Overcoming Obstacles to Ethical Culture

The modern business environment requires significant consideration of ethical practice where leaders and their subordinates adhere to standards set by the organization and the industry alike. The senior executives of the company act as integral factors for ensuring that the entire workforce maintains the highest level of morals and ethical conduct through their practices on a daily basis. Besides, Yidong and Xinxin (2013) indicate that the increased importance of corporate social responsibility and the focus on business ethics, more than ever prompts leaders to behave in an ethical manner. The issue of an ethical leadership and maintaining such a culture in an organization has been a common emphasis by the scholars and politicians across the globe. The medical and nursing domains clearly highlight the concern prompting a closer review of the current practices that these professionals employ. The ability to ensure morality in these vocations is critical to guarantee appropriate care and treatment of the patients within the health institutions.

The concern of ethical culture and the role played by leaders in preserving such practices comes from the numerous scandals that plague business industries and organizations such as Enron, Madoff, and others in the early years of the 21st century. These scandals cause public distress on all industries including the health sector. The career of nursing is a fulfilling one where the professional gets the opportunity to save lives and enable patients to realize good health. However, it has its numerous challenges and concerns where leaders consider the ethical standards that they should apply with every action they take. The aforementioned scandals highlighted by cases of greed and lack of adherence to business practice create doubt on the individuals in powerful positions and authority (Brown, & Bryant, 2015). Subordinates in particular may believe that their leaders misuse power for their personal gain even when this may not be the case. This occurrence creates a feeling of doubt and may replicate into unethical practices in the organization.

The vocation of nursing particularly on management positions recognizes the importance of using leadership as a gateway to ethical culture. According to research by Brown and Bryant (2015), servant leadership is a phenomenon that could be incorporated in the leadership process as a means of maintaining ethical practice. However, the numerous challenges affecting the incorporation of the philosophy into the management operations of nursing have created an obstacle to overcome. Over the years, studies have identified the important role played by nursing leaders in promoting ethical behavior in the provision of care and treatment within the organization. The research, however, fails to identify the significant obstacles that may hinder the realization of an ethical culture. The healthcare institutions cannot achieve this goal without addressing the barriers identified. Some of these challenges are extremely difficult to be solved by a single person. Therefore, even the best leader can fail in this attempt.

In many ways, healthcare institutions and business firms hold various similarities in the quest for ethical leadership. The latter identified the importance of maintaining a positive image as a means of attracting the clients. In the same way, healthcare organizations have recognized the need to develop an ethical culture where the workforce incorporates morally upright standards in the quest to realize patient satisfaction. This similarity acts as a driving force of incorporating business standards into care and treatment operations. The medical professionals that take up management positions have a responsibility of undertaking these norms as a measure of upholding the positive image. The leaders recognize that failing to adhere to ethical practices may result in insurmountable blunders in provision of care. Events such as poor health conditions and in adverse cases death may occur. In this regard, administrative personnel have emphasized the importance of employees within the realm of healthcare to uphold codes of ethics and professional standards of providing care to the patients.

The nursing profession experiences numerous obstacles in ensuring ethical behavior that prevent effective delivery of care. Some of these challenges stem from individual behavior taken up early on in life. Studies demonstrate that incivility behavior among nursing students at the university levels brings about a belief that their actions have little effect on the future. Practices like rude comments, violence, and plagiarism of academic work may influence the performance of professional roles. Such barriers for ethical practice in a healthcare institution prevent effective practices implemented by the administrative personnel. The alleviation of the problem at its very beginning could help develop a medical workforce that understands the importance of ethical and moral standards at the workplace. The incorporation of ethics in the nursing profession is of major concern following the improvement in policies and demands for quality healthcare. The practitioners in their respective roles should identify the importance of conforming to these standards in achieving the outcomes and objective goals. 

Thesis Statement

There are numerous instances showing the importance of ethics in management and leadership. However, there have been significant obstacles and influences that bring about ethical problems. The severity and frequency of these issues along with their distinction at the different levels of management are a source of major concern. Recent research focuses on the individual basis of ethical leadership while the current trends portray the importance of organizational culture. Strategies for overcoming obstacles that hindering ethical behavior at the workplace, particularly the resources and mechanisms within the company, enable transformation and achievement of an ethical culture.

Literature Review

Conducting an extensive literature review is an integral factor towards the effective understanding of the problem and its possible solutions. In its performance, it helps elaborate the possible outcomes of identifying obstacles that hinder achievement of an ethical culture at the organization. Numerous empirical studies will be outlined in the following section to identify the various perspectives that have been drawn on related issues on ethical behavior at the workplace. Majority of research undertaken previously usually identify the importance of ethical behavioral practices from the individual perspective rather than the organization aspect. There has been extensive research on the various ways of improving ethical behavior among senior executives while few have investigated the strategies of overcoming obstacles that hinder ethical culture in the organization as a whole.

Prevalence of Unethical Culture Problem

Ethical Awareness

In an extensive review of the global prevalence of unethical behavior among nursing professionals, it is evident that ethical culture stems from individual behavior early on in life before it is adopted into practices in the workplace. The process of ensuring effective moral action among professionals in the nursing vocation involves three primary components, moral awareness, ethical judgment, and acting in conformity with the discernment of ethical standards. Studies related to ethical issues in the nursing and medical professions seek to observe the ethical awareness of students while in undertaking their undergraduate degrees. The concept of moral perception involves the process of recognizing ethical problems involved, the affected parties in the behavior, possible outcome, and the various options to act on. Research by Park, Park, and Jang (2013) identifies the growing practice of academic dishonesty among nursing students. An incorporated survey of academic cheating among undergraduate students from five different institutions in South Korea showed significant prevalence of the problem. Approximately, 50% and 78% of the respondents of the study identified to have engaged in exam cheating and assignment cheating behaviors, respectively. A similar study by Woith, Jenkins, and Kerber (2012) demonstrated an equal experience of academic dishonesty among nursing students in North America. The latter research indicates significant influence of students, faculty, and system factors alike in the spread of the problem.

Individuals in leadership roles have impact on the perception of ethical awareness among the subordinates or followers in the given organizations. For the undergraduate institutions of nursing, the faculty members bear responsibility of establishing this goal. The integral objective is to inform nursing students of the importance of ethics in their future careers. The university staff members that interact with the nursing students on a regular basis should be able to implement the objective into the daily practices. The research by Cannaerts, Gastmans, and de Casterlé, (2014) identifies the challenging decisions that arise in the nursing profession with the primary view of providing “good care”. The study identifies that clinical competence is a necessary skill to achieving this goal. However, it is also essential that the professionals incorporates “ethical competence” (Cannaerts, Gastmans, & de Casterlé, 2014). This practice involves more than just understanding the numerous ethical theories in the nursing vocation. Ethical awareness is an integral factor towards achieving ethical competence. It entails the ability to identify the presentation of a situation that requires ethical decisions. The undergraduate institutions serve as appropriate place for developing such a skill. Educators provide the nurses with ethical education to prepare them for their roles as professionals.

The practice of ethical awareness at the student level is an integral factor to the development of the skills and competencies in behaving in a morally upright manner. However, achieving these skills cannot take place when the educator does not apply such beliefs. The research by Wong and Laschinger (2012), points out that perceptions of authentic leadership, which involve emphasis on transparency, self-awareness, balanced processing, and high ethical standards have a similar effect on the subordinates’ behavior. The study recognizes the strategic management as an effective tool towards empowering followers to replicate the same standard. The authentic leader serves as a role model to the nursing students during the learning phase. The treatment that an educator will incorporate in the interaction process with the students will serve as a major factor in determining their perception of him or her. Significant contradiction between the curriculum in ethics education and the behavior of the faculty members creates confusion on the appropriate practice. The nursing students should receive a clear direction on ways of identifying situations of ethical dilemma and reflection on what nurses know, are and do such cases. The latter, ethical reflection, is critical towards the suitable practices that professionals in the health sector should implement.

The ability of a nursing practitioner in employing ethics in the daily operations requires the internalization of professional nursing values. The rapid changes in the healthcare environment including technological development and conflict of values at the personal, professional, and organizational level ensure that the ethical dilemmas are more complex than before. According to a study conducted by Iacobucci, Daly, Lindell, and Griffin (2012), the professional identity and competence of ethical behavior is critical to the development of skills of coping with such issues in practice. The research identifies the crucial role that educators have towards realizing these abilities. The development of professional nursing identity is made possible through exposure to the various complex dilemmas (Iacobucci et al., 2012). The healthcare organizations that recognize low levels of ethical culture should note that its occurrence is a reflection of the poor internalization of professional values in the field of nursing among other health vocations. The values of the profession are integral to providing practitioners with direction and influence in their actions, strategies, and actions. The leadership personnel in nursing institutions should ensure clarity of these ideals in ensuring the appropriate enforcement to workforce practices. 

The lack of appropriate implementation of ethics in nursing practice may be a lack of professionalism and practical approach. Research has shown that nurses have significantly high levels of principled thinking, but demonstrate average levels in practical consideration (Cerit & Dinç, 2012). The study by Cerit and Dinç (2012), identifies the principled thinking as the ability of practitioners to demonstrate situations or events that require ethical consideration and the most appropriate action to undertake. Practical consideration, on the other hand identifies the importance of incorporating these beliefs and practices as an effective measure of ensuring the best possible outcome for the patients. Due to high levels of fatigue and work-related stress, nurses have a high likelihood of encountering similarity conflict when two or more seek leave at the same time. However, the shortage of staff prompts the supervisor to choose one of the two leaving the other feeling bad (Aitamaa et al., 2016). The problems of ethical leadership usually identify ethical distress as one of the issues where managers experience conflict of their actions and their beliefs. In this regard, it is evident that despite clear understanding of the theoretical aspect of ethical awareness, the health workers are unable to apply the information into their daily activities effectively (Cerit & Dinç, 2012). The research draws its conclusion after administering the Nursing Dilemma Test (NDT) and the Behavioral Inventory for Professionalism in Nursing (BIPN) on Turkish nurses recruited from university hospitals. The former measures ethical decision-making levels while the latter seeks to identify the professionalism nature of the practitioners. The study recognizes that nursing professionals feel that their level of autonomy is under siege primarily due to external restraints including professional and legal obligations (Cerit & Dinç, 2012). Nurses have a legal duty to carry out written orders by physicians other than in cases that could pose a risk to the patient while also being required to respect the rights of patients by informing them on their medical conditions.

The research by Cerit and Dinç (2012) is a clear indicator that despite a clear awareness of the ethical standards that nurses and other health practitioners should employ, the lack of autonomy in practice hinders the it effective implementation. The medical profession is noted for its strict adherence to hierarchies where the lower ranked professionals should enforce orders made by the senior personnel. However, a clash in the values and obligations of the practitioner may prevent implementation of appropriate behavior. Despite the desire to undertake morally upright actions, a conflict of interest is a major hindrance to ethical practice (Iacobucci et al., 2012). It is for this reason that the prevalence of immoral conduct in the healthcare sector realizes such high occurrences. The practitioners are pitted between the law and the professional code. The nursing field is one that experiences continuous changes and developments in the delivery of care for the professionals (Iacobucci et al., 2012). Professionals in both management and subordinate roles bear the responsibility of keeping up with the evolving changes. The main goal of undertaking such practices is to maintain ethical awareness on the newer situations that require ethical consideration. Failure to improve knowledge will lead to high occurrence of immoral conduct among the practitioners. 

Moral Judgment

Moral judgment is another component involved in the process of undertaking an ethical action. This factor identifies the action of evaluating the moral considerations that are evident in the situation and determining the appropriate course of action. In this regard, students in the healthcare disciplines will usually incorporate an assessment of the practices in their surroundings prior to making decisions on the most appropriate action to undertake. According to Park, Park and Jang (2013) low levels of perceived seriousness of cheating and higher levels of perceived similar behavior among peers were effective predictors of academic dishonesty for both exams and assignments. In this regard, many of the students usually emphasize the positive impacts of cheating and neglect the negative outcomes hence the widespread practice of dishonesty. The research by Jiang, Emmerton, and McKauge (2013) identifies that when studying academic integrity among students, disciplines of interest are the health professions where expectations set for the individuals include high levels of integrity, trustworthiness, and honesty. Despite the presence of established code of conduct, codes of ethics, and professional practice standards, the unethical behavior continues. However, the research found that publicizing warnings of the consequences of breaching expectation standards is a particular means of reducing the spread of the immoral action.

Medical practitioners who wish to make moral judgments on a presenting situation usually progress through three levels. The first is the pre-conventional levels where the decisions made by a nurse or health worker take into consideration the rewards, punishments, and obedience to authority (Cerit & Dinç, 2012). In this case, it is clear that healthcare professionals are able to make judgments on complex dilemmas based on the rewards or punishments they will encounter. As previously mentioned, the healthcare industry employs strict enforcement of a hierarchy system. Despite the recognition that nursing professionals have significant autonomy in the performance of their daily practices, the structure and culture of the healthcare sector creates some restraint to the enforcement of ethical practice (Storch, Makaroff, Pauly, & Newton, 2011). The individuals may feel that their leaders do not appropriately provide the quality equality in decision-making during the delivery of care. Lack of leadership support was a major hindrance towards conducting appropriate moral judgments (Storch, Makaroff, Pauly, & Newton, 2011). Research clearly highlights the importance of supporting the followers in making morally upright decisions and not micro managing their practices. 

The second level that a medical professional progresses through to make a moral judgment is the conventional level. At this instance, individuals identify societal norms and rules, and the concerns on collective welfare (Cerit & Dinç, 2012). The practitioners incorporate these beliefs due to the high levels of diversity on measures to employ in the provision of care and treatment. The beliefs that the society from which the patient comes from are taken into consideration during the decision-making process. The same applies to the geographical location of the healthcare organization, which determines the societal norms for the collective welfare of individuals (Cerit & Dinç, 2012). For instance, there are various American states such as, Washington, Colorado, and California, have legalized assisted suicide which may involve a physician. However, it is important to note that nearly 44 states categorically reject the practice among individuals. In light of this, medical workers should take into consideration the societal beliefs that may be reflected by laws. In cases where medical practitioners are unaware of the societal norms, it is likely that the operations of the medical worker will employ immoral actions. The health workers who travel around the world are likely to encounter such occurrences while addressing the health conditions of the diverse populations.

The third and final level that individuals progress through when making moral judgments is the post-conventional level. It is in this case that health practitioners base moral decisions on the internalized moral values and abstract principles (Cerit & Dinç, 2012). The study by Cerit and Dinç (2012) identifies that it is at this point that individuals experience principled thinking at this stage. Each individual health worker has moral values and principles that they hold dear to themselves. These values are based on beliefs developed as an individual and those as a professional. In this regard, the two factors that help define the self are integral to making moral judgments. The research notes that many nursing professionals are unable to realize this phase of ethical consideration primarily due to the cognitive conflict of moral reasoning to solve dilemmas (Laschinger, Wong, & Grau, 2013). As a result, individual workers may undertake immoral actions after failing to employ principled thinking. The process involves concern for human rights and justice that based on these universal principles that the individual has internalized. In this regard, medical workers usually identify the importance of upholding the rights of the individual workers as they seek to maintain high levels of quality care. 

The ability of nursing professionals to make appropriate moral judgments looks into the issue of collegiality and adhering to the guidelines provided by the code of ethics. In this case, each practitioner has an obligation to respect the skills and techniques of other individual workers in the healthcare institution. A survey on multiple care institutions recognize that each member of the workforce portrays different capabilities and ideas of providing quality care. Therefore, it is essential that the individual workers to show respect to peers in the health sector as an effective measure of realizing the goals and outcomes of care. According to research conducted by Park and colleagues (2012), the freshman students from eight baccalaureate nursing programs in South Korea showed low levels of moral sensitivity as opposed to the seniors. The study measures scores in patient-centered care and conflict among peers. In this regard, the nursing students at freshman level are less likely to demonstrate appropriate moral judgments in practice. However, the research shows that integration of ethics content for longer hours in the curricula enabled higher levels of principled thinking. The results clearly emphasize the importance of developing competency among future nursing professionals to help realize appropriate moral reasoning in the industry.

In ensuring appropriate implementation of a morally upright workforce in a healthcare organization, it is essential that an appropriate examination and support for ethical competence be present in the recruitment and performance review processes. Poikkeus, Leino-Kilpi, and Katajisto (2013) identified that value of this practice following responses from nursing leaders in the two university hospitals in Finland. The research included a sample size of 198 nurse leaders where 94% of the respondents were women of a mean age of 50 years. The demographic data of participants in the study ranges from 30 to 63 and nearly 40% of them had significant experience as managers with 10-20 years of service or more in management positions. Majority of the respondents noted that the healthcare organizations they worked for had an ethics committee and clearly documented ethical values and principles at 84% and 62% respectively. In this research, the practitioners note the importance of organizational support in emphasizing ethics in practice in the daily operation of tasks. However, there seems to be a problem in dealing with ethical issues during arranged ethics education that takes place only for 37% of the participants. Only half of the participants identified that the arising issues on moral judgment were dealt with as the other half noted that the concerns were either disregarded completely or dealt with at minimal levels. 

Acting in conformity with the discernment of ethical standards

In process of undertaking effective ethical action, individuals act according to the moral reasoning and undertake significant measures in the delivery of quality care. The behavior involves recognizing that behaving the right way is not enough. The individuals should develop the intention to act in a morally upright manner and cope with the practical hindrances in the process. It is evident that the process of delivering care incorporates more than just acting in accordance to duty. In this regard, the nurses among other medical professionals should strive to go beyond the required the tasks within their roles as a measure of ensuring quality care and treatment of the patient. According to research conducted by Basso-Musso (2012), the technical dimension of a nurses work refers to conducting objective role effectively. However, the ethical dimension is different as it involves improving oneself to achieve perfection (Basso-Musso, 2012). The nurse as an individual attempts to make appropriate decisions based on the arising dilemmas during practice (Basso-Musso, 2012). The author of the study recognizes that this action may require common sense and intuition to achieve quality delivery of care. However, there are instances that may incorporate more than that as a search for resolution and consensus seeks to comply with the ethical principles critical to the profession (Basso-Musso, 2012). The primary purpose of the nursing roles is focusing on the human being, who is the patient and maintaining his/her dignity (Basso-Musso, 2012). The practitioners in this practice require the assistance of one another to develop this mentality in their daily tasks. 

Nurses and other healthcare professionals may find it difficult to employ ethical standards appropriately due to the nature of tasks. The high level of stress created by the interaction of various factors influenced the ability to make effective decisions. The ability of nursing professionals to make appropriate moral judgments looks into the issue of collegiality and adhering to the guidelines provided by the code of ethics. In this case, each practitioner has an obligation to respect the skills and techniques of other individual workers in the healthcare institution. A survey on multiple care institutions recognize that each member of the workforce portrays different capabilities and ideas of providing quality care. Therefore, it is essential that the individual workers to show respect to peers in the health sector as an effective measure of realizing the goals and outcomes of care.

The availability of an effective workforce is crucial to the delivery of quality care. In the modern day practice, numerous institutions identify the lack of resources to hire enough health practitioners (Crippen, 2016). As a result, the available practitioners are forced to take up multiple roles to fill the gap. The nurse managers are the most affected by the occurrence of such instances whereby subordinate staff request leave of absence due to personal reasons, but are denied, as it would cause a shortage of labor (Shirazi et al., 2014). In this regard, workers are forced to undertake double the work to effectively cater to the demands of the clinical setting. Subordinate staff will rarely receive the opportunity to provide input in the process creating an issue of ethical conflict when new ethical models are introduced (Shirazi et al., 2014). This practice has been a primary factor towards the failure to empower nurses in the profession. The leaders in the organization incorporate a condescending attitude towards the less experienced nurses and provide little room for ethical culture in the institution (Epp, 2012). In this regard, the organization points out the negative measures of incorporating student nurses in the health organization when seeking to ensure seamless transition.

On the other hand, the high level of uncertainty and the personal impressions drawn from their occurrence could be detrimental to the performance of the organization. In the incidence of these issues, the actions of the leaders in nursing and other health professionals have significant impact on the patient, subordinates, and others who come into contact with them (Pavlish et al., 2014). The ethical problem arises when the behavior brings inconsistent influence and uncontrolled harm on the individuals. Lack of supportive leaders to guide workers and take into consideration their needs will result in ineffective measures of upholding ethical notions. Due to the significant developments taking place in research and technology, the public raises their expectations for the treatment options (Pavlish et al., 2014). It is for this reason that numerous medical professionals affirm the high incidence of ethical conflict in the clinical setting as opposed to other environments related to healthcare. The occurrence of competing obligations significantly put nurses and physicians alike in difficult situations. For instance, the patient has a right to receive medical attention, but lack of insurance coverage or the financial health of the organization leads to delays in delivery of care. Workers have to struggle with competing ideas of ethical performance of their tasks resulting in disregard of patient outcomes.

Acting in conformity with the discernment of ethical standards shows going above and beyond the duties of nursing care. In this practice, workers struggle to identify the limit and criteria for going beyond requirements. The health practitioners reported challenges administering treatment that may cause suffering for patients and being honest to the patients and their families without removing hope of recovery for the patients (Pavlish et al., 2014). The occurrence of moral disagreements between the nurse’s obligations and the personal values places patients at the epicenter. It is more likely for the practitioners to act unethically further placing the burden on medical workers particularly nurse managers to identify the most appropriate action for care (Pavlish et al., 2014). The occurrence of competing obligations significantly put nurses and physicians alike in difficult situations.

Stress is a difficult concept to define precisely, primarily due to the abundance of different disciplines with different perspectives on this subject. Despite substantial literature available on this concept there is considerable absence of an exact definition of stress in relation to nursing (Suresh, Matthews, & Coyne, 2013). This would help gain insight into stress or stressors particular and in some cases exclusive to nursing. Many disciplines, which have studied this concept ranging from psychological, physiological, occupational and sociological perspectives have led to varied definitions on stress. The study also showed the multifaceted approach of identifying stress as it relates to nursing practice. It is shown as a stimulus by searching for the various factors that lead to stress, as a response by identifying ways people react when under stress, and as an intervening process between stimulus and response (Suresh, Matthews, & Coyne, 2013). The likely response that fits with this research is the feeling of being undervalued in the workplace, though personality traits and work-home interface are not taken into account. The nursing practitioners usually identify a lack of respect from peers in the organization, as they are perceived as regular help in the delivery of care. The immense knowledge and support they provide other health workers goes unrecognized. 

In the quest to act in conformity with the discernment of ethical standards, it is difficult for workers to demonstrate significant concern for patients when their needs are not met. The issue of moral distress in health care has been identified as a growing concern and a focus of research in nursing and health care for almost three decades (Pauly, Varcoe, & Storch, 2012). Researchers and theorists have argued that moral distress has both short and long-term consequences. Moral distress has implications for satisfaction, recruitment and retention of health care providers and implications for the delivery of safe and competent quality patient care (Pauly, Varcoe, & Storch, 2012). They observe that moral distress has been used with various understandings of preconditions for the development of unethical practices in the workplace (Pauly, Varcoe, & Storch, 2012). These authors argue that we need a more critical stance towards moral distress and additional explorations of moral distress in relation to the ethical dimensions of practice (Pauly, Varcoe, & Storch, 2012). They suggest the need for an overhaul of the concept of moral distress including examination of philosophical perspectives informing moral decision making and accompanying emotional responses (Pauly, Varcoe, & Storch, 2012).

It is also evident that serving the individual needs of the patient is of greater importance to the process of delivering quality care. In recent years, social values have undergone radical change, from the broad public interest approach to a narrower perspective with more focus on the individual (Shahriari et al., 2011). The nursing profession has followed trends set by society, searched for convenience, fought for economic stability, power and control, by waiving professional values such as altruism and equality (Shahriari et al., 2011). In this regard, nurses emphasize the importance of taking into consideration the culture and religious beliefs of the patient before delivery of care. Though the individual may want to deliver quality care, it becomes difficult when it conflicts with the beliefs of the patients. The ability of a nursing practitioner in employing ethics in the daily operations requires the internalization of professional nursing values (Cerit & Dinç, 2012). The rapid changes in the healthcare environment including technological development and conflict of values at the personal, professional, and organizational level ensure that the ethical dilemmas are more complex than before. The lack of appropriate implementation of ethics in nursing practice may be a lack of professionalism and practical approach. Research has shown that nurses have significantly high levels of principled thinking, but demonstrate average levels in practical consideration (Cerit & Dinç, 2012).

Practical consideration, on the other hand identifies the importance of incorporating these beliefs and practices as an effective measure of ensuring the best possible outcome for the patients. In this regard, it is evident that despite clear understanding of the theoretical aspect of ethical awareness, the health workers are unable to apply the information into their daily activities effectively (Cerit & Dinç, 2012). The medical profession is noted for its strict adherence to hierarchies where the lower ranked professionals should enforce orders made by the senior personnel. However, a clash in the values and obligations of the practitioner may prevent implementation of appropriate behavior. Despite the desire to undertake morally upright actions, a conflict of interest is a major hindrance to ethical practice (Iacobucci et al., 2012). It is for this reason that the prevalence of immoral conduct in the healthcare sector realizes such high occurrences. The practitioners are pitted between the law and the professional code.

In many ways, healthcare institutions and business firms hold various similarities in the quest for ethical leadership. The latter identified the importance of maintaining a positive image as a means of attracting the clients. In the same way, healthcare organizations have recognized the need to develop an ethical culture where the workforce incorporates morally upright standards in the quest to realize patient satisfaction (Iacobucci et al., 2012). This similarity acts as a driving force of incorporating business standards into care and treatment operations. The medical professionals that take up management positions have a responsibility of undertaking these norms as a measure of upholding the positive image (Iacobucci et al., 2012). The leaders recognize that failing to adhere to ethical practices may result in insurmountable blunders in provision of care. Events such as poor health conditions and in adverse cases death may occur. In this regard, administrative personnel have emphasized the importance of employees within the realm of healthcare to uphold codes of ethics and professional standards of providing care to the patients (Iacobucci et al., 2012).

Over the years, studies have identified the important role played by nursing leaders in promoting ethical behavior in the provision of care and treatment within the organization. The research, however, fails to identify the significant obstacles that may hinder the realization of an ethical culture. The healthcare institutions cannot achieve this goal without addressing the barriers identified. Some of these challenges are extremely difficult to be solved by a single person. Therefore, even the best leader can fail in this attempt. Such barriers for ethical practice in a healthcare institution prevent effective practices implemented by the administrative personnel (Wiegand, & Funk, 2012). The alleviation of the problem at its very beginning could help develop a medical workforce that understands the importance of ethical and moral standards at the workplace. The incorporation of ethics in the nursing profession is of major concern following the improvement in policies and demands for quality healthcare (Wiegand, & Funk, 2012). The practitioners in their respective roles should identify the importance of conforming to these standards in achieving the outcomes and objective goals. The nursing students should receive a clear direction on ways of identifying situations of ethical dilemma and reflection on what nurses know, are and do such cases (Cerit & Dinç, 2012). The latter, ethical reflection, is critical towards the suitable practices that professionals in the health sector should implement.

Employee Job Performance

A perennial question asked by the public, management, nursing students, and the medical professionals is, the impact that leadership has on the followers. The clear identification of roles of nursing managers and their followers effectively pointed towards the ability to perform the tasks as required. Retaining skilled and engaged nurses is critical during a time of shortage, however growing reports of workplace bullying threaten wellbeing of nurses, especially during the transition of newly qualified nurses entering the healthcare sector (Laschinger, Wong, & Grau, 2012). High rates of burnout and turnover among new nurses puts additional strain on limited financial resources in healthcare organizations and can compromise the quality of care provided to patient (Laschinger, Wong, & Grau, 2012). The cross-sectional survey study that incorporated the views of 342 graduate nurses sought to identify the concerns of burnout, authentic leadership, workplace bullying, turnover intentions, and job satisfaction. The findings showed that authentic leadership had a negative direct effect on workplace bullying, which in turn had a direct positive effect on emotional exhaustion (Laschinger, Wong, & Grau, 2012). The style of leadership also affected job satisfaction indirectly through practices of bullying and emotional fatigue. Overall, authentic leadership, bullying at the workplace, and emotional fatigue all had significant direct impact on job satisfaction, which also related to a decline in turnover intentions (Laschinger, Wong, & Grau, 2012).

The research conducted by Lachman (2014) and Ditmer (2010), having a safe working environment for the medical workers is an effective measure of ensuring ethical behavior outcomes. In relation to academic integrity, incivility issues in the higher education institutions have brought about disregard for the moral standards in the healthcare profession (Schaeffer, 2013). The students exposed to an environment of violence and unruly behaviors are more likely to incorporate medical malpractices and errors in their professional activities (Wiegand, & Funk, 2012). Workplace and institutional violence not only incorporates physical assault but also an array of disruptive activities, such as verbal abuse, sarcastic gestures, intimidation, and yelling at faculty, peers, or students. According to Lachman (2014), nearly 39% of graduates witnessed cases of bullying in the workplace within their first year of practice while 31% experienced it first-hand. The high occurrence of incivility in both the workplace and the educational institutions prevent individuals from making appropriate moral judgments subsequently creating a widespread occurrence of unethical actions. 

Taking up administrative positions in the healthcare organization is a burdensome task that requires intent focus by the supervisors. Identifying an error in the normative practices in delivery of care and treatment could be perceived as an attack on the actions and behaviors of the staff. Research by Barkhordari-Sharifabad, Ashktorab, and Atashzadeh-Shoorideh, (2017) shows that numerous nurse leaders are set back in their actions when making efforts to improve quality of care. Providing an example of an unethical practice that may be detrimental to the overall health and wellness of the patient could make individual groups upset (Barkhordari-Sharifabad et al., 2017). In this regard, nurse managers experience a heavy responsibility of ensuring support and leadership of followers. The discontent demonstrated by numerous workers on the administration’s desire to address the numerous issues they encounter significantly affects job performance (Barkhordari-Sharifabad et al., 2017). Many of them may perceive that the nurse manager is not effective in ensuring developments are made to change the problems they encounter. Providing an example of an unethical practice that may be detrimental to the overall health and wellness of the patient could make individual groups upset (Barkhordari-Sharifabad et al., 2017). In this case, some health workers may believe that the reason for taking up the meeting was intended to highlight their errors. The adverse result causes the leader to doubt their ability to ensure ethical performance of tasks and duties to the patients. Additionally, the followers demonstrate resistance towards changes intended to improve quality of care. 

The emotional and task-intensive nature of oncology practice increases the potential of ethical conflict among nurses caring for the patients. The health practitioners reported challenges administering treatment that may cause suffering for patients and being honest to the patients and their families without removing hope of recovery for the patients (Aitamaa et al., 2016). To avoid the occurrence of ethical misconduct a professional has to align their personal opinions with the beliefs that the institution establishes. A barrier exists in the performance of moral behavior when the social and organizational cultures are in conflict with one another creating a situation where the healthcare worker has to make a critical decision. Research shows that ethical leaders usually struggle to strike a balance between these opposing aspects of acting in an ethical manner (Aitamaa et al., 2016). Therefore, when the senior employees do not show compassion to their subordinates and other healthcare help, it is more likely to result in burnout and dissatisfaction among the workers (Epp, 2012). The behavior could continue without end over various generations of healthcare workers. The nurse leaders have a difficult task to eliminate such treatment of subordinate staff in the development of an ethical culture.

In majority of the hospitals, there is little room for democratic leadership where hierarchical beliefs are integral to the operations. Subordinate staff will rarely receive the opportunity to provide input in the process creating an issue of ethical conflict when new ethical models are introduced (Shirazi et al., 2014). This practice has been a primary factor towards the failure to empower nurses in the profession. The leaders in the organization incorporate a condescending attitude towards the less experienced nurses and provide little room for ethical culture in the institution (Shirazi et al., 2014). From an ethical perspective, the aims of a healthcare system in relation to patient safety can be considered in two ways. First, it is understood as a practical value: where the benefits, outcomes, effectiveness and economic drivers of care provided matter (Kangasniemi et al., 2013). In that respect, patient safety is a reasonable way to decrease costs and the burden of healthcare within a society (Kangasniemi et al., 2013). Second, the aim of patient safety is perceived as a moral value, with the role of the human being emphasized as a main argument: safety of care is pursued to protect and promote human dignity (Kangasniemi et al., 2013). 

In the process of ensuring significant consideration of ethical behavior in an organization, it is important to identify the individual commitment to providing quality care. Research by McCabe and Sambrook demonstrates that few studies explore the link between the psychological contracts and the commitment of nursing professionals in the healthcare sector, and how perceived breaches of the psychological contract can impact on nurses’ commitment levels (2013). This realization prompted the search on factors that influence nurses desire to undertake caring obligations on a population of 28 nurses and 11 nurse managers (McCabe & Sambrook, 2013). The search brought up two general themes, professional and managerial values. Each of the themes provided numerous sub-themes, such as professional recognition, leadership and peer support, training and professional progression falling under professional values (McCabe & Sambrook, 2013). Additionally, the sub-themes under managerial values would include involvement in decision-making processes, management practices in addressing the issues that nurses encounter, and resource management (McCabe & Sambrook, 2013). The managerial problems were integral to the negative consequences that impede the ability to enforce ethical behavior in the performance of tasks. The report by Abualrub and Alghamdi (2012) affirmed the finding of the study stating that transformational leadership was a necessary component of increasing nursing satisfaction and intention to stay in the organization. 

Increased restoration of nursing leaders has taken place in numerous organizations that seek to ensure high levels of ethical culture in the clinical setting. However, the practice has had little effect in providing the practitioners with the necessary power to influence change in the practices. A review of the common practices by health organizations shows emphasis of equality and similarity of all nursing personnel despite the clear distinction in the roles they play. The respondents in the research by Barkhordari-Sharifabad and colleagues (2017), show that the criteria used in the employment process are the same. The study shows that healthcare organizations have shown little regard to the performance and roles played by nursing managers. In this case, the sub-theme of professional recognition under professional values is identified. The nursing managers will not effectively deliver the demands and requirements of their roles if the organization does not demonstrate its active involvement in rewarding their efforts. The findings suggest that nurses and nurse managers are governed by relational psychological contracts, underpinned by an affective and to a lesser extent normative commitment towards the nursing profession (McCabe & Sambrook, 2013). They emphasize ‘professional values’, and professional commitment, as the basis for positive psychological contracts amongst nursing professionals.

Barriers of Ensuring Ethical Culture

As mentioned earlier, nursing among other medical disciplines require professionals to uphold a high standard of ethical behavior. The issue is of particular concern due to the numerous events of substandard patient outcomes. In the US, the government has taken retrospective action in the provision of public funding in making payments for care costs. Patient satisfaction has become a paramount measure of identifying the practices of the medical workers. In this regard, administrative personnel have emphasized the importance of employees within the realm of healthcare to uphold codes of ethics and professional standards of providing care to the patients. Nursing managers, for instance, have a responsibility to monitoring quality of care, employee grievances, and effective operation of the healthcare institution. Ethical practice plays an integral role in the appropriate carrying out of the above responsibilities (Aitamaa, Leini-Kilpi, Iltanen, & Suhonen, 2016). In this regard, numerous studies on ethical functioning of a healthcare organization put the burden on administrative medical staff in their interactions with subordinates (Aitamaa et al., 2016). Recent research has found that there are three primary problems or obstacles associated with ethical leadership: ethical, cultural, and managerial (Barkhordari-Sharifabad, Ashktorab, & Atashzadeh-Shoorideh, 2017).

Burke-Litwin Change Model

The Burke-Litwin Change model identifies how internal and external factors could influence the performance of the organization. In this regard, the external environment is the most powerful aspect that triggers organizational change. The model also emphasizes that these external changes result in amendments made in the internal practices of the company. The authors refer to the internal factors as transformational as any adjustment on them ensures significant impact in the entire organization. The changes occurring in the transformational factors result in the modification of the transactional practices of the company. In this regard, the transactional factors include the management climate and practices, systems, and structure. The changes in the transactional aspect of the firm are primarily operational and may not influence much change in the performance of the company. The Burke-Litwin change model can be used to highlight the numerous barriers that prevent healthcare institutions from ensuring an ethical culture in their operations.

The external environment factors, for instance, have significant impact in the organizational quest to achieve ethical adherence. These aspects include legislation, markets, competition, and the economy. The legislation may enforce particular rules and regulations on the practices of medical workers. Euthanasia is one of the major issues of contention in the medical field. Practitioners emphasize the importance of providing the patient with the option of continuing with treatment options or seeking a peaceful and painless death. According to numerous physicians, euthanasia is an appropriate option for the patient if the continued provision of treatment will result in more pain and suffering. However, only a few countries and some states in the US have legalized the practice. The medical workers identify the lack of an effective external environment for the performance of ethical behavior as the law categorically prevents its practice. 

Other drivers of change that may prevent effective enforcement of ethical practice in the organization include; mission and strategy, leadership, organizational culture, structure, work unit climate, systems, management practices, task and individual skills, individual needs and values, individual and organizational performance, and motivation. All the above are discussed in detail below. 

Ethical Problems

In the healthcare setting, ethical problems have had significant impact in hindering the effectiveness of ethical leadership. In nursing, such problems are crucial to the administrative team as they are sophisticated and pervasive in nature. The negative impacts that they cause extend from the senior workforce to the untrained staff in the institution hence requiring multiple efforts to solve them (Wiegand, & Funk, 2012). On the other hand, the high level of uncertainty and the personal impressions drawn from their occurrence could be detrimental to the performance of the organization. In the incidence of these issues, the actions of the leaders in nursing and other health professionals have significant impact on the patient, subordinates, and others who come into contact with them (Wiegand, & Funk, 2012). The ethical problem arises when the behavior brings inconsistent influence and uncontrolled harm on the individuals. Three major subcategories are identified in this case including, doubt in action, ethical conflict, and ethical distress (Barkhordari-Sharifabad, Ashktorab, & Atashzadeh-Shoorideh, 2017). The activities that a nursing leader undertakes will bring about negative consequences to the subordinate staff and eventually to the patients served. It is for this reason that numerous studies focus on the impact that leaders have on the development of an ethical culture in the healthcare organization. 

The action that a nurse leader undertakes could bring about negative reaction from the staff members. The research showed that nursing leaders experience adverse results when seeking to introduce new models of acting ethically resulting in an issue of doubt among groups of people (Barkhordari-Sharifabad, Ashktorab, & Atashzadeh-Shoorideh, 2017). In this case, when undertaking significant measures of improving ethical performance in the delivery of care, the consequences of the decisions are not always clear to the nursing help creating doubt in the performance of the leaders and their ability to ensure ethical conduct. Taking up administrative positions in the healthcare organization is a burdensome task that requires intent focus by the supervisors. Identifying an error in the normative practices in delivery of care and treatment could be perceived as an attack on the actions and behaviors of the staff. Research by Barkhordari-Sharifabad, Ashktorab, and Atashzadeh-Shoorideh, (2017) shows that numerous nurse leaders are set back in their actions when making efforts to improve quality of care. Providing an example of an unethical practice that may be detrimental to the overall health and wellness of the patient could make individual groups upset. In this case, some health workers may believe that the reason for taking up the meeting was intended to highlight their errors. The adverse result causes the leader to doubt their ability to ensure ethical performance of tasks and duties to the patients. 

Doubt may also occur in the delivery of improved and innovative ideas intended to ensure quality of care. It is evident that the nursing profession, similar to other healthcare practices, experiences significant use of hierarchical structure in the organization. Health practitioners are constantly competing to achieve recognition as being of a higher rank than the others. Such practices may bring about adverse effects in upholding ethical culture in the organization (Laschinger & Fida, 2014). It is evident that leaders are not born but are made. However, majority of healthcare leaders are unable to nurture improved leadership skills despite a clear lack of change in behavior among the subordinates. Coercion is a morally problematic incidence that requires critical reflection (Laschinger & Fida, 2014). When the workforce is resistant to the enforcement of change towards developing an ethical culture, it is essential that significant examination of practices is noted to prevent negative effects on the patients served. According to research conducted by Molewijk and colleagues, various health workers who served as respondents for the study showed uncertainty in the use of coercion as a justified practice (2017). As a result, the continued practice of the behavior among the respondents brought about the incorporation of unethical practices in the delivery of care (Laschinger & Fida, 2014). It is important that health organizations address this issue to prevent severe consequences on the patients and the staff members. 

In an alternative case, the nurses like other medical workers encounter events that call attention to their ethical understanding. These dilemmas may accelerate to become ethical conflicts to the critical nature of concerns at hand. The experience may have harmful and severe consequences to the nurses and the patients alike. The occurrence of ethical conflict may arise from the increased lifespan, technological development, unrealistic expectations from the public, limited resources, focus on the rights of a patient, and rapid cultural and religious diversity (Pavlish, Brown-Saltzman, Jakel, & Fine, 2014). The research by Pavlish and colleagues recognizes the increased incidence of ethical conflict among the oncology nurses had increased in the recent years. The emotional and task-intensive nature of oncology practice increases the potential of ethical conflict among nurses caring for the patients. The health practitioners reported challenges administering treatment that may cause suffering for patients and being honest to the patients and their families without removing hope of recovery for the patients. The occurrence of moral disagreements between the nurse’s obligations and the personal values places patients at the epicenter (Wiegand, & Funk, 2012). It is more likely for the practitioners to act unethically further placing the burden on medical workers particularly nurse managers to identify the most appropriate action for care.

As mentioned earlier, an ethical conflict takes place during decision-making processes where health providers and the families of the patient deliberate on the most effective treatment option. The issue may also take place when the desires of the practitioners are similar. Due to high levels of emotional fatigue and work-related stress, nurses have a high likelihood of burnout with many of them seeking to take time off from work before they can return to their regular duties (Barkhordari-Sharifabad, Ashktorab, & Atashzadeh-Shoorideh, 2017). However, for the nursing managers and administrative personnel at the healthcare organization it may not be always possible to fulfill the needs of all individuals at the same time. The lack of resources in majority of hospitals and care homes results in a shortage of nurses. However, the shortage prompts the supervisor to choose one of the two leaving the other feeling bad (Aitamaa et al., 2016). The worker whose desires have not been met will usually present feelings of negativity that may result in poor performance of duties. In some cases, the needs and expectations of the practitioners are in conflict creating a dilemma for the supervisors in charge of various departments. During the planning of shifts, it is essential that nurse managers distribute the personnel evenly to prevent lack of skillful workers. The novice should be paired with more experienced employees (Barkhordari-Sharifabad, Ashktorab, & Atashzadeh-Shoorideh, 2017). However, the latter may request another worker who is more skillful as they feel that the workload significantly increases when the planning takes place. In such cases, nursing managers encounter dilemmas on where to place the novice workers to prevent acceleration of burnout among the more experienced workers.

In an effort to improve the quality of care provided to the patients, healthcare organizations along with the government identify the importance of patient satisfaction. In this case, the health practitioners are required to undertake significant measures of meeting the needs of the patients. Due to the significant developments taking place in research and technology, the public raises their expectations for the treatment options (Pavlish et al., 2014). It is for this reason that numerous medical professionals affirm the high incidence of ethical conflict in the clinical setting as opposed to other environments related to healthcare. The occurrence of competing obligations significantly put nurses and physicians alike in difficult situations. For instance, the patient has a right to receive medical attention, but lack of insurance coverage or the financial health of the organization may result in a delay in the delivery of treatment (Pavlish et al., 2014). 

Leaders seeking to enhance quality practice in a clinical setting identify ethical distress as one of the issues hindering the enforcement and preservation of ethical culture. According to research conducted by Dodek et al. (2016), moral distress takes place when a healthcare professional is certain of an ethical course of action but is prevented from taking the desired action. The nurse managers experience challenges that force them to employ actions that are contrary to their individual beliefs. It is also evident that when individuals act contrary to their personal values, they feel dissatisfied, discomfort, and frustration in their objective tasks. Organizational policies and lack of support from the senior leaders of the institution are integral to the development and continued prevalence of this stress (Dodek et al., 2016). It is evident that leaders of healthcare institutions may compel the medical workers to perform actions that are not within the rules and regulations, but are right logically and in relation to humanity. However, if anything was to go wrong during or after the procedure, the individual nurse or physician is held accountable (Dodek et al., 2016). Such incidences invoke feelings of discomfort and sadness among health practitioners, which may subsequently lead to unethical behavior in delivery of care. 

The availability of an effective workforce is crucial to the delivery of quality care. In the modern day practice, numerous institutions identify the lack of resources to hire enough health practitioners (Crippen, 2016). As a result, the available practitioners are forced to take up multiple roles to fill the gap. The nurse managers are the most affected by the occurrence of such instances whereby subordinate staff request leave of absence due to personal reasons, but are denied, as it would cause a shortage of labor (Shirazi et al., 2014). Particularly for nurses who may have sick children, working at odd hours may result in significant discomfort or lack of satisfaction in their job. In this case, it is evident that the administrators of the health organization are responsible for the moral distress (Crippen, 2016). Failure to increase financial resources that they can boost the number of practitioners available is perceived as a lack of support for the health workers’ needs. 

Cultural Concerns

Culture is another integral factor that hinders leaders from upholding standard practices of ethical behavior among workers. Similar to business organizations, healthcare institutions incorporate their unique beliefs and norms that help direct employee behavior, decision-making, and performance outcomes as representatives of the organization. The beliefs and opinions of the individual health workers reflect their upbringing and ethnic backgrounds. Each nurse, physician, and non-physician practitioner in the healthcare organization will usually takes into consideration these personal values in the roles they undertake (Abualrub, & Alghamdi, 2012). To avoid the occurrence of ethical misconduct a professional has to align their personal opinions with the beliefs that the institution establishes. A barrier exists in the performance of moral behavior when the social and organizational cultures are in conflict with one another creating a situation where the healthcare worker has to make a critical decision. Research shows that ethical leaders usually struggle to strike a balance between these opposing aspects of acting in an ethical manner (Abualrub, & Alghamdi, 2012). Furthermore, a similar experience may affect the subordinate staff as well.

Social culture refers to the model of beliefs, attitudes, and values that people uphold drawn from life experiences, interaction, and informal teaching by the society. A similar form of practice may also arise in the organization where association between peers and the senior personnel results in an assumed way of behaving. Unfortunately, for the health sector, this usually brings about a social culture that shows lack of respect for the nursing profession (Barkhordari-Sharifabad, Ashktorab, & Atashzadeh-Shoorideh, 2017). Since the establishment of the vocation in the Victorian era, other medical practitioners usually identify nurses as subordinates and not partners in the delivery of care. Despite the significant developments taking place in the society ensuring equality between both genders and all racial groups, there has not been a full eradication of the attitude (Abualrub, & Alghamdi, 2012). Nurses continue to be perceived as servants for use by the more sophisticated professionals like doctors and surgeons. The behavior may result in some employees feeling inadequate in the roles they play. Even in the society, the members usually provide a positive acknowledgement for individuals who take up the physician profession and ignore achievements of those seeking to become nurses. Numerous nursing leaders report to have experienced such treatment resulting in low levels of self-confidence and motivation to perform their roles effectively (Barkhordari-Sharifabad, Ashktorab, & Atashzadeh-Shoorideh, 2017). In this regard, the leaders that they will meet in the workplace will have a burdensome task of lifting their spirits and making them feel proud of the responsibility they have in the institution.

Despite the continued prevalence of such beliefs, nursing remains an integral aspect of care and potential outcome for the patient. Nearly half of the healthcare workforce in Canada comprises of nurses (Laschinger & Fida, 2014). However, recent research shows that the hospitals and other clinical settings are encountering a nursing shortage as the present employee base continues to age. Therefore, healthcare institutions have to identify significant measures of retaining the newcomers to sustain effectively the future of the profession. For the organization to achieve this feat, it is essential that the leaders take the time to identify the numerous needs and problems that the employees may face. Research shows that lack of support from the superiors (Epp, 2012). It is evident that the lack of effective empowerment of the subordinate nurses in the organization is a critical factor towards low levels of morale. In the event that the leaders fails to demonstrate significant support for the needs of the nurses, the patients are likely to experience the negative consequences. The study by Storch, Makaroff, Pauly, and Newton (2013) shows numerous cases of retractions to the ethical guidelines in the leaders’ ethical obligations. This practice over the past decade causes a decline in patient outcome.

The cultural concerns are also prevalent in the workplace where interaction between the peers and their leaders is integral to the development of an ethical culture. Research by Lachman (2014) also shows that nursing graduates are likely to experience instances of inadequacy because of intimidation and bullying within their first year of practice. This behavior includes a patronizing attitude from the physicians and lack of respect to the integral role played by nurses (Lachman, 2014). Individuals in the nursing profession are expected to take orders and not weigh in on the decision-making process to identify options of care. Regular demonstration of such behavior creates a normative attitude towards coercion in the healthcare setting (Lachman, 2014). It is likely that the individual workers will experience burnout and change careers in search of appropriate treatment (Abualrub, & Alghamdi, 2012). In most regions, majority of the individuals in the nursing profession are women. The research by Barkhordari-Sharifabad and colleagues (2017) identifies that the society in the Middle Eastern countries is family-centered meaning that women are required to be at home and caring for their families. However, due to the rotation of shifts and the attending to the needs of the individual nurse, it is essential that nurses take up late hours and night shifts. A negative attitude towards the female personnel hinders upholding of ethical culture in the organization (Barkhordari-Sharifabad et al., 2017). According to the respondents in the research, families may intervene in the normal operations of the healthcare institution seeking special treatment of female nurses to prevent them from undertaking night shifts making it even more difficult for the nurse managers to enforce ethical practice.

Organizational culture is another crucial component of ethical leadership where the healthcare institution shapes attitudes of the workers (Shirazi et al., 2014). In majority of the hospitals, there is little room for democratic leadership where hierarchical beliefs are integral to the operations. Subordinate staff will rarely receive the opportunity to provide input in the process creating an issue of ethical conflict when new ethical models are introduced (Shirazi et al., 2014). This practice has been a primary factor towards the failure to empower nurses in the profession. The leaders in the organization incorporate a condescending attitude towards the less experienced nurses and provide little room for ethical culture in the institution (Epp, 2012). As previously mentioned, the nursing profession on its own is a stressful practice. Therefore, when the senior employees do not show compassion to their subordinates and other healthcare help, it is more likely to result in burnout and dissatisfaction among the workers (Epp, 2012). The behavior could continue without end over various generations of healthcare workers. The nurse leaders have a difficult task to eliminate such treatment of subordinate staff in the development of an ethical culture. Working with the numerous departments is a necessary approach to demonstrating democratic leadership in the delivery of care. 

It is evident that the transition process from student nurse to newly qualified nurse is a difficult one that requires critical assessment. Research has shown that the newly qualified nurses experience a reality shock that makes it nearly impossible to ensure appropriate enforcement of ethical practice in the organization (Shepherd & Uren, 2014). There are four processes involved in the transition termed as ‘Rites of Passage’ which are integral to the development of a effective worker dedicated to providing quality care to the patients (Epp, 2012). There is a consensus in the recent research identifying this process as a major factor for the development of stress among newly qualified nurses. The first phase is ‘skill and routine mastery’ where the nurse experiences mixed emotions in the workplace. On one hand, there is excitement to participate in the provision of care to the various clients (Suresh, Matthews, & Coyne, 2013). On the other hand, there is apprehension, as the individual worker believes that he or she could fail to live up to the standards of the profession. The conflicting state of emotions causes significant stress on the newly qualified nurse making it difficult to uphold ethical standards. 

The second phase of the transition is ‘social integration’ where individuals develop relationships with the various employees seeking to establish an understanding of the organizational culture (Suresh, Matthews, & Coyne, 2013). It is this point of the transition that newly qualified nurses should receive guidance from the respective leaders on the most appropriate behavior expected in the institutions (Epp, 2012). As previously mentioned, more experienced workers will usually provide the education and may focus on the negative aspect of the institution. In this regard, the newly qualified personnel may realize that there is a misfit between the ethical ideals that the curriculum teaches and the reality of practice in a clinical setting (Suresh, Matthews, & Coyne, 2013). The third phase subsequently takes place in the form of ‘moral outrage’. The qualified nurse demonstrates feelings of discontent and resentment to the working conditions that make them aware of the stressors at the workplace (Suresh, Matthews, & Coyne, 2013). The phase is yet another that influences the development of the novice as a professional in the healthcare sector. The administrative personnel should take up duties of addressing issues and concerns that the new employees experience at the workplace (Shepherd & Uren, 2014). The conflicting nature of the expectations and reality could cause negative consequences on the individual and patients served. 

The final phase of the transition process is the ‘conflict resolution’ where the new nurse adopts the most appropriate measure of coping with the changes from a student to a professional. The research shows that individuals may undertake a wide array of reactions that significantly influence the attitude towards the nursing practice (Suresh, Matthews, & Coyne, 2013). The reactions may include withdrawal, acceptance, or resistance. It is evident that there is a lack of time and shortage of personnel that hinders the effective possibility of guiding the newly qualified nurses in the transition process (Shepherd & Uren, 2014). Additionally, a significant disregard for the new professionals in clinical settings can bring about a feeling of isolation or ‘being in the way’ (Suresh, Matthews, & Coyne, 2013). The shortage of staff and strains in relationship between the new nurses and experienced employees lead to the enhancement of work-related stress. The style of leadership employed by the senior healthcare workers is integral to the development of a positive perspective among these individuals (Shepherd & Uren, 2014). According to the research, transformational and authentic leadership helps ensure a seamless transition process. 

The supernumerary status of new nursing professionals has become a widely supported measure of extending the transition process from student to qualified personnel. It identifies the importance of freeing these individuals from the obligation of delivering nursing care and instead focuses on educational needs and clinical exposure (Suresh, Matthews, & Coyne, 2013). The measure of providing learning in a clinical setting noted as an effective measure for developing a positive notion to ethical practices and its implementation in practice (Abualrub, & Alghamdi, 2012). The findings on the supernumerary status were conflicting with some researchers recognizing its effectiveness in developing individuals prepared to undertake the demands and tasks of the role. On the other hand, others identified a lack of effectiveness in the approach particularly due to the limiting clinical exposure of the nursing students (Suresh, Matthews, & Coyne, 2013). In this regard, the status inadvertently impedes the ability to develop professionals who can cope with the arising challenges (Shepherd & Uren, 2014). The positive attitude of the registered nurses is pivotal to the outcome of the transition process for the new nurses as they attempt to cope with the new roles.

Managerial Problems

It is also apparent that managerial problems have far-reaching implications in the effective ethical leadership within the organization. These issues usually revolve around procedures, guidelines, performance, and evaluations taking place. The two subcategories highlight the concerns related to the organization and those associated with the health workers. In the clinical setting, it is evident that administrative personnel have an integral role in establishing and enforcing an ethical culture. According to research carried out by Storch and colleagues (2013), an extensive fiscal reduction in majority of the Canadian provinces led to the removal of nearly 7000 nurse leaders from managerial and administrator positions. The prevalent restructuring and re-engineering of the healthcare sector had severe effects on the ethical climate and upholding of ethical standards in the various organizations. The managerial problems were integral to the negative consequences that impede the ability to enforce ethical culture (Storch et al., 2013). The transformation of the structure and hierarchies of clinical settings championed the motto that all nurses are leaders on their own right. In this regard, the reform was a measure of recognizing the autonomy of nurses in their various roles while diminishing the impact of the nurse leaders. The extensive support from the frontline registered nurses showed the positive impact of the practice. However, studies on the impact of this practice have brought about feelings of discomfort and moral distress (Storch et al., 2013).

As per the standards and requirements of the nursing profession, patient safety is an integral factor to the application of ethical practice. In this case, practitioners should demonstrate high levels of values and principles in the provision of care to the patients. However, the objective goal of ethical practice cannot be achieved without a stable foundation to help realize this practice (Storch et al., 2013). For instance, to ensure patient safety during the provision of care, it is essential that the organization employ a large workforce to match the demands and challenges of the practice. The nurse managers have trouble in the delegation of duties, as the workload on a single individual is huge and may result in complete disregard for ethical standards. The professionals recognize the importance of providing attention to each patient to meet their needs effectively (Storch et al., 2013). However, with a burdening workload, the individual nurse will take little consideration on the needs of the client and focus will be to complete the tasks at hand before moving on to the next patient. The practice is detrimental to the health outcome and contradicts the primary ideals of nursing. The managerial issue at hand relates to the organizational practices of hiring and retaining employees. It is essential that a clear balance be struck between demand and supply to prevent the disregard of ethical practice.

Nursing leaders have increasingly been restored in numerous organizations that seek to ensure high levels of ethical culture in the clinical setting. However, the practice has had little effect in providing the practitioners with the necessary power to influence change in the practices. Research conducted by Poikkeus, Leino-Kilpi, and Katajitso (2013) recognize the importance of ethical competence of nurse recruits as a measure of effective incorporation of an ethical culture in the institution. A review of the common practices by health organizations shows emphasis of equality and similarity of all nursing personnel despite the clear distinction in the roles they play. The respondents in the research by Barkhordari-Sharifabad and colleagues (2017), show that the criteria used in the employment process are the same. The recognition and acknowledgement of the work performed is the same despite the variation of the tasks. This practice clearly demonstrates a lack of appreciation for the nurse leaders who are greatly undermined in the healthcare setting. The managerial problem in question reflects the issues associated with the organization (Barkhordari-Sharifabad et al., 2017). The lack of significant disparity created in the numerous nursing roles and attempts to reinforce the motto that “all nurses are leaders” is detrimental to the administration of justice. The practitioners in leadership roles cannot influence change in ethical climate if the institution itself cannot recognize them as important factors to this measure.

Another managerial process that is of concern in the quest to achieve ethical culture is the hiring and retention of nursing professionals. A review of the common practices by nursing leaders shows emphasis of ethical behavior during performance reviews as opposed to during the recruitment process (Wiegand, & Funk, 2012). Despite nursing leaders having significant authority in operation of the numerous duties, they are rarely included in hiring procedures resulting in employment of individuals with little regard for ethical values (Shirazi et al., 2014). The nursing leaders are required to enforce a strict adherence of values and principles of the profession in their followers. However, when these leaders are not included in the activities of hiring and firing workers it becomes even more difficult to achieve. The administrative personnel in the healthcare organization seem to exert their authority as a source of power for the nursing leaders (Shirazi et al., 2014). The majority of nurse managers identify the lack of fairness in the evaluation method incorporated. The administrators will rarely receive an evaluation of their performance and in many private institutions the primary focus is ensuring profits. The differences in the needs of the patients do not account for much of the criteria used in the assessment of the nurses’ practice (Barkhordari-Sharifabad et al., 2017). 

Employee action of undertaking moral or immoral behavior results in subsequent positive or negative implications at organizational level. In this issue, nursing leaders recognize that individual personalities have significant impact on the behavior depicted. Despite the manager’s attempts to provide the subordinates with the best workplace environment conditions to realize positive outcomes, there are those who will complain showing lack of gratitude (Barkhordari-Sharifabad, Ashktorab, & Atashzadeh-Shoorideh, 2017). Nursing managers experience a mammoth responsibility to guarantee the effective adherence to ethical practices in such scenarios. Human dignity is a central phenomenon in professional nursing (Kangasniemi, Vaismoradi, Jasper, & Turunen, 2013). The strongest ethical motive in all caring involves respect for the absolute dignity of the human being. Dignity implies inner freedom and responsibility for one’s own and others’ lives (Kangasniemi et al., 2013). The incorporation of human dignity in ensuring quality care for the patient is noted as an integral factor in the delivery of care. Individual principles and values are critical in guaranteeing that the patient needs are provided in the nursing practice. The practitioners who have low levels of ethical and moral concern will impede the nurse managers’ attempt to enforce the behavior in the organization. In this case, the role of the leaders in the profession comes about, seeking to identify measures that will lead to employment of workers who understand the importance of ethical practice.

Practices and Techniques of Overcoming Problems to Ethical Culture

Organization Learning Theory

In comparison to other industries in the global economy, the healthcare industry is lagging behind particularly in adoption of technology use. However, various healthcare organizations in the developed countries have incorporated measures to begin merging their operations with available technology. Employing technology use in healthcare has been a primary source of conflict and barriers to ensuring ethical leadership (Smith, Barnes, & Harris, 2014). The research shows that the incorporation of organizational learning theory effectively explains the occurrence of problems arising in ethical leadership. The theory identifies the process of developing, retaining, and transferring information and knowledge within the institution. The practice enables the healthcare institution to gain experience and ensures a smooth transition as changes take place (Smith, Barnes, & Harris, 2014). The use of the theory prevents disruptive interferences drawn from conflict and resistance from the workforce.

Research by Berta et al., (2015) identifies facilitation as an integral component of organizational learning theory. The approach strategy incorporates a guided interaction process between healthcare workers within the institution. Additionally, the technique ascertains the potential of supporting adoption and application of scientific knowledge in the development best clinical and administrative practices. The above obstacles of ethical leadership in the healthcare institutions arise from the failure to incorporate empirical data in the improving interactions between the leaders and the subordinate staff (Smith, Barnes, & Harris, 2014). The issue of ethics in care and treatment procedures has become an issue of great concern in the recent years. Numerous scholars and practitioners in the field of nursing are conducting research to develop measures that could improve adherence to the professional code of ethics (Wong, Cummings, & Ducharme, 2013).

Servant Leadership Theory

One of the major problems affecting ethical leadership in the modern healthcare organization is cultural issues. In this case, the medical industry as a whole has been reluctant in eliminating the strict structural formats in effective performance of tasks (Brown, & Bryant, 2015). Hierarchies are quite important to the individual professionals in the industry despite the fact that they have created a strain between the managers and the subordinates (Smith, Barnes, & Harris, 2014). The specialization of skills among physicians, nurses, and surgeons, the practitioners continue to maintain traditional beliefs on the importance of one’s role over the other. The higher-ranking members will usually demonstrate a condescending attitude towards the lower ranking counterparts (Brown, & Bryant, 2015). For instance, physicians believe that their role is more important than that of the nurse creating significant animosity between the two medical practitioners. A similar interaction may be evident in the relationship between a Registered Nurse (RN) and unlicensed assistant personnel (UAP). 

The concept of leadership in any given organizational structure is to develop a means of influencing followers by directing and motivating them towards a specified goal. However, in the context of servant leadership, it incorporates a longer approach to achieve the ultimate objective. The manager or supervisor identifies the importance of prioritizing service to the needs and interests of the followers rather than those of the institution (Brown, & Bryant, 2015). In this strategic method, the leader takes the position due to the desire of serving others, not to have a higher status than the others. The theoretical measure employs ethical beliefs in the leadership practices. The shared vision of the members takes into consideration self-reflection, moral-centered management, and advanced shared vision in the tasks of the leader (Brown, & Bryant, 2015). The head nurse utilizes various mechanisms of improving the followers as an effective approach of developing a shared vision. In this practice, the process merges the goals and interests of the organization and its workforce into one.

The issue of leadership is a critical factor towards the enactment of an ethical culture. Some studies show that by having an ethical policy even without enforcing it provide the perception that the firm upholds ethical behavior. In this regard, workers and critical members of the firm are likely to uphold the practice as they engage in their various roles. A high level of motivation is evident among workers who perceive that the leadership of the company adheres to the ethical policies governing the health sector. According to the study by Brown, & Bryant (2015) employees who perceive their leader as one who upholds ethical policies will believe that he or she could attend to their needs whenever they arise. The individual health practitioners incorporate this factor as a major driver to conduct their objective roles in a morally upright manner. 

Socio-cognitive theory

The process of ensuring ethical leadership in the healthcare organization involves an exchange between the leader and the healthcare workers. The administrative personnel serve as representatives of the organization in this interaction (Phillips, 2015). Therefore, to ensure appropriate adoption and implementation of ethical practices, it is essential that the exchange between the two parties be of high quality (Phillips, 2015). In this regard, the socio-cognitive theory in leadership provides an effective research of the interaction and ultimate achievement of desired goals. The participants of the exchange activities are human beings who develop perceptions of the leaders and draw conclusions of their character. A similar practice is evident in the performance of a leader who establishes notions on the followers. 

The influence of the leader behavior affects coworker exchange and this occurrence acts as a moderator in the relationship between the workplace milieu and follower perceived empowerment. The socio-cognitive theory identifies the incorporation of social practices and cognitive techniques in the development of an ethical culture in the organization (Phillips, 2015). Through the behavior demonstrated by the leaders in the institution, individual workers will recognize the encouragement of ethical practice in the entire firm. The nature of addressing ethical issues by such leaders also influences a similar perception (Phillips, 2015). These activities will also encourage the followers on whether to incorporate ethical behavior or not. Addressing the needs and interests of the workforce is an integral measure to developing motivation towards improved moral practices within the organization.

Summation

The nursing profession is one that requires critical concern in the development and enforcement of an ethical culture. There are numerous instances showing the importance of ethics in management and leadership. However, there have been significant obstacles and influences that bring about ethical problems. The severity and frequency of these issues along with their distinction at the different levels of management are a source of major concern. Recent research focuses on the individual basis of ethical leadership while the current trends portray the importance of organizational culture. Strategies for overcoming obstacles that hindering ethical behavior at the workplace, particularly the resources and mechanisms within the company, enable transformation and achievement of an ethical culture. The process of ensuring effective moral action among professionals in the nursing vocation involves three primary components, moral awareness, ethical judgment, and acting in conformity with the discernment of ethical standards. The concept of moral perception involves the process of recognizing ethical problems involved, the affected parties in the behavior, possible outcome, and the various options to take action. 

In an extensive review of the global prevalence of unethical behavior among nursing professionals, it is evident that ethical culture stems from individual behavior early on in life before it is adopted into practices in the workplace. The process of ensuring effective moral action among professionals in the nursing vocation involves three primary components, moral awareness, ethical judgment, and acting in conformity with the discernment of ethical standards. However, through the enforcement of these practices, the practitioners of nursing encounter numerous obstacles that impede effective enforcement of an ethical culture. Some of the barriers associated with ethical leadership are the ethical, cultural, and managerial issues revolving around the practices of ethical leaders. 

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