course material

1. Leadership in Nursing discussion part 1 and part 2: minimum of 150 words
each. Readings are included for both parts, NEEDS TO BE COMPLETED IN
LESS THAN 3 HOURS.
READINGS:IntroductionUnit II examines ethical, legal, and legislative issues affecting
leadership and management as well as professional advocacy. This chapter focuses on
applied ethical decision making as a critical leadership role for managers. Chapter 5
examines the impact of legislation and the law on leadership and management, and Chapter
6 focuses on advocacy for patients and subordinates and for the nursing profession in
general.Ethics is the systematic study of what a person’s conduct and actions should be with
regard to self, other human beings, and the environment; it is the justification of what is
right or good and the study of what a person’s life and relationships should be, not
necessarily what they are. Ethics is a system of moral conduct and principles that guide a
person’s actions in regard to right and wrong and in regard to oneself and society at
large.Ethics is concerned with doing the right thing, although it is not always clear what that
is.Applied ethics requires application of normative ethical theory to everyday problems. The
normative ethical theory for each profession arises from the purpose of the profession. The
values and norms of the nursing profession, therefore, provide the foundation and filter
from which ethical decisions are made. The nurse-manager, however, has a different ethical
responsibility than the clinical nurse and does not have as clearly defined a foundation to
use as a base for ethical reasoning.In addition, because management is a discipline and not a
profession, its purpose is not as clearly defined as medicine or law; therefore, the norms
that guide ethical decision making are less clear. Instead, the organization reflects norms
and values to the manager, and the personal values of managers are reflected through the
organization. The manager’s ethical obligation is tied to the organization’s purpose, and the
purpose of the organization is linked to the function that it fills in society and the
constraints society places on it. So, the responsibilities of the nurse-manager emerge from a
complex set of interactions.Society helps define the purposes of various institutions, and the
purposes, in turn, help ensure that the institution fulfills specific functions. However, the
specific values and norms in any institution determine the focus of its resources and shape
its organizational life. The values of people within institutions influence actual management
practice. In reviewing this set of complex interactions, it becomes evident that arriving at
appropriate ethical management decisions can be a difficult task.In addition, nursing
management ethics are distinct from clinical nursing ethics. Although significant research

2. exists regarding ethical dilemmas and moral distress experienced by staff nurses in clinical
roles, less research exists regarding the ethical distress experienced by nursing
managers.Nursing management ethics are also distinct from other areas of management.
Although there are many similar areas of responsibility between nurse-managers and non–
nurse-managers, many leadership roles and management functions are specific to nursing.
These differences require the nurse-manager to deal with unique obligations and ethical
dilemmas that are not encountered in nonnursing management.In addition, because
personal, organizational, subordinate, and consumer responsibilities differ, there is great
potential for nursing managers to experience intrapersonal conflict about the appropriate
course of action. Multiple advocacy roles and accountability to the profession further
increase the likelihood that all nurse-managers will be faced with ethical dilemmas in their
practice. Nurses often find themselves viewed simultaneously as advocates for physicians,
patients, and the organization—all of whose needs and goals may be dissimilar.Nurses are
often placed in situations where they are expected to be agents for patients, physicians, and
the organization simultaneously, all of which may have conflicting needs, wants, and
goals.To make appropriate ethical decisions then, the manager must have knowledge of
ethical principles and frameworks, use a professional approach that eliminates trial and
error and focuses on proven decision-making models, and use available organizational
processes to assist in making such decisions. Such organizational processes include
institutional review boards (IRBs), ethics committees, and professional codes of ethics.
Using both a systematic approach and proven ethical tools and technology allows managers
to make better decisions and increases the probability that they will feel confident about the
decisions they have made. Leadership roles and management functions associated with
ethics are shown in Display 4.1.DISPLAY 4.1 LEADERSHIP ROLES AND MANAGEMENT
FUNCTIONS ASSOCIATED WITH ETHICSLeadership Roles1. Is self-aware regarding own
values and basic beliefs about the rights, duties, and goals of human beings2. Accepts that
some ambiguity and uncertainty must be a part of all ethical decision making3. Accepts that
negative outcomes occur in ethical decision making despite high-quality problem solving
and decision making4. Demonstrates risk taking in ethical decision making5. Role models
ethical decision making, which is congruent with the American Nurses Association (ANA)
Code of Ethics for Nurses With Interpretive Statements (ANA, 2015), the ANA Nursing
Administration: Scope and Standards of Practice (2016), and professional
standards6. Clearly communicates expected ethical standards of behavior7. Role models
behavior that eliminates theory–practice–ethics gaps and promotes ethical behavior as the
norm8. Promotes patients’ self-determination and informed decision
making9. Collaborates with others to protect human rights and promote social
justice10. Assures that nurses are represented on interprofessional teams addressing
ethical risks, benefits, and outcomesManagement Functions1. Uses a systematic approach
to problem solving and decision making when faced with management problems with
ethical ramifications2. Identifies outcomes in ethical decision making that should always be
sought or avoided3. Uses established ethical frameworks to clarify values and
beliefs4. Applies principles of ethical reasoning to define what beliefs or values form the
basis for decision making5. Is aware of legal precedents that may guide ethical decision

3. making and is accountable for possible liabilities should they go against the legal
precedent6. Continually reevaluates the quality of personal ethical decision making based
on the process of decision making or problem solving used7. Constantly assesses levels of
moral uncertainty, moral distress, and moral outrage in subordinates and intervenes as
necessary to protect quality patient care and worker’s well-being8. Establishes systems
whereby ethical issues impacting stakeholders (health-care consumers, workers,
community, etc.) can be addressed and resolved9. Recognizes and rewards ethical conduct
of subordinates10. Takes appropriate action when subordinates demonstrate unethical
conductMoral Issues Faced by NursesDespite 2017 Gallup poll findings that show
Americans have ranked nursing as the most honest ethical profession for the 16th
consecutive year (Jimenez, 2018), ethical issues are commonplace in nursing. Peter (2018)
agrees, noting that “nurses’ moral lives are growing in complexity given rapid changes that
are the result of scientific advances, a growing business ethos, and technological processes
aimed at standardizing patient care. At times, nurses believe that they cannot respond
adequately to the ethical issues that they encounter because of their enormity and nurses’
responsibility to continue to care for patients despite the obstacles” (para. 1).There are
many terms used to describe these moral issues including moral indifference, moral
uncertainty, moral conflict, moral distress, moral outrage, and ethical dilemmas. Moral
indifference occurs when an individual questions why morality in practice is even
necessary. Moral uncertainty or moral conflict occurs when an individual is unsure which
moral principles or values apply and may even include uncertainty as to what the moral
problem is.On the other hand, moral distress occurs when the individual knows the right
thing to do, but organizational constraints make it difficult to take the right course of action.
Thus, morally distressed nurses often demonstrate biological, emotional, and moral stress
because of this intrapersonal conflict (Edmonson, 2015). Indeed, morally distressed nurses
often experience anger, loneliness, depression, guilt, powerlessness, anxiety, and even
emotional withdrawal. This then leads to turnover as the nurse leaves the stressful situation
for a less stressful environment (Edmonson, 2015). Barlem and Ramos (2015) suggest that
moral distress is one of the main ethical problems affecting nurses in all health systems and
thus is a threat to nurses’ integrity and to the very essence of quality of patient care.Moral
outrage occurs when an individual witnesses the immoral act of another but feels powerless
to stop it. Lastly, the most difficult of all moral issues is termed a moral or ethical dilemma,
which is being forced to choose between two or more undesirable alternatives. For
example, a nurse might experience a moral or ethical dilemma if he or she was required to
provide care or treatments that conflicted with his or her own religious beliefs. In this case,
the nurse would likely experience an intrapersonal moral conflict about whether his or her
values, needs, and wants can or should supersede those of the patient. Because ethical
dilemmas are so difficult to resolve, many of the learning exercises in this chapter are
devoted to addressing this type of moral issue.Individual values, beliefs, and personal
philosophy play a major role in the moral or ethical decision making that is part of the daily
routine of all nurses as well as managers.How do managers decide what is right and what is
wrong? What does the manager do if no right or wrong answer exists? What if all solutions
generated seem to be wrong? Remember that the way managers approach and solve ethical

4. issues is influenced by their values and basic beliefs about the rights, duties, and goals of all
human beings. Self-awareness, then, is a vital leadership role in ethical decision making, just
as it is in so many other aspects of management.LEARNING EXERCISE 4.10 PART 1:The
Untruthful Employee (Marquis & Huston, 2012)You are the registered nurse on duty at a
skilled nursing facility. Judy, a 35-year-old, full-time nurse’s aide on the day shift, has been
with the skilled nursing facility for 10 years. You have worked with Judy on numerous
occasions and have found her work to be marginal at best. She tries to be extra friendly with
the staff and occasionally brings them small treats that she bakes. She also makes a point of
telling everyone how much she needs this job to support her family and how she loves
working here. She has a disabled daughter who relies on her hospital-provided health
insurance to have her health-care needs met.Most of the other staff seem willing to put up
with Judy’s poor work habits, but lately, you have felt that her work has shown many
serious errors. Things are not reported to you that should have been—intake and output
volumes that are in error, strange recordings for vital signs, and so on. She has tried to cover
up such errors, with what you suspect are outright lies. She claims to have bathed patients
when this does not appear to be the case, and has said some patients have refused to eat
when you have found that they were willing to eat for you. Although the chief nursing
officer acknowledges that Judy is only a marginally adequate employee, she has been unable
to observe directly any of the behaviors that would require disciplinary action and has told
you that you must have real evidence of her wrongdoing in order to for her to take
action.During morning report, you made a specific request to Judy that a confused patient,
Mr. Brown, assigned to her, be assisted to the bathroom, and you told her that someone
must remain in the room to assist him when he is up, as he fell last evening. You also told
Judy that when in bed, Mr. Brown’s side rails were always to be up. Later in the morning,
you take Mr. Brown his medication and notice that his side rails are down and after pulling
them up and giving him his medicine, you find Judy and talk with her. She denies leaving the
side rails down and insisted someone else must have done it. You caution her again about
Mr. Brown’s needs. Thirty minutes later, you go by Mr. Brown’s room and find his bed
empty and discover he is in the bathroom unattended. As you are assisting Mr. Brown back
to bed, Judy bursts into the room and pales when she sees you with her patient. At first, she
denies that she had gotten Mr. Brown up, but when you express your disbelief, she tearfully
admits that she left him unattended but stated that this was an isolated incident and asked
you to forget it. When you said that it was her lying about the incident that most disturbed
you, she promised never to lie about anything again. She begged you not to report her to the
chief nursing officer and said she needed her job.You are torn between wanting to report
Judy for her lying because of concerns about patient safety and also not wanting to be
responsible for getting her fired. To reduce the emotionalism of the event and to give
yourself time to think, you decide to take a break and think over the possible actions you
should take.ASSIGNMENT PART 1: 4.10Evaluate this problem. Is this just a simple
leadership–management problem that requires some problem solving and a decision or
does the problem have ethical dimensions? Using one of the problem-solving models in this
chapter, solve this problem. Health Insurance Portability and Accountability Act of
1996Another area of the law that nurses must understand is the right to confidentiality.

5. Efforts to preserve patient confidentiality increased tremendously with the passage of the
HIPAA of 1996 (also known as the Kassebaum–Kennedy Act). Unauthorized release of
information or photographs in medical records may make the person who discloses the
information civilly liable for invasion of privacy, defamation, or slander. Written
authorization by the patient to release information is needed to allow such disclosure.Many
nurses have been caught unaware by the telephone call requesting information about a
patient’s condition. It is extremely important that the nurse does not give out unauthorized
information, regardless of the urgency of the person making the request. In addition, nurses
must be careful not to discuss patient information in venues where it can be inadvertently
overheard, read, transmitted, or otherwise unintentionally disclosed. For example, nurses
talking in elevators, the hospital gift shop, or in a restaurant for lunch need to be aware of
their surroundings and remain alert about not revealing any patient information in a public
place.HIPAA essentially represents two areas for implementation. The first is the
Administrative Simplification plan, and the second area includes the Privacy Rule. The
Administrative Simplification plan is directed at restructuring the coding of health
information to simplify the digital exchange of information among health-care providers
and to improve the efficiency of health-care delivery. The privacy rules are directed at
ensuring strong privacy protections for patient without threatening access to care.The
Privacy Rule applies to health plans, health-care clearinghouses, and health-care providers.
It also covers all patient records and other individually identifiable health information.
Although there are many components to HIPAA, key components of the Privacy Rule are
that direct treatment providers must make a good faith effort to obtain written
acknowledgment of the notice of privacy rights and practices from patients. In addition,
health-care providers must disclose protected health information to patients requesting
their own information or when oversight agencies request the data. Reasonable efforts must
be taken, however, to limit the disclosure of personal health information to the minimum
information necessary to complete the transaction. There are situations, however, when
limiting the information is not required. For example, a minimum of information is not
required for treatment purposes because it is clearly better to have too much information
than too little. The HIPAA Privacy Rule and Common Rule also require that individuals
participating in research studies should be assured privacy, particularly regarding personal
health information.The Privacy Rule attempts to balance the need for the protection of
personal health information with the need to disclose that information for patient
care.Because of the complexity of the HIPAA regulations, it is not expected that a nurse-
manager would be responsible for compliance alone. Instead, it is most important that the
manager work with the administrative team to develop compliance procedures. For
example, managers must ensure that unauthorized people do not have access to patient
charts or medical records and that unauthorized people are not allowed to observe
procedures.It is equally important that managers remain cognizant of ongoing changes to
the guidelines and are aware of how rules governing these issues may differ in the state in
which they are employed. Some provisions of the Privacy Rules mention “reasonable
efforts” toward achieving compliance, but being reasonable is provision specific. The
American Recovery and Reinvestment Act applies several of HIPAA’s security and privacy

6. requirements to business associates and changes data restrictions, disclosure, and
reporting requirements.Legal Considerations of Managing a Diverse WorkforceDiversity has
been defined as the differences among groups or between individuals and comes in many
forms, including age, gender, religion, customs, sexual orientation, physical size, physical
and mental capabilities, beliefs, culture, ethnicity, and skin color (Huston, 2020b).
Demographic data from the United States Census Bureau continue to show increased
diversification of the US population, a trend that began almost 40 years ago.As discussed in
later chapters, a primary area of diversity is language, including word meanings, accents,
and dialects. Problems arising from this could be misunderstanding or reluctance to ask
questions. Staff from cultures in which assertiveness is not promoted may find it difficult to
disagree with or question others. How the manager handles these manifestations of cultural
diversity is of major importance. If the manager’s response is seen as discriminatory, the
employee may file a complaint with one of the state or federal agencies that oversee civil
rights or equal opportunity enforcement. Such things as overt or subtle discrimination are
prohibited by Title VII (Civil Rights Act of 1964). Managers have a responsibility to be fair
and just. Lack of promotions and unfair assignments may occur with minority employees
just because they are different and this is illegal.In addition, English-only rules in the
workplace may be viewed as discriminatory under Title VII. Such rules may not violate Title
VII if employers require English only during certain periods of time. Even in these
circumstances, the employees must be notified of the rules and how they are to be
enforced.Clearly, managers should be taught how to deal sensitively and appropriately with
an increasingly diverse workforce. Enhancing self-awareness and staff awareness of
personal cultural biases, developing a comprehensive cultural diversity program, and role
modeling cultural sensitivity are some of the ways that managers can effectively avoid many
legal problems associated with discriminatory issues. However, it is hoped that future goals
for the manager would go beyond compliance with Title VII and move toward
understanding of and respect for other cultures.Professional Versus Institutional
LicensureIn general, a license is a legal document that permits a person to offer special
skills and knowledge to the public in a particular jurisdiction when such practice would
otherwise be unlawful. Licensure establishes standards for entry into practice, defines a
scope of practice, and allows for disciplinary action. Currently, licensing for nurses is a
responsibility of State Boards of Nursing or State Boards of Nurse Examiners, which also
provide discipline as necessary. The manager, however, is responsible for monitoring that
all licensed subordinates have a valid, appropriate, and current license to
practice.Professional licensure is a privilege and not a right.All nurses must safeguard the
privilege of licensure by knowing the standards of care applicable to their work setting.
Deviation from that standard should be undertaken only when nurses are prepared to
accept the consequences of their actions, in terms of both liability and loss of
licensure.Nurses who violate specific norms of conduct, such as securing a license by fraud,
performing specific actions prohibited by the Nurse Practice Act, exhibiting unprofessional
or illegal conduct, performing malpractice, and abusing alcohol or drugs, may have their
licenses suspended or revoked by the licensing boards in all states. Frequent causes of
license revocation are shown in Display 5.4.DISPLAY 5.4 COMMON CAUSES OF

7. PROFESSIONAL NURSING LICENSE SUSPENSION OR REVOCATION Professional
negligence Practicing medicine or nursing without a license Obtaining a nursing license by
fraud or allowing others to use your license Felony conviction for any offense substantially
related to the function or duties of a registered nurse Participating professionally in
criminal abortions Failing to follow accepted standards of care Not reporting substandard
medical or nursing care Providing patient care while under the influence of drugs or
alcohol Giving narcotic drugs without an order Falsely holding oneself out to the public or
to any health-care practitioner as a “nurse practitioner” Failing to use equipment safely and
responsiblyTypically, suspension and revocation proceedings are administrative. Following
a complaint, the Board of Nursing completes an investigation. Most of these investigations
reveal no grounds for discipline; however, there are things a nurse should do if he or she
becomes aware they are being investigated by the board. These are shown in Display
5.5.DISPLAY 5.5 ACTIONS A NURSE SHOULD TAKE WHEN BEING INVESTIGATED BY THE
BOARD OF NURSING1. Do not ignore the Board’s notification. It won’t go away.2. Do not
unnecessarily share news of the complaint with friends and colleagues as it may undermine
your credibility.3. Read employee handbooks/contracts/policy and procedures to
determine if must report the investigation to your employer.4. Consider contacting an
attorney.5. If a lawyer is needed, hire an experienced one.6. Carefully consider anything
you put in writing.7. Contact your malpractice insurance provider.8. If the investigation
involves a patient, do not violate HIPAA by copying the patient’s medical record.9. Do not
alter the patient’s medical record.10. Be prepared for a lengthy process of
investigation.Source: Extracted from Mackay, T. R. (2018). What do you mean there’s a
complaint?! Texas Nursing, 92(1), 20–22.If the investigation supports the need for
discipline, nurses are notified of the charges and can prepare a defense. At the hearing,
which is very similar to a trial, the nurse can present evidence. Based on the evidence, an
administrative law judge makes a recommendation to the LEARNING EXERCISE 5.8: PART
2:Legal Ramifications for Exceeding One’s DutiesYou have been the evening charge nurse in
the emergency department at Memorial Hospital for the last 2 years. Besides yourself, you
have two licensed vocational nurses (LVNs) and four registered nurses (RNs) working in
your department. Your normal staffing is to have two RNs and one LVN on duty Monday to
Thursday and one LVN and three RNs on duty during the weekend.It has become apparent
that one of the LVNs, Maggie, resents the recently imposed limitations of LVN duties
because she has had 10 years of experience in nursing, including a tour of duty as a medic in
the first Gulf War. The emergency department physicians admire her and are always asking
her to assist them with any minor wound repair. Occasionally, she has exceeded her job
description as an LVN in the hospital, although she has done nothing illegal of which you are
aware. You have given her satisfactory performance evaluations in the past, even though
everyone is aware that she sometimes pretends to be a “junior physician.” You also suspect
that the physicians sometimes allow her to perform duties outside her licensure, but you
have not investigated this or seen it yourself.Tonight, you come back from supper and find
Maggie suturing a deep laceration while the physician looks on. They both realize that you
are upset, and the physician takes over the suturing. Later, the doctor