another problem, limited power, was described as situations where legislation sets limits
to care. Especially, with children, there are situations where parents have a right to
make decisions which nursing professionals do not think are in the child's best interest.
Third, limited circumstances in patient care were described especially with long-term or
dying patients. The hospital culture or physical circumstances set limitations to a natural
death in a peaceful environment with one's own familiar belongings.
▪ Related to staff, experienced inadequacy related was reported by NMs as fatigue on the
part of staff. Multiple and rapid changes in the healthcare system were described as
being more or less exhausting for staff. Managers feel that so much is demanded of the
professionals, and they cannot do enough for staff's welfare in midst of all the changes.
Meaning and Service Value of Medical Care
Another important area of concern for nursing leaders is the medical care that is often rendered
to patients in need of medical attention based on urgency. The value that underlies the
implementation of medical care can be measured by the improvement of patients' outcomes for
the cost of achieving the said desired outcome (Teisberg et al, 2020). With that being said, the
concept of VALUE-BASED HEALTH CARE is introduced. This concept and strategy was a result of
decades of research into organizations that have achieved better outcomes while often lowering
costs (Teisberg et al, 2020).
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Universidad de Sta. Isabel Vincentian Learning Module
College of Health Sciences HEALTH CARE ETHICS
Nursing Program Abbie Mae SJ. Panday, RN
The goal of value-based care transformation is to enable the health-care system to add more
value to patients' lives. Because value is created only when a person's health outcomes improve,
cost-cutting descriptions of value-based health care are inadequate. Cost reduction is important,
but it is not sufficient: If the true goal of value-based health care was cost reduction, pain
relievers and compassion would suffice.
Value-based health care is frequently confused with quality, a nebulous concept that implies a
plethora of virtues and, in health care, frequently focuses on inputs and process compliance.
A. Allocation of Resources
Health care requires resources, and resources in turn entails cost and budgetary
requirements, therefore as value-based healthcare is to be promoted it is imperative to
allocate adequate resources that are cost-effective to meet the patient's outcome.
Different approaches in our country's health care system have been applied in relation to
value-based health care such as the provision of clinical pathways wherein
multidisciplinary approach is documented, well planned and foresees the needs of
patients with common medical problems relative to its cost. For example, since dengue
is a common medical problem in the country among children, a clinical pathway where
the day to day list of medical treatment, diagnostic procedures, laboratory work-ups and
nursing care needed are placed with the end goal of achieving cost-effective care.
Teisberg et al. (2020) emphasize that value-based care should focus on three key health
outcomes: capability, comfort, and calm.
➢ Capability is the ability of patients to do the things that define them as individuals and
enable them to be themselves. It is often tracked with functional measures
➢ Comfort is relief from physical and emotional suffering. In addition to reducing pain,
improving patients' comfort requires addressing the distress and anxiety that frequently
accompany or exacerbate illness.
➢ Calm is the ability to live normally while getting care. It encompasses freedom from the
chaos that patients often experience in the healthcare delivery system, and it is
especially important for people with chronic and long-term conditions.
Care that improves outcomes in all 3 of these dimensions creates a better experience for
patients. Moreover, capability, comfort, and calm describe outcomes that result from the efficacy
and empathy of health care, rather than its hospitality (Teisberg et al, 2020).
B. Issues involving access to care
Access to health care means having "the timely use of personal health services to
achieve the best health outcomes" (AHRQ, 2018 on IOM, 1993).
In order to understand what issues are involved with regards to access to care, we must first
determine the elements of access to healthcare according to the Agency for Healthcare Research
and Quality (AHRQ) in 2018.
Elements of Access to Healthcare (AHRQ, 2018):
➢ Coverage: facilitates entry into the healthcare system. Uninsured people are less likely to
receive medical care and more likely to have poor health status.
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Universidad de Sta. Isabel Vincentian Learning Module
College of Health Sciences HEALTH CARE ETHICS
Nursing Program Abbie Mae SJ. Panday, RN
➢ Services: Having a usual source of care is associated with adults receiving recommended
screening and prevention services. Timeliness: ability to provide health care when the
need is recognized.
➢ Workforce: capable, qualified, culturally competent providers.
Issues on access to healthcare:
“Bahala Na" mentality drains our healthcare system. Shortage of healthcare workers, limited
access to healthcare facilities, and high out of pocket expenses for hospitalization and healthcare
needs are among the problems that we face because of "Bahala Na" mentality.
The Universal Health Care (UHC) policy aims to resolve these issues. The three lessons that I
have learned from this article are as follows: Increased coverage of Philhealth, Clarification of
roles of Government Agencies, and Health human resources development.
Increased coverage of Philhealth or the National Health Insurance Program refers to the
automatic inclusion of Filipino citizens to the health insurance program. As compared before
where there is a large portion of high out of pocket health care expenses of the people. It may
not cover 100% of the hospital bill but it decreased the high out of pocket expenses. The law
also addresses the overlapping roles and responsibilities of different health agencies due to the
devolved set-up. The law clarified these roles wherein the Department of Health (DOH) and local
government units (LGU) will be responsible for population-based interventions and health
services, which involves immunization and health promotion programs, while PhilHealth will be
responsible for financing individual-based health services. This will now mean that people will no
longer have to visit one charitable institution to another. Finally, the law ensures that there will
be development of the health system's human resources through the formulation and
implementation of the National Health Human Resource Master Plan, which ensures that all
health professionals have permanent employment and competitive salaries as well as the
provision for the creation of national health workforce support system that will aid local public
health systems in addressing human resource needs while prioritizing deployment in the
Geographically Isolated and Disadvantaged Areas (GIDAs).
The UHC law also tasks the Education sector and the DOH to develop existing and new allied
and health-related degrees and training programs, and to regulate the number of its enrollees
depending on the needs of the population. The law provides scholarship grants for graduate and
undergraduate allied and health-related programs, and in return graduates will be required by
law to render at least three years of return service with compensation under the supervision of
the DOH. Incentives will be given to those who will render an additional two years of return
service.
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Universidad de Sta. Isabel Vincentian Learning Module
College of Health Sciences HEALTH CARE ETHICS
Nursing Program Abbie Mae SJ. Panday, RN
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-End of this Module-
THANK YOU, BSN 2 STUDENTS.
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