Realizing ethics in the work place
A pilot study
Tom Eide, Sandra van Dulmen & Hilde Eide
Faculty of Health Sciences
Buskerud University College
• In the health care sector violations of ethical
standards, moral stress and a relatively high level of
sick leave is quite common (NBHS 2011-13; Zuzelo 2007;
• Leadership is considered important to realize ethics,
quality aims and a health promoting working
environment (Currie 2006; Embertson 2006; EUPAN 2008;
Andreassen 2011; Eriksson 2011).
• It is also assumed that systematic moral reflection will
improve the work environment and reduce sick leave
(NOU 2010:13; Aakre 2012).
• There is little research on how to realize ethics in the
work place (Suhonen et al 2011; Storch et al 2013).
How to stimulate ethical leadership?
• A pilot with eight participants was set up in order
to develop and try out some ideas for an ethical
leadership training program for health care
• The key elements:
– the participants ran small ethics project in their own
departments/units in order to improve ethical reflection
among the staff
– the participants kept an ethics reflection diary
(questionnaire) and received web-based, situational
feedback/coaching (on leading change)
Intervention and aims
(If it works, what are the working mechanisms?)
• The overall aim of the training
– was to stimulate moral reflection, experiential learning
and ethical leadership performance,
– i.e. realizing ethics in the work place (to the benefit of
• Educational design
– Traditional leadership course
– web based reflections and situational feedback
• The aim of the pilot
– to try out the blended learning training program: how
does it work? What do the participants get out of it?
Sample, material & methods
– 8 health care middle managers
– master students of value-based leadership
– participating in the master course “Leadership, Ethics
and Moral Judgment” (15 ects)
– (7 of the 8 participants completed the course/pilot study)
• Qualitative, explorative design
– reflection and evaluation questionnaires (web)
– situational, tailored written feedback (web)
– open, explorative focus group interviews (2 groups)
– text analysis/close reading
Experiential learning: course and practice
• The course part: On leadership and ethics
– leadership theories and leadership roles
– ethical theory and practice: moral reflection skills
– organizational ethics; practical approaches
– literature/drama: Sophocles and Ibsen
• The web-based part: Leading change & reflection
1. defining their “kings-thought” (Ibsen), their “ground
project”; their ethical vision & mission (discussions)
2. chosing a concrete ethics projects to develop (together
with the staff) as a part of realizing their vision
3. Develop and run the project at work (6 weeks) and
receive web-based coaching and support (weekly)
Point of departure: Individual reflections
• What kind of leader am I, and what kind of leader
do I want to be?
• What is my ethical vision for my service, my
ground project, my ”kings-thought”? (Ibsen 1863/1962)
• How can I involve my staff in reflecting on and
improving the ethical quality of our services?
• What is ethically needed in my organization?
• Which project might be suited to enhance the
ethical quality at our unit? (Eide & Aadland 2007/12)
• How to involve and co-operate with my staff to
develop and realize the project in practice?
Self chosen ethics projects
Objectives Means (when, where, how) Participants
Daily moral reflection at lunch, using an
Ethics advent calendar
Moral reflection at the end of each day,
20 minutes, with colleague
Weekly one hour systematic moral
reflection in reflection group
Every 14 days, moral reflection group,
one hour, using checklist
Involve affected parties in conflict
solving at the work
Weekly reflection on communication
issues at staff meetings
Weekly systematic moral reflection at
Web based feedback and support
• Task: weekly filling in a reflection questionnaire
and report and reflect on process and progress
of running the project (on the web)
• Receiving written feedback within a short
period of time (0-24 hours); motivational and
situational feedback from a trainer/coach
• Feedback principles (Eide & Eide 2007)
– mirroring, not judgmental
– appreciative, not critical
– supportive, not directive
– perspective, not details (vision as context)
Ethics project (example / print screen app)
My kings-thought is ... a unit with an
ethically reflective staff working to
realize our health care values.
My ethics project
The concrete project I want to develop
and run is ... creating an ethics advent
calendar together with my staff and
opening it daily and discuss the ethical
question of the day at lunch.
Thanks for your reflections! I understand that the caledar is already
a success. Fantastic! It sounds like you are really in a flow realizing
your vision. Just keep up the good work. Good luck!
Reflection – and feedback (example)
”Developing the calendar went well, I did it with two
of the most dedicated nurses. We now open it at
lunch every day. Lot of discussion and engagement! It has come
new energy into the group, and people are more concerned about
difficult matter concerning the patients, and we dicuss it. People
now look forward to the lunch break to open the calendar. Nice!”
(6 of 7 completing participants)
Examples of reflection statements
I am conscious of my values as a
2 4 - -
Patient relatives do not always
understand what it is all about
- 3 1 2
The Board of Health Supervision
will not find anything to criticize at
3 - 2 1
I use the action space that I have as a
leader to safeguard ethical practice
2 4 - -
Our conditions/budgets are
incompatible with standards of
1 4 1
Evaluation – questionnaire
(6 of 7 completing participants)
Evaluation: statements/questions agree partly
This pilot project made me conscious of
what ethical leadership is all about
3 3 - -
The pilot helped me carrying out my ethics
project in my work place
4 2 - -
Keeping an “I’m OK diary” has
empowered me as an ethical leader
2 2 2 -
Doing mindfulness exercises made me
more conscious as an ethical leader
3 1 1 1
The reflection questions has made me
more conscious as an ethical leader
2 4 - -
• All the web-based elements were considered useful
and stimulating, some more than others
• Receiving tailored feedback was considered by far the
most important element, stimulating motivation,
cooperation and project performance.
• Several participants in both groups stated – without
being asked – that had it not been for the situational
feedback, they would probably have given up or
postponed the ethics project.
– “It was so important knowing that there was someone there,
who was interested, who believed in me”
– “Leadership is such a lonely thing, I have no one to talk to.”
– “Those tiny positive comments were extremely encouraging”
• How to explain the results?
– Leadership theory: In many aspects consistent with
basic principles of transformational, values-based,
servant and health promoting leadership
• Communicating a vision; leading by expectations
• Listening to employees; co-operation and involvement
• Focussing on essetials: values and ethics at the work place
– Self determination theory (Ryan & Deci 2008)
• Coping/competence: personal ethical reflection skills and
knowledge of ethics and leadrship roles and strategies
• Autonomy/self determination: Determining the process
themselves: Identifying challenge, chosing ethics project,
• Relation/attachment: A person/coach giving regular contact and
support; involving staff creating dialogue and social contact
Conclusion and follow up
• The pilot indicates that web-based, situational
feedback is effective and the concept promising
• Education: A new leadership further education
will be run as a pilot 2013-14 (30 ects) at the
Faculty of Health Sciences, BUC
• Further research is necessary to investigate the
feasibility and possible effects in practice
– middle managers: ethical leadership + implication for
– units/organizations: collective mindfulness + ethical
practice + implications for health?
– accessibility/feasibility + improvements
Andreassen, Gerd (ed. 2011). Flink med folk i første rekke 2007-2010. Oslo: KS.
Currie, Graeme. 2006. Reluctant but resourceful middle managers: the case of nurses in the NHS. Journal of nursing
management 14 (1) :5-12.
Eide, Hilde & Tom Eide (2007). Kommunikasjon i relasjoner [Interpersonal communication]. Oslo: Gyldendal
Eide, Tom & Einar Aadland (2008/12). Etikkhåndboka for kommunenes helse- og omsorgstjenester. Oslo:
Kommuneforlaget, 2008 (rev. edition 2012).
Embertson, Mari K. (2006). The importance of middle managers in healthcare organizations. Journal of healthcare
management 51 (4): 223-32.
Eriksson, Andrea (2011). Health-Promoting Leadership (Doctoral thesis). Gothenburg: Nordic School of Public Health.
EUPAN (2008). European Primer on Customer Satisfaction Management. Maastricht: European Public Administration
Ibsen, Henrik (1863/1962). The Pretenders [Kongs-emnerne]. In The Oxford Ibsen (Vol. II). London: Oxford University
NBHS (2011-13). Annual Supervision Reports. Oslo: Norwegian Board of Health Supervision [Helsetilsynet].
NOU (2010:13). Arbeid for helse. Sykefravær og utstøting i helse- og omsorgssektoren. Oslo: Departementenes
Ryan, Alan & Edward Deci (2008). Self-Determination Theory. In International Encyclopedia of the Social Sciences.
Storch, J, KS Makaroff, B Pauly & L Newton (2013). Take me to my leader: The importance of ethical leadership
among formal nurse leaders. Nursing Ethics 20 (2):150-157.
Suhonen, Riitta, Minna Stolt, Heli Virtanen, and Helena Leino-Kilpi (2011). Organizational ethics: A literature review.
Nursing ethics 18 (3): 285-303.
Zuzelo, Patti Rager (2007). Exploring the moral distress of registered nurses. Nursing Ethics 14 (3): 244-259.
Aakre, Birgit (2011). Om etikkarbeid og sykefravær. Kan systematisk etikkarbeid føre til reduksjon i sykefraværet?
[Can systematic ethical reflection reduce sick leave?](Master thesis). Oslo: Diakohjemmet Univeristy College.