REFLECTION JOURNAL

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 profes-

sions 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 spe-

cialties. 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 behav-

ior: 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 indi-

vidual. 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 in-

tegrity. Often, the issues at the lower end of the

severity scale are forgotten, whereas more serious

issues may lead to significant crises with high lev-

els of moral distress and negative personal, profes-

sional, or organizational outcomes. Moral distress

results from value conflicts; moral courage de-

scribes 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 environ-

ment.2 Organizational pressures to perform may moti-

vate 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, pro-

fessional, or organizational framework.

Healthcare organizations have a defined mis-

sion, vision, and values statement to provide addi-

tional 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 princi-

ples that support the overall vision and mission.

Ethically sound organizations have leaders and

employees who are aware of these values and inte-

grate them into their decision making. When the

organization’s actual practices conflict with the

stated values, staff morale is undermined, cyni-

cism 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 prac-

tice 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 contra-

dicts a leader’s mandates and ex-

pectations. 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 misrep-

resenting a situation either in per-

son 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 de-

liver a set of completed records that

meet the requirements, is the leader

implying that it’s all right or even

mandated that the individual cor-

rect 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 inadver-

tently 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, organiza-

tional values, and acceptable

behaviors should be completed on

an annual basis for all staff and lead-

ers. In nursing, significant attention

should be paid to an in-depth re-

view 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 ex-

pectations 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 Stan-

dards of Practice” and “Nursing’s

Social Policy Statement: The Essence

of the Profession” should be in-

cluded. 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 be-

havior are one of the primary ele-

ments that define us as a profession.

By ensuring that our staff members

are knowledgeable about these stan-

dards, we’re strengthening the pro-

fession for the present, as well as for

the future. The Social Policy State-

ment is important because this pro-

vides 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 vola-

tile 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 Stan-

dards of Practice, in general, and

nursing administration in particu-

lar.6 The nurse leader has the addi-

tional responsibility to ensure that

effective structures and processes

are in place to support an ethical

practice environment. The Ethics

Resource Center, in its 2014 Na-

tional Business Ethics Survey, iden-

tifies three factors that employees

use to judge their leaders’ charac-

ter.7 All three factors relate specifi-

cally to transparency. Employees

draw conclusions about their lead-

ers’ character based on (1) their per-

sonal interactions, (2) how the lead-

ers handle crises, and (3) the

policies and procedures that the

leaders adopt to guide their organi-

zations.

In order to be fully transparent,

the effective nurse leader interacts

consistently and regularly in a man-

ner that exposes the leader’s values

and decision making for the critique

of his or her team members. In cri-

ses, employees notice whether lead-

ers hold themselves accountable or

shift blame to others, thus damag-

ing their integrity. Employees assess

the extent to which leaders recog-

nize 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 Health-

care Executives’ Policy on Ethical

Decision Making for Healthcare

Executives offers guidance on

leadership decision making in an

increasingly complex healthcare

environment.8 Leaders are ex-

pected 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 pro-

cess 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 lead-

ers have additional responsibilities.

Nurse leaders are obligated to re-

spond to the ethical and moral con-

cerns 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 expecta-

tions in a manner that emphasizes

the results at the expense of how to

reach those results. Expectations ex-

pressed too forcefully imply permis-

sion 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 devi-

ations from acceptable practice. Per-

ceptions that leaders look the other

way provide the slippery slope for

further transgressions. Zero toler-

ance for unethical behavior sends a

consistent message to leaders and

staff that even the seemingly least

significant transgression is unac-

ceptable when establishing a culture

of high integrity.

The value of integrity Nurse leaders’ integrity is of the ut-

most concern in today’s highly vola-

tile, 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 understand-

ing 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-rate- nurses-highest-honesty-ethical-standards.aspx.

2. American Nurses Association. Code of Ethics for Nurses with Interpretive State- ments. Silver Spring, MD: American Nurses Association; 2015.

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-for- Nurse-Leaders.html.

5. Nelson WA, Gardent PB. Organizational val- ues statements. Healthcare executives need to lead the organization’s culture in review- ing 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.

7. Ethics Resource Center. Ethical leader- ship: a research report from the National Business Ethics Survey. http://www.ethics. org/nbes/wp-content/uploads/2014/12/ ExecSummaryLeadership.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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Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.