The importance of creating healthy and ethical work environments in the clinical setting has been a focus in nursing for several years. However, research has found that incidents of incivility and bullying occur in academia as well. Nurse educators often face complex situations in the academic workplace that have ethical implications, including relationships with each other, academic administrators, and students. A review of the evidence indicates that studies have considered the importance of creating an ethical environment in nursing practice, and incivility, but few have focused on healthy work environments in academia. This article presents the nine provisions of the ANA Code of Ethics for Nurses in the context of the nursing academic environment as a framework to discuss the philosophical and practical importance of envisioning an ethical environment within academic settings. Examples of relationships are provided that demonstrate a positive ethical climate or illustrate areas in need of reflection for improvement, with suggested implications for practice.
Key Words: ethics, nursing education, ethical climate, ethical environment, ANA Code of Ethics for Nurses, ethical practice, incivility, nursing academic leadership, healthy work environment.
Ethical behaviors result in our being prepared to put the right choice into action.The profession of nursing, grounded in its core values, principles, and commitment to society, has traditionally expressed a focus on ethics. Ethics is a branch of philosophy that reflects on values and practices that guide expected behaviors in terms of right and wrong. Ethical behaviors result in our being prepared to put the right choice into action.
The importance of creating healthy and ethical work environments in the clinical setting has been a focus in nursing for several years. However, research has found that incidents of incivility and bullying occur in academia as well, often leading to moral distress and faculty turnover (Clark, 2020; Stalter et al., 2019). As a result, recent efforts have targeted the academic work environment. The American Nurses Association (ANA) Code of Ethics for Nurses with Interpretive Statements (2015a; referred to hereafter as the Code) is the ethical gold standard for the profession of nursing. The nine provisions of the Code can serve as a framework to discuss the philosophical and practical importance of creating an ethical environment within academic settings.
The Code is "more relevant than ever" in today’s workplace and academic environment (Morin, 2015). The Code provides a guide for nursing practice and for the profession, and serves as a resource for nurses in all roles and settings (Epstein & Turner, 2015). Other foundational documents of the nursing profession that guide nursing practice include professional standards of practice (ANA, 2015b; Olson, 2012); Nursing’s Social Policy Statement (ANA, 2010; Fowler, 2015b) which describes the relationship of the profession to society; and state nurse practice acts (Olson & Stokes, 2016).
Ethical climate...consists of the organizational conditions and practices that influence the ways that ethical issues and concerns are identified, discussed, and decided.In addition, themes inherent within the concept of ethical climate provide additional guidance for this discussion. Ethical climate, as a type of organizational climate, consists of the organizational conditions and practices that influence the ways that ethical issues and concerns are identified, discussed, and decided. The Hospital Ethical Climate Survey (HECS) measures how nurses perceive the ethical climate of their work environment (Olson, 1998). The HECS is organized according to key relationships within the work environment, which encompass conditions of power, trust, inclusion, role flexibility, and inquiry. Key relationships within the practice environment include relationships with one’s colleagues and direct manager/administrator; physicians; and interdisciplinary team members; and with the hospital as a whole through its policies, procedures, and the values expressed in its mission and goals.
This article presents the nine provisions of the ANA Code of Ethics for Nurses in the context of the nursing academic environment as a framework to discuss the philosophical and practical importance of envisioning an ethical environment within academic settings. Examples of relationships are provided that demonstrate a positive ethical climate or illustrate areas in need of reflection for improvement, with suggested implications for practice.
Review of Evidence
Nursing education programs are where students experience the framework for their practice, and especially for their ethical practice.Numerous articles and research studies about ethical climate have been undertaken in nursing practice settings, both nationally and internationally (Fogel, 2007; Hamric & Blackhall, 2007; Pauly et al., 2009; Silén, 2011). However, no studies that considered ethical climate in nursing academic settings were found, and similarly, no articles that specifically discuss creating an ethical climate in nursing academia. Why not? Nursing education programs are where students experience the framework for their practice, and especially for their ethical practice.
Because ethics occurs within the context of relationships, those with whom nurses interact must be included in creating an ethical work environment. In the clinical area, these are one’s peers, employers, managers, physicians and other members of the healthcare team, and of course, patients and families. The key relationships in the academic environment in nursing programs include leadership (e.g., deans, associate deans), faculty, and students, in addition to partners in the clinical areas of practice, and the patients and families with whom nursing faculty interact in student clinical experiences.
An ethical culture consists of the mechanisms in place that promote awareness and discussion of ethical issues and concerns...One often uses the terms ethical environment, ethical culture, moral community, and ethical climate interchangeably. An ethical culture consists of the mechanisms in place that promote awareness and discussion of ethical issues and concerns, such as hospital ethics committees, ethics consultants, or ethics educational activities. Since climate is about perception, ethical climate is concerned with whether these mechanisms are working. Ethical climate is one type of organizational climate, which has as its focus ethics and ethical practices.
The ethical climate of an organization can be assessed by measuring employee perceptions of conditions or practices that allow them to engage in ethical reflection and discussion, and that facilitate resolution of ethical issues. Members of a moral community practice self-reflection about their practice and core values, and build their relationships on intention and respect, thereby recognizing that differences in perspectives are important (Wocial, 2018).
In an ethical work environment, the values of trust and respect are paramount.When nurses perceive a positive ethical climate, they feel can raise ethical concerns without fear of retribution, can discuss difficult issues with their peers and their managers, and are participants in decision-making. In an ethical work environment, the values of trust and respect are paramount. There are mechanisms in place for discussion of issues of concern. Nurses feel empowered as members of the healthcare team where their viewpoints and opinions are heard and valued. They feel they are respected by the facility in which they work (Olson, 1998, 2018). Similarly, nurse educators need to feel that someone listens to their concerns and that they are included in decisions that affect their work, their relationships with students, and the curriculum. They must feel comfortable to voice their viewpoints without fear of retribution.
In practice settings, nurses interact with and problem-solve on an ongoing basis with members of the interdisciplinary team. In academic settings, nurses are primarily interacting with other colleagues in their own discipline, and are working independently. This difference can sometimes create problems when some faculty become involved in groups known as cliques. Cliques can lead to situations where not all members of a faculty perceive that they are included in important decision-making.
In academic settings, nurses are primarily interacting with other colleagues in their own discipline...A number of studies have found a relationship among the concepts of ethical climate, moral distress, and intent to leave a position and/or job satisfaction in clinical settings (Fogel, 2007; Olson, 2018; Silen et al., 2011; Ulrich & Grady, 2018). Although moral distress occurs among faculty and others in academic settings, there is little research that explores moral distress and ethical climate specifically related to nursing education (Ganske, 2010).
Healthy Work Environments in Academia
Professional Guidelines
To improve nurse job satisfaction and retention, recent efforts have focused on healthy work environments in clinical practice, promoting professional practice, and improving patient safety and quality patient outcomes (Brady, 2010, LaSala & Bjarnason, 2010). Professional organizations, such as the American Organization of Nurse Leaders ([AONL], 2019) and the American Association of Critical Care Nurses ([AACN], 2005; Ulrich et.al., 2019) have developed criteria and standards that contribute to a healthy work environment. The AONL Nine Elements of a Healthy Practice Environment (2019) include the presence of a collaborative practice culture focused on respectful, collegial communication and behavior and the presence of trust. The AACN “Healthy Work Environment standards,” which include six evidence-based standards for creating a healthy work environment, have been used as an assessment tool to measure the work environment in clinical practice (AACN, 2005).
Strong leaders in both healthcare practice and academic environments serve as role models for high professional and ethical standards...In academia, the National League for Nursing (NLN) “Healthful Work Environment Tool Kit” (2018) addressed areas that contribute to a healthy nursing academic work environment. These components, which include salaries, workload, collegial environment, role preparation and professional development, scholarship, institutional support, marketing and recognition, and leadership can be used to survey faculty satisfaction with their work and work environment (Brady, 2010). Strong leaders in both healthcare practice and academic environments serve as role models for high professional and ethical standards, and are responsible to foster and sustain ethical environments (Murray, 2007).
Incivility in Academia
In the academic environment, incivility includes remarks that are insulting and disruptive and can lead to psychological or physiological distress...Numerous articles and studies have been published about the prevalence of incivility, both in practice settings and in academia (Clark & Springer, 2007; Clark et al., 2013; Clark, 2020; Peters, 2014; Peters & King, 2017; Rawlins, 2017; Stalter et al., 2019). Incivility, also referred to as lateral violence, or in more serious cases as bullying, impacts nurses in all roles and settings, including faculty and students. In the academic environment, incivility includes remarks that are insulting and disruptive and can lead to psychological or physiological distress; these are considered verbal abuse. Such comments can potentially lead to actions that are violent or threatening (Clark & Springer, 2007; Clark et al., 2013). In the current settings of nursing education, incivility by technology also occurs, potentially creating an environment that disrupts the workplace and faculty relationships (Peters & King, 2017). The aftermath of emotional and moral distress can ultimately impact patients and patient safety, and retention of nurses in organizations and in the profession.
In academia, studies have addressed incivility in the forms of faculty-to-faculty, faculty-to-student, and student-to-faculty. Instances of incivility also occur between educational administrators and faculty. Heinrich (2007, 2017) conducted early studies referred to the concept of scholarly joy-stealing, in which she identified stories by faculty of conflict in relationships with colleagues. Based on 261 stories of educators, which Heinrich defined as “incivility with a scholarly twist” (p.34), ten scholarly joy-stealing games emerged. The themes in these stories stem from “conflicted relationship with colleagues” (2007, p. 34). Many resulted from the focus in academia on scholarship and competition, and on what can be referred to as academic jealousy.
Many resulted from the focus in academia on scholarship and competition...With the highly competitive climate and “publish or perish” imperatives in academia, nurse academics are challenged to be optimistic about creating and maintaining a positive and ethical workplace environment (Heinrich, 2010). Heinrich suggests shifting the rules in academia from competition to cooperation to change the way that faculty educate and interact with peers and administrative colleagues. One way to do this is to create a caring culture in which faculty celebrate each other’s accomplishments.
Examples that demonstrate conflicted relationships in academia include situations between academic administrators and faculty, among individual and groups of educators, and between faculty and students. There are numerous examples in the literature on incivility in nursing education, as well as from observations from personal and professional experiences, and from those shared by faculty colleagues. Some common examples include lack of support for one’s work and scholarly endeavors, excluding some faculty from professional activities, and criticizing, making insulting comments, or verbally attacking colleagues (Clark et al., 2013; Heinrich, 2007; Peters & King, 2017). Examples shared from faculty colleagues include a dean announcing to faculty that she has strategies; an academic administrator complaining about individual educators to other faculty members; faculty openly criticizing other faculty for their work or scholarly achievements; and faculty making disparaging comments to students. Many other examples could be offered. Instead of conflict, nurse educators can be empowered with a commitment to transform their workplaces to an ethical environment, with perceptions of a positive ethical climate.
Instead of conflict, nurse educators can be empowered with a commitment to transform their workplaces to an ethical environment...Clark’s (2019, 2020) 2020 extensive research about incivility among faculty led to a variety of teachable, evidence-based strategies that can help when confronted with incivility. Many educators can identify situations in relationships with colleagues where they have been spoken to in a condescending way or disrespectful way, leading to conflict and perceptions of a negative workplace environment. Clark (2019, 2020) provides approaches to address incidents of workplace bullying. Organizations that foster and maintain healthy, ethical workplace environments are able to build trust among colleagues and between educators and academic administrators when faculty are empowered to speak, listened to, and encouraged to express viewpoints about issues and concerns.
The Code and the Nursing Academic Environment
All nine provisions of the Code (ANA, 2015a) have relevance to nursing education programs and relationships. The nine provisions of the Code are presented in the Table. The key relationships that comprise an ethical climate, along with the conditions of power and trust, inclusion, and role flexibility and inquiry are also discussed in this section, as they apply to the ethical environment in nursing education.
Table. Code of Ethics for Nurses: Provisions with Interpretive Statements
| Provision 1 | The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person. |
| Provision 2 | The nurse’s primary commitment is to the patient, whether an individual, family, group, community, or population. |
| Provision 3 | The nurse promotes, advocates for, and protects the rights, health, and safety of the patient. |
| Provision 4 | The nurse has authority, accountability, and responsibility for nursing practice; makes decisions, and takes action consistent with the obligation to promote health and to provide optimal care. |
| Provision 5 | The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth. |
| Provision 6 | The nurse, through individual and collective effort, establishes, maintains, and improves the ethical environment of the work setting and conditions of employment that are conducive to safe, quality healthcare. |
| Provision 7 | The nurse, in all roles and settings, advances the profession through research and scholarly inquiry, professional standards development, and the generation of both nursing and health policy. |
| Provision 8 | The nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities. |
| Provision 9 | The profession of nursing, collectively through its professional organizations, must articulate nursing values, maintain the integrity of the profession, and integrate principles of social justice into nursing and health policy. |
(Used with Permission) (ANA Code of Ethics for Nurses with Interpretive Statements, 2015a)
...respect for all individuals with whom faculty and educational administrators interact includes students and affiliated agencies.Application of the Code
Respect for Others. Provision 1 of the Code (ANA, 2015a) focuses on the core value of respect for others, highlighting compassion, each person’s inherent dignity, worth, and unique attributes. Provision 1.5 specifically refers to relationships with colleagues and others, and extends the value of respect to “all individuals with whom the nurse interacts” (p. 4). In the academic setting, respect for all individuals with whom faculty and educational administrators interact includes students and affiliated agencies. The Code emphasizes that the creation of an ethical environment encompasses a culture of civility. The elimination of incivility in practice must start in education.
It is essential that students view faculty members as role models for professional behaviors.Commitment. Provision 2 of the Code (ANA, 2015a) expresses that the primary commitment of the nurse is to the patient; this is true in education settings as well as in practice. An additional primary commitment of the nurse educator and administrator is to students, who are in the process of forming their professional identities as future nurses (Godfrey, 2020). Just as it is important for nurses in clinical practice to exhibit genuine caring for their patients, it is equally important that nursing students perceive that faculty care about them and their education as developing nurses. It is essential that students view faculty members as role models for professional behaviors (Savage & Favret, 2006).
Protecting Rights. Provision 3 of the Code (ANA, 2015a) focuses on the role of the nurse to promote, advocate for, and protect the “rights, health, and safety of the patient” (p.9). It is important for students to learn about protecting patient rights to privacy and confidentiality; protecting the rights of patients who participate in research; and taking responsibility for patient safety. It is no less important for faculty members to advocate for students, and for leaders in educational administration to advocate for faculty. These leaders in nursing education (i.e., deans, directors), in addition to supporting faculty and students, also advocate to both higher level academic administrators and the community the values of the nursing profession and requirements to safely and ethically meet the needs of the nursing program (Gray, 2008).
Competency. Another component of Provision 3 (ANA, 2015a) addresses the responsibility of nurses to act on questionable practice. Along with this is the ethical responsibility for nurses in all roles and settings to maintain competence, as addressed in Provision 4 of the Code. A condition within the work and academic environments, and a component that supports a positive ethical climate, is the perception that nurses work with competent colleagues, including faculty (Olson, 1998).
Power and trust are two conditions addressed when assessing ethical climate.Power, Trust, and Inclusion. Power and trust are two conditions addressed when assessing ethical climate. With power, faculty, students, and others feel that they have the right to express their viewpoints, and to agree or disagree with other viewpoints without fear of reprisal. The “ethical dimension in education” exists as a result of faculty who possess the power to provide students with the necessary knowledge to succeed and to achieve their educational goals (Savage & Favret, 2006, p. 48). Everyone involved in the educational process has a right to receive relevant information, and to express their views, which is also a component of academic freedom.
Another condition within an ethical climate is inclusion, which is met when individuals and groups who have a role in an issue or decision are involved in conversation and discussion, as well as the decision-making process. Thus it is important for academic leaders to include the voice of the faculty in decisions that affect their work, working conditions, or the curriculum. In addition, the student voice contributes to academic policy and decision-making.
...nurse leaders are responsible to foster a balance among health-promoting and satisfying work.Duty to Self. Provision 5, new to the Code in the 2001 version, continues as a provision in 2015. This provision expresses the concept of duty to self (ANA, 2015a). These “self-regarding duties” include promotion of personal health and safety as well modeling health promotion measures through teaching and research. As expressed in Provision 5.2, nurse leaders are responsible to foster a balance among health-promoting and satisfying work. A component of preserving personal wholeness of character and integrity is feeling free to express one’s opinions and viewpoints without fear of reprisal, thereby facilitating an ethical environment and reducing moral distress.
Actively listening to a different viewpoint, whether between faculty or administrative members, demonstrates understanding and value for the other person whether or not there is agreement about the perspectives. The Code (ANA, 2015a) also views maintenance of competence and ongoing professional growth as a self-regarding duty. This is consistent with the importance of our own competence as well as working with competent colleagues, both essential to practice in an ethical work environment. By fostering an attitude of continuous and life-long learning in themselves and in students, faculty demonstrate a duty to self, others, and to the profession.
...the responsibility to create an ethical environment falls upon all nurses...Responsibility for an Ethical Environment. As Provision 6 of the Code (ANA, 2015a) notes, the responsibility to create an ethical environment falls upon all nurses, and especially on those in formal leadership positions. As stated in Provision 6.3, those in nurse executive roles, such as academic deans and associate deans, are particularly responsible for treating employees fairly and justly, and for involving them in decision-making. Participation in decision-making is a key component that leads to job satisfaction and retention. The condition of inclusion is met when those who are affected by or have a role in the outcome of decisions have the opportunity to be involved in the process. The conditions of inquiry and role flexibility occur when questions and different viewpoints are encouraged to share and gain information between those in leadership positions and those affected by the issues.
Advancing the Profession. Provisions 7, 8, and 9 of the Code (ANA, 2015a) address aspects of nursing duties that extend beyond individual patient encounters, and also relate to the responsibility for nurses in all roles and settings to participate in activities that advance the profession (Provision 7); promote community and world health (Provision 8); and promote the nursing profession (Provision 9). While nurse educators have an important role in evidence informed practice, not all nurses are expected to conduct research (Fowler, 2015a). Nurse educators often conduct and disseminate research. They promote professional practice standards of nursing and the values and ethics of the profession in local, national and global arenas.
Support and recognition for each other’s scholarly accomplishments transforms the focus to “scholarly caring.”Awareness of, and contributions to, health policy maintains the integrity of the nursing profession and promotes the health and safety of patients, whether individuals, families, groups, communities, or populations. Scholarship in these areas often leads to competition and conflict in relationships with colleagues, and to what Heinrich referred to as “scholarly joy-stealing” (2017, p. 2). Support and recognition for each other’s scholarly accomplishments transforms the focus to “scholarly caring” (Heinrich, 2017, p. 3). In an ethical academic climate, relationships encompass mutual respect in which there is recognition and learning from differing perspectives.
Implications for Practice: Creating Ethical Environments in Academia
...academic administrators and educators make the concepts of ethics a priority by discussing these in various venues...The professional obligation for nurses to contribute to and assure an ethical practice environment is clearly specified in the Code (ANA, 2015a). In providing ethical leadership, academic administrators and educators make the concepts of ethics a priority by discussing these in various venues; by encouraging discussion about ethics and ethical concerns; and by modeling behaviors that foster creation and maintenance of an ethical environment and culture throughout their own academic setting and in interactions with others.
There are specific activities and initiatives that could be useful to enhance and support ethical practice in academia. One strategy is to use guiding documents of the nursing profession as a collaborative effort to conduct an analysis of strengths, weaknesses, opportunities, and threats (SWOT) in the academic environment. This should include a focus on the stated mission and values of the institution. Steps of this assessment would be to create, review, and update policies to address unethical and uncivil behaviors in the academic workplace, as well as with students and each other.
One strategy is to use guiding documents of the nursing profession...to conduct an analysis of strengths, weaknesses, opportunities, and threats in the academic environment.An assessment of the ethical climate of the academic work setting would serve to highlight areas in which interventions are needed (Olson, 2018; Ulrich & Grady, 2018). Policies that indicate intolerance for behaviors or show lack of respect for each other, or that promote support and recognition, are important to eliminate situations of incivility and academic jealousy. Heinrich (2017, p. 3) suggested shifting the focus of faculty groups to “scholarly caring”, and creating a “code of scholarly etiquette,” in which faculty as a group dialogue to imagine what would make a positive ethical climate with mutual respect and recognition. Such an initiative would ideally align with the academic institutional policies and guidelines, and mission, vision, and values.
Faculty serve as role models for students, the future nurses will who carry forth behaviors seen in the academic setting to their workplaces. As role models, nurse educators are expected to treat their colleagues with respect, and to be open and willing to listen to and recognize diverse viewpoints among each other and with students (Olson, 2012). By demonstrating professional behaviors, faculty prepare students, who will face difficult and ethical situations as graduates in practice. Faculty need to ensure that students can engage in ethical reflection in order to recognize everyday ethical issues, make ethical decisions, and solve problems (Benner et al., 2010). Administrators in the academic environment also contribute to this process. University administrators are responsible for helping to create an ethical environment and for helping faculty and students learn how to deal with conflict and unhealthy behaviors.
Integration of the values of inclusion, trust, and respect for differences of opinion are essential to create an ethical climate.Integration of the values of inclusion, trust, and respect for differences of opinion are essential to create an ethical climate. Offering courses dedicated to ethics content at all levels of the nursing curriculum (i.e., undergraduate, graduate, doctoral) demonstrates that ethics is a priority. Some academic nursing programs regularly offer continuing education programs about ethical content and ethical issues and concerns that are open for inclusion of faculty, staff, students, other academic disciplines, and the community. These programs provide an opportunity to invite and hear from experts on ethics, and to prepare students for issues they will find in their practice settings as graduates. Casale (2017) suggested implementing a foundation of emotional intelligence, along with coaching and mentorship as strategies to promote job satisfaction. These approaches would also promote perceptions of a positive ethical climate.
Conclusion
This article has used the Code of Ethics for Nurses (ANA, 2015a) as a framework to consider philosophical foundations and strategies important to ensure an ethical environment in academic settings where nursing programs are administered. There are numerous anecdotal accounts and research studies that demonstrate incivility in academic settings, resulting in moral distress. Although studies about ethical climate and the relationships to moral distress, job satisfaction, and retention have considered practice settings, little research has been conducted in nursing academic settings. Creating and fostering an ethical environment in academic work settings and taking actions to result in positive perceptions of ethical climate would benefit relationships among faculty, between academic administrators and faculty, and between faculty and students. An active focus to create and sustain an ethical environment within academic settings benefits nurse educators, students, the nursing profession, and ultimately, the patients for whom nurses care.
Author
Linda L. Olson, PhD, RN, NEA-BC, FAAN
Email: lalolson@gmail.com
Linda L. Olson, PhD, RN, NEA-BC, FAAN attended the University of Illinois at Chicago for her PhD and MBA, and Northern Illinois University for her BSN and MSN. Dr. Olson is the author of the Hospital Ethical Climate Survey (HECS), an instrument that has been used by researchers, educators, and Hospital Ethics Committees, both nationally and internationally. She is a member of the American Nurses Association Ethics Advisory Board and the ANA/Illinois Nurses Foundation Board of Directors and was a member of the taskforce that revised the ANA Code of Ethics for Nurses in 2001. Dr. Olson has experience as a Director of Nursing Research and Education at a hospital medical center in Chicago, and over 20 years’ experience as a nurse educator, including Professor and Dean at a university school of nursing. She most recently directed a national/international research fellowship program in nursing regulation for members of boards of nursing. Dr. Olson is currently an independent consultant.
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