“Explore your own values. Cultivate deep insight into your own value system,
maintain integrity, and exercise moral courage while remaining professional.
Speaking up when your moral standards have been violated is how we can build
and maintain trusting relationships and a culture of psychological safety where
people feel safe to speak up. When enough of us exercise this strategy, we build
moral communities and healthy, thriving workplaces.”

Q: What’s your experience in keeping ethics front and center in your practice?

For me personally, it’s sticking to my principles even when it’s hard or unpopular. For example, my research team discovered that nurses were at higher risk of suicide than non-nurses and that female nurses are at greater risk than other females in society. In reading death narratives from investigations recorded in the National Violent Death Reporting System (NVDRS) of the Cender for Disease Control (CDC), we found several job-related issues associated with nurse suicide, some of which were very unpopular to talk about. We don’t have the potential to save lives in the future unless we embrace these complex, controversial issues which are difficult to solve. We found a link to the way nurses are disciplined through boards of nursing, which of course is a sensitive issue. The boards are there to protect the public, not to hurt anybody intentionally. We know now that some long-held best practices can actually cause harm and are associated with suicide. I had to raise my voice in a manner that could have been career limiting. The National Council of State Boards of Nursing (NCSBN) invited our research team to speak to lawyers and investigators in the attorney generals’ offices that discipline nurses and pull their licenses. We had to stand up in front of these people who really thought that they were protecting the public all those years. We tried to reframe disciplinary action into a more holistic and healing process for nurses who have mental health problems. They never thought about their actions being linked to suicide. That day, saying it out loud at the podium, you could hear a pin drop. It took a really firm act of moral courage to stand up in front of a powerful group and say that some of our long-held practices at the systems level are associated with harm and that we need to rethink and retool to move forward.

Q: What advice would you give to new healthcare professionals about keeping ethics centered in their practice?

Explore your own values. Cultivate deep insight into your own value system, maintain integrity, and exercise moral courage while remaining professional. Speaking up when your moral standards have been violated is how we can build and maintain trusting relationships and a culture of psychological safety where people feel safe to speak up. When enough of us exercise this strategy, we build moral communities and healthy, thriving workplaces. Integrity is partnered with moral courage. We need to have the moral courage to stand up against wrongs or infractions of what we hold as truths. Everyone has their own marker of right and wrong. It’s based on the way you were raised, your family values, and the values you’ve cultivated throughout your adult life. Our values are each individualized and different one person to the next. You need to be firm about certain values, not bend on them, and have the integrity and moral courage to stand by your principles, to stand up when you or someone you know has been wronged.

Q: What advice would you give to healthcare leaders about building community with frontline staff?

Learn from recent pandemics. I was once the chair of the ethics committee for the Society of Critical Care Medicine, and my chairmanship was during the Ebola outbreak. We developed guidelines for how leaders can lead during crisis and maintain the trust of the public and the staff. Fast decisions needed to be made, and who made those decisions shifted – from individual doctors and nurses to regulatory, accreditation, and government bodies. One of the problems we faced during the COVID-19 pandemic was that we did not educate the public or staff about how and why this shift happened, at least not in a way that they could accept or understand. Our gut instinct as leaders, especially inexperienced leaders, was to immediately revert to autocratic decision-making. Autocracy in a culture that once supported shared decision-making can lead to an erosion of trust, because decisions are being made behind closed doors, without representatives of key stakeholders.

After the pandemic, Dr. Sid Zisook and I interviewed our team of suicide prevention therapists about what they heard from staff who came in with psychological symptoms and harm during the pandemic. It came across loud and clear that they wanted to have a member of staff present in the command center during the crisis. We open the command center and who’s there representing the staff that can speak for them and bring word back about how and what decisions are being made? The whole structure of shared decision-making – professional governance in organizations and also for patients and families – needs to be preserved even during crisis. We need to over-communicate. A mistake leaders sometimes make – when they don’t know the answer, don’t know yet, or the answer is unknown – is they’ll clam up. They don’t want staff to know they don’t know the answer. That approach can cause harm and a loss of faith and trust. Staff will better understand if you say “I don’t know” or “we don’t know, but we’re going to move forward with the best available evidence.” Transparency during times of uncertainty helps build the moral communities we desire to work within.

To build moral communities, system leaders should also expand the role of the ethics committee to include institutional or organizational consults. Most committees focus on case-based clinical consults, but there are systemic issues that predictably cause moral injury. To prevent repeated moral injury, we need to use an ethics framework to address those situations. Any staff member, any patient, any family member should be able to report an issue that may not relate specifically to a case but to the systems and standards in place at the time.

Q: What will your presentation at the conference focus on, and why is this topic important right now?

We’ll be talking about endurance culture. Most are familiar with the colloquialism “pull yourself up by the bootstraps” and keep going. Endurance culture fosters the mentality that we should be able to persevere despite hardship without the appropriate resources or in terrible situations. That endurance culture is very harmful to your mental health and to the culture of the organization. We’ll be talking about how the words we use to each other when things are tough can shift that endurance culture. We’ll practice how to talk to somebody who might be expressing suicidality, using words to affirm their feelings and not negate or downplay them. The words we say and how we use them can break the cycle of endurance culture and help people feel more psychologically safe with help-seeking behaviors. Words really matter, especially around mental health.