READINGS: Introduction Unit 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 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 m.

1. READINGS:
Introduction
Unit 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

2. 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 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-

3. 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. 4.1
LEADERSHIP ROLES AND MANAGEMENT FUNCTIONS
ASSOCIATED WITH ETHICS
Leadership Roles
1.
Is self-aware regarding own values and basic beliefs about the
rights, duties, and goals of human beings
2.
Accepts that some ambiguity and uncertainty must be a part of
all ethical decision making
3.
Accepts that negative outcomes occur in ethical decision
making despite high-quality problem solving and decision
making
4.
Demonstrates risk taking in ethical decision making
5.
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 standards

5. 6.
Clearly communicates expected ethical standards of behavior
7.
Role models behavior that eliminates theory–practice–ethics
gaps and promotes ethical behavior as the norm
8.
Promotes patients’ self-determination and informed decision
making
9.
Collaborates with others to protect human rights and promote
social justice
10.
Assures that nurses are represented on interprofessional teams
addressing ethical risks, benefits, and outcomes
Management Functions
1.
Uses a systematic approach to problem solving and decision
making when faced with management problems with ethical
ramifications
2.
Identifies outcomes in ethical decision making that should
always be sought or avoided
3.
Uses established ethical frameworks to clarify values and
beliefs
4.
Applies principles of ethical reasoning to define what beliefs

6. or values form the basis for decision making
5.
Is aware of legal precedents that may guide ethical decision
making and is accountable for possible liabilities should they go
against the legal precedent
6.
Continually reevaluates the quality of personal ethical decision
making based on the process of decision making or problem
solving used
7.
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-
being
8.
Establishes systems whereby ethical issues impacting
stakeholders (health-care consumers, workers, community, etc.)
can be addressed and resolved
9.
Recognizes and rewards ethical conduct of subordinates
10.
Takes appropriate action when subordinates demonstrate
unethical conduct
Moral Issues Faced by Nurses
Despite 2017 Gallup poll findings that show Americans have
ranked nursing as the most honest ethical profession for the
16th consecutive year (
Jimenez, 2018

7. ), 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,

8. 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.

9. 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 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

10. 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

11. 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: 4.10
Evaluate 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 1996
Another area of the law that nurses must understand is the right
to confidentiality. 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

12. 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.

13. 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 requirements to business associates and changes data
restrictions, disclosure, and reporting requirements.
Legal Considerations of Managing a Diverse Workforce
Diversity
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.

14. 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 Licensure
In general, a

15. 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 PROFESSIONAL NURSING LICENSE
SUSPENSION OR REVOCATION

16. 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 responsibly
Typically, 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

17. 5.5
ACTIONS A NURSE SHOULD TAKE WHEN BEING
INVESTIGATED BY THE BOARD OF NURSING
1.
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.

18. 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 Duties
You 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

19. 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 comes to you and says, “Don’t worry! She
does a great job, and I’ll take the responsibility for her actions.”
You are not sure what you should do. Maggie is a good
employee, and taking any action will result in unit conflict.
ASSIGNMENT PART 2: 5.08
What are the legal ramifications of this case? Discuss what you
should do, if anything. What responsibility and liability exist
for the physician, Maggie, and yourself? Use appropriate
rationale to support your decision.