Posted: March 16th, 2022

Performance potential

Performance potential
Putting the I in integrity
By Richard A. Ridge, PhD, MBA, RN, CENP, NEA-BC
I
ntegrity is often mentioned as a requirement
for leaders, in general, and healthcare and
nursing leaders in particular. Since 2005, at
least 80% of Americans responding in the
annual Gallup poll on perceived honesty of professions and occupations have ranked nurses at the
top of the list for honesty and ethics.1
The nursing
profession has taken great pride in this consistent
finding, which is being reinforced this year as the
American Nurses Association (ANA) launches its
“Year of Ethics” to coincide with the revision of
the Code of Ethics for Nurses.2
Yet, how we define integrity? Often, how our
definition of integrity and morality relates to
our understanding of ethical behavior isn’t well
identified or clearly defined. Integrity is viewed as
an essential component of professional nursing and
a core value for nurses at all levels and in all specialties. We provide a framework for defining and
understanding integrity in nursing practice so you
can be better prepared to assess your own integrity
and the integrity within your organizations.
How do you define integrity?
Integrity is adherence to the interrelated sets of
standards, values, and principles derived from the
three domains that affect our decisions and behavior: personal, professional, and organizational.
(See Figure 1.) The extent to which a leader adheres
to the standards or codes that emanate from each
of these domains defines the integrity of the individual. Integrity isn’t a value by itself, but rather
the level of fit between an individual’s decisions
and behaviors and his or her relationship to the
values and morals of the communities in which he
or she lives and works.3
Our personal values are grounded in the moral
framework that we were raised to believe and
integrate into our decision making and behavior.
Many of us have faced and resolved challenges of
varying degrees of severity related to our own integrity. Often, the issues at the lower end of the
severity scale are forgotten, whereas more serious
issues may lead to significant crises with high levels of moral distress and negative personal, professional, or organizational outcomes. Moral distress
results from value conflicts; moral courage describes the ability of an individual to speak up and
alleviate or reduce moral distress experienced by
others.4
The ANA Code of Ethics recognizes that nurses face
threats to their integrity in any healthcare environment.2
Organizational pressures to perform may motivate nurse leaders to violate their own personal moral
code to accomplish specific goals and objectives. These
situations may result in significant moral distress for
the nurses and nurse leaders. The undesired result is
when the individual rationalizes his or her behavior to
mitigate the moral distress, violating the personal, professional, or organizational framework.
Healthcare organizations have a defined mission, vision, and values statement to provide additional guidance to leaders and staff regarding the
overall aim and purpose of the organization and
the values that must be considered when making
decisions regarding ethical behavior. The values
statement describes the organization’s core principles that support the overall vision and mission.
Ethically sound organizations have leaders and
employees who are aware of these values and integrate them into their decision making. When the
organization’s actual practices conflict with the
stated values, staff morale is undermined, cynicism develops, and the risk of unethical behavior
increases.5
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Performance potential
Integrating integrity
So what can we do to foster a practice setting that values integrity?
1. Model appropriate behavior.
“Do as I say, and not as I do” is a
classic idiom used to characterize
hypocritical behavior that contradicts a leader’s mandates and expectations. As leaders, our behavior
is closely scrutinized and modeled
by others on our teams; our
behavior influences team member
behavior. Verbalized expectations
aren’t as strong as behaviors that
are modeled. For example, if a
senior leader is observed misrepresenting a situation either in person or on a report, others are given
the message that deception is
acceptable under the correct
circumstances.
When a leader during The Joint
Commission or other regulatory
review asks a direct report to deliver a set of completed records that
meet the requirements, is the leader
implying that it’s all right or even
mandated that the individual correct these before handing them off
to the surveyor? Where does one
draw the line? For example, when
annual performance evaluations
need to be completed, is it expected
that the manager signs and dates an
evaluation that has been inadvertently unsigned by the employee? If
a leader asks for this behavior, most
would see this as unacceptable. If
the leader tells the manager that he
or she really doesn’t want to know
how the manager came up with the
results but he or she is pleased with
the outcome, is this acceptable?
2. Ensure comprehensive ethics
education for nurses at all levels.
Education on compliance, organizational values, and acceptable
behaviors should be completed on
an annual basis for all staff and leaders. In nursing, significant attention
should be paid to an in-depth review and understanding of the ANA
Code of Ethics. Use interactive
learning methods that focus on the
application of the Code of Ethics
within the context of your specific
organization. Disseminate clear expectations about acceptable behavior
related to falsifying documents.
A robust educational program
for nurses would be based on three
foundation documents published by
the ANA. In addition to the Code of
Ethics, “Nursing: Scope and Standards of Practice” and “Nursing’s
Social Policy Statement: The Essence
of the Profession” should be included. Knowledge of the standards
drives professional practice and
sound decision making consistent
with the values and expectations of
the nursing profession. The codified
standards of practice and ethical behavior are one of the primary elements that define us as a profession.
By ensuring that our staff members
are knowledgeable about these standards, we’re strengthening the profession for the present, as well as for
the future. The Social Policy Statement is important because this provides the foundation for connecting
nursing’s value and accountability
to society. By better understanding
nursing’s social context and contract
with society, as manifested by state
nurse practice acts, nurses are better
prepared to practice in highly volatile and rapidly changing healthcare
environments.
3. Create effective structures and
processes to support transparency.
Practicing at a high ethical level is
embodied within the ANA’s Standards of Practice, in general, and
nursing administration in particular.6
The nurse leader has the additional responsibility to ensure that
effective structures and processes
are in place to support an ethical
practice environment. The Ethics
Resource Center, in its 2014: 2024 – Essay Writing Service | Write My Essay For Me Without Delay National Business Ethics Survey, identifies three factors that employees
use to judge their leaders’ character.7 All three factors relate specifically to transparency. Employees
draw conclusions about their leaders’ character based on (1) their personal interactions, (2) how the leaders handle crises, and (3) the
policies and procedures that the
leaders adopt to guide their organizations.
In order to be fully transparent,
the effective nurse leader interacts
consistently and regularly in a manner that exposes the leader’s values
and decision making for the critique
of his or her team members. In crises, employees notice whether leaders hold themselves accountable or
shift blame to others, thus damaging their integrity. Employees assess
the extent to which leaders recognize and reward ethical behavior or
whether bending or violating rules
is preferentially rewarded and/or
recognized. By being transparent,
employees are able to adequately
and effectively judge these three
factors.
4. Promote systematic
ethical decision making.
The American College of Healthcare Executives’ Policy on Ethical
Decision Making for Healthcare
Executives offers guidance on
leadership decision making in an
increasingly complex healthcare
environment.8
Leaders are expected to establish a sound
decision- making framework so
that highly complex decisions
aren’t made by a single individual.
Ethical decision making includes
insight and perspective from those
affected by the decision; a full
depth and breadth of information
to support the decision; and a process that ensures beliefs, ideals,
and principles are consistent with
team member and organizational
values.
Provision 5 of the ANA Code
of Ethics specifically addresses
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Performance potential
character and integrity of nursing
practice, but with regard to the
preservation of integrity, nurse leaders have additional responsibilities.
Nurse leaders are obligated to respond to the ethical and moral concerns of nurses and ensure that
these concerns are resolved in a
manner that preserves the integrity
of the staff members.
5. Promote accountability.
Don’t express performance expectations in a manner that emphasizes
the results at the expense of how to
reach those results. Expectations expressed too forcefully imply permission to do whatever is necessary to
accomplish the goal. Phrases such
as “I don’t care how you get it
done,” “get the results no matter
what,” and “don’t come back next
month without the results we need”
may create incentives for employees
to “game the system,” withhold or
misrepresent information, or “fudge
the numbers.”
Accountability is also established
by identifying and addressing deviations from acceptable practice. Perceptions that leaders look the other
way provide the slippery slope for
further transgressions. Zero tolerance for unethical behavior sends a
consistent message to leaders and
staff that even the seemingly least
significant transgression is unacceptable when establishing a culture
of high integrity.
The value of integrity
Nurse leaders’ integrity is of the utmost concern in today’s highly volatile, competitive, and high-stakes
environment. Nurses, in general,
and nurse leaders in particular are
faced with difficult decisions every
day and, as identified by the Gallup
survey, are typically held in high
regard by the public. By understanding the personal, professional, and
organizational standards that form
the basis of our integrity, we can be
better prepared to promote high
levels of integrity within our
organizations. NM
REFERENCES
1.Riffkin R. Americans rate nurses highest
on honesty, ethical standards. http://
www.gallup.com/poll/180260/americans-ratenurses-highest-honesty-ethical-standards.aspx.
2. American Nurses Association. Code of
Ethics for Nurses with Interpretive Statements. Silver Spring, MD: American Nurses
Association; 2015 – Research Paper Writing Help Service.
3. Tyreman S. Integrity: is it still relevant
to modern healthcare? Nurs Philos.
2011;12(2):107-118.
4. Edmonson C. Moral courage and the nurse
leader. http://www.nursingworld.org/
MainMenuCategories/EthicsStandards/
Courage-and-Distress/Moral-Courage-forNurse-Leaders.html.
5. Nelson WA, Gardent PB. Organizational values statements. Healthcare executives need
to lead the organization’s culture in reviewing and implementing values statements.
Healthc Exec. 2011;26(2):56, 58-59.
6. American Nurses Association. Nursing:
Scope and Standards of Practice. Silver
Spring, MD: American Nurses Association;
2010 – Essay Writing Service: Write My Essay by Top-Notch Writer.
7. Ethics Resource Center. Ethical leadership: a research report from the National
Business Ethics Survey. http://www.ethics.
org/nbes/wp-content/uploads/2014: 2024 – Essay Writing Service | Write My Essay For Me Without Delay/12/
ExecHomework help – SummaryLeadership.pdf.
8. American College of Healthcare Executives.
Ethical decision making for healthcare
executives. http://www.ache.org/policy/
decision.cfm.
RESOURCES
American Association of Critical-Care Nurses.
The 4 As to rise above moral distress. http://
www.aacn.org/WD/Practice/Docs/4As_to_
Rise_Above_Moral_Distress.pdf.
American Nurses Association. Ethical issues.
http://www.nursingworld.org/MainMenuCategories/
EthicsStandards/Resources.
Ethics Resource Center. http://www.ethics.org/.
National Center for Ethics in Healthcare.
Integrated ethics. http://www.ethics.va.gov/
integratedethics/.
Richard A. Ridge is the director of Nursing
Innovation and Outcomes at Texas Children’s
Hospital in Houston, Tex.
The author has disclosed that he has no
financial relationships related to this article.
DOI-10.1097/01.NUMA.0000462381.26593.91
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