Realizing ethics in the work place A pilot study

Tom Eide, Sandra van Dulmen & Hilde Eide Faculty of Health Sciences

Buskerud University College Contact: tom.eide@hibu.no

Background

•  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; NOU 2010:13).

•  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 middle managers.

•  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

patients/employees) •  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

•  Sample –  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

Stimulating staff’s moral reflection

Daily moral reflection at lunch, using an Ethics advent calendar

leader/staff

Moral reflection at the end of each day, 20 minutes, with colleague

staff

Weekly one hour systematic moral reflection in reflection group

staff/coach

Every 14 days, moral reflection group, one hour, using checklist

staff

Improving organi-zational culture

Involve affected parties in conflict solving at the work

leaders/staff

Weekly reflection on communication issues at staff meetings

leaders/staff

Stimulating leaders’ moral reflection

Weekly systematic moral reflection at managers’ meeting

managers

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)

• 

Mildred My vision 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.

Feedback Dear Mildred! 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! Best wishes, Maria

Reflection – and feedback (example)

Reflection ”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!”

Reflection questionnaires (6 of 7 completing participants)

Examples of reflection statements agree partly

agree partly

disagree disagree

I am conscious of my values as a leader

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 my place

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 moral responsibility

1 4 1

Evaluation – questionnaire (6 of 7 completing participants)

Evaluation: statements/questions agree partly agree

partly disagree

disagree

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 - -

Results

•  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”

Discussion

•  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

health? –  units/organizations: collective mindfulness + ethical

practice + implications for health? –  accessibility/feasibility + improvements

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