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Weekly UpdatesEXECUTIVE SUMMARY
Research into the importance of organizational healthcare ethics has increasingly appeared in healthcare publications. However, to date, few published studies have examined ethical issues from the perspective of healthcare executives, and no empirical study has addressed organizational ethics with an explicit focus on rural hospitals. For our study, we sought to identify the frequency of ethical conflicts occurring within 12 general categories (domains) of administrative activities. Also, we wanted to determine what ethics resources are currently available and whether additional resources would be helpful.
We conducted a structured telephone interview of all 13 chief executive officers (CEOs) of critical access hospitals in New Hampshire. All the CEOs in the study indicated that they encountered ethical conflicts. On average, the three most frequently noted domains were organizational-professional staff relations, reimbursement, and clinical care. All CEOs indicated they would like to have additional ethics resources to address these conflicts.
This study verified that CEOs encounter a broad spectrum of ethical conflicts and need additional ethics resources to address them. Because this study used a small sample of CEOs and represented only one New England state, further ethics-related research in rural healthcare facilities is warranted. Follow-up study would allow for (1) a higher level of generalization of the findings, (2) clarity regarding specific ethical dilemmas that rural healthcare executives encounter, and (3) an assessment of ethics resources and training that healthcare executives need to address the ethical conflicts.
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The U.S. healthcare services system is both complex and costly (Anderson and Frogner 2008). Researchers and healthcare providers alike strive to establish evidence and practices based on both safe and high-quality healthcare standards. Practicing safe and high-quality healthcare includes care that is linked to ethical standards (ACHE 2006; Meslin, Lemieux-Charles, and Wortley 1997; Nelson and Gardent 2008; Nelson et al. 2008). The presence of ethical conflicts can affect the quality and costs of today's healthcare organizations (Nelson, Weeks, and Campfield 2008). However, the importance of recognizing and addressing ethical conflicts in the current dynamic healthcare management environment has been sparsely investigated, particularly in relationship to rural healthcare environments.
Our review of the literature between 1992 and 2008 revealed 15 empirical studies that specifically assessed ethical issues (defined as ethical challenges, dilemmas, or conflicts) described by healthcare leaders, including those identified as "executives," "administrators," "management," and "directors" (Bantz, Wieseke, and Horowitz 1999; Borawski 1995; Bryson 1999; Camunas 1994; Cooper et al. 2002, 2004; Harrison and Roth 1992; Jurkiewicz 2000; Lemieux-Charles and Hall 1997; Lemieux-Charles et al. 1993; Redman and Fry 2003; Reeleder et al. 2005; Saeed 1999; Sibbald and Lazar 2005; Weber 2005). Among these studies a majority (14) investigated the experiences of mid-level, nurse, or physician executives, while the remaining (3) studies included chief operating officers and a variety of other senior-level, non-clinically prepared executives. Four of these studies were completed in non-U.S. countries. All 15 studies used survey designs to investigate the types of ethical issues encountered by the executives and their potential impact. These studies can be grouped into three general categories based on content: (1) unethical business practices and/or perceptions of such practices (Jurkiewicz 2000; Weber 2005), (2) ethical issues surrounding resource allocation (Bantz, Wieseke, and Horowitz 1999; Lemieux-Charles and Hall 1997; Lemieux-Charles et al. 1993; Reeleder et al. 2005), and (3) other ethical issues (Borawski 1995; Bryson 1999; Camunas 1994; Cooper et al. 2002, 2004; Harrison and Roth 1992; Redman and Fry 2003; Saeed 1999; Sibbald and Lazar 2005).
Unethical Business Practices and/or Perceptions of Such Practices
Two studies focused on unethical business practices (Jurkiewicz 2000; Weber 2005). One survey of American College of Physician Executives members focused on conflicts of interest. The study found a high level of concern about unethical practices regarding conflicts of interest (Weber 2005). In the second study, senior and mid-level healthcare executives reported the extent of unethical practices in their organization (Jurkiewicz 2000).
Ethical Issues Surrounding Resource Allocation
Several studies examined ethical issues regarding resource allocation concerns among CEOs, managers, and nursing administrators (Bantz, Wieseke, and Horowitz 1999; Lemieux-Charles and Hall 1997; Lemieux-Charles et al. 1993; Reeleder et al. 2005). One study sampled 86 CEOs or their designee in Ontario hospitals concerning the fairness of allocation priority setting (Reeleder et al. 2005). The second study, also conducted in Ontario, assessed 1,675 nurse, physician, and other professional managers' level of satisfaction of organizational practices used to address resource allocation ethical issues (Lemieux-Charles and Hall 1997). The last study asked nurse executives, using the 27-item Nursing Administrator Ethic-Economic Survey, to assess resource allocation practices (Bantz, Wieseke, and Horowitz 1999). The findings of this last study indicate a disparity in the perception of the impact of resource allocation between staff nurses and nurse executives. Staff nurses perceive that budget cuts have a greater impact on the quality of patient care than do the nurse executives.
Other Ethical Issues
The remaining 9 studies surveyed administrators, managers, and executives in the United States and worldwide. The results of two surveys, administered in New Zealand and Saudi Arabia, indicated that differences in ethical issues encountered and even in the definition of what constitutes an ethical issue (Bryson 1999; Saeed 1999). The remaining studies focused on various U.S. administrative positions, especially within the nursing professions (Borawski 1995; Camunas 1994; Cooper et al. 2002, 2004; Harrison and Roth 1992; Redman and Fry 2003). These studies examined the frequency of ethical issues encountered: Irrespective of a specific time frame, respondents ranked ethical issues from a pre-selected list of potential issues (Borawski 1995; Camunas 1994; Cooper et al. 2002, 2004; Harrison and Roth 1992; Redman and Fry 2003). Across all of these studies the most commonly identified issues in terms of importance included quality of care, resource allocation, staffing levels and mix, conflicts with professional standards, standards of care, and staff competency. Among these studies, only one provided respondents the option to self-identify as CEOs (Cooper et al. 2002). One study surveyed nurse leaders in New England on how frequently they experienced ethical and/or human rights issues in the previous 12 months, the level of disturbance, and the resources used to address the most recent ethical or personal rights issue (Redman and Fry 2003). Using the 32-item Ethical Issues Scale, the authors found the three most frequently experienced issues were protecting personal rights and dignity, informed consent, and use of physical and chemical restraints (Redman and Fry 2003).
Some of these studies also asked healthcare executives how ethics issues are addressed in their organization. The studies identified the percentage of respondents who had an ethics committee within their organization (ACHE 2006; Camunas 1994; Cooper et al. 2002, 2004; Harrison and Roth 1992); however, only three studies (ACHE 2006; Camunas 1994; Redman and Fry 2003) assessed the degree to which respondents used ethics committees when responding to an ethical issue. One study indicated that 20.9 percent of executives had consulted an ethics committee when confronting their most recent ethics issue (Redman and Fry 2003).
The only CEO-focused study was conducted in 2006 and surveyed 388 American College of Healthcare Executives (ACHE) affiliates about the function of hospital ethics committees and their use of those committees (ACHE 2006). The vast majority (84 percent) of the CEOs reported that their organization had an ethics committee. The most common issues addressed by ethics committees were clinical (98 percent) and legal (62 percent). About one-third of the respondents reported they use their ethics committee to discuss financial issues, such as whether the organization provides a fair share of uncompensated care (ACHE 2006).
The studies reviewed here were limited to a narrow range of administrative activities with the potential for ethical conflicts. They were also restricted to contextual, organizational, and geographic settings. For example, theses studies tended to focus on larger hospitals or urban academic hospitals. Lastly, these studies did not investigate CEOs' perceptions of ethical challenges. In fact, to date, no study of executive-level leaders has focused solely on administrators or CEOs of the large number of U.S. rural hospitals and, in particular, critical access hospitals (CAHs). (1)
To address these gaps in the literature, we designed a structured telephone survey to be administered in New Hampshire. The specific aims of our study were to (1) establish the frequency of ethical issues encountered by CAH healthcare executives across a large spectrum of potential domains, (2) assess the availability and use of ethics resources by CEOs, and (3) assess the need for further ethics resources.
METHODS
To investigate the study aims, we chose to use survey methodology to elicit responses on a number of questions from the CEOs on rural hospitals in the state of New Hampshire.
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