Institutional Integrity and Organizational Ethics

1. Institutional Integrity and Organizational Ethics Carol Taylor, PhD, RN Georgetown University School for Nursing and Health Studies taylorcr@georgetown.edu

2. Objectives Upon completion of this session participants will be able to: • Define ethics, moral agency, and moral integrity • Describe how both individuals and institutions develop moral agency and integrity and the consequences of honoring or dishonoring integrity • Identify common ethical challenges in the workplace and strategies for resolving these problems • Contrast integrity-based and compliance-based organizational ethics programs

3. Objectives(time permitting…) Upon completion of this session participants will be able to: • Describe the hallmarks and challenges of quality institutional ethics programs • Distinguish ethics concerns/challenges and related resources from legal, safety/quality, human resources, etc. concerns/challenges • Develop strategies for raising ethical awareness within institutions and bringing forward ethical challenges • Utilize processes for resolving clinical and organizational ethical challenges

4. Starting Assumptions

5. Glaser’s three realms of ethics

6. Ethics ProgramsState of the art…

7. Common challenges • Many health care organizations have an ethics consultation service, but do not know how to evaluate and ensure ethics consultation quality. • Ethics programs tend to be primarily reactive and case-based, and lack effective approaches for addressing ethical issues proactively and systemically. • Leaders are not always aware of ethical problems in their organization until a crisis occurs. 

8. Effective Ethics ProgramsVeterans Association’s Integrated Ethics Program • respond to ethical questions at the level of actions and decisions through Ethics Consultation; • address ethics quality gaps at the level of systems and processes by applying a quality improvement approach in Preventive Ethics; and • foster a strong ethical environment and culture through Ethical Leadership.

9. Discrete situation at a particular time A question about what is the best ethics practice Goal to improve ethics quality by responding to an ethics question Ongoing situation involving organizational systems & processes A systemic gap between current and best ethics practice Goal to improve ethics quality by reducing ethics quality gaps at a systems level Ethics Case versus Ethics Issue

10. What is Ethics Quality in Health Care? Decisionsand actions (Ethics Consultation) Environment Decisionsand actions (Ethics Consultation) Decisionsand actions (Ethics Consultation) Systems and Processes((preventive ethics) Ethics) Environmentand culture (Ethical Leadership)

11. Check out this resource http://chausa.org/excellenceinethics/

12. There are two parts to the resource they developed: a printed booklet and a website. The booklet includes an introduction, recommended standards for eight core components of a robust ethics service, and a tool for assessing a particular organization’s performance with regard to each component as well as each
of its standards

13. COMPONENTS OF A ROBUST ETHICS SERVICE • ETHICS EXPERTISE • ETHICS SUPPORT COMMITTEES • LEADERSHIP • INSTITUTIONAL INTEGRATION • COMMUNITY OUTREACH • STRIVING FOR EXCELLENCE IN ETHICS • CONSULTATION & ADVISEMENT • EDUCATION & FORMATION

14. Clarifying Concepts • Ethics • Moral Agency • Moral Integrity

15. What is Ethics?

16. What is Ethics? • Ethics is the formal study of who we ought to be and how we should make decisions and behave in light of our identity

17. Dan Callahan (1995) writes that at the heart of bioethics lie three paramount human questions: • What kind of person ought I to be in order to live a moral life and make good ethical decisions? • What are my duties and obligations to other individuals whose life and well being may be affected by my actions? • What do I owe the common good or the public interest, in my life as a member of society? Rephrased, what do we, XXXX, owe the common good in our corporate life as a member of society?

18. Two Approaches to Morality • Morality is knowledge • Morality is something we do together, social and collaborative

19. What signals you to an ethical challenge? • Intellectual disconnect? • Queasy feeling in the pit of your stomach? • Discomfort or disappointment in the way you or your team are responding?

20. Response • Pay attention to how you reason as you think about how you should and would respond.

21. What counts as a good response? • Promotes human dignity and the common good • Maximize good and minimize harm • Just distribution of goods and harms • Respects rights • Responsive to vulnerabilities • Promotes virtue • Other

22. What criteria do you use to evaluate your response? • We stayed out of trouble—not greatly inconvenienced. • We made money or at the very least didn’t lose money! • Able to put your head on your pillow and fall asleep peacefully • My/our reputation is intact. • Transparency [Washington Post test; “I could share how I/we responded with my children and feel proud.”] • Consistency • Other

23. Ethical Competent Professionals… • Are competent for their assigned roles • Can be trusted to act in ways that advance the best interests of their clients and employees • Hold themselves and their colleagues accountable for their practice • Work collaboratively to advocate for clients, families, communities • Mediate ethical conflict • Use as their primary lens human well-being, human flourishing • Pass the transparency test

24. Distinguishing Clinical and Institutional Ethics • Clinical ethics is an interdisciplinary activity to identify, analyze, and resolve ethical problems that arise in the care of particular patients. The major thrust of clinical ethics is to work for outcomes that best serve the interests and welfare of patients and their families [J. Fletcher, The Bioethics Movement and Hospital Ethics Committees, Maryland Law Review 50 (1991):859n, note 1.].

25. Organizational Ethics • The intentional use of values to guide the decisions of a system. • Objective: strong “FIT” between the system’s stated mission and decision making at all levels of the system

26. Difference between Ethics and Compliance • The compliance strategy, which is predominantly lawyer driven, meets the basic needs for legal compliance. • The integrity-based strategy is characterized by a conception of ethics as a driving force of an enterprise. Lynn Sharpe Paine

28. What is moral agency?

29. Dr. Bob Barnet’s Human Drivers: 5 P’s • Power • Position • Prestige • Profit • Politics Strikingly Absent: • Patients, People, the Public

30. This requires formation…

31. Ethical Capacity • How charged are you this morning?

32. Who or What Exercises Moral Agency? • an individual • individuals in relation (the moral agency of collectives) • individuals in relation within institutions(the moral agency of the health care community) • individuals in relation within institutions within particular societies and cultures

33. We know the right thing to do but it is almost impossible… • Deficient moral agency • Ethical Distress •  Ethical Residue •  Disengagement

34. Constraints involved in moral distress (Epstein & Hamric, 2009) Internal Constraints • Lack of assertiveness • Self-doubt • Socialization to follow orders • Perceived powerlessness • Lack of understanding of full situation

35. Constraints involved in moral distress (Epstein & Hamric, 2009) External Constraints • Inadequate staffing • Hierarchies within the healthcare system • Lack of collegial relationships • Lack of administrative support • Policies and priorities that conflict with care needs • Compromised care due to pressure to reduce costs • Fear of litigation

36. Consequences of not addressing moral distress • Lost capacity to care, avoidance of patient contact (disengagement), failure to give good care • Physical and psychological problems • Diminished self-worth and moral integrity or moral well-being • Transferring from a department/service/place of work  leaving profession • Poor communication, lack of trust, high turnover rates, defensiveness, and lack of collaboration across disciplines • Abusive behaviors, disrespectful communication, or worse • Erosion of team cohesion, intensifying the distress of the situation • Quality of patient care suffers (AACN’s 4 A’s to Rise Above Moral Distress)

37. How ethically buff are you and your team?

38. What is Moral Integrity? • Integrity: • soundness of and adherence to moral principle and character; uprightness and honesty. • the state of being whole, entire, or undiminished. • a sound, unimpaired, or perfect condition. • From Webster’s Encyclopedic Unabridged Dictionary of the English Language

39. Snicker Test

40. Why be a person/ministry of Integrity? • “American Baptist Homes of the West will continue to hold the trust of its constituency by keeping its promises with integrity, stability, and intentional ethical behavior in the provision of quality services for older persons”

41. Short Inventory • I prize my integrity so highly that I never make decisions or engage in behaviors that compromise my integrity. • Highly agree • Somewhat agree • Somewhat disagree • Highly disagree

42. When I am aware of situations in my work environment that need change I “say the hard things that need saying” even if this makes me unpopular or has other consequences. • Highly agree • Somewhat agree • Somewhat disagree • Highly disagree

43. I believe my institution prizes integrity and consistently hires and rewards individuals of good character. • Highly agree • Somewhat agree • Somewhat disagree • Highly disagree

44. Leadership in my institution is willing to hear about and to address integrity challenges in the work place. • Highly agree • Somewhat agree • Somewhat disagree • Highly disagree

45. My institution sets excellence as its goal and holds employees accountable to high standards. • Highly agree • Somewhat agree • Somewhat disagree • Highly disagree

46. The integrity of our institution would be enhanced if we do the following. Check all that apply. • _____ Clone me • _____ Fire me • _____ Clone my supervisor • _____ Fire my supervisor • _____ Support our senior leadership • _____ Replace our senior leadership

47. Would we pass the snicker test for personal and corporate moral integrity?

48. Organizational Ethics • Potter initially defined organizational ethics as the intentional use of values to guide the decisions of a system. • The objective was a strong “fit” between the system’s stated vision, mission, and core values and decision-making at all levels of the system. • Reworded, organizational ethics is about organizational integrity, a commitment to promote that condition/culture in which the system’s moral activity (valuing, choosing, acting) is intimately linked to its conception of what a morally good system looks like.

49. Organizational Ethics • The intentional use of values to guide the decisions of a system. Objective: strong “FIT” between the system’s stated mission and decisionmaking at all levels of the system... as reflected in the system’s people, culture and infrastructure!

50. The Big Picture • The What of Organizational Integrity • The Why of Organizational Integrity • The When of Organizational Integrity • The How of Organizational Integrity • Organizational Ethics is a Work in Progress • Organizational Ethics • Is more than the personal integrity and goodness of those in the organization • Is more than business ethics • Is definitely more than compliance