Prepare to be alone when blowing the whistle on unethical practices
Prepare to be alone when blowing the whistle on unethical practices
High-profile cases, new research highlight lack of ethical oversight
In 1996, Barry Adams, a nurse in a subacute care unit at a New England Hospital in Boston, was fired after blowing the whistle on what he felt were unsafe conditions resulting from low staffing levels and inappropriate nurse-patient ratios. He sued the hospital and won his job back. Since then, five of the hospital’s units have closed for financial reasons.
Recent episodes of two TV news shows have detailed stories of physicians fired by hospitals or terminated from health plan contracts for questioning business practices. Across the country, stories of health care workers reporting unsafe conditions caused by cost-cutting measures are becoming more and more familiar.
As health care organizations, particularly hospitals, face increasing pressure to cut costs to stay competitive, the health care community will be rocked by more whistleblowing, argue the authors of a recent article on the state of organizational ethics oversight in American health care institutions.
The problem is not that unscrupulous business managers are running the health care systems, but that there is no effective communication of ethical standards or means for addressing internal concerns, explains Mary Cipriano Silva, PhD, RN, FAAN, director of the Office of Healthcare Ethics at the Center for Health Policy and Ethics in the School of Nursing and Health Sciences at George Mason University in Fairfax, VA.
"You don’t have too many organizations that really have an intent to be administratively unethical, but there is a breakdown in communication," Silva says.
The article, "Whistleblowing as a Failure of Organizational Ethics," appeared last Decem - ber in the Online Journal of Issues in Nursing. Its authors, three faculty members at the center, contend that while hospitals have paid attention to clinical ethics and external dealings with patients and payers, they have failed to establish protocols for ensuring administrative ethics. They define administrative ethics as communi cation of the ethical mores of the institution and policies for the way internal disputes are to be addressed and resolved.
The hospital administration and management indeed may see providing good patient care as their primary function. Unless they adequately communicate these priorities to all levels of the organization, however, the message that comes across is that cost-saving measures and following orders are the highest goals, she says.
"You can have ethical leadership at an institution, but have unethical followership and you are going to have problems," Silva continues. "These things have to be institutional. You need policies not only involving clinical care, but you need to go way beyond that."
Adams attempted all other avenues
The whistleblower article uses the Barry Adams case to illustrate the basic problem of poor organizational ethics. Adams had a stellar professional record at his hospital. When he became concerned about how the change in staffing levels was affecting patient care, he pursued every process outlined by his organization to communicate his concerns. He documented unsafe practices and correlated those instances with inadequate staffing and supervision in the unit. Instead of addressing his concerns, hospital leadership criticized Adams for collecting the information.
Adams then decided to take his concerns public. Shortly thereafter, he was threatened with termination and eventually fired.
Several components of the Adams case make it an example of "genuine whistleblowing," the authors conclude. First, his personal reputation was above reproach. He clearly was not motivated by a desire for fame or revenge. Second, he pursued all internal options before going public. Third, he was willing to accept the consequences, sometimes severe, of his actions.
Unfortunately, adds Silva, the Adams case is not unique. "Most institutions don’t really have a remedy when there is an internal dispute over health practices. He exhausted all opportunities, and they just didn’t want to hear it."
Adams was fortunate in that he was "exonerated" by the court system and was able to clear his reputation, says Silva. There are many other whistleblowers whose careers and lives have been ruined or severely tarnished because they came forward with their concerns but were unable to stand up to such intense scrutiny, she adds.
What should a hospital do?
A key recommendation is that hospital ethics committees formulate guidelines for adminis trative ethics as well as oversee clinical ethics, says Jeanne Sorrell, PhD, RN, a co-author of the article and associate professor in the College of Nursing and Health Science at George Mason. "In general, ethics committees don’t look at those issues," she says. "They consider issues of clinical ethics: end-of-life questions, treatment decisions, things like that."
The article uses a definition from Robert Potter that defines organizational ethics as "the intentional use of values to guide the decisions of a system."1 Potter is the author of another study on organizational ethics in health care. To base the decisions of the hospital on the values of the hospital, the committee must ensure that the institution articulates a moral code that identifies the basic values the hospital professes, according to Potter’s definition. The institution then must develop a method for adequately communicating those values to the staff, and establish procedures that staff should follow if they believe the organization’s practices are inconsistent with its stated values.
"One thing we have observed in our research is that many hospitals have gotten the cart before the horse," says Silva. "They have addressed the big issues’ like end-of-life care and termination of life support. But if you don’t have an admin istration with integrity, you are going to have more and more clinical issues to deal with."
In addition, organizations charged with establishing ethical guidelines and enforcing compliance with accepted health care practice offer little guidance on internal administrative issues, say Silva and Sorrell.
For example, the American Nurses Association in Washington, DC, has numerous guidelines for nurses on their ethical obligations to patients, but it offers almost no guidance for instances in which nurses’ opinions conflict with actions the physicians or hospital managers ask them to take.
The Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, accredits 90% of the hospitals and 30% of the nursing homes in this country. Although the Joint Commission has adopted guidelines for organizational ethics, they are largely concerned with business practices and external relations, says Silva.
"We need to address this at the institutional level and the national level as well," she notes. "The Joint Commission has guidelines, but they don’t go far enough. One of the main things we are trying to say is that the Joint Commission is responsible as well as the institution."
The authors recommend that the Joint Com mission require health care organizations to articulate and publish a moral code and develop a method for ensuring that it adheres to its published statement of values.
In addition, they say the Joint Commission and the American Nurses Associa tion, as well as other professional organizations, should work together to provide guidance for the health care organizations on what those statements should cover, particularly in the context of a rapidly changing health care environment.
Little information available
Health care administrators cannot be faulted for difficulty in finding resources for setting up protocols to ensure organizational ethics, Silva says. She teaches a doctoral course in ethics and health care administration at the university and had to search extensively for a text to use in her class.
"If you look in the literature, there is a lot of information about clinical ethics, but almost none about administrative ethics related to health care organizations," she says. "If you want to look at a model for administrative ethics, you pretty much have to use examples from the business management resources."
Once a hospital has a framework for ethical administrative decision making, whistleblowing should become largely unnecessary, the study authors contend. While whistleblowing will be necessary in extreme cases, it is not always the right solution.
"In an ethically responsible HCO [health care organization], whistleblowing should not have to occur because there would be internal procedures to address staff concerns," the article reads. "We believe that whistleblowing is a moral action of last resort and that, under certain circumstances, it is not only appropriate, but necessary."
Reference
1. Potter RL. From clinical ethics to organizational ethics: The second stage of the evolution of bioethics. Bioethics Forum 1996; 12:3-12.
Additional reading
• Fletcher J, Sorrell J, Silva M. Whistleblowing as a failure of organizational ethics. Online Journal of Issues in Nursing Dec. 31, 1998.
• Silva MC. Organizational and administrative ethics in health care: An ethics gap. Online Journal of Issues in Nursing Dec. 31, 1998.
(For more information about the Online Journal of Issues in Nursing, visit the Web site: http://www. nursingworld.org/ojin.)
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