Exploration of pioneering as a major element of ethical leadership in nursing: A qualitative study

Abstract

Background

Commitment to ethical behavior is considered as an essential part of occupational responsibilities of nursing, and leaders’ pioneering in ethical growth and development has led to the emergence of the concept of ethical leadership.

Objective

The purpose of this study was to explain the nursing leaders’ perception and experiences of pioneering in the field of ethical leadership.

Methods

In this qualitative study, data were collected through semi-structured individual interviews. A total of 14 nursing leaders at different levels who were selected by purposeful sampling method participated in the study. Latent content analysis was used to analyze the data.

Results

Of 14 participants of the study, 8 were male and 6 were female aged 38 to 56 years old with a mean managerial experience of 12 years. In the analysis of interviews, 4 subcategories of “Role Modeling”, “Empowerment”, “Knowledge and Skill”, and “Recognition” were obtained which formed two main categories. These categories included “Leader as mentor” and “Professional insight”.

Conclusion

Pioneering leaders are an important part of ethical leadership, and nursing leaders should not only be moral people, but also go a step further and actively promote moral behavior with a role as a mentor and model as well as having professional insight. Nursing leaders with a better understanding of these aspects can develop their capacity of strong ethical leadership and consider the aspects in their activities.

1. Introduction

Ethical values in health care and the nursing profession are regarded as highly important factors (1, 2). Ethical behavior is one of the basic features of the nursing profession (3). In other words, the nature of the nursing profession is ethical effort (4), and commitment to ethical behavior is considered as an essential part of the occupational duties of nursing (5). The ethic of care is a function that requires specific moral features that focus on proper function. Elements of ethic of care include traits such as attention, responsibility, competence and accountability, including empathy, emotional commitment, and tendency to do something for those with whom we are in touch. This is clearly necessary not only for nurses in their relationships with patients, but also with other nurses and health care team members (6). Today, a Code of Ethics has been developed for nurses that is a nursing morality compass explaining moral commitments, duties, standards and principles that all nurses in any role, position and functional environment should be accountable and responsible for. Codes of professional morality and interpretations towards each other provide a framework by which nurses can make moral decisions and carry out their professional responsibilities appropriately for the community, other members of the health care team, and their profession (7). What is certain is that nursing leaders should be pioneers and nursing leadership plays an important role in moral care and in creating care culture (8). The influence is on leadership essence, and leaders can use their influence in a positive way to promote moral behavior and/or negatively to encourage immoral behavior. Accordingly, organizational leaders play a major role in creating moral guidelines (9). Adherence to moral values is a characteristic of leaders with high effectiveness (10), and ethical leadership is defined as behavior manifestation, an appropriate norm through personal actions and interpersonal relationships, and promoting such behavior among followers through two-way communication, strengthening and decision-making (11). Ethical leaders promote moral behavior among followers. A person as a moral leader advocates personal integrity and perfection and by asking followers for moral behavior and facilitation, guides them toward true moral behavior. Ethical leadership has an important effect on creating ethical atmosphere and behavior of personnel (12–14). Ethical leadership approach induces the sense of being useful and effective in nurses and health care professionals by valuing, supporting and inspiring human values, to induce them to feel useful and effective, and provides grounds for doing their duties effectively and somehow satisfies their psychological needs (15). In recent years, the importance of ethical leadership has been increased due to important and positive outcomes. Research has shown that manifestations of ethical leadership behavior can lead to job satisfaction and organizational commitment (16, 17), tendency to report problems to supervisors (11), and improve the health and welfare of personnel (18). Also, a strong relationship is found between ethical leadership and positive results including trust in the leadership, leadership effectiveness, supervision, team work, efficiency, staying in work, and keeping the personnel (11, 17, 19, 20). A meta-analysis study showed that immoral behavior of leaders may have a negative impact on the results of personnel work and although the effects of such immoral acts may not be visible at the time of doing but over time negative results can be seen in the personnel (17). The meta-ethnography study by Makaroff et al. (21), showed that a nursing ethical leader should be responsive to the personnel and system, and needs to receive and provide support to promote moral performance and discuss morality. The four themes of integrity, justice, wrestling with decisions in the light of consequences, and the power of information have been reported in a qualitative study conducted by Gray on ethical leaders in nursing education (22). Other qualitative studies have been done on the ethical behavior of leaders in non-medical literature (23–26). The nature of moral issues is such that it has different aspects in various social and cultural fields (27). On the other hand, evaluation and the meaning of behavior and leaders’ features are, to a large extent, different in various social and cultural contexts (28). The Islamic Republic of Iran enjoys one of the most ancient civilizations. Islam is the formal religion of this country and the Iranian identity consists of an integration of Iranian-Islamic culture. The religious discipline and cultural beliefs of Iranians have entered the health-care system so that ethical issues are outstanding in the patient-care protocols (29,30). Like any other developing country, the health-care system of Iran suffers from limited manpower and financial resources (2), while the Iranian nurses tolerate the work overload (31). Moreover, they are not satisfied with their jobs due to inappropriate work climate, lack of support, discrimination, and lack of social dignity (32). The nursing managers’ leadership style can exert a significant effect on nurses’ occupational satisfaction. Nonetheless, some studies have demonstrated that the duty-oriented leadership style dominates most leaders of health-care systems in Iran (33). Therefore, research on certain underlying features of leadership in nursing is required for more accurate clarification (8), to help the use of strategies to create a work environment based on ethical leadership, act, and courage (6). In the present study, an attempt was made to explore pioneering as a major element of ethical leadership in nursing using a qualitative method assuming that for those who experience the phenomenon, many hidden aspects will be revealed and thus, lead to new knowledge and insight.

2. Material and Methods

2.1. Setting and study design

This was a qualitative study conducted using content analysis approach. In this method, through the process of systematic classification, codes and themes are identified (34). In this study, purposive sampling was used to select the intended sample, i.e. managers who have hospital nursing management experience as well as nursing instructors as experts of nursing management and morality. To find samples experienced with rich data, initial samples were used to identify them. The study data were collected through semi-structured interviews. Selection criteria for managers’ participating in this study included: at least two years of experience in nursing management and expressing willingness to participate in the study. In this study, 14 participants were interviewed for data saturation. Data saturation was achieved with the first 11 interviews. However, for work richness, interviews continued up to 14 participants. Participants in terms of work experience, age, gender, education, and management position had quite diverse features. Interviews were done individually and in the work environment. Interviews began with open-ended questions such as: “What is the position of morality in your leadership and guidance?” Interviews continued based on participants’ answers with probing questions to explore the related data. The interviews were recorded by mp3 player. Interviews’ lasted at least 35 and at most 90 minutes.

2.2. Data Analysis

After the completion of each interview, the full text was heard first carefully and then transcribed verbatim in Word doc. The process of collecting and analyzing data was done simultaneously and latent content analysis was used to analyze the data. Interviews were processed and analyzed by comparative analysis. Data analysis was based on Graneheim and Lundman method (35). Thus, in this study, as explained under the section of “Participants”, concepts were encoded, summarized, and classified. In the initial coding, each interview text was read several times. The main sentences and initial codes were extracted. The codes were extracted based on semantic units of participants’ description and the classifications were then based on differences or similarities, so that each code is only in one category.

2.3. Trustworthiness of the Study

To ensure the accuracy and reliability of the data, credibility, dependability, confirmability, and transferability were used as measures of scientific accuracy in qualitative studies. Data credibility was realized using the researcher long participation, assigning enough time to collect data, controlling obtained concepts with participants (Member Check), and ensuring their opinion about the extracted concept. Data confirmability was realized by regular data collection, recording and writing stages and process of the research accurately and in compliance with the researcher neutrality. Data transferability was established by a detailed description of data collection and analysis procedures, as well as the selection of samples with maximum diversity. For data dependability, people who had experience in doing qualitative research (Peer Check) were asked to examine interviews, initial codes, and conceptual categories, and frequent reviews were done.

2.4. Ethical Considerations

Obtaining permission to do interviews from given universities and hospitals, informed consent completed by all participants, permission to record interviews, moral standards of anonymity, information confidentiality, the right to withdraw at any time and the use of information without mentioning any name were moral issues that were taken into consideration. Also, the study was approved at Medical Research Ethics Committee of the university with the code of ethics sbmu.rec.1393.697 on 02/15/2015.

3. Results

Fourteen subjects participated in this study, 8 men and 6 women, aged 38 to 56 years old with a mean managerial experience of 12 years. The majority had worked in multiple wards. In terms of education level, 5 subjects held nursing Ph.D., 3 subjects held M.Sc. in nursing, and 6 subjects held nursing B.Sc., 5 participants were nursing professors, 3 participants were supervisors with a history of matron and 5 participants head nurses. In interviews’ analysis, 342 initial codes were extracted that were reduced to 37 cases after integrating similar cases and finally, 4 sub-categories were obtained in two main categories (Table 1). Based on the experience of participants, the act and effect of the leader on subordinates as a mentor and instructor and having professional insight are the prerequisites of ethical leadership in nursing.

Table 1.

Main categories, subcategories and examples of codes

Main categories	Subcategories	An example of Codes
Leader as Mentor	Role Modeling	Manager as a model; Introducing positive models to nurses; Observational learning; Modification of personnel work with the manager; Proper work
	Empowerment	Personnel guide; Motivating; Encouraging personnel positive work; Personnel growth and enhancement; Personnel justification
Professional Insight	Knowledge and Skill	Understanding proper work; Increasing information; Better work to seek knowledge; Leader re-thinking
	Recognition	The necessity of recognition of organizational atmosphere; Considering personnel abilities; Recognizing moral spirit

3.1. Leader as Mentor

One of the abstract themes is the leader in the role of mentor. A mentor is a person who can be a good model for others, and plays an important role in professionalism as well as guides and empowers personnel to do the right things. This category includes two sub-categories of “role modeling” and “empowerment”.

3.1.1. Role Modeling

A manager in work environments through the established authority (and informal in some cases) and the position is considered as a model for personnel and is modeled by them. In this case, participants refer to the unconscious and latent aspect of ethical leadership. Participant No. 1, Ph.D. in nursing with 22 years of management experience at various levels reflects the idea: “…It is not necessary for me to note in my daily diary that I want to do this affair today. For ethical leadership, whether I write it or not, whether I pay attention to it or not, it’ll have its effect [on the personnel as a model] anyhow, i.e. I mean its effect on how I come, how I go, how I communicate, trust, keep secrets, honesty, etc…” Some participants have pointed to and presented a model in this field: Participant No. 2, Ph.D. in nursing and 8.5 years’ management and leadership experience at various levels, stated his experience as follows: “…I said that if one is good in every sense of discipline, precision and conduct, I want him to be all model, I wish all would be like this…” Also, participants acknowledged that they consider other leaders as models to follow and how to deal with personnel during studying or at work. Participant No. 13, 44 years old, B.Sc. in nursing with 15 years nursing work experience at different levels stated: “...I learned assertiveness from Mrs. ... When I was a nursing trainee, she was head nurse. After her, Mrs. ... came who was incredible, she paid so much attention to the personnel, for example, when planning, she considered all conditions or spent a long time to hear the personnel’s opinions. I learned things from her because she had a good effect on me so in this regard I try to be like her…” Almost all participants stated in an interview that if they want personnel to do something or respect regulations, first they should make it a reality. Participant No. 11, 45-year-old, 9 years of management experience at middle and operational levels stated: “…When I tell the personnel that cell phones are prohibited, should not be used in the ward and station, first I observe this myself, I mean that my speech should be consistent with my act, you cannot say do it, it is right, do not do it, this is not right, but you do not act. In my opinion, this is simply not moral and I insist on this issue…”

3.1.2. Empowerment

Moral leaders provide grounds and opportunities needed to empower personnel and try in this field by developing empowering measures in this regard. They have a positive attitude to personnel. In this regard, participant No. 8, 54-year-old, Ph.D. in nursing and faculty member, with a 6-year history of management at different levels stated: “…Ward nurses went on saying we want to do this, but we do not know how, but we know it now, then ethical leadership is that you provide the right perspective for the development and growth, or whatever else, of other people…” Empowerment of personnel is done through the development of competence. Participants expressed this: “…My goal should be the others’ growth, not my own growth or development at the expense of others’ failure and elimination…” (Participant No. 1). Also, participant No. 3, 52-year-old, Ph.D. in nursing and 7 years of experience in the management stated: “…I tried to help the people who are with me and work with me grow while I grow myself, they help me to grow, too…” Expressing personnel work value helps them feel efficacy, competence and effectiveness, and thus it is effective on empowering them. In this regard, one of the participants stated: “…You should tell the personnel their work value. Even when I talk to the ward footmen, I tell them that their work is as important as a surgeon’s, because the footman’s or housemaid’s work results in the surgeon’s success, then you’re just as important, when you remind them of the importance of their job, they try to do work better…” (Participant No. 13). Informing personnel in the fields of rules and nursing errors’ consequences, also the results of proper work to grow and improve performance and reduce errors are measures done by ethical leadership of the nursing profession. Participant No. 10, a 46-year-old, with 15 years of experience in management stated: “…I already try to make the personnel’s errors less and urge them to work better, I explain to them the medical errors that have occurred in nursing, and complications of the patient after discharge as a result of our error, this alerts them…” Also in the category, participant No. 8 stated: “…Let them see the results, I say, really, I always say that we try to bring these two standards in nursing that say, for example, when dressing, demonstrate to them that this dressing is good, show it, let them see the result, they do not see the results of proper work…”

3.2. Professional Insight

Professional insight is another category that an ethical leader has in nursing. An ethical leader has much needed knowledge and skill in the profession and deep consciousness and correct understanding of the problems related to the nursing profession, as well as adequate understanding of organizational atmosphere and beneficiaries, including personnel.

3.2.1. Knowledge and Skill

Having knowledge, skill and its effective use, as well as data analysis, were emphasized by participants. High public information and expertise, logical thinking, proper work knowledge and qualifications are some codes in this category obtained from their statements. Nursing leaders should have insight, knowledge, awareness and knowledge of professional issues. In this case, a participant with 7 years of management experience in various wards and different levels of management stated: “…I think one of the features that a head nurse or nurse manager should have now is to know what is happening in the nursing, to be consistent, and be a master of all aspects and I tried to be like this…” Ethical leadership is doing the right things instead of doing things right. For example, participant No. 8 stated: “…Morality is doing proper work properly as nurses, and doing what the whole world says is right, and yes, we do it right, so we should have knowledge of it and I really do it…” The participants believe that the nurse leader performance, based on knowledge and scientific intervention, can increase trust in personnel and statements’ effect. One of the participants stated the experience in this regard as follows: “…I’ve always tried to increase my information by reading books or using the experiences of others, when you have a strong underlying information you can talk in front of others, as you know, you commit little mistakes, leading to others’ trust and they know what you say or do is right, and then you can readily have the leadership…” (Participant No. 4, a 47-year-old with 20 years of head nurse experience). Of course, participants in this study had also pointed to the fact that despite having knowledge about the subject, they could not act it in practice, and even doing the right thing scientifically led to reverse results. “…Sometimes, it happens that you have the required knowledge, but when you want to use it in practice, you’ll surprisingly face reverse results, for instance: I once arranged a meeting and introduced one as the model for personnel, I did what I had read, but I saw reverse results, I thought deeply about it, about why what we read in books does not apply, because it really annoyed a few…” (Participant No. 2)

3.2.2. Recognition

Another sub-category of professional insight from the perspective of participants in this study was recognition. Participants emphasized the importance of the aspect and their experiences showed that the aspect is one of the serious factors in playing the role of ethical leadership. Identifying organizational atmosphere, understanding the personnel differences, delegating responsibilities proportional to differences, recognizing moral spirit and personal values and knowledge of personnel conditions were the factors making ethical leadership based on the experience of participants. Organizational atmosphere is one of the factors emphasized by participants for a dynamic nursing system that, by its identification, even we can know the organization management. Participant No. 2 stated: “…When I came here an administrative post was imposed on me very soon, I still did not know organizational atmosphere, maybe it was bad, yet I had heard about this type of atmosphere previously. Anyhow, it exists, whether in this post or in another one...” Participants believed that leaders need to be aware of individual and personality differences of their nursing personnel that can help them solve many problems. For example participant No. 5, B.Sc. in nursing with 20 years of experience in various wards stated: “…Everyone has their own talent, it’s not the case that one is good in all aspects, I know strengths and weaknesses of new or past workforce…” Based on the experience of participants, when managers accept humans in terms of innate and adaptive abilities, and that they are different from everyone, they do not expect equal behavior by all, and proportional to their ability they delegate responsibilities. “…Everyone is an individual, you should see and accept people as they are, you should see and accept people’s differences, and accordingly delegate responsibilities that are suitable for them with those differences in mind, you must behave and approach everyone in terms of differences really…” (Participant No. 3). Respect for values, interests and spirit of personnel was another issue referred by one of participants: “…You should know what is worthy for personnel, what matters for them, you should become familiar with their moral spirits,, when you give the personnel an assignment in which they are interested, they do it in a much better way, they do it with interest and more motivation, but when you do not care, the result is not motivating, there will be lack of interest, then you cannot say that you are acting morally…” (Participant No.12, 38-year-old and 4 years of head nurse experience)

4. Discussion

Regarding the key role of leaders in moving the organization toward achieving the goals set and the continual organizational survival, leaders try to provide individual, group and organizational growth and development by adopting different leadership styles appropriate to the culture, maturity, and organizational development. Leaders’ pioneering in ethical growth and development has led to the emergence of the concept of ethical leadership. This concept in the present study was specified by two categories “leader as mentor” and “professional insight”. Participants stated the theme of leader in the role of mentor. This theme had two sub-categories. One of sub-categories extracted is the role modeling. Participants stated that an ethical leader should be a moral role model for personnel, and provide personnel with positive models. The basis of role modeling is built on the provision of objective and practical samples (36), and it is an attempt to provide us all with an example of good behavior and needed conditions for modeling (37). Other research in line with the results of the present study referred to the variables (11, 13, 26, 38, 39). Leaders are responsible for influencing and ensuring psychological standards and ethical behavior. A good leader does not rely on merit alone, but also as an instructor, should promote morality among subordinates. Subordinates learn through observation and influence of the leaders about what to do and what not to do. Therefore, ethical leaders should be wary of what they say and what they do, because they should gain the trust of subordinates (40). A leader in managerial roles should consider both ethical roles in interacting with others and personal ethical characteristics. Individual aspect refers to having good characteristics such as honesty, trust and bring prosperity and happiness to personnel. In management aspect, the leader tends to lead others to moral principles and supervise personnel to find out what is expected of them and implement accountability in the organization (38). Freeman and Stewart believed that moral leaders have strong characters. These characters inspire them to be models for others (39). Therefore, managers should speak as they act and act as they speak (17, 41–44). Another sub-category is empowerment. There is no doubt that the growing and dynamic system of nursing requires nurses with appropriate functional skills, high power of critical thinking, clinical decision-making, clinical judgment, moral reasoning, and effective communication with the patient. Empowerment occurs when people are adequately trained, all relevant information is provided, people are fully involved and participate in decisions, and are also aware of the value and results of their work and that optimal results are appropriately rewarded. These findings are consistent with what was reported by Den Hartog and De Hoogh, and Javed et al. (20, 45). It is expected that moral leaders, more so than the rest of the leaders, consider developmental and evolutionary needs of personnel, and put personnel in positions where they can harmonize them with work role experience and a significant sense in job. Moral leaders likely create opportunities to make the personnel aware of the effect on their position and on their organization in general (46). Today, empowerment is considered as one of the useful tools to improve the quality of followers, and enhance organizational effectiveness. In order to succeed in today’s changing environment, organizations need knowledge, ideas, energy and creativity of all members including those at the forefront to high level executives (47). Leaders, by demonstrating honesty and respect in interactions and relationships, involving people in decision-making and showing trust in them, provide grounds of self-worth and efficiency (15). Open and clear communication of leaders with their subordinates helps them know what to expect and understand when the performance is good. Moral leaders’ loyalty (i.e. being responsible, reliable, and accurate), moves not only themselves but also personnel to do the right things (40). Subordinates learn through the use of reward, punishment and discipline of leaders. Also, when an immoral practice is removed by a leader, it conveys the message that such behavior is not correct and acceptable (48). Moral leaders can affect personnel through clear behavior, and honest and moral practices (40). Another category of the theme is professional insight. Nursing leaders should have insight, knowledge, and awareness about professional issues leading to professional analysis and finally professional sensitivity. “Knowledge and skill” and “Recognition” were two sub-categories the existence of which is required to achieve professional insight. Nursing leaders with knowledge of scientific and practical capabilities in the field of doing proper work in the right way and strengthening it, can use the maximum intellectual capabilities to the dynamics of the nursing system and thus as role models, strengthen scientific courage, criticism, and scientific and research spirit of personnel. Gary, in his research, pointed out the information power and the importance of open communication with maintaining the confidentiality of sources (22). Binns examined the effect of knowledge on the development of individual morality of leaders, and believed that leaders who did not learn morality cannot develop morality. With knowledge, leaders will be able to remove wrong practices and think freely and without prejudice to moral issues (49). Heres and Lasthuizen showed that ethical leadership in interpersonal situations think about problems in different ways, and are aware of a large number of behavioral options (42). Morality is perceived as a critical reflective practice through which leaders are aware of the effects of their behavior and can alter their performance (49). Understanding organizational atmosphere, individual and personality differences especially abilities and interests, moral features and characteristics, and awareness of personnel conditions were the cases referred to by the participants. Brun and Dugas stated that recognition is an issue related to human dignity and social justice, and is not only an organizational function or a mental health issue of workplace. The concept of equality among people known worthy only for human beings, also concepts such as considering others, and outcomes and effects of the measures taken are in connection with an employee recognition (50). The performance of each individual is due to personal characteristics, skills, and so on, if personnel have the necessary skills and abilities to do a job when they can demonstrate the behavior. In order to achieve competitive advantages, characteristics, behaviors and results should be linked to organizational strategies (51). Although employees and managers in organizations have similarities, they are different from some points of view, and these differences make human managing more difficult. If managers’ awareness of the diversity among these differences is increased, the possibility that they can better coordinate efforts of those under supervision in order to achieve the objectives of the organization and increase individual and employment efficiency would be higher. In order to work well with others and force them to work, hiring, training and putting everyone in its proper place to work should be done well. In addition, it is necessary that needs, demands and desires of people in the workplace should be considered. Handling such things is not possible without knowing the talents, emotions, and the type and level of motivation and personality, because each person has a different behavior and how to deal with him requires a good understanding of him (52).

5. Conclusions

Leaders sing the organization’s morality and are the tool of encouraging ethical behavior. The study findings showed that leaders should not only be moral, but also should go a step further and actively promote moral behavior by the role as mentor and model as well as professional insight. Leaders’ pioneering is an important part of ethical leadership with the potential for increasing the level of ethical leadership. Nursing leaders with a better understanding of these aspects can develop their capacity for strong ethical leadership and pave the way for individual and organizational success and effectiveness of their functioning. On the other hand, these aspects can help build this leadership style as an assessment tool for health planners. Given that this research was conducted only in schools and hospitals affiliated to the Ministry of Health and Nursing established leaders of Iran, it is suggested to do a qualitative study in non-governmental hospitals and other health-care professionals. Also, it is suggested to consider subordinates and other stakeholders’ experiences in this field.