How does the nurse manager or leader play a role in the reengineering of health care?
Decisions based on ethical and legal principles are common in a person’s life. Choices such as whether
to indulge in gossip (breaching confidentiality) or driving too fast on the highway are examples of
these decisions. Making good ethical and legal decisions in nursing management or leadership practice
requires understanding of the underlying principles and incorporating that knowledge into the
decision-making process.
Ethical Decision-Making
Ethical decision-making is similar to other decision-making processes in that it requires the manager to
gather information, identify the problem, generate alternatives, or select an alternative to implement,
and evaluate the results. The difference in ethical decision-making depends on the identification of the
ethical principles that guide the selection and expectations of the outcome.
The principles underlying ethical decision-making include concepts that are familiar to practicing
nurses. Is it best for the nurse to use specialized knowledge to make decisions for a patient
(paternalism) or to support patients in making their own decisions (autonomy)? Are there circumstances
in which the need to benefit the majority of staff (utility) outweighs the need to treat everyone fairly
(justice)? Is telling a white lie (violating the principle of truth-telling) justified when it is
believed that the withholding of the truth will benefit the recipient (beneficence)? These are the
competing obligations that create ethical dilemmas. Ethical decision-making requires the identification
of competing principles as a part of describing the problem.
Ethical frameworks and professional codes of ethics exist to assist the manager in ethical
decision-making. Both frameworks and codes provide guidance in valuing one principle above another, but
do not directly provide the solution. There are several ethical frameworks. Two commonly used frameworks
are utilitarian-based and rights-based. A utilitarian framework advocates selecting an alternative that
will result in the greatest good for the greatest number of people, focusing on the projected outcome.
An example of using a utilitarian framework is the isolation of a patient with a communicable disease.
Although this isolation infringes on the person’s autonomy, the common good (utility) of not spreading
the disease is served. A rights-based framework focuses on the process of decision-making and
utilization of identified rights or entitlements. This type of framework is evident in The Bill of
Rights for Registered Nurses (The American Nurses Association, n.d.).
Professional codes of ethics have been published by several professional nursing organizations. These
codes generally support the principles of autonomy, justice, and beneficence, but they also acknowledge
that there are times when competing obligations may require the nurse to select alternatives based on
other principles.
Ethical decision-making is also unique in that it often entails choosing among less than desirable
alternatives. The outcome of the decision may not be judged as good but as better than other outcomes.
When evaluating the outcome of ethical decision-making, reviewing the process used to make the decision
is as important as the result (Marquis and Huston, 2009).
Legal Environment in Nursing Management
Ethical frameworks and codes of ethics provide guidance for decision-making, but are not required. Laws
are written to support the values and ethics of society, requiring citizens to act in a certain manner
or face the consequences in a court of law. There are wide ranges of laws that affect the practice of a
nurse manager. Legislation directly affects both patient care and professional relationships with
employees.
Patient care related legislation primarily supports patient autonomy. Laws exist to require informed
consent prior to performing a procedure on a patient. This allows patients to make informed choices
regarding their health care. Ignoring informed consent can lead to charges of assault and battery
(causing the patient to feel threatened or touching the patient who has not consented). The unwarranted
use of restraints can constitute false imprisonment. The nurse manager is responsible for ensuring that
organizational policies provide guidance to staff in avoiding these legal issues. The HIPAA Standards
for Privacy of Individually Identifiable Health Information Act supports patient confidentiality by
regulating how and when an individual’s information may be shared (U.S. Department of Health and Human
Services, 2007).
Legislation that affects employee relations covers general topics such as discrimination and fair labor
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