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JUDITH COHEN, PHD, RN PROFESSOR COLLEGE OF NURSING & HEALTH SCIENCES BETTY RAMBUR, PHD,RN PROFESSOR COLLEGE OF NURSING & HEALTH SCIENCES JILL MATTUCK TARULE,

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Presentation on theme: "JUDITH COHEN, PHD, RN PROFESSOR COLLEGE OF NURSING & HEALTH SCIENCES BETTY RAMBUR, PHD,RN PROFESSOR COLLEGE OF NURSING & HEALTH SCIENCES JILL MATTUCK TARULE,"— Presentation transcript:

1 JUDITH COHEN, PHD, RN PROFESSOR COLLEGE OF NURSING & HEALTH SCIENCES BETTY RAMBUR, PHD,RN PROFESSOR COLLEGE OF NURSING & HEALTH SCIENCES JILL MATTUCK TARULE, EDD PROFESSOR COLLEGE OF EDUCATION & SOCIAL SERVICES CAROL VALLETT, EDD RESEARCH ASSOCIATE PROFESSOR COLLEGE OF EDUCATION & SOCIAL SERVICES THE MORAL CASCADE MODEL: THE INTERSECTION BETWEEN LEADERS' MORAL DECISION MAKING AND ORGANIZATIONAL VIRTUOUSNESS

2 Context and Assumptions Moral distress occurs at the interface of the individual and the organization Organizations shape individuals as the individuals shape the organization

3 Gaps in Existing Knowledge Little evidence based research on individual/organizational interaction. Research establishes moral distress but does not address when there is a positive outcome for the individual and organization. Methodological challenges including examining individual/organization interaction, complex moral real- life decision making, and assessing thought processes regarding moral action/decision making.

4 Major Points and Rationale A n I nteractive D ialectic A mong  individual experience and moral decision-making  virtuousness of the employing organization.

5 Moral Stress Cascades via two pathways  Moral distress and its sequelae, moral residue and negative organizational outcomes  Moral eustress with corresponding moral and organizational enhancement

6 The Moral Cascade Theory  Theory created first ( Rambur, Vallett, Cohen,& Tarule, 2010)  Scholarly Influences include  Moral Development (Kohlberg, 1984; Gilligan, 1982)  Positive Psychology (Seligman & Csikszentmihalyi, 2000)  Virtuous Organizations (Cameron, 2003; Dutton, Glynn, & Spreitzer, 2006)  Stress (Selye, 1974; Csikszentmihalyi, 1990 )

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8 Testing the Model Health care and Higher education institutions Triangulation of Data Defining Issues Test (Rest et al, (1999) Interview of 10 Leaders Positive Practices Survey (Cameron, Mora, Leutscher, & Calarco, 2011)

9 Research Questions  What themes emerge that illuminate the nature and quality of moral distress and eustress?  Can both moral distress and moral eustress be further differentiated by an individual’s cognitive moral developmental stage?  Does an institution’s virtuousness profile correlate with how workers’ respond to moral stress?

10 Data from interview Two forms of analysis  Grounded theory approach identifying themes  ‘Mapping’ leaders’ narrative about their decisions on the Cascade

11 Interview themes Eustress & distress may emerge during the same decision making narrative How the leader views the organization and his or her role in it influences how moral stress is experienced. The decisions varied significantly between the two organizations:  Health care – quality patient care vs economics and efficiency  Higher education – personnel and student progression decisions, i.e., tenure, dismissing a student

12 Stated and unstated organization (espoused/enacted)  Both provide context & content for decisions  Alignment of individual with both can create a positive context for decision making  Most frequently expressed stated vs unstated = service mission vs. resources & efficiency (shifting corporate expectations)  Healthcare:  Patient care vs “money talks in this institution”.  Higher education:  “Why are we here.. To really provide the best service we can for the students…[or] to fill all the beds and to fill all the seats in the classroom”

13 Mapping the Cascade Moral Identity, moral prehension, moral at-tension organizational effects Moral stress Moral certainty Moral Transaction Intention to act Effect of action E ustress and/or distress

14 Moral identity, prehension, attention create focus & readiness for engaging a moral decision Moral identity = moral compass  Can stand in conflict with institutional position “ I expect people to treat me how I would want to treat them and to be upfront.” Moral prehension - awareness beginning  “it (a care decision) made the hair stand on the back of my neck” Moral attention (at-tension)  Prompts for attention = power, safety issues, right vs good for the organization, anger

15 Cascade to Action moral stress - certainty – intention to act Moral stress “Moral struggles are really interesting. They engage the heart as well as the intellect”. Moral Certainty “I don’t think that I can say that I am absolutely sure before I have my intention to act. “ “This is going totally against my moral beliefs.” And not acting on that distress. I think that’s what I’ve learned. When I feel like my morals are being pushed or threatened that if mine are being threatened then a lot of other people’s are being threatened too. And if I’m in the position where I can impact that for the patients and nurses that I am there to represent, then that’s my moral responsibility. Intention to act ( “Do you stay in this or do you get out? Does this cross my personal moral line? “ Awareness of the issue Dawning sense of needing to pay attention Disputed: certainty vs ‘satisfizing’ in higher education (not life and death) Certainty vs “a balancing act of competing values” Moral Line in the sand Preparing: imagining ideal, possible actions, or outcome Role of dialogue/relationships in gaining new perspectives, “checking it out” Weighing alternatives and potential impact(s)

16 Mapping the Cascade Moral Identity, moral prehension, moral at-tension organizational effects Moral stress Moral certainty Moral Transaction Intention to act Effect of action E ustress and/or distress

17 Moral Eustress Moral Transaction Act Effective Individual Moral Enhancement Positive Organizational Outcomes

18 Moral transaction Often dependent upon moral courage, despite awareness of risk, action is taken with resulting impact on both the individual and organization. Call a meeting –communication to share perspectives/understanding Write a business plan envisioning new modes of operation Dismiss someone Engage others and/or the opposition, negotiating new vision with others, seeking out resources Compromise Quit (“it was for moral reasons and just that feeling of being out of alignment with the corporate culture that caused me to vacate the for profit sector and move into an environment where it was much more about the individuals and the greater good),

19 Act effective Judged as effective by addressing the problem, meeting needs of many. “So, it’s been pretty successful…a patient satisfier and a staff satisfier…it took a lot of buy in.. And there’s been a lot of work in the organization…just getting the right group together and doing the communications made a huge difference and then the satisfaction’s just been tremendous for everybody involved”. Melinda, pg 6

20 Moral Eustress The institution, despite challenges, changes practices, which feels like support to the leader and like the solution has moved the unit to “a good place.”, i.e. Positive Organizational Outcomes “I get an awful lot of support and it’s not easy business. You know, just everything: delivering safe care, quality care, and all that sort of stuff under the pressure of all the regulatory agencies…it’s been a lot of hard work but, you know, I’m really pleased with where the unit’s at. And if I left today I’d feel like it’s in a good place.” Melinda, pg 42

21 Moral Distress Moral Transaction Act Ineffective Moral Residue Negative Organizational Outcomes

22 Moral Distress  Thwarted  By a more powerful colleague/boss  By organizational ‘rules’,.e.g. tenure “I felt angry. I just feel at times that we are not looking at patients as people, but as statistics. But really that this person was a mother and a sister, and a daughter at one time and we are losing sight of that.” Brenda. P. 2  More moral distress in health care than higher ed.  Power structure: relation between nurses and doctors  More likely to occur in institutional structures in which there is assigned responsibility without accompanying authority  Proximity to patients within life/death contexts

23 Act Ineffective Thwarted from doing what the leader knows is the right thing to do Frustration distress Emotional distress vs moral distress Emotional distress always accompanies moral distress but not visa versa

24 Emotional distress I felt very good of what I accomplished. I felt leaving was the right thing, but it was very sad for me. It was just like leaving this dysfunctional home. You know that’s always a sad thing to have to do, but it was the right thing to do. So that’s why I, you know, I felt like this relief when I finally made that decision, “Yes. This is the right thing to do.” Karen, pg. 19 I mean it – it hurts, I think its – its tough because I think that it’s – you know, I use the word agony very intentionally when I’m talking about some of these decisions. Don pg.3

25 Leaders’ moral developmental stage Two thirds of the leaders interviewed were at the highest moral stage Further analysis is needed to establish if this measure appears to have explanatory power about leader’s decisions.

26 Positive Practices Survey 29 items, 7 point Likert scale  6 Factors  Caring  Compassionate support  Forgiveness  Inspiration  Meaning  Respect, integrity, and gratitude Administered online to 50 randomly selected employees from each organization 17 respondents from each organization, phone follow up with additional 5 non-respondents from each organization 44% overall response rate

27 Positive Practices Survey No significant differences between respondents and non- respondents Comparing organizations  No significant differences on all scales  Forgiveness was very close to being significant different with Healthcare scoring noticeably lower on this scale  Small sample size did hamper power to detect 1 pt differences  Higher ed: impressive agreement on institutional mission & trust in consensus as a decision making strategy.  Healthcare: multiple layers of authority & a significant conflict between mission of patient care vs measured efficiency, efficacy and economic outcomes

28 Some preliminary conclusions Moral eustress is significantly under studied. Moral distress and eustress may occur in the same moral decision. Moral decisions engage and are influenced by the individual, the unit and, where relevant, the larger organization. Moral distress is currently defined and applied in health care settings, almost exclusively. This pilot suggests it can effectively illuminate moral decision making in other settings as well. The Cascade provides a model for preparing future leaders so they become skilled in identifying aspects of a decision making process.

29 Questions to pursue Does the size and complexity of the organization impact leaders’ moral decision making process and outcome? Are decisions that deal with life and death circumstances more likely to produce moral distress? Does institutional mission coherence inoculate against moral distress?

30 Works cited  Cameron, K. S. (2003). Organizational Virtuousness and Performance. In K. S. Cameron, J. E. Dutton & R. E. Quinn (Eds.), Positive organizational scholarship (pp. 48-65). San Francisco: Berrett-Koehler. Cameron, K., Mora, C., Leutscher, T.,& Calarco, M. (2011).Effects of Positive Practices on Organizational Effectiveness. The Journal of Applied Behavioral Science,47, 266-308. Cohen, J., Tarule, J., Vallett, C., & Rambur, B. (2011). Stress and the Workplace: Theories and Models of Organizational Stress. InV. H. Rice (Ed). Handbook of stress, coping, and health. Thousand Oaks, CA: Sage Publications (in press)., J., Vallett, C., & Rambur, B. (2011). Stress and the Workplace: Theories and Models of Organizational Stress. InV. H. Rice (Ed). Handbook of stress, coping, and health. Thousand Oaks, CA: Sage Publications (in press). Czentmihalyi, M. (1990). Flow: The psychology of optimal experience. New York, NY: Harper and Row. Dutton, J., Glynn, M. A., & Spreitzer, G. (2006). Positive Organizational Scholarship. In J. H. Greenhaus & G. A. Callanan (Eds.), Encyclopedia for career development: Sage Publications.

31 Works cited (continued) Gilligan, C. (1982). In a different voice: Psychological theory and women's development. Cambridge, MA.: Harvard University Press. Kohlberg, L. (1984) The psychology of moral development. NY: Harper Rambur, B. A., Vallett, C., Cohen, J. A., & Tarule, J. M. (2010). The moral cascade: Distress, eustress, and the virtuous organization. Journal of Organizational Moral Psychology, 1(1), 1-14. https://www.novapublishers.com/catalog/product_info.php?products_id=24686 https://www.novapublishers.com/catalog/product_info.php?products_id=24686 Rest, J., Narvacz, D., Bebeau, M. J., & Thoma, S. J. (1999). Postconventional moral thinking: A neo-Kohlbergian approach. Mahway, N.J.: Erlbaum. Seligman & Csikszentmihalyi, M. (2000). Positive Psychology. American Psychologist, 55, 5-14 Seyle, H. (1974). Stress without distress. Philidelphia, PA: Lippincott.


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