Interest in clinical ethics typically focuses on moral dilemmas for individual cases. Interest in clinical ethics typically focuses on moral dilemmas for individual cases. When grappling with individual patient cases nurses must first discern that there is an ethical dilemma and then use a stepwise process to determine a course of action. This is accomplished by being curious and uncovering the relevant facts of the case; organizing those facts to paint a clear picture of the ethical question; and then applying ethical principles, theories, and concepts to identify how to address the ethical question.

This article will focus on collective responsibility for creating a moral community, without which resolution of individual moral dilemmas becomes problematic. The article is written to help the reader reflect on what makes a moral community and to identify strategies to create one. The discussion also includes resources to support moral communities and organizational trust, and thoughts to help nurses to find their places in a moral community.

Anyone who has been a part of a moral community knows it and feels it.The complexity of healthcare demands that we work in synchronous harmony to achieve positive outcomes for patients. Nursing, when practiced to its fullest potential, is a team effort. Even one who practices with the highest ethical standards will rarely be successful in helping patients achieve their goals if that individual does not work together with other clinical care providers. By creating what amounts to a local moral community, high functioning teams typically represent microcosms of the larger moral community.

Without a moral community, nurses are apt to feel isolated and less likely to be able to effectively deal with the ethical challenges they encounter. Anyone who has been a part of a moral community knows it and feels it. The profession of nursing specifies norms of behavior in a code of ethics (American Nurses Association [ANA], 2015) which is frequently operationalized in a code of conduct (Kaplan, Mestel & Friedman, 2010; Rushton & Brooks-Brunn, 1997) or established in practice standards, such as the standards for a healthy work environment (American Association of Critical-Care Nurses, 2016). Even with these guideposts nurses may not feel they are part of a moral community, either locally or more broadly within the profession. Without a moral community, it has been my experience that nurses are apt to feel isolated and less likely to be able to effectively deal with the ethical challenges they encounter.

What is a moral community?

Nursing is considered a moral enterprise and so those who practice within the profession are de facto members of a large moral community. Members are bound to each other through common ethical commitments whose purpose extends beyond, but must include, self-interest in the form of self-care. Leaders of a moral community know that if we fail to take care of ourselves, we cannot care for others and so build self-care into the work.

A moral community in healthcare is a place where its members are encouraged to reflect on their practice... A moral community in healthcare is a place where its members are encouraged to reflect on their practice and engage in deliberations and negotiations about what is a right course of action (Walker, 1993). A moral community is a group of people who demonstrate supportive relationships in pursuit of a common moral goal (Traudt, Liaschenko, & Peden-McAlpine, 2016). In a moral community, leaders embrace honest mistakes as opportunities to learn, not reasons to punish. Relationships are built with intention and founded on respect. When there is conflict everyone engages in discussion to resolve the conflict, remaining focused on the issue and not the people. Members of a moral community feel free to explore emotionally charged issues that are typical when grappling with an ethical dilemma.

When we do not feel part of a moral community, we may want to search for one. Before searching for a new community, we should begin with reflection about whether or not we are contributing members to the community in which we practice. Members of a moral community are not passive, but rather are actively engaged in shared goals. It takes effort to become a trusted member of that community (i.e., reflecting on what makes a moral community and identifying strategies to promote one). Core values are those that we honor even, and especially when, it is difficult. Before reading further, take a moment to reflect on your values and purpose in reading this article (Table 1). You need to know who you are before you can become who you want to be (Gentile, 2010).

Table 1. Short Values Reflection Exercises

*Used with permission

Creating a Moral Community

The previous section encouraged beginning reflection on a moral community. This section will discuss self reflection in more detail, and include two additional concepts important to creating a moral community, becoming an agent of change, and summoning collective courage.

Engaging in Self Reflection
Reflection is the single most effective strategy to establish ethical practice and contribute to a local moral community. Reflection is the single most effective strategy to establish ethical practice and contribute to a local moral community. Searching for a moral community must begin with a mirror. Reflection about core values allows an individual to create a narrative, describing how acting on core values helps that person become who he or she wishes to be (Gentile, 2010). Genuine self-reflection can be unnerving. It is a hard thing to identify and embrace strengths while acknowledging and accepting shortcomings. It can make a person feel unworthy and vulnerable, particularly when one is a member of a moral profession like nursing, where expectations are high.

One vastly under-appreciated provision in the Code of Ethics for Nurses with Interpretive Statements (hereafter referred to as Code of Ethics) may be the provision that reminds us we owe the same duty to ourselves that we do to those in our care; we need to take care of ourselves, physically and emotionally (ANA, 2015, provision 5). Healthcare is a high stakes environment where mistakes and imperfections can lead to serious harms for the people in our care. Since we are human, we may falter at times. What is not stated outright in the Code of Ethics is the need for patience, self-compassion, and forgiveness when we find ourselves in circumstances where we fail to uphold the highest standards set forth in the code. Perhaps this provision is hard to honor because nurses mistakenly believe self-care is promoting self-interest above commitment to patients. Including this provision in the Code of Ethics is a clear statement that self-care is part of the foundation of ethical practice.

In a landmark report from the Institute of Medicine, To Err is Human:Building a Safer Health System, authors Kohn, Corrigan, and Donaldson (2000) put the spotlight on the consequences of errors in medicine. The intensity of that spotlight increased recently with the publication of a study suggesting that deaths from harm events are under-reported (Makary & Daniel, 2016). Add to these stressors the lack of reimbursement for those events considered preventable, and one can appreciate the stress that healthcare workers feel. Preventable implies control over the event and sets a false standard that perfection is possible. Not all harms are preventable, because often they are beyond the control of clinicians. If we are unsuccessful in preventing a harmful event, it feels like a failure on our part.

A moral community is one where its members are supported in moments of imperfection. A new initiative from the National Academy of Medicine to address burnout among healthcare professionals highlights a potential unrecognized threat to safe patient as care from stressed clinicians (Dyrbye et al., 2017). Strong core values may contribute to feelings of distress when we find ourselves in situations where things do not turn out as we hoped they would. The emphasis on patient safety and a potential link to clinician wellness emphasizes how important it is for clinicians to treat themselves with the same care and compassion that they expend on patients. It is a delicate balance to hold ourselves accountable while being at peace with our imperfections. A moral community is one where its members are supported in moments of imperfection.

Different is not necessarily unethical. Beyond exploration of personal values, one must also engage in identifying potential biases by examining strongly held positions. Take a moment to complete the position exercise (Figure 1). The exercise is offered as an opportunity to appreciate how one’s values can lead to strongly held positions, which in turn may blind one to considering a perspective different from one’s own. First, identify your perspective on the continuum for each statement. Next, identify positions that are held strongly and ask, “How would a nurse with a good moral character offer a values based defense for the viewpoint diametrically opposed to ones that are most strongly held?” The goal in this exercise is to imagine that a different perspective can be held by someone with strong values. Different is not necessarily unethical.

Figure 1. Moral Community Positions Inventory

Modeled after the Bioethics Position Inventory (Fiester, 2015).

Being part of a moral community means sharing a covenantal relationship with each other and society, in spite of our differences (Pellegrino, 1990). Each of us must move beyond the “me” and focus on the “we.” We cannot depend on one moral expert to guide but rather expect that building and sustaining a moral community is everyone’s responsibility (Bates, McHugh, Carbo, O”Neill, & Forrow, 2016). In the profession of nursing, we are called to contribute to an ethical work environment (ANA, 2015, provision 6). We are not called to change others; only to hold ourselves to high standards, accept our imperfections, and be respectful of those with whom we disagree.

We may be connected to others in a moral community even if we disagree with them and do not hold the same views. Human beings are intrinsically relational, which is why connection with others in a shared moral community is so important (Traudt et al, 2016). The previous exercises are designed to help readers explore the boundaries of their ability to accommodate values and commitments that are different from their own. We need not force others to change to accommodate our perspective. We may be connected to others in a moral community even if we disagree with them and do not hold the same views.

Becoming an Agent of Change
While we must all learn to accept what we are not able to change, each of us can be an agent of change. While we must all learn to accept what we are not able to change, each of us can be an agent of change. In the Change Agents’ Handbook, Hutton (1994) emphasized the importance of investing in relationships when one faces the challenging task of influencing for change, without authority to make it happen. Strong relationships are central to the high functioning teams and healthy work environments where moral communities thrive.

The vital skill essential to a strong moral community is giving voice to values, particularly in times of conflict. The profession of nursing authorizes us to act as moral agents, however moral agency requires individuals to choose to act. Even though we are empowered by our profession to insist on and work toward building a moral community, the body of work known as “silence kills” is clear evidence that healthcare environments are not always moral communities (Maxfield, Grenny, McMillan, Patterson, & Switzler, 2005; Maxfield, Grenny, Lavandero, & Groah, 2011). Nurses and other clinical care providers sometimes avoid conflict and remain silent, even when presented with opportunities to protect patients from harm. Each of us has within our control the power to learn a new skill. The vital skill essential to a strong moral community is giving voice to values, particularly in times of conflict. If we are going to build moral communities, we have to change. We must develop skills necessary to break the habit of silence. When individuals recognize a need to create a moral community, they must be prepared to navigate complex change.

Lippitt (2003) was the first to describe five essential components for leading complex change. There must be a shared vision. People must have skills. Resources must be dedicated to the effort. There needs to be a clear plan. Incentives will accelerate the rate of change. Without a vision, there is confusion. Without skills, people will be anxious. Without resources, there is frustration. Without incentives, there will likely be resistance. Without a plan, there will be false starts. The path to successful change is not linear through these five components but rather depends on a dynamic interaction of these five components (Lippitt, 2003).

Nurses must practice behaviors that exemplify our values and our commitment to creating moral communities. In a plenary session for the American Academy of Nursing on social justice, ethics, and workforce issues, speaker G. Rumay Alexander noted, “We cannot talk our way out of something we have behaved ourselves into.” (2017). Consider the scenario in Table 2 below and reflect on what the actions of the individuals in the story communicate about their values and positions.

Table 2: Values and Positions Exercise

Summoning Collective Courage
One might argue that the team in the above scenario caring for the newborn with a cardiac defect does not exemplify a moral community. The nurse and the physician clearly are focused on different values and have indirectly stated their positions. Even this short dialogue demonstrates an absence of an ability to engage in shared moral reflection, an essential activity for moral communities to exist (Bates et al., 2016). There are countless examples of behaviors in healthcare that exemplify an unhealthy work environment, which in turn compromise a moral community. Chief among them are behaviors that undermine respect for one another, as illustrated in the scenario above.

Disrespect is known to contribute to unhealthy and consequently unsafe work environments (Kaplan et al., 2010; Leape et al., 2012; Maxfield et al., 2005; Maxfield et al., 2011; Simpson, 2017; The Joint Commission, 2008). The nurse in the scenario attempted to give voice to her values. The response of the physician was disrespectful of her and dismissive of her values. Her silence, and the silence of others following the outburst, was no doubt due in part to the sense of vulnerability, a common response to the experience of disrespect. Because actions are often directed by emotions, before one can engage fully in the practice of giving voice to values (particularly when challenged) one must first attend to the intensely emotional experience of an ethically challenging situation (Wocial, 2012).

Courage should never be required to ask a question to invite exploration of a difficult topic. There is real danger in celebrating individual courage when someone gives voice to values in a difficult situation (Hamric, Arras, & Mohrmann, 2015). In the scenario, if the nurse remains silent, she has failed to engage in the difficult work of exploring conflicting values and positions. This does not however represent an individual failing on her part. Courage should never be required to ask a question to invite exploration of a difficult topic (Hamric et al., 2015). In this scenario, one would have to question the sense of justice in the environment and might rightly conclude that what is needed is collective courage to address this lapse in support of a fully open moral community.

In the beginning, breaking the cycle of silence in an effort to establish a strong moral community may require some courage. The source of courage can be enhanced by one’s ability to imagine positive outcomes when performing the challenging behavior (Gentile, 2010). In the scenario of the newborn, a genuine desire to explore harms and benefits of treatment and patient best interest should be a strong motivator to raise up one’s voice. The point of the scenario of the newborn is that those in attendance were incapable of holding an open dialogue about different courses of action that represented different values. Over time, speaking up in challenging situations should require less courage, if the skill is practiced and there are processes in place to support individuals who speak up and hold accountable those who undermine that behavior (Kaplan et al., 2010). Acts of courage come from habits of the heart (Serkerka & Bagozzi, 2007).

Disrespectful behavior presents a unique form of conflict for teams. Disrespectful behavior presents a unique form of conflict for teams. In the scenario above, the disrespect complicates a genuine values conflict. Members of a moral community depend on each other to address conflict in constructive ways, even when confronted with disrespect (Traudt et al., 2016). Active members of a moral community have done the hard self-reflection and are not afraid to engage in serious group self-reflection on a regular basis, especially when challenged.

Use the questions in Table 3 to reflect on the team of people with whom you work. These questions are based on Lencioni’s (2002) five dysfunctions of teams: absence of trust, fear of conflict, lack of commitment, avoidance of accountability, and inattention to results. Consider what ways the members of your team use to address team dysfunction. Imagine a team where members are willing to call attention to others on the team when they do not behave in a way consistent with the goals of the local moral community, and rather than defensiveness, the reaction is gratitude for the opportunity to correct the behavior. Teams that have opportunities to improve skills that would promote such an environment could benefit greatly from engaging in a well-known, research-based program called TeamSTEPPS (Agency for Healthcare Research and Quality [AHRQ], 2007).

Table 3. Reflection on Team Function

(Lencioni, 2002)

Resources to Support Moral Communities

Structure and order bring an opportunity for clarity around shared social norms (i.e., expected behaviors in a moral community). TeamSTEPPS identifies multiple strategies to improve team communication to promote mutual support and situational monitoring, essential relationship focused elements of a moral community. One recommended strategy is to use is “CUS” words as follows: express concern; an individual is uncomfortable; [because] there is a safety issue (AHRQ, 2007). Teams that wish to be explicit about generating a moral community might consider modifying this strategy to use “CUES” to: express concern, an individual is uncomfortable because an ethics concern is compromising the safety of the situation.

In an ethical environment, beyond the code of conduct, there must be a transparent process to resolve disputes. A code of conduct can be the central focus for a team wishing to develop structures and processes that help to monitor and evaluate the moral community (Kaplan et al., 2010). A code on paper is not enough to create a healthy work environment. In an ethical environment, beyond the code of conduct, there must be a transparent process to resolve disputes. Kaplan et al. (2010) also presented a comprehensive blueprint for creating a culture of mutual respect, otherwise known as a moral community. Steps in this blueprint included selecting advocates; implementing a system to reconcile disputes; tracking and addressing systems issues; providing staff training, developing a formal process to ensure accountability; and measuring results.

Organizational Trust

...forgiveness is such an important part of courage – self-forgiveness, in particular. Wisdom comes from experience, but only if one is able to reflect on the experience to gain insight. Heathcare providers are not oblivious to harms that result when mistakes happen in the course of providing patient care. This is why forgiveness is such an important part of courage – self-forgiveness, in particular. There is mounting evidence that clinicians are traumatized when they are involved in events that result in harm to patients (Seys et al., 2013). Despite available resources and descriptions of programs to support clinicians involved in harm events (see examples in Table 4), there is rising concern that healthcare environments are deficient in providing these resources and establishing programs to support clinicians involved in these circumstances (NAM call to action) (National Academy of Medicine, 2018)

Table 4. Select Resources to Develop Clinician Support Programs

A just culture is necessary for moral communities to thrive. When clinicians are accountable for their actions, they deserve TRUST, or treatment that is just; respect; understanding and compassion; supportive care with transparency; and the opportunity to contribute to recovery (Denham, 2005). These elements of TRUST are consistent with an environment (i.e., a just culture) that is supportive of open dialogue between members who feel safe when they question existing practices, express concerns or dissent, and admit mistakes (Khatri, Brown, & Hicks, 2009). A just culture is necessary for moral communities to thrive. When individuals feel trusted and allowed to work autonomously they are more able to commit to an organization and engage fully to establish a moral community. While individuals must develop courage to raise their voices in ethically challenging circumstances, they must also see the wisdom of asking for organizational support to create strong moral communities. Wise leaders will recognize that without adequate resources dedicated to support moral reflection, trust cannot exist and, without trust, moral communities cannot exist.

Finding One’s Place in a Moral Community

Without collective moral support from members of a local moral community, few individuals could fulfill their individual obligations in a complex healthcare environment. Each of us must focus on the thought that individuals in the healthcare professions are, in general, people of good conscience trying to do what is right by the patient. A strong local moral community depends on individuals having relationships that allow for questioning and that can tolerate the expression of uncertainty, even in the face of conflict (Traudt et al., 2015). Sometimes, that will require compromise.

Compromise with integrity requires mutual respect, sharing a common language, acknowledgement of moral uncertainty, and limits to the compromise (Rushton & Brooks-Brunn, 1997). By no means are all members of a moral community equal. Authority gradients are inescapable in the world of healthcare.

In the end, each of us must decide whether or not we have done all we can do to be present in, and role model behaviors essential to, the moral community. Kritek (2002) offered sound advice for those who feel they are working at an uneven table: find and inhabit the deepest and surest human space that your capabilities permit; honor your integrity even at great cost; find a place for compassion; stay in the dialogue; and know when and how to leave the table. Resolving conflict is a moral enterprise and is everyone’s responsibility (Kritek, 2002). To remain in dialogue, each of us must develop humility, respectful listening, and accommodation for views different from our own. In the end, each of us must decide whether or not we have done all we can do to be present in, and role model behaviors essential to, the moral community. If we have changed all that is within our power to change and still do not feel we are in a strong local moral community, we may need to consider walking away in search of a new one or staying with intention to continue efforts to create one where we are.

Closing

As in clinical ethics, the best interests of an individual can rarely be considered in isolation of the community in which the individual lives. You will not find a text, “Building Moral Communities for Dummies,” on the bookshelf. There are no short cuts. This is hard and essential work. It must not be IF we decide to build moral communities. It can only be WHEN we search for them that we are able to uncover and contribute to them.

...one person alone cannot be responsible for creating a moral community. Promoting strong moral communities in healthcare depends on each of us learning to be civil in the broader society, a civilization currently undergoing tremendous social upheaval by many accounts. While each of us has a part to play, one person alone cannot be responsible for creating a moral community. There must be commitment from all who are members of the community and organizations must create processes to support the establishment and maintenance of this culture.

Author

Lucia D. Wocial, PhD, RN, FAAN
Email: lwocial@iuhealth.org

Dr. Wocial is a graduate of the Oregon Health and Sciences University School of Nursing, undergraduate and graduate programs. In her current role as Nurse Ethicist with the Fairbanks Center for Medical Ethics (FCME), she focuses on supporting the ethical practice of nurses at the Indiana University Health Academic Health Center in Indianapolis, Indiana and serves as faculty for the FCME ethics fellowship as well as adjunct assistant professor in the Indiana University School of Nursing teaching applied ethics. She is a well published author and member of the steering committee for the 2015 revision of the ANA Code of Ethics for Nurses.

Lencioni, P. (2002). The five dysfunctions of a team. San Francisco: Josey-Bass.