The importance of a positive moral culture within healthcare organizations

Introduction

Healthcare organizations are a crucial part of society as they are responsible for the health and well-being of the communities they serve. Just like individuals, organizations possess a moral agency that guides them in their decisions and actions with regard to patient care and organizational efficacy. They promote within their professional environment a specific moral culture that reflects the perception of ethical behaviour and affects all aspects of their everyday activity. In practice, the method in which moral agency is applied and maintained within an organization directly influences its moral culture. Organizations function through a series of systems that work dynamically to achieve success. In order to implement the systems effectively, all employees, at every level, are essential and must work congruently. This results in a moral culture that aligns with the institution’s mission, vision, and values and promotes a moral culture of the highest standard, therefore resulting in the highest and most effective level of care.

Considerations at the level of the organization

In an ideal situation, the components that make up an organization are rooted in specific values that reflect their goals. ¹ This encourages the employees of the institution, as well as the public, to associate that particular organization with ethical practice. A positive moral culture is created that maintains the principles that the organization has established. A moral culture is directly dependent on how the general morality of an organization is regarded. ² Hospitals, for example, are required to serve communities, but some may have a higher moral standing than others. If the hospital has an outreach program for vulnerable patients in the community, or families who have loved ones admitted to the hospital share positive experiences with their neighbours, it would indicate that it has a high moral standing. This also implies that the moral culture within the institution is positive, demonstrating alignment with the values of the organization and those of the community. ³ If a hospital begins to experience a lack of ethical decision-making, or the implementation of unethical policies, a moral culture will still arise that corresponds to the actions and morality of the organization. This negative moral culture may not be reflective of the patients it is serving, and there would be a need to re-evaluate procedures and protocols. ⁴

In order for an organization to remain ethical, it must implement systems and policies that promote morality for the institution, its employees, and the care that it provides. The systems are all based on the organization’s values that drive the entire morality of the institution. These values are based on the highest priorities that an organization has and demonstrative of the type of care they aim to provide to their patients. This ultimately creates a moral culture that further influences organization-level decisions. In practice, this is executed through a mission statement or a value statement, which summarizes the main purpose of the organization and its guiding principles. While providing quality care to individuals should be at the forefront of its values, a hospital’s distinctive mission statement may also include adherence to religion, research, or community outreach. ¹ These principles allow an institution to be held accountable by stakeholders, as well as the general public, to ensure that they are upholding their outlined principles. A positive moral culture within an organization would also benefit from the creation and maintenance of an effective ethics program, which may include a diverse ethics committee that includes patients and families, or access to a clinical ethicist. By insisting that all systems, policies, and employees are considering and following these guidelines, ethical decision-making that corresponds with the healthcare institution’s moral goals should prevail and create a positive moral culture. ⁵

In order to achieve this ideal environment and moral culture, there must be a level of moral reasoning that is influenced by those values outlined by the organization. In healthcare, this moral reasoning can be demonstrated at every level of an institution, since policies should be created with the established values in mind. ⁶ Individual parts or systems all work dynamically to ensure a successful medical organization. If they reflect the values of the hospital, ethical decision-making should, in theory, be guaranteed. This further reinforces the morality of the institution itself to be well regarded. However, there is always a risk of moral system failure. Indeed, when a system fails or promotes an unrealistic message or ethical principle, policies or decision-making methodologies fail to uphold the core values of a moral organization. For example, if a hospital continually makes decisions at a high level with only the input of senior managers and physicians, it promotes a paternalistic set of values. By not empowering frontline staff, for example, or including the voices of patients and families, such a hospital is creating a negative moral culture within itself and within the community. Furthermore, there should be a neutral and external evaluation to ensure that an organization is able to function in an ethical manner and maintain a positive moral culture. An established ethics program, as mentioned previously, may be able to assist in this evaluation. ⁵

It is also evident that if there is a shift in a moral culture, there will also be a shift in the moral agency of the organization. Thus, the cycle of change is echoed throughout the system and culture itself, resulting in the modifications of them both. For example, if a healthcare organization implements a policy that coincides with its values, such as the opportunity to provide services free of charge, it is expected that the moral culture will be reflective of success. However, if the practice of the policy begins to shift at the employee level, those who disagree with the policy will begin to modify it, and the culture will begin to change and become different. This may eventually instigate the creation of a new system or prompt a modification of the previous one, if the hospital decides that its values may have shifted or that the policy must be changed. ⁵ In general, there may also have to be a re-evaluation of how organizational practices contribute to a moral culture that aligns with the values established initially.

Considerations at the level of the individual

An organization’s moral agency is somewhat abstract, as the institution is not technically a physical entity capable of moral reasoning. It is individuals who create the “entity” of an organization and reflect its moral agency. These employees are responsible for maintaining moral reasoning throughout all decisions, which is imperative in healthcare, when lives and well-being are at stake. The use of a framework for ethical decision-making that is used by every member of an organization will ensure that a positive moral culture is maintained. Both leaders and frontline staff within a healthcare organization should use the same process in order to make decisions that align with the institution’s mission, vision, and identified values and reflect its guiding principles. When there is disagreement or uncertainty about the decision, for example, regarding a controversial practice, an ethicist or ethics committee would be beneficial to contribute to the decision-making process.

Ethical decision-making and promotion of a positive moral culture starts with the leaders of an organization. There are many levels of leadership, including CEOs and senior management, clinical care managers, and attending physicians, all of whom are responsible for abiding by a code of conduct that requires them to be a “moral” person/clinician. Their purpose is to ensure that they are acting as an example for other employees, as well as promoting the ethical behaviour and decision-making of their colleagues, and to ensure that the organization is maintaining its values and ethics. ⁵ For example, if a leader frequently uses a decision-making framework and is transparent about their process, their employees will mimic these actions and use the same methods to solve challenging ethical issues. It is also important that leaders understand their roles and how to deal with power, privilege, and loyalty. They are required to lead but also have a responsibility to create an ethical environment that upholds the values of the organization. ⁷ This mentality can be achieved through training courses and peer-mentoring, as well as frequent opportunities to self-evaluate professional practices.

Managers and leaders alone are not solely responsible for maintaining and promoting a positive moral culture throughout the organization. Indeed, a top-down approach to demonstrate appropriate decision-making is effective; everyone within a healthcare institution can learn from leaders who are exemplifying a moral or ethical way of working. However, an organization cannot solely rely on this approach to encourage staff and others to consider ethical decision-making. All employees, students, and volunteers should be trained in ethical decision-making and use of an ethical framework or method, which will increase awareness of the importance of maintaining a positive moral culture both internally and externally throughout the community being served. All individuals within the organization should be comfortable making ethical decisions and contributing to the preferred moral culture and should feel supported by leaders when they experience challenges. This, in itself, promotes teamwork and brings about the desired positive moral culture.

Nonetheless, there is always a risk that the system may fail; an individual employee may disagree with policy or witness behaviour which does not correspond to the established institutional values. Not only does this create a negative environment, but the overall system’s moral culture may be negatively affected. One example of this is moral distress. In an ideal moral culture, all employees should be able to exercise conscientious objection if they have a personal disagreement with a procedure and feel comfortable speaking to a director if they feel uncomfortable with an issue or event in the workplace. However, this is not always the case, and many individuals cannot identify their moral distress, nor do they feel supported in speaking up; hence, they refrain from voicing concern. This causes a build up of moral distress and conflict, which negatively affects the moral culture within an organization and can damage both system and the integrity of an institution. The best solution is to promote effective communication in order to solve problems efficiently and effectively. ⁸

Conclusion

A healthcare organization’s moral agency allows it to determine the values and goals that influence the moral culture both within the institution and around it. Systemically, this is crucial to ensure that all aspects of the organization act in accordance with a core set of moral values that reflect its mission. Employees have a responsibility to uphold these values and to contribute to a positive moral culture free of moral distress with effective communication practices in place to address challenges that may arise. This ideally results in the most effective healthcare that can be provided to the community which the organization serves. Even with impediments, an organization should be able to uphold its values and maintain its moral status. Promoting morality at all levels of a healthcare organization’s activity results in an effective moral culture and ethical medical care.