Over time, nursing leadership and management skills have become subjects of many issues and criticism. The issues range from shortage in the curriculum being provided to nursing education to quality and quantity of nurses, inefficient and ineffective health care practices, nursing ethics, and nurses’ poor decision-making skills. Some medical and nursing professionals found that the root of all nursing problems lies on the deficient curriculum of nursing education. Some nurse leaders claim that a BSN degree is not an adequate preparation for the expanded role of nurses. They believe that a nursing student must be required to obtain first a master’s or doctoral degree before entering into practice for registered nurses (Huston, 2003). The same insight is expressed by Rabetoy (2003), adding that there are individuals who lack required nursing education but are able to enter into the field of nursing practices:
The lack of mandatory BSN entry level is the heart of the poor nursing image, nursing shortage, attrition for students entering nursing, and poor retention of seasoned nurses. It is also the reason why bright, career-oriented students and second career individuals should be directed away from entering nursing education in its present format. These individuals are being deceived and mistakenly led to believe that they are entering into a profession when, indeed, nursing is a vocational trade group.
There are several studies which prove that highly educated nurses are much capable of providing accurate health care services regardless of their age and gender. In the study conducted by Aiken, Clarke, Cheung, Sloane, and Siber (2003), they found that the mortality and failure rates of rescuing or reviving patients is significantly lower in hospitals that employ well-educated nurses compared to hospitals employing nurses with only college-level education. Nurses who are highly educated (those with master’s or doctoral degree) are more capable of providing direct patient care than those graduates of BSN.
The study indicated that a 10% increase in the proportion of nurses holding BSN degrees decreased the risk of patient death and failure to rescue by 5%. Furthermore, patient mortality and failure to rescue were predicted to be 19% lower in hospitals where 60% of nurses had BSNs or higher degrees than in hospitals where only 20% of nurses were educated at that level. (Aiken, Clarke, Cheung, Sloane, & Siber, 2003, p. 1619).
With such significant findings, many nursing professionals are urging to include leadership and management as well as research, home health, and community health courses to nursing curriculum to improve nursing quality (Huston, 2003). Leadership and management skills are strongly required for nursing because nurses are exposed to different complicated health scenarios everyday. As the Canadian Nurses Association (CNA) (2002) expressed in their “Position Statement”: “Leadership plays a pivotal role in the lives of nurses. It is an essential element for quality professional practice environments where nurses can provide quality nursing care” (p. 1). Being an adherent of quality care, a visionary, a role model, a risk-taker, a collaborator, a mentor, and an articulate communicator are some of the important traits that a nurse leader should possess (CAN, 2002).
Nursing Leadership Theories
There are different leadership theories being adopted into nursing education and practices. Huber (2006) categorized leadership theories in nursing into three groups: trait leadership theory, attitudinal leadership theory and situational leadership theory. The trait leadership theory states that specific traits or characteristics of an individual make up his or her leadership skills. The premise of this theory is that leaders are made, not born. To elucidate, in trait leadership theory, leadership skills could be “both taught and learned” (Huber, 2006, p. 10). Thus, nurses are provided with opportunities to “learn, practice and improve” their personal leadership capabilities (Huber, 2006, p. 10). In addition to this, trait leaders are often guided by these questions: What are the problems? What actions need to be done to solve the problem? What can I do to solve the problem? What are the objectives of these actions? What are the possible result and consequences of such actions? (Huber, 2006). When facing moral problems such as stress and anger, safe staffing, cost containments, patient’s rights, and ethical dilemma, nurse-leaders are required to make tough decisions wherein they are expected to correctly identify right from wrong based on their conviction (Clancy, 2003). A good nurse leader should be equipped with courage to overcome the fears associated with the available unpopular choices of solving ethical problems. As Bennis and Thomas (2002) stated, “One of the most reliable indicators and predictors of true leadership is an individual’s ability to find meaning in negative events and to learn even the most trying circumstances” (p. 39). Thus, effective leaders are those who posses the following characteristics or traits: courage, knowledge, vision, trust, motivating other people, enthusiasm, communication, and ability to take the risks (Clancy 2003).
On the other hand, attitudinal leadership theories are more focused on the attitudes of individuals toward leader behavior. The attitudinal leadership is reflected in the leadership style of an individual. In this kind of theory, the behavior of a leader is composed of two separate dimensions: the “initiating structure and consideration” which is autocratic in style and the “employee-orientation and production-orientation” which is democratic in nature (Huber, 2006, p. 15). In autocratic style of leadership, the leader has the full authority to command his followers of what they need to do to meet their goal. On the other hand, in the democratic or participative leadership, a leader gives importance to his followers and encourages participation from his or her subordinates in the decision-making process (Theofanidis & Dikatpanidou, 2006).
Lastly, the situational approach of leadership, which was developed from contingency theories, involves the behaviors of leaders and the application of a particular leadership style based on what the situation requires (Huber, 2006). In any situation, leaders are required to possess a diagnostic ability wherein they would first observe the abilities of their followers; afterwards, they are expected to motivate their followers. It is important for leaders to bear in mind that people make choices and the leadership style that would be utilized depends on these choices. In order to adapt to any situation, the leader must be flexible and capable of altering his or her behavior and the utilization of leadership style (Hubert, 2006).
In solving ethical or moral problems especially in the nursing field, nurses must first analyze the situation and then choose which leadership theory is suited to adapt. Even though these leadership theories are designed for effective leadership and management of situation and people, not all theories are adaptable to every situation. There are still limitations on these theories. Thus, a careful understanding and analysis is required before taking any course of action, especially in the nursing field where situations are more sensitive as nurses always deal with health, survival, and life. A more systematic understanding and analysis are required whenever a nurse is facing an ethical dilemma where oftentimes, more choices are available, yet such choices are undesirable solutions.
Types of Ethical Issues
Nursing is a sensitive field in which nurses are required to deal with patients’ survival; this is part of their practice and job. Everyday, nurses are exposed to clients who are seeking treatment for their health conditions and disorders, and to clients who need a kind of health care that only nurses can provide. Thus, nurses are prone to confront different ethical issues relating to their field and to patients’ care. Laabs (2005) identified different terms to describe the ethical issues faced by nurses. These include moral uncertainty or moral conflict, moral distress, moral outrage, and moral or ethical dilemma. Moral uncertainty or moral conflict happens when a nurse is uncertain about the nature of the ethical problem. Uncertainty about the problem leads to inaction as the nurse is unsure which moral values or principles should he or she apply to solve the problem. On the other hand, moral distress occurs when a nurse knows the right action, yet he or she is being limited by the existing organizational structure, making it difficult for him or her to take the right course of action that could solve the problem. Meanwhile, moral outrage takes place when a nurse has seen or witnessed an immoral act of a co-nurse, another medical employee, or patient but feels inadequate or powerless to stop such action. The last and most difficult of all ethical issues is known as moral or ethical dilemma. Ethical dilemma occurs when two (or more) apparent moral principles are present, yet both (or all) of these principles support inconsistent courses of action. As Marquis and Huston (2009) wrote, “An ethical dilemma may […] be described as choosing between two or more undesirable alternatives and attempting to select the least damaging from the choices available” (p. 71).
Ethical Dilemma: The Case of 16 Year Old Lymphoma Patient
Recently, I have encountered a case which is more of an ethical dilemma. I have a 16-year old patient who was diagnosed with Stage 4 Hodgkin’s Lymphoma. The National Cancer Institute (2009) identifies Hodgkin’s Lymphoma as a cancer of the immune system where a Reed-Sternberg cell is present. Patients diagnosed with such disease show symptoms such as enlargement of lymph nodes and other immune tissues, weight loss, fever, night sweats, and fatigue (National Cancer Institute, 2008a). In identifying which parts of the body are affected by Hodgkin’s Lymphoma, the following tests were conducted: physical exam; blood tests; chest x-rays; and biopsy which could either be excisional or incisional depending on the affected part of the body. To determine the stage of the disease, the following tests were performed: CT scan; MRI; PET scan; and bone marrow biopsy. A patient is identified to be suffering from Stage I lymphoma if the lymphoma cells are present only in one lymph node group or part of an organ or tissue such as underarm, neck or lung. A patients in on the second stage of lymphoma when lymphoma cells are present in two lymph node groups in either of the two sides of human diaphragm. A patient diagnosed with Stage III of the said disease when both sides of the diaphragm carry lymphoma cells. Finally, the Stage IV of lymphoma involves the presence of lymphoma cells in several parts of the body’s organ or tissue particularly in bone marrow, blood and liver (National Cancer Institute, 2008b). Treatment includes chemotherapy, radiation therapy, and/or stem cell transplantation. However, side effects of chemotherapy and radiation therapy include damaging healthy tissues and cells (National Cancer Institute 2008b).
In the case of my patient, the teen was diagnosed with Stage IV of Hodgkin Lymphoma. The lymphoma cells are present in his bone marrow and other parts of the body. He has undergone a series of chemotherapy and radiation therapy to reduce the lymphoma cells. Note, however, that Hodgkin’s Lymphoma is recurrent. Meanwhile, during one of our encounters with the patient while preparing him for chemotherapy, he refused to get such treatment. His parents, on the other hand, are demanding that he should undergo chemotherapy. An ethical dilemma arises as the patient is only 16-years of age, yet there are two contradicting demands. On the legal side, the parents have the right to make decision on the situation. On the moral side, since the patient is experiencing unexplainable pain (and fear), he could be right in refusing the chemotherapy as he knows his body reaction better than the knowledge of his oncologist, parents, and other people around him.
Solving the Ethical Dilemma
In guiding nurses to solving difficult moral issues such as ethical dilemma, Wueste (2005) stated that the Nurses’ “task as ethical decision makers is to identify the best answer from among the available alternatives and see to it that [nurses] are in a position to meet the challenge of justifying [nurses’] ethical judgments.” As a nurse, I was in charge of exploring the patient’s condition and perception concerning the treatment. Since the patient refused chemotherapy and could not agree with the decision of his parents, I took time to talk directly with him. I asked him about his understanding of the Hodgkin’s Lymphoma disease and the treatment associated with it. As he is only a minor, he has limited knowledge about his disease and about the treatment. During the conversation, he kept on citing other cases he heard where patients, despite undergoing chemotherapy, did not manage to survive. In one of our meetings, I brought him books and other reading materials (with visual presentation and photographs) about Hodgkin’s Lymphoma patient and how they managed to survive. His parents and I waited until he was ready for the treatment. After a series of conversation with the patient, I managed to motivate him. Later, he submitted to chemotherapy treatment.
In this case, I managed to solve the problem simply by dealing with my patient. However, there are possible cases where such resolution may not took place. Nurses are prone to experience such ethical dilemma where two or more choices are available, yet these choices may not contain any moral standard. I read a case where a minor suffering from cancer refused to undergo chemotherapy, but his parents supported the child’s decision. A social worker even asked the court intervention as she perceived parents’ action as neglectful. Court intervention may not be needed if only the caregiver is able to manage the ethical dilemma properly (“Teen Wins Right to Refuse Chemo,” 2006). There are even cases where the family must need to choose whether to prolong or not the suffering of a baby born with a deadly disease or abnormalities which could result in immediate death. For many health care providers, particularly those who are working in countries where euthanasia is not legal and not practiced, it is not easy to change an aggressive treatment objective to a “palliative” one:
Reasons for this may be due to health care professionals’ lack of formal palliative care education in medical or nursing school, their difficulty acknowledging an infant’s terminal prognosis, and a possible lack of coping with their own personal spiritual, emotional, and psychological values and feelings about death. (Catlin & Cater, 2002, p. 184).
In cases where minors (those aged 18 years and below) suffering from cancer (particularly Hodgkin’s Lymphoma) refuse treatment, nurses are required to manage the situation and provide alternative actions especially when two conflicting decisions are being offered. Neglect to understand the situation of patients could also mean neglecting medical duty. There are cases where nurses would automatically recommend the decisions of parents (those who prefer chemotherapy treatment for their children) to physicians, since the patient who is suffering from cancer is under legal age. Being a nurse-leader, such action should not be always put into practice unless the medical practitioners are certain that the treatment administered to patient (e.g. chemotherapy) is the only cure that can prolong the life of the patient. For cases like these, situational leadership theories are more effective than any trait or attitudinal leadership theory.
The Situational Leadership Theory in Solving Ethical Dilemma
Situational leadership theory is neither about trait nor the attitude of leaders. It is more focused on the situation; thus, it is more applicable when solving ethical dilemmas. Situational leadership involves the utilization of any leadership style which could be autocratic, democratic or participative, or laissez faire in nature. In solving ethical dilemma, autocratic leadership and democratic leadership are preferable. Autocratic leadership is a style of leadership wherein the nurse-leader considers his or her full authority to command or influence his or her patient of what is needed to be done. In democratic or participative leadership, on the other hand, the nurse-leader values the importance and participation of his or her patient (and to some extent the patient’s family) in the decision-making process (Theofanidis & Dikatpanidou, 2006).
In cases where patients refuse life-sustaining treatment, medical practitioners, especially nurses, must conduct the following preliminary procedures: (1) identify and analyze the patient’s reason for refusal of treatment; (2) find alternative treatment to pain and disease symptoms; (3) re-assess the health response of the patient to identify whether alternative treatment is effective; (4) assess and treat the “psychological, social and spiritual distress” of the patient; (5) assess the relationship between patient and the physician; (6) asses and analyze the relationship of patient with his or her family; and (7) assess and analyze the capacity of patient in making decision (Rosenblatt & Block, 2001, p. 321). Such procedures require more democratic leadership skills and few autocratic leadership skills. As mentioned, democratic leadership is participative; thus, to establish rapport with the patient who is refusing treatment, the nurse-leader must be able to encourage his or her patient to participate in finding solution to the health problem. Autocratic leadership, though not required, could be of help when persuading or motivating the patient to accept the treatment or other possible alternative treatment which is proven to prolong the life of the patient.
If the patient is of legal age, “refusal procedures require that physicians respect their patients’ decision to forgo possibly life-sustaining chemotherapy” where their capacity to decision making is recognized (Huijer & Leeuwen, 2000, p. 361). On the other hand, if the patient is minor, more factors are needed to consider such as the patient’s personal values, attitude, and beliefs towards life, emotions, suffering, and fear (Huijer & Leeuwen, 2000). Age could not be the sole basis of whether to recognize the patient’s refusal to chemotherapy or not. Being in a working relationship with both patients and doctors, nurses are expected to weigh the pros and cons of the situation and other factors affecting the choices available. First and foremost, nurses must provide the minor patient with enough information about the disease and treatment available. As Wilson-Barnett (1986) stated, “One of the most important resources a nurse has to give patients is relevant information about their condition, their treatment and ways of coping with both” (p. 124). The nurse needs to gain the trust of his or her patient while maintaining the patient’s trust in his or her physician. Such action is popular among democratic leaders and is perceived to be effective in the nursing field where ethical dilemmas are present.
Although paternalism could be an option in dealing with nursing ethical dilemma, many medical professionals believe that this leadership style is already outmoded as patients and medical environment are changing. Representing the welfare of the patients by medical practitioners is no longer practiced since many issues and criticism arose from concerned citizens and organizations. This is because oftentimes, medical practitioners are overreacting to a particular situation without really understanding their patient’s condition. As Wilson-Barnett (1986) wrote:
Nursing paternalism is very common, particularly with elderly people who are too weak or confused to refuse all the washing and exercise they are forced to receive. However, the recent changes in nursing philosophy which emphasize shared goals and maximal patient participation attempt to combat this. (p. 124)
Thus, democratic leadership is more precise when solving ethical dilemmas since it requires participation from the patient, his or her family, nurses, and physicians involved in the situation. Cooperation and partnership among persons involved in solving ethical dilemmas have been proven to reduce distress and conflict between patient and medical practitioners (Wilson-Barnett, 1986).
Conclusion and Recommendation
Solving ethical dilemma is indeed difficult since oftentimes, available choices are undesirable. Most of the time, nurses are required to come up with feasible and effective solution especially when the person involved are patients with whom nurses have a direct contact. In solving the problem, a nurse must act as a leader capable of analyzing the patient’s condition, the available choices, the alternative solutions, and the possible outcome of any action. Upon analysis, nurses should always come up with solution to the problem to satisfy both the patient’s need and the nurse’s duty and responsibility to improve health condition and prevent death. The most practical leadership theory that can be applied when facing an ethical dilemma is the situational leadership where nurses are required to analyze the situation. Moreover, it involves a selection of leadership style most suitable to the situation and to the available choices.
In the case of a minor suffering from cancer but refusing chemotherapy treatment, a democratic style of leadership must be employed to further assess the situation and the patient’s condition. Democratic style of leadership requires participation from the patient and family members (if present). Thus, medical practitioners, particularly nurses, may reduce the risk of representing only the medical side upon curing a minor patient. If there are conflicting opinions between the minor cancer patient and the family members, especially the parents, democratic nurse-leaders are expected to get all the cooperation and participation from both parties to formulate alternative solutions in case when the patient holds on to his position of not accepting chemotherapy treatment.
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