I read with great interest Silva's article, Organizational and Administrative Ethics in Health Care: An Ethics Gap", as well as "Whistleblowing as a Failure of Organizational Ethics", by Fletcher, Sorrell and Silva. I concur with many of the conclusions of these articles.
However, I wish to point out that the administrator in the case study presented by Silva had many advantages related to organizational structure, allowing her to correct her situation that many other administrators and nurses, such as Barry Adams, do not have.
Jane, the administrator in the case study, was a part of a bureaucratic organization (a state health department) with strict rules and regulations. She was also attempting to correct a situation that was regulated by the federal government. While many people currently feel that bureaucratic structures are outmoded and thwart creativity and productivity, it was this very structure which allowed Jane to correct her ethical dilemma. State governments and the federal government recognize that there will be those who misappropriate funds and who engage in ethically deviant behaviors. As a result, they develop mechanisms to assure that this can be corrected if it does occur. The bureaucratic structures which require creation of policies and procedures to meet established specifications, documentation standards, and the chain of command all lend themselves to correction of a situation which has gone astray.
In private organizations often no such formal structures exist to correct ethical dilemmas, and those who bring issues forward are subject to much criticism. The story of Barry Adams is an example. While nurses and nurse administrators may be required by professional ethics to take appropriate actions to correct ethical dilemmas, there are literally no mechanisms in place in most states to protect the nurse in taking such actions. Neither, as pointed out in the whistleblowing article, are there ways to bring issues forward for discussion and solution within organizations which are not open to discussion. This is an unfortunate situation.
In Texas, when nursing and specifically the Texas Nurses Association (TNA) learned that nurses at both the top and the bottom of organizations were experiencing dilemmas related to restructuring of health care, we passed legislation to assist nurses who find themselves in situations which are ethically untenable. In 1987, TNA placed a whistleblowing clause into the Texas Nursing Practice Act that was recently upheld. Then in 1995 and 1997, TNA was successful in passing a Patient Advocacy Act. This act allows nurses to "refuse to engage" without fear of discipline, discrimination, or termination of their job, if they are asked to do something which would result in the omission of patient care, or subject the nurse to report to the Board of Nurse Examiners. In such a case, the nurse can request peer review of the situation in question. Health care facilities in Texas that employ ten or more Registered Nurses are required to have a peer review mechanism. What is unique about the Texas approach is that it does exactly what is proposed in the whistleblowing article by Fletcher, Sorrell, and Silva, it provides a mechanism which creates an environment for principled discussion of nursing practice issues. The use of the Nursing Practice Act for this purpose is something that should be considered more widely by the profession.
I send this letter to the editor in order to urge the nursing profession and nursing organizations across the country to work toward statutes similar to the Texas statute. Texas Nurses Association worked with the Hospital Association and others to pass this legislation. The Patient Advocacy Act has been used successfully by Texas nurses to solve practice problems within their organizations. Employing nursing peer review committees to deal with such problems could help nurses in every state.
Director of Practice, Texas Nurses Association
Graduate Student, University of Texas at Austin School of Nursing