Copyright is owned by the Author of the thesis.  Permission is given for 
a copy to be downloaded by an individual for the purpose of research and 
private study only.  The thesis may not be reproduced elsewhere without 
the permission of the Author. 
 
 
 
 
 
 
 
 
Nurse Managers’ Ethical Conflict with Their 
 Health Care Organizations: 
A New Zealand Perspective 
 
 
 
A thesis presented in partial fulfillment of the requirements 
 for the degree of 
Master of Management 
in Health Service Management 
at Massey University, Palmerston North, New Zealand. 
 
 
Linda Maree Chalmers 
2008 
 
ABSTRACT 
 
Immersed in a context of constrained heal th resource s , nurse managers are at 
great risk of the experienc e and negative consequenc es of values clashes and 
ethical conflict , such as burnout and attrit i o n . Replic a t i n g a qualit a t i v e 
descriptive study previously conduct ed in Canada (Gaudine & Beaton, 2002) 
this research is aimed at increasing knowledge of the experience of nurse 
managers’ ethical conflict with their health care organiz ations in New Zealand. 
Semi-st r u c t u r e d intervi e w s were used to  gather data from eight nur se manager s 
in New Zealand, which was analyzed us ing a general inductiv e approac h to 
qualitat i v e research . The ex perience of advocating fo r values that may be 
shared by both nursing and the health ca re organization, such as safety, 
teamwork and quality patient car e, were revealed in the conceptual category of 
Nursing Management Advocacy . As with their Canadi an study counterparts, 
Isolation was reveal e d as a key factor t hat made the experie n c e of ethical 
conflict worse and involves the social ex periences of silencing, employment 
barriers and inv isibility. Support describe s the factors that mitigat e d the 
experience of ethical conflict and in v olves per sonal, pro f essional and 
organizational support, and are likewise sim ilar to the experie n c e s of Canadia n 
nurse managers. The Bottom Line describes a focal point of the exper ienc e of 
ethical conflict where the health care organiz ations predominantly fiscal botto m 
line was confronted and challenged by nu rse managers, and where the nurse 
manager might reach their own botto m line and choos e to leave the 
organiza t i o n . Being and Becoming Nursing Leaders describes the outcomes of 
ethical conflict for nurse managers who were not only transformed into nurs ing 
leaders, through learning, reflection, and growth but al so counted the costs of 
nursing leadership.  This study conc lud e s that support i v e colleag u e s , 
organizational structures and culture are essential to mitigating the experienc e 
of ethical conflict and isolation whic h nur se managers enc oun t e r . The study 
also concludes that reducing isol ation and supporting nurse managers wil l 
ensure that nursing values are appropriately represent e d and artic ul a t e d in the 
health care organization’s decis i on making systems and processes. 
 i
ACKNOWLEDGEMENTS 
 
T h e first and most importa n t acknowl e d g e m e n t that I need to make in respec t of 
this thesis, is the contribution of my whanau, who make all things possible and 
meaning f u l . In particu l a r my hus band Rudi and daughte r Gabby, whose 
patience, understanding and to lerance of my nearly thr ee year distraction has 
never bee n underestimated and will alway s be part of this journey. Adde d to 
this is the beloved, but now long past contribution of my parents, Kathleen and 
David. Their influence on me as a pr ofessional nurse, scholar and ethica l 
human being, is manifest in all that rests betw een the covers of this project.  
Nga roimata aroha e mairingi mai nei. 
 
The second set of acknowle d g e m e n t s is to the eight researc h partici p a n t s who 
willingly contributed their ti me and experience to this  research . My sincer e 
thanks for sharing what is the essence of the project. 
 
Acknowledgement also goes to the College of Nurses Aotear o a and the 
Nursing Council of New Zeal and for their kind assistanc e with the recruitment of 
participants for this study. 
 
Finally, and by no means least, I ack nowledge the wisdom and guidanc e of my 
research supervisors, Dr Craig Prichard and Dr Denise Wilson. It has perhaps 
been a longer than expected pr ocess, and I am humbled to have been your 
studen t .  
 
 ii
TABLE OF CONTENTS 
                 
                                                                                                       Page 
 
Abstract   i  
Acknowledgements         ii 
Table of Contents           iii 
List of Figures          v 
 
    
Chapter 1. Introduction        1 
 
Chapter 2. Review of the Literature   6 
2.1 The Economic and Political Cont ext of Change      7 
2.2 Health Policy, System and Structural Reform 11 
2.3 The Impact of Reform on Nursing   
An International Perspective 17 
2.4 The New Zealand Nursing Experience of Health Reform 23 
2.5 Values and Ethics in Health Care Organizations 30 
2.6 Ethical Conflict for Health Professionals and 
Nursing 36 
2.7 Literatu r e Review Summary and Rationale for Study 48 
 
Chapter 3. Method  52 
3.1 Methodological Under pinnings 52 
3.2 Participant Recruitment and Selec t ion 54 
3.3 Data Collection 56 
3.4 Date Analy sis 59 
3.5 Establishing Research Rigour 61 
3.6 Ethical Considerations and Activities 62 
 
 
 
 iii
Chapter 4. Data Analysis  64 
4.1 The Health Care Organization 65 
4.2 Nursing Management Advocacy 67 
4.3 Isolation 77 
4.4 Support 82 
4.5 The Bottom Line 84 
4.6 Being and Becoming Nursing Leaders 87 
4.7 Summary of Data Analysis 92 
 
Chapter 5. Discussion  95 
5.1 The Health Care Organization 95 
5.2 Nursing Management Advocacy 98 
5.3 Isolation 106 
5.4 Support 108 
5.5 The Bottom Line 109 
5.6 Being and Becoming Nursing Leaders 112 
 
Chapter 6.     Conclusion and Implications  114 
 
Appendices  121 
       Appendix I: Invitation to participate in research distributed 
 by the Nursing Council of New Zealand 122 
 Appendix II: Invitat i o n to parti cipate in researched listed 
 on the College of Nurses Aotearoa website 123 
 Appendix III: Research Information Sheet 124 
 Appendix IV: Participant Consent Form 127 
 Appendix V: Biographical & Prof essional Data Collection Form 128                            
 Appendix VI: Interview Schedule 130 
 
References  131 
 
 
 iv
LIST OF FIGURES 
 
                   Page 
Figure 1.  Framework of analytic findi ng s : concept u a l categor i e s , 
         themes, dimensions & relationships.                                              60 
 
 
 v
CHAPTER 1 – INTRODUCTION 
 
As with many of its international counterparts, New Zealand’s public 
health care system and services hav e undergone 20 years of significant 
and continuous reform and restructur ing (Gauld, 2003; Seedhouse, 
1995). Indeed, not only does New Ze alan d have the most restru c t u r e d 
health care system in the worl d (Gauld, 2003), changes have gone 
further and occurred faster than any  other developed country (Davis & 
Ashton, 2001). Under pinne d by rapid and broad ne oliberal economic 
reform, the initial key policy driv er in the transformation of New 
Zealand’s public health system was cost containment (Health Benefits 
Review Committee, 1986; Treasury, 1984). With emphasis on structural, 
administrative and fiscal management to produce more effective and 
efficient utilization of h ealth resource s , particul a r change activities have 
included the separation of funding fr om provision of health care, 
population based and cappe d global budgets, and the institution of 
generic management structures and pr ac tices into health ser vices 
(Ashton, 1995; Ashton, Mays & Devlin, 2005).  
 
The embrace of managerialism in New Zealand’s reformed health 
system has, and continues to have, a marked impact on nursing 
(McCloskey & Diers, 2005; Ashton et al., 2005; Gauld 200 1; Wells, 
1999). A reflection of market place business ideology, managerialism 
emphasizes efficienc y and effectiveness in service deliv ery (Gower, 
Finlays on & Turnbull, 2003; Gaul d 2003; Finlayso n &Gower, 2002; 
Beardwood, Walters, Eyles & French,  1999; Wells, 1999). Restruc t u r i n g 
of health services and hospitals to achiev e efficienc y, resulted in the 
collapse of many nursing structures , reduction of nursing numbers, and 
in many cases the loss of nursing control over clinical budgets 
(McCloskey & Diers, 2005; Gower et  al., 2003; Gauld 2003; Carryer, 
2001).  
 
 1
The role and respons ibilities of t he nurse manager in the reformed and 
restruc t u r e d context have not only enlarge d but offer new challen g e s 
(Thorpe & Loo, 2003; Wells, 1999; Inge rsoll, Cook & Fogel, 1999). 
Managing service redesign, restruct ure and re-engineering ac tivities, 
managing and auditing clinical st anda r d s , assumi n g corpor a t e 
responsibility, managing qua lity of service, recr uiting and retention of 
specialist nursing staff, and managing the frustrations  of staff  are but a 
few of the new challenges facing today’s nurse mangers (Thorne & Loo, 
2003; Wells, 1999; Ingerso ll, Cook & Fogel, 1999).  
 
Thus, contemporary nursing manager s have been reinv ented (Thorpe & 
Loo, 2003; Wells, 1999). Not only do the y embrace the core and 
essential caring and humanistic values  of their profess i o n , they also 
embrace the values of the health care organization in a fiscally prudent 
and soc ially responsible environment. It is a duality of values however, 
that is fraugh t with tensio n and et hical conf lict (Gaudine & Beaton, 2002; 
Gaudine & Thorne, 2000; Wells, 1999).   
 
This study, Nurse Managers’ Ethical Conflict with Their Health Care 
Organizations: A New Zealand Perspective , is unquestionably mot ivated 
by my own experiences as a nur se manager in the reformed and 
restruct u r ed New Zealand health care  system . My first role as a nurse 
manager was brief (a mere 15 months ), fractiou s , painful, distress i n g 
and dis appointing. I believed, per haps naively, that  over 20 years 
experience as a Registered Nurse, and significant advanced st udy in 
nursing and management would pr ovide me with the requisite 
competence for nursing management prac tice . Howev er, there was little 
consistenc y between my nursing managem e n t job and what I had 
studied – and I believ ed it was more  than a mere theory-practice gap. 
Moreover there were few who coul d or would help me to understand 
inherent inconsistencies, in all facets  of the role. Frequently I would say, 
‘I just cannot win’. On the one hand I would focu s on ensuring that the 
 2
p a t i e n t ’ s needs were met as best as possible within the scope and 
resources of my role. On the ot her hand, to do so would earn me 
tremendous criticism from the clin ical nurses whom I managed, my 
nursing management peers and my own general managers . Even 
though it might have been my responsib ility to do so, taking a firm stand 
in particul a r circumst a n c e s , balancin g all the necessar y demands, 
expectat i o n s and values, was oft en met with treacherous repost. I 
began to wonder if my colleagues and bosses exis ted in a different 
world from me; were they protecting their own professional aspir ations, 
were they trying to win accolades fr om the organization, and did they in 
fact apply any values , nursi n g or otherw i s e in their pr actice . In the end, 
my decision to leave my first nursing management role was bas ed on 
keeping my professional integrit y inta ct, and the belief that I was hitting 
my head against brick walls and sustaining  injuries that I simply did not 
have to. There would be other  opportunities, but there were things that I 
needed to know and understand first. This  research project is therefore 
an endeav or of great prof essional and pers onal im portance, and as the 
study will demonstrate, I have not been alon e in my exp eriences. 
 
Stepping out and away from the day  to day struggl e s of nursing 
management provided me with the opport unity to reflect on my nursing 
manageme n t experien c e and to formu late important questions: 
 
• Why was there so much confli c t in nursing manageme n t and 
was it always a question of fiscal limits? 
• Were the organization’s values  consistent with professional 
nursing? 
• Why did I not feel suppor ted and who should have been 
supporting me in my nursing management role? 
 
This study addresses all of thes e questions and many others, by 
investig a t i n g the experien c e of nu rse managers’ ethic al conflicts with 
 3
their health care organizations . I wa s fortunate to find a previous 
qualitative study (Gaudine & Beat on, 2002) conducted in Canada in 
2001-2002, that tackled many of my concerns and question s , and 
helped to place my inquiry into a meaningful framework. It has thus 
provided the foundations for this st udy and is discussed in some detail 
in the review of the literature in Chapter 2. After outlining the political 
and economic context and cons equences  of reform and its effects on 
the public sector, Chapter 2 then s pecifically address es the effects of 
reform on health polic y, health care structures, professional nursing and 
patient car e outcome s , both in New Zealand and internationally. Values 
in professional nursing and reform ed health care systems are outlined 
next. A review of empirical and theoretic al literature concerning ethics in 
nursing and health care generally is provided , followed by a detailed 
examination of the conc ept and experience of ethi cal conflict in nursing 
and nursing managem e n t . 
 
Chapter 3 sets out the methods for t he study. Replicat ing the qualitative 
descriptive approach of the study by Gaudine and Beato n (2002 ) , this 
part outlines the methodological under pinnings for the current study. 
This chapter also addresse s parti cipant recruitment and selection, 
followed by data collec tion and analysis.  An outline of the establis hment 
of research rigour and ethical considerations is provided. 
 
A detailed presentat ion of conceptual, desc r ipti ve and thematic findings 
from data analys is is provided in C hapter 4. Following this, Chapter 5 
provides a comprehensive disc ussion  of the study findings inc l uding 
comparison and contrast with t he foundational study and other 
literature. Conclusions and implications of the study are set out in 
Chapter 6.  
 
This study is grounded in a context of ideologically dr iven politic a l and 
economic reform, which has tran scended health policy, health systems 
 4
and hea lth care structures, to affe ct the roles, responsib ilities and 
experiences of nurse managers. It is  theref o r e not a study conc erned 
with ethics, values, conflict, nursing or managem e n t individ u a l l y per se, 
but the transcendenc e and intersection of all these things within the 
social experience of nurse managers, immersed in managing and 
leading nur sing care in contempor ary health care organizations. 
 5
CHAPTER 2 – REVIEW OF THE LITERATURE 
 
The objective of this chapter is to  review several dimensions of the 
literature as it pertains to the experience of nurse manager s ’ ethical 
conflict wit h their health care organizations. The first part places the 
study into a context of politic al and economic reform from 1980-1999, 
and is aimed at highlight ing the politic al ideol ogical foundations of 
reform and restructuring in the public sector. Following this, a review of 
the consequences of reform on the New Zealand healt h se ctor is made, 
including health polic y, health syst em and health services structure. 
Next, a review of the impact of re form and restructuring on professional 
nursing is made drawing on both t heoretical and empirical sources. 
International and New Zealand  based lit er ature is outlined with a focus 
on the impacts of change to nursing services and the nursing workforce, 
the quality of nursing care and t he effect on patient outcomes. 
 
The review then narrows its focus to outline how reform has affected the 
values of health car e services, in particular the interface of health 
professional and health care or ganiza t i o n a l values.  Ethics in nursing 
practice and the phenom enon of ethical conflict and  it s implic ations for 
nursing and most importantly nurse  managers is introduced. At this 
juncture ethical conflict is defined, along with its implic ations. To support 
the current project, a literature s earch was conducted to identify both 
theoretical and empirical literature  whic h specifically address ed the 
concept and problem of et hical conflict in nursi ng. The method for this 
literature search involved five elec tronic databases, Web of Science, 
Medline, CINAHL, Academic Search  Elite, and Medic al Databas es on 
Ebsco Megafile, using the search words, ethics, values, nursing, 
management and conflict in the abstrac t and topic fields, and limited to 
the period of 1995 onwards.  Literature was selected for its academic 
accessib ilit y as well as relevan c e to  the topic. of nurse managers’ 
ethical conflict with their health care  organiz a t i o n s .  The chapter is 
 6
concluded with a summary  of the literature t hat has been reviewe d, 
followed by the identification of the rationale for the present study. 
 
 
2.1 THE ECONOMIC AND POLITICAL CONTEXT OF CHANGE 
T h e Labour movemen t that grew througho u t the world from the 1930’s, 
defined its role as one addres sing t he inequities of the rewards of 
capitalism (Castles & Shirley, 19 96). In both the post war periods, New 
Zealand cit izens were concerned wit h eco nomic, strategic and social 
security issues, in times of sickness, old age or unemploy ment 
(Gustafson, 1997).  Michael Savage’ s fir st Labour government in the 
1930’s, did much to appease these conc erns by the introduction of 
social sec urity and a universally a ccess ible largely tax-pay er funded 
health car e system (Gustafson, 1997). The tenants of social security 
transcended the ideological refinem ents of succeeding liberal and 
reformist National gov ernments, to ma intain the ideals of an egalitarian 
society (Blank, 1997). 
 
Orthodox Keynesian economics, whic h dominat e d not only Labour but 
National party politics prior to t he 1980’s, is based upon the principle 
that markets cannot automatically mainta in stable activ ity at full potential 
(Gustafson, 1997). Where the “...market is clearly failing to  foster growth 
or cope with temporary economic crisis to deal with social inequalities, 
then the government should intervene to achieve the desired result” 
(Gustafs o n , 1997, p.6). When Great  Britain entered the European 
Community in the 1970’s however, New Zealand’s insular and 
protective Keynesian economic polic ies falt ered (Sautet, 2006). Some 
concess i o n s for a failure to reform dramatically, may rest upon the fact 
that the third Labour gov ernme n t took office during and economic cycle 
upturn, and it was a time of relati ve l y full employme n t (Rudd, 1997). 
After the first of the oil shocks in  1974, and a prolonged and difficult 
stagnation in agricultural exports, parti cularly wool, policies of economic 
 7
diversification prolifer ated in an attempt to combat the growing 
economic recession (Easton, 1997). The end of New Zealand’s golden 
era of prosperity provided the platform for extens ive and rapid politic al 
and economic reform (Sautet, 2006; Aberbach & Christensen, 2001).  
 
The era of neolibe r a l transfo r m a t i on of New Zealand has been well 
documented and critic ally  examined by political  and legal analysts and 
academics (see for example: Castles, Ferritsen & Vowles, 1996; 
Easton, 1997; James, 1997; Kelsey , 1993; Kelsey, 1997; Miller, 1997). 
With philosophical roots in the Chicago School of Economic and 
Politic al Thought, neoliberalism and monetarist economic policy hav e 
dominated New Zealand’s polit ical landsc ape from the mid 1980’s 
(Brook Cowen, 1997). Neoliber al t heory involves classical liberal and 
economic philosophy combined with pres ent day market orientation 
(Brook Cowen, 1997). N eoliberalism advoc ates, inter alia : respo n s i b l e 
economic policy and fiscal rectit ude,  free and deregul a t e d markets and 
trade, privatization, ut ility maximization, minimalist labour laws and 
restricted welfare provision (Rod rik, 1996; Tenbensel & Gauld, 2001). 
Ideologically, monetarism espous es the superio r i t y of the market place 
over government, competition over co-operation, and self-reliance over 
community responsibility (Brook Co wen, 1997). Aimed at deprote c t i o n 
and deregula t i o n of the economy, key macroeconomic changes of the 
era of 1984-1990 inc luded a series of  tax reforms, alongside dives t ment 
and corporatisation of gover nm e n t assets (James, 1997). 
 
Yet not only did aba ndonment of Keynes ian ec onomi c managem e n t 
reduce gov ernment intervention in the ma rket place, it also cons iderably 
altered political commitment to an egal itarian society (Boston & Dalzie ll, 
1992). The value of human dignity, distributive justice, and social 
cohesion, gave way to a more limited state, the pursuit of efficiency, 
self-relianc e, and fiscal balance (Boston & Dalz iell, 1992). Whilst New 
Zealand was indeed gripped by a then globa l economic recession, 
 8
r e f o r m came surprisi ngly at the hand of  a Labour government, 
previously entrenched in the i deals of egalitari anism and the 
amelioration of social injustices (Castles & Shirley, 1996; James, 1997; 
Street, 1997).  
 
Politic al ec onomics were therefore im perative, but the impact of these 
considerations on social policy, in particular health polic y, was tempered 
by the mould of Labour’s egalitarian predec essors an d to a lesser extent 
Prime Minister Lange’s refusal to allo w eco n omic policy to spill ove r into 
social polic y (Rudd, 1997). However, in December 1990 a newly elected 
National government released an ec onomic package aimed specifically 
at reduction of the fiscal burden of t he welf are state (Scott, 1994). It was 
considered that the ma ssive rise in social spending was regarded as a 
principle cause of New Zealand’s  large debt burden (Scott, 1994).  
 
To the extent that the Fourth Labour Government had resisted 
signific ant reform of social policy ,  the National Governments of 1990-
1999 (including a coalition governm ent with the populist New Zealand 
First party) did not (Miller, 1997a;  Wood, 2001). A more targeted 
approach to social services and security was born out in ar eas of 
education, housing and health (S cott, 1994). Simult an e o u s l y , further 
deregul a t i o n and liberal i z a t i o n of  the economy occurred through 
reductions in gover nment assist ance in industry, alongs ide the 
deregulation of banking, finance , energy and telecommunic ations 
(Scott, 1994).  
 
To facilitat e reform, it was als o nec essary to systematically deregulate 
and alter industrial relationships through lais sez faire legislation such as 
the Employ ment Contracts Act 1991 (Walsh, 1997).  The Act replace d 
centralized wage bargaining wit h decent r a l i z e d entrep r e n e u r i a l 
bargaining, weak ened unionism, and gave employ e e s and employ e r s 
the choic e of individ ual or collective cont ra cts (Walsh, 1997; Sautet, 
 9
2006). Because labour is the primary factor in all bus inesses, the Act 
was therefore a key mechanism in shifting the locus of labour market 
control and with this , the social pr osper i t y of the workfor c e , to the 
entrepreneurs of the busine ss sector, where the ability to exploit the 
workforce for productivity and effi ciency was realized (Sautet, 2006). 
The Act has since been replac ed by the Employme nt Relations Act, 
2000, that in principle, promot es the creation of employment 
relationships, and good faith in those employm e n t relatio n s h i p s (Brown, 
2005). 
 
The shift from government regulati on of economic growth and pr osperity 
to the private sector was institutionaliz ed not only through 
macroeconomic policy and change, but also the influence of human and 
organizational theory in the organiza tion and management of the public 
sector. Public choice, agency, and new  public management theory or 
managerialism have been highly influential in contemporary New 
Zealand public policy and reform (Bost on, Martin, Pallot & Walsh, 1996; 
Tenbens el & Gauld, 2001). Public choice  theorists posit that the primary 
factors motivati n g people are self-interest and personal gain (Tenbensel 
& Gauld, 2001; Brook Cowen, 1997). In order to counter these 
motivations, public choice theorist advance restrictions on the 
constitutional power of politic ians , polic ies that restrict and split 
government bureaucracies and policy proc esses free from the influence 
of interest groups (Mitchell & Si mmons 1994, cit ed in Tenbensel & 
Gauld, 2001; Brook Cowen, 1997). Agency theory views the world in 
terms of the economics of organizati ons and relations hips, and focuses 
on the establishment of wr itten contract relationships to ensure delivery 
of the requirements of the rela tionship (Tenbensel & Gauld, 2001). 
Managerialism draws its influenc e from the manage m e n t of privat e 
organizations and is a response to perceived adminis trative 
shortcomings in public organizat ions  (Tenbensel & Gauld, 2001 ). The 
proponents of managerialism see no difference between the 
 10
management of public and pr ivat e organi z a t i o n s , “...a rgu i n g that public 
agencies will be more efficient and responsive if private management 
practices are adopted” (Tenbensel  & Gauld, 2001, p. 37). 
Managerialism is thus built around the idea that management is a 
function that is the same regardle ss of the organizat ion or persons to 
which it related (Wells, 1999).  
 
At the institutional le vel, these theories have had a marked impact. The 
public serv ant is no longer  the apolitical agent providi n g their ministe r s 
with policy advice (Martin , 2001). Aided by the State-Ow n e d Enterpri s e s 
Act 1986, the State Sector Act 1988,  and the Public Finance Act 1989, 
the centralized machinery of gov er nm e n t has been transfo r m e d (Martin , 
2001). Alongside the devolution of public sector activities into the private 
sector, public servants now operate in an entrepreneurial, results-focus 
business environment (Martin, 2001). The common themes in a globa l 
moveme n t of public sector tr ansformation are efficiency and 
effectiveness with focus on out puts not inputs, and performance 
measured in quantitative rather t han qualit ative terms (Martin, 2001). 
The devolution of management responsibili t i e s to chief executi v e s is a 
hallmark of New Zealand’s public sector reform (Martin, 2001). 
 
 
2.2 HEALTH POLICY, SYSTEM AND STRUCTURAL REFORM 
In the two decades prior to the neol iber al reform era, New Zealand’s 
dominant coinciding demographic trends  were: increased net migration, 
particularly from Europe; decline in  mortality rates generally and in 
particular in the Mao r i popu lation; record fertility rates; and lastly a 
steady incr ease in the populati o n aged 65 years and over (Poole , 1991). 
As a conseq u e n c e these demand s were re flect e d in the hea lth sector by 
a marked increase in overall public  health expenditur e (Departm e n t of 
Health, 1969), increased hos pit al i npatien t treatmen t (Departm e n t of 
Health, 1972), and increased hospital bed capacit y (Department of 
 11
Health, 1975). In no small way can t he rising cost of funding health 
services, improved mortality ra tes and an ageing popula tion be 
attributed to the advances in m edicine and technology such as 
antibiotics, modern surgical procedur es, chemotherapeutics and many 
others. All these factor s, alongside the social and economic prosperity 
that New Zealand enjoyed in the post World War II period, impacted on 
the health system. Indeed, creatin g a sce nario where the availability of 
medical treatment was reinforced as  a fundamental human right, in a 
regime of politics that saw it s mandate resting in an open ended 
commitment to universal health care for all citizens (Blank, 1997).  
 
Health policy change s in the pre 1980’s reform era included increases in 
the gener al medical, physiother apy and dental benefits schemes 
(Basset, 1976). Greater regulati o n and  coordination of  health sector 
efficiency was reflected in changes to hospital administration 
(Department of Healt h, 1969). Planning  for the transfer of control of 
mental hospital to Hospital Board control was commenced and 
continued through Labours’ gover nment  in 1972 (Depar tment of Health, 
1975; Truman, 1984). 
 
In 1975, during the term of the third Labour Government, the 
Department of Healt h in New Z ealand telegraphed princ iples of 
important reform of the hea lth system by way of the White Paper 
(Department of Health, 1975). These pr incip l e s , which remain influen t i a l 
today, are summarized as: a shift to community responsib ility for healt h 
needs; the alignment of financ ial and administrative control of health 
services ; the organiz at i o n and administ r a t i o n of services on the basis of 
community health needs; functional integration of health service 
component s; rationality in planning and future development; and a 
national health service (Departm e n t of Healt h, 1975). Yet reform did not 
automatically follow the policy advice at this time, waiting another 
decade to be initiated. 
 12
The pre 1980’s organizing structure of locally elect ed hospital boards 
was coupled with the triumvirat e management model: the chief 
exec utive, the medical superintendent and the chie f nurse (Ashton , et 
al, 2005; Jacobs, 1994). A natural product of hos pital development 
rather than planned management , the triumvirate model was seen as a 
desirable and efficient st ructure that appropriately  reflected the multi-
disciplinary nature of health services, and the equal status of team 
members and consens us decision-making (Jacobs, 1994).  
 
During the term of the Fourth Labour Government, two signific ant policy 
reviews of health sector structur e and performance  were undertaken, 
‘Choices for Health Care’ (Sco tt, Fougere & Marwick, 1986) and 
‘Unshackling the Ho spi t a l s ’ – the Gibbs Report (Gibbs, Frazer & Scott, 
1988). The reports placed emphasis on the structure and funding of 
primary and secondary services, inefficiencies in the hospital system 
and hospit al management (Scott, et al ., 1986; Gibbs, et al., 1988; Scott, 
1994; Jacobs, 1994; Asht on et al., 2005). The Gibbs Report in particular 
recommended replac ement of the triu mvirate management model with a 
single general manager responsible for all aspects of performance 
(Gibbs et al., 1988). The rationale  provided was that triumvir a t e 
management stifled leadership, dilut ed acc o untability, resulted in poor 
management relationships and cons equential ignorance of 
management responsibilities (Gibbs  et al., 1988; Jacobs, 1994). 
Furthermore the report suggested that  professional groups could unduly 
influenc e decision-making without bal anced consider ation of the goals 
and priorities of health services. 
 
The influence of organizational theor ies such as public choice, agency 
and new public management is clearly  manifest not only in the 
aforementioned polic y advice but also in  a raft of structural changes in 
New Zealand’ s health syst em. It was also evidenc ed in international 
trends in health car e system reform , such as those of the United 
 13
K i n g d o m , Spain and Swe den where mar ket led reform significantly, 
although more slowly, underpin n e d politic a l and economi c 
transformation (Laugesen, 2005; Seedho us e, 1995). In New Zealand, 
local hospital board governance struct u r e s were repla ce d by fewer and 
larger Area Health Boards, and triumvirate management was replaced 
with general management (Scott, 1994;  Gauld, 2000). The objectives of 
change were dominated by the need to contain health spending through 
emphasis on structural, administr ative and fiscal management to 
produce more efficient and effective utilization of health res ources 
(Jacobs , 1994; Ashton et al, 2005). Ho wever the introdu c tion of generic 
managers to traditional social servic es has been critic ized as a fallacy, 
“...that a foodstuff CEO may ma ke an admirable hardware CEO does 
not mean that inevitably he or she will make a competent health 
services CEO” (Easton, 1997, p. 166). 
 
Under the wing of National and Nati onal - N e w Zealand First Coalitio n 
Governments from 1990-1999, the ideologic al commitment to a 
competitive market in the health se ctor was further realiz ed (Ashton, 
1995; Asht on, et al., 2005; Scot t, 1994). A central feature of the health 
system restructuring in this period wa s the division of the purchaser and 
provider roles previous l y carried out  by Ar ea Health Boards (Ashton, 
1995; Asht on et al., 2005; Scot t, 1994) . Purchasing of primary and 
secondary health care was devolved from the Ministry of Health to four 
Regional Health Aut horities (RHA’s),  that were am algamated into a 
single Health Funding Authority (HFA) in 1998 (Gauld, 2000). Both 
community and hos pital healt h servic es were rec onfigured into 23 
Crown Health Enterprises (CHE’s).  Requir ed to act as independent, 
profit seeking, contra ctually bound business es, CHE’s were subject to 
the payment of tax and div idends to  the government (Ashton, 1995). 
These par ticular changes were ai med at enhancin g competit i o n 
between pr oviders of health care in order to improve productivity and 
enhance performance (Laugesen, 2005). In 1996 the harsher 
 14
profitability agen da of CHE’s was m odifie d, since profitability never 
really gained traction within the or ganiz ations, the health professions 
and public opinion at large (Laugesen, 2005). By 1998 CHE’s were 
again reformed as Hospital and Health  Service s with the intenti o n of 
reducing mounting hospita l debts and improve deficits in service 
provision (Gauld, 2000). A Public Health Commission was established 
to purchase and coordinate public  health ser vices, and was 
disestablis hed after 18 months in 1995 (Gauld, 2003). A National 
Advisory Committee on Core Health Services (NACCHS) was 
established in 1992 to advise the Mini stry of Health (MOH) on what 
services should be pr ovided and priorit i z e d (Scott, 1994). Lastly, but by 
no means least, a regime of income testing and targeted assistance 
was introd uced to facilitate and monitor access and support to social 
and health services for low incom e groups (Scott, 1994).  
 
The health reforms pursued in the 1990- 1999 era were in part designed 
to reduce fiscal risk by cost shifting to individu a l s , employ er s and 
providers of health care (Ashton et al., 2005; Gauld, 2000). However 
little of the complex program of re form introduced through the 1990 ’s 
survived int o the new millen nium, other than the NACCHS, renamed the 
National Advisory Committee on Health and Disability in 2000, 
expanding its brief to inc lude disa bilit y services (National Health 
Committ e e , 2007).  Under a Labour- A l l i a n c e Coalitio n Governme n t and 
then Labour Government to this point, health sys tem design has 
returned to structures similar to those of the 1980’s. The commerc i a l 
and competitive model of heath system managem e n t was replace d by a 
model bas ed on the principles of cooperation and collaboration (Ashton 
et al., 2005). Elected District Health Boards (DHB’s) hold the budget for 
both secondary and primary healt h se rvice s and reflect a middle- g r o u n d 
mediation between regional and loc a l health service gov ernance 
(Ashton et al., 2005) . Guided by Mini st r y of Health strate g i e s and 
priorities for improving health out co mes in their popula tions, DHB’s are 
 15
funded on a capped populati o n basis, and must provide health services 
themselves, or purchase them from non-government providers (Ashton, 
et al., 2005).  
 
Four key strategic policy program s under pin New Zealand’s current 
health sect or environment: The Ne w Zealand Health Strateg y (MOH, 
2000), The New Zealan d Disabi l i t y Strate g y (MOH, 2001), The Primar y 
Health Care Strategy (MOH, 200 1a), and He Korowai Oranga – Maori 
Health Strategy (MOH, 2002). The key policy directives in this 
framewo r k are: health promoti o n and disease prevention with par ticular 
emphasis on the dev elopment  of the prim ary heal th sector ; equita b l e 
public health service access includi ng a focus on the developm ent of 
Maori health services and the Maori health workforce; high performance 
health services within a framework of quality improvement; community 
engagement in all levels of the health sector; population health 
objectives specifica lly targeting the major causes of ill-he alth in our 
community; and lastly, a targeted appr oach to the development of 
disab ility services that reduce barrier s to access and promote the quality 
of life of disabled people.  
 
Many elemen t s of stru ctural change to New Zealand’s hea l th care 
system have been continuous throughout the era of reform (Ashton et 
al., 2005; Campbell, 2006). Themes of  centralized vs. local control, 
cooperation vs. competiti o n , integr a t i o n vs. a funder- p r o v i d e r split – 
have exist ed through the various perio ds of reform. Despite the 
engaging rhetoric that these policie s and directives ent ail, healthier 
indiv iduals and communities will in  the future reduce the dem and for 
publicly funded health and dis a bility se rvices (Ashton, 1995; Ashton et 
al., 2005; Davis & Ashton, 2001). 
 
 
 
 16
2.3 THE IMPACT OF REFORM ON NURSING – AN INTERNATIONAL 
PERSPECTIVE 
The impact of continuous reform on health care systems has taken a 
signific ant toll on the health profe ssions, particularly nursing, whose 
sheer size in the health workforce has made them a natural target for 
efficiency gains and cost restrain ts wrought by generic management 
practices and objectiv es (Campbell, 2006; Gower et al., 2003; Finlays o n 
& Gower, 2002; Carryer, 2001). Specif i c reform in g strate g i e s and 
activities involving nur sing servic es inc lude: downsizing, restructuring, 
reengineering and mer gers (Campbell, 2006). Whilst downsiz ing 
involv es reducing staffing numbers and or bed numbers by eliminating 
services such as particular units or  hospitals, restructuring concerns 
changing the infrastructure of an organiz ation including channels of 
authority, spans of control and lines of communication (Campbell, 
2006). Reengineering encapsulates pr ocess redesign suc h as 
modificatio n of clinic al staffing work assig nments and skill mix – for 
example through the use of unskilled or ancillary st aff to take on patient 
care, and mergers involve the combining of two or more organiz ations 
to improve financial or market  positions (Campbell, 2006). 
 
In this part of the literature review the aim is to outline the im pact of 
reform and restructuring on professi onal nursing from an international 
perspect i v e , in two key areas. Firs tly, the impact of reform and 
restructuring on nursing leadership st ructures, roles and responsibilities, 
and second l y , the impact of refo rm and restructuring on nursing 
service s , the nursing workfor c e , the quali t y of nursi n g care and patient 
outcomes.  The ensuing part of the review presents se lected lite r ature 
that outlines the impact of reform and restructuring on nursing in New 
Zealand. 
 
 
 
 17
Nursing leadership structures, roles and responsibilities 
In the early years of health reform in the National Health Service (NHS) 
in the Unit ed Kingdom, hospital re structuring set general managers or 
administrators alongs ide the traditionally powerful matron structure, and 
resulted in a decline of the matrons’ in fluenc e, as well as signific ant role 
variation (Wells, 1999). In turn this lead to growing ins ecurity for nurses 
and negative attitudes toward management (Wells 1999). Studies 
conducted in the Unit ed Kingdom betw een 1960 and 1980 found “...that 
nurses viewed management, nurse s in manageme n t and the 
manage m e n t role negati v e l y ” (Wells , 1 999, p. 60). Ward sister s became 
immersed in conflict between t heir clinic al and management roles 
(Redfern , 1981). Nurses were a lienated from management by a 
perceived industry oriented appr oach believ ed irrelevant to clinical focus 
(Lathlean & Farnish, 1984). A study by  Wilson-Barnett (1973) confirmed 
a general perception amongst nurses,  that colleagues promoted on the 
basis of their clinical ability from ward sister to senior nursing officer, no 
longer utiliz ed their clinical expertise.  
 
A reflecti o n of bureauc r a t i z a t i o n , the ward sister’ s role became 
increasingly an administrat i v e one (Wells, 1999). Emphasis on resource 
managem e n t , devolve d budgeti n g , cost-ef f ective inter ventions, clinical 
governance and commissioning “...change the identity and focus of 
work for nurses who take on those re sponsibilities” (Wells, 1999, p. 77). 
Changing the ward sister or char ge nurse job title to ward manager 
reflects a focus on responsibility and accountability for the ward budget 
as well as the link to maintaining standards of care by way of auditing 
activities (Wells, 1999). A consequence of this refocus was possibly that 
the nursing manager became more dom inant rather than inclusive in 
management style, and in order to conserve resources, changed their 
relationships with their patients and staff (Wells, 1999). When res ource s 
became straine d one was “... more likely to find the ward manager 
 18
arguing for less patient throughput than for more money to  meet patient 
demand” (Wells, 1999, p.74). 
 
Elsewhere in the world, nursing lead ers at all levels of healt h care 
organizations have had their roles transformed. Gelin as and Manthey 
(1997) conducted a five year long study of more than 5000 executiv e 
nurses in the United States r egarding the impact of organiz ational 
redesign on nurse executive leadersh ip. These researchers come to two 
important conclus ions from  their study; that the extent of redesign on 
nurse executive roles and functions  is massive, and that nurse 
exec utive involvement in the process of redesign is enormous (Gelinas 
& Manthey, 1997). To be success ful they  describe that nurse exec utives 
must understand how to: lead across cultural, functional and department 
boundaries ; promote and build effect ive teams; manage their personal 
growth by challenging their own behaviors; tolerate ambiguit y; and 
promote the continue d developm e n t of  the nursing prof ession (Gelinas 
& Manthey, 1997).  In summary, the ex pectations of nursing leaders are 
broad and their learning needs are great (Gelinas & Manthey, 1997). 
 
In a qualitative study also conducted in the United States, Ingersoll, 
Cook and Fogel (1999) sought to  understand the implications of 
redesign on the roles and responsibilit ies of mid-level nurse managers. 
These researchers found that the m agnitude of change has result ed in 
nurse managers struggling to k eep pac e with the demands of change 
and with recognition of the import ance of remaining com m itted to 
uncertain institutional goals (In gersoll et al, 1999).  Nurse managers 
were frustrated by their perceiv ed inab ility to fix situations and meet 
multiple st aff needs (Ingersoll et al , 1999).  The researchers conclude 
their study by asking what must new nurse managers without a similar 
level of education and experience  be going through? (Ingersoll et al., 
1999).   
 19
Thorpe and Loo (2003) investigated and identif i e d the major challen g e s 
impacting on first-line nurse managers in Canada. The term first-line 
nurse managers is defined by the study  as indiv iduals who overs ee the 
daily operations of nursing units, regar dless of their titles (Thorpe & Loo, 
2003). This triangu l a t e d researc h (invest i g a t o r , methods and data) 
identified several chal len g i n g themes in the first-l i n e nursing 
management role, including: job enlar gement; emphasis on efficiency; 
focus on human resources; staffing and retention; and management of 
staff frustrations (Thorpe & Loo, 2003). After, concluding that 
professional and personal life balanc e is essential for first-line nurse 
managers’ job satisfaction, the resear chers recommend that health care 
administrators and nurse educators give clos er attention to the provision 
of adequate resources, training and dev elo pment and a more supportive 
work environment (Thorpe and Loo, 2003). 
 
The Nursing Workforce, Quality of Nursing Care and Patient Outcomes 
F i v e studies conducte d in Canada t hat conc erned the impact of reform 
and restructuring on nursing include: t he effects of hospital restructuring 
on nursing employm ent (Cummings & Eastabrook s, 2003);  flexible 
labour and casualisat ion in the nursing workforc e (Grinspu n , 2003); 
nursing staff attitudes to the heal th care organiza t i o n followin g 
restructuring (Burke, 2003); dimensi ons of control and nursing reaction 
to hospital amalgamation (Arms trong-Stassen, 2003); and nurse 
absenteeis m , stress and workplace inju ry (Shamian, O’Brien-Pallas, 
Thomson, Alksnis & Kerr, 2003). A brief outlin e of these Canadi a n 
studies and their findings follows. 
 
Some of the main effects of hos pital res t ructuring on nurses were 
identified in the systematic revi ew by Cummings and Eastabrooks 
(2003) and include: signifi cant decreases in job satisfaction and ability 
to provide quality care, affects on the physical and emotional health of 
nurses, and increases in nursing turnov er . After a review of employme n t 
 20
theories and empirical evidence, Grin spun (2003) proposes that whilst 
the move to part-time and casualizat ion of the nursing workforce during 
the 1990’s was intent ional,  it is doubtful that it  was intended to reach 
such high levels, indicating that em ployer s lost control of their own 
strategies (Grinspun, 2003). The poor  outcomes of casualization and 
part-time working st ructures in clude: nur sing shortages; decreased 
professi o n a l satisfac t i on of nurses; reduced organi za t i o n a l performa n c e ; 
and negative impacts on patient care and outcomes (Grinspun, 2003). 
Burke (2003) evaluated nurses’ perc eptions of organizational support 
during a period of hospital res t ruct uring. Examining the variable of 
perceived organizational support (POS),  the study reveal ed that levels 
of POS remained unchanged or declined slightly during the study period 
(Burke, 2003). POS was found to m ediate the relationship between 
restructuring process and job satisf action (Burke, 2003). The study by 
Armstrong-Stassen (2003) highlighted that the ways in whic h nurses 
perceive control (personal, job and or ganizational) during a hospital 
amalgam a t i o n , were vital to the effectiveness and process of change. A 
study to determine how job strain (inc luding staffing and work load) 
affected the health of nurses, revealed that adequate staffing and 
reasonable workload were the most impor tant interventions in improving 
nurses’ health and reducing abs enteeism (Shamian et al., 2003). 
 
It has also been highlight e d that in Canada , managerialism along s id e 
consumerism in health care (includi n g th e power of the public in 
disciplinary processes ) have redu ced nursing autono my and made it 
difficult to meet professional nur sing standards (Bear dwood, Walters, 
Eyles & Fr ench, 1999). Of the empiri cal evidence in general regarding 
the Canadian health and nursing re structuring experience, Burke 
(2003a) suggests that restructuring in  order to contain costs, had at 
best, mixed success. Nurses were dem oralized, the profession was in 
crisis, costs had not been reduced an d the quality of patient care had 
deteriorated (Burke, 2003a).  
 21
Other international studies, inc ludi ng some cross-national studies , have 
evaluated the relationship between regist ered nursing staff numbers, 
education and skill mix and its relationshi p to the qualit y of nursing care 
and patient outcomes (for example s ee: Aiken, Clarke, Cheung, Sloane 
& Silber, 2003; Aiken, Clarke & Sloan e, 2000; Aiken, Clarke, Sloane, 
2002; Aiken, Clarke, Sloane, Schol ask i, Busse, Clar ke, et al., 2001; 
Aiken, Clarke, Sloan e, Scholas ki & Silber , 2002; Blegen , Goode & 
Reed, 1998; Blegen & Va ughan, 1998; Cho, Ketefian, Barkaus kas & 
Smith, 2003; Czaplins k i & Diers, 1998;  Needlema n , Buerhaus , Mattke, 
Stewart & Zelevinski, 2001; Shewar d, Hunt, Hagen, McLeod & Ball, 
2005; Tourangeau, Giovanetti, Tu & Wood,  2002). Key implications from 
this growing and important body of nursing research may be 
summar i z e d in three themes . Reduct i o n in register e d nurse staffing 
levels, skill mix, professional ex perience and educ ation, reduces the 
quality of patient care pr ovided. Whilst average lengt h of stay (ALOS) of 
patients has decreased, patient out comes such as morbidity and 
mortality are negatively associat ed with reduced ALOS, nurse staffing 
and skill. Increased job stress, burnout and injury in nurses are related 
to increased workloads and reduced nurse staffing. 
 
Given the literature and research imp lications set out above, it is not 
surprising to identify a global shortage of nurses that has gained 
momentum in the past 20 years (Int ernational Council of Nurses, 2006; 
Buchanan & Calman, 2006; Heinz, 2004). Poor workin g condit i o n s and 
experiences such as work injury, burnout and job dissatisf action 
contribute to higher rates of turnover in the nursing workforce 
(International Counc il of Nurs es, 2006; Buchanan & Calman, 2006; 
Heinz, 2004;) . Thus, health care re form has implicat i o n s on nursing and 
its workforce well beyond the boundar ies of hospitals and national 
health systems, but also the abilit y of  health care systems internationally 
to meet the needs of populations (I nternational Council of Nurses, 
2006). 
 22
2.4 THE NEW ZEALAND NURSING EXPERIENCE OF HEALTH 
REFORM 
Finlays on and Gower (2002) were membe r s of a large team of 
researchers who undertook a proj ect examining the links between 
hospital restruct u r i n g , patient outcome s and nursing workfor c e issues in 
New Zealand (Hospital Restructuri n g : Patient Outcomes and Nursing 
Workforce Implications Study). The three research strands examined by 
the team were: mapping the hospital restruc t u r i n g ; identif i c a t i o n of a 
range of patient outcomes; and a surv ey of all New Zealand hospital 
nurses (Finlay s o n & Gower, 2002) . The New Zealand hospital 
restructuring project is itself asso ciated with an internat ional program of 
researc h (a number of which have already been identif i e d in the 
precedin g part of this review) across at least sixtee n other cou ntries.  
The first two of these strands of the New Zealand project are discussed 
here. 
 
Aimed at identifying the impact of hospital restru cturing on nurses, the 
study by Gower, Finalyson and Turnbull (2003) involved 16 New 
Zealand hospitals, and 20 individual informants. This study reported 
several inc r emental structural changes to nursing services on three 
tiers. A central feature of hospital reorganization was the dismantling of 
the centralized nursing and triumvir ate management structures evident 
in hospitals prior to 1988 (Gower et  al., 2003). Principal Nurse posit ions 
were dis es t ablished and replac ed with the position of Nurse Advisor 
who in many cases had no management  authority over provision of 
nursing ser vices, and in some instances  reported to chief execut ives in 
the provision of adv ic e over nurs ing-re lated issues (Gower et al., 2003). 
Some Nur se Adv isor positions were  then also disest ablis hed and not 
replaced, resulting in a four to seven year period where there was 
possibly no centraliz ed nursing leader at all (Gower, et al., 2003). By 
1995 hos pitals began to establish the pos ition of Director of Nursing, 
and whilst similar to the nurse advisor role, they are executiv e positions 
 23
within a general management  structure (Gower et  al., 2003).  However, 
the Director of Nursing may still have la cke d the infrastructure to provide 
appropriate professional support and leader s h i p (Gower et al., 2003).  
 
Second tier nursing  management pre-1988 c onsisted of Nursing 
Supervisor s whose positions were als o disestablished, although in 
some cases the role was ret ained for after hours patient services 
management, reporting to general manage ment (Gower, et al., 2003). 
Traditionally known as Charge Nurs es, the third tier of nursing 
management pre-1988 was res ponsible for the efficient and ef fective 
deliv ery of nursing ser vices at ward level and had been subject in some 
instances to multiple rounds of change (Gower et al., 2003). Line 
accountability to the Principal Nur se was lost when thes e positions were 
disestablis hed and as a consequence Charge Nurses may have been 
the only remaining nursing management position in the health care 
organiz a t i o n (Gower et al., 2003). Financial respons ibility previously 
held at the second or th ird tier of the nursing  management structure was 
devolved to general managers at a servic e level (Gower et al., 2003).  
 
Reflecting a great deal of intra and inte r hospita l varianc e , the new third 
tier of nursing mana gers have expa nded roles and responsib ilities 
reflecte d in a raft of differen t titles such as “...unit nurse manager, 
clinical coordinator, clinical nurse leader or team leader ” (Gower et al., 
2003, p. 131). The nurse manager’s attention was divided between 
general management and clin ical lead ership resp onsib ilities, with 
general management tasks taking precedent.  In partic u l a r this resea r c h 
highlighted that the new third tier of nursing managers exper ienced 
great diffic ul t y working with and reporting to general management who 
lacked at understanding of  the complex responsib ilities involv ed in 
nursing and ward management (Gower et al., 2003).  
 
 24
Service managers were not necessarily  people with health backgrou n ds . It 
caus ed quite a few problem s . They had no underst an d i n g of nursing . There was 
no nursing leaders h i p at servic e level. We seemed to have a success i on of 
general manager s with no experie n c e of the health system. (Gower et al., 2003, 
p. 131). 
 
The loss of nursing leadership and its influence in hospital structures 
and services have resulted in a raft of  issues for the nursing profession 
in New Zealand.  Gower et al. (2003) identified the following themes in 
their study: lack of nursing invo lve m e n t in managem e n t changes ; 
reorganizat ion of nur sing career pathw ay s; loss of senior nurses – 
sometimes to gener al management or out of the hospital sector 
completely; lack of hospital- wide strategic workforce planning, 
recruit m e n t and retenti o n ; changes to  the  composition of the work force 
including casualization; and signific ant variations in  the quality and 
availability of professional devel opment and education of nurses. 
 
McCloskey and Dier s (2005) advanced t he investigation of health 
reform impact on nursing in New Zeal and to patient outcomes as well. 
Utiliz ing data from all adult med i cal and surgical patie nt discharg es in 
New Zealand hospitals between 1989 and 2000, this study determined 
ALOS and adverse clinic al outco me rates, including mortality 
(McCloskey & Diers, 2005). Cor r esponding nursing workforce data was 
also examined between 1993 and 2000.  T he findings from this study in 
summary are: a decrease in nurs e FTEs and associat ed work hours of 
around 36%; cost effectiveness and process efficiency resulted in a 
20% decrease in overall ALOS; and a marked incr ease in adverse 
clinical outcomes rates, with mo rtality rates remaining stable or 
decreasing. McCloskey and Diers (2005) explain that lowering nurse 
staffing levels and increasing workload results in hurried, delayed, 
omitted and fragmented care that pr ecipitates errors, and reduces 
opportu n i t i e s to detect and report errors . These research e r s assert that 
“...the introduction of New Zeala nd’s health care reengineering polic ies 
 25
signific antly influenc ed the fre quency of adverse outcomes among 
hospitalized patients with the effect  occurring at the same time the 
nursing workforce decreased in size” (McCloskey & Diers, 2005, p. 
1145).  
 
The case study by Campbell (2006) examined the impact on hospital 
nurses of organizational change at Auckland Distric t Health Board from 
2001-2004. The study utilize d secondary dat a arising from the Survey of 
New Zealand Hospital Nurses conducted in 2001 and 2004 whic h was 
part of the broader research progr am in New Zealand noted above. 
Campbell (2006) desc r ibes that the objectiv es of the change program in 
this health care organization included: building of a new hospital, 
integrating services to improve ca re for patients and the environment for 
staff, improving nursing skills match to patient workload and the 
standardis ation and integration of  managem e n t roles. The change 
program occurred in a cont ext of “…constant pressu re to deliver quality 
health car e within a substantial bu dget deficit and increasin g fiscal 
constraints” (Campbell, 2006, pg1). Whilst the nursing workforce was 
not downsized during restructuring, the number of in patient beds was 
(Campbell, 2006). Several set s of selec t ed variables impacted by 
organizational change were invest igated that enabled the comparison 
between 2001 and 2004 data, including: job sa tisfac tion, management 
support, perceptions of quality of patient care, intention to leave, staffing 
and model of nursin g care, and the hos pital and work envir onment. 
Selections of the key findings are set out next. 
 
Despite the introdu c t i o n of a team nursing model int e nded to improve 
staffing and workload issues, the study  found that this change did not 
alter the nurses percep t i o n s about staffi n g betwee n 20 01 and 2004, with 
only 40% of nurses agreeing there were enough registered nurses to 
provide quality care (Campbell, 2006) . There was als o no signif icant 
change in nurses’ ratings of job sa tisfaction, levels of burnout and 
 26
intention to leave bet ween the tw o study dates, with nurses reporting 
being moderate l y or very satisfie d with their jobs (Cam pbell, 2006 ). The 
researcher suggests that this finding may be a consequence of a new 
physical environment and effective c harge nurse leadership (Campbell, 
2006). The only statis tically significant  finding from the study was that 
associated with management s upport, where nurses’ ratings 
demonstrated perceiv ed lack of management responsiveness to nursing 
concerns and limited nursing parti cipation in decis ion-making 
(Campbell, 2006). As well, loss of line nursing manager and leadership 
roles increased the distance bet w een Char ge Nurses and nurse leaders 
such as the Director of Nursing, and in so doing resulted in lost 
opportun i t i e s for open dialogue and t he development of meaningful 
relatio n s h i p s (Campbe l l , 2006). 
 
As a precursor to a longi tudinal national cost of nursing turnover study 
(also part of an internat i o n a l re searc h program ) , a survey was 
undertaken of current practices and pol ic ies related to turnover of 
nurses in New Zealand’s public hospitals (North, Hughes, Finlayson, 
Rasmussen, Ashton, Ca mpbell et al., 2004). The key objectives of the 
long itudina l study, still in progre ss, are to document and deter m ine 
costs associated with nursing turnover  and to identify nursing turnover 
as a key performance indicator in Ne w Zealand health services that is 
calculated and reported consistently (North et al, 2004). Aimed at 
providing descriptive information, data was collected fr om 20 Dir ectors 
of Nursing in 20 of New Zealand’s 21 District Health Boards (DHB) 
(North et al., 2004). 
 
The study found that nursing turnov er (rates normally between 12 and 
25%) was a problem for at least 13 of the 20 participants, or was 
becoming an increas ing priority , with at least five DHB’s reporting 
nursing turnover rates greater than 20% (North et al., 2004). Some of 
the negativ e impacts of turnover were  identified as nurse shortages and 
 27
consequential bed closures, restrictions  on elective sur gery, emergency 
departme n t service restrict i o n s and r educed inpatient admissions (North 
et al., 2004). The study found that little information on reas ons for 
turnover was being collected, with onl y three DHB’s routinely collecting 
and collating data (North et al., 20 04). Strategies being used to improve 
retention and reduc e turnover focused on retention by way of 
professional dev elopment, intr oducing Charge Nurses and nurse 
leaders where there were  none previously , and improving the working 
environment by way of family focus and flexible rostering (North et al., 
2004).  Recruitment policies and in itiatives were focused on new 
graduate and international rec r uitm ent, with the use of temporary 
internal staffing pools one of the ac tivities employed to manage nursing 
vacancies (North et al., 2004). Stra tegies for improving the nursing 
workforce diversity were also identifi ed in the study, including a targeted 
approach to recruitment and retention of Maori and Pac ific Island nurses 
(North et al., 2004). The study report ed that in almost  every DHB there 
were tight controls over recruitm ent of new staff including a review 
process, and in some in stances freezes on recrui ting registered nurses 
(North et al., 2004) 
 
Cobden-Grainge and Walker (2002)  undertoo k a survey of 300 
registered nurses in New Zealand with three key objectives: to identify 
career paths of regist ered nurses and factors influenc ing job choice and 
post-registration educ ation; to de scribe relationships between these 
factors and the career choices made; and to analyze the implications of 
career paths and influencin g factors.  Some of the key findings from 
Cobden-Grainge and Walker’s  (2002) study, of relevance to the present 
literature review are c oncerned with evalu ation of working conditions, 
aspects of work, and working rela tion s h i p s . Concerni n g working 
conditions, the study found: that onl y 42% of responde n t s were satisfie d 
with the ratio of permanent staff to  agency staff on day and night shifts; 
there was a moderate level of satisf action of 53%, with availability of 
 28
equipment and resour ces; and that ov er 53% of respondents indicated 
dissatisfaction with their pay in re lation to level of responsibility 
(Cobden-Grainge & Walker, 2002). In rela tion to aspects of work, the 
study found that only 53% of respondents wer e satisfied with 
opportunities to provide quality ca re (Cobden - G r a i n g e & Walker, 2002). 
In relation to working relations hips, the study identified that only 54% of 
nurses were satisfied with the level of  support they received from their 
Charge Nurse or Unit Manager (Cobden-Grainge & Walker, 2002). 
When ask ed to ident ify aspects of prac tice in their job that research 
participants would change, themes highlighted wer e: patient care, 
organizational systems, communicati on and profession al dev elopment 
(Cobden-Grainge & Walker, 2002) 
 
Motivated by concer ns regarding t he reintro d u c t i o n of second level 
(enrolled) nurse training into the heal th sec t or, Carryer (2001) offers a 
perspective on the New Zealand nursi ng workforce that considers many 
of the features and impacts  noted previou s l y and offers other ins i ght s as 
well. Carryer explains that the reintroduction and training of more 
enrolled nurses (previously dis cont inued in 1994) was part of the 
response of the health sector to nu rsing shortages by way of a cheaper 
and less skilled nursing workforce option (Carryer, 2001). The ef fect of 
restructuring has taken a consider able toll on nursing, whose workforce 
is ageing, whose clin ical and professional confidence was destroyed 
and whose education had been underinvest ed (Carryer, 2001).  Nurses 
are visible and invis ible simultaneously , greatly respec ted by the public, 
yet poorly paid, struggling continuous ly to be seen, valued and 
effectively applied to healthcare services, beyond the handmaiden of 
doctors’ image, and beyond the grasp of generic management (Carryer, 
2001). Resistance to nurse prescribing and reluct ance to nursing 
autonomy in the primary health sect or mainly from the medical 
profession, are exam ples of the ex ternal pressures to keep nursing 
confined (Carryer, 2001).  Accordi ng to this commentary, a strong 
 29
climate of anti-professionalism transcended the health sector forcing 
many nurses to abandon their prof ession and oppress ions, some into 
generic management positions, in the belief that thei r contribution to the 
health workforce was not taken seriousl y (Carryer , 2001). In summary, 
Carryer’s opinion may be seen as a professi o n a l res pons e to reform 
and restructuring and its effects on nursing in New Zealand, by placing 
emphasis on reinvigorating clinical nursing leadership, as a central 
means not only of addre ssing nursing workforce issues, but also the 
health needs of communities. 
 
The env ironment in which nurses now  pr actice in New Zeala nd and 
elsewhere is marked by the objecti ves and activities of neoliberal 
politic al reform that has transc ended the economy, politics and public 
organizations. Market sector values  and objectiv e s aimed at ensuring 
efficiency and effectiveness of health service deliv ery have impacted or 
nursing structures, roles, clinic al experienc e and effectiveness, as well 
as nursings ’ future contribu t i o n s to  health care in the community. This 
new envir onment, its demands and cu lture, challenge profes sional 
nursing values, and in so dong have im portant implications for the 
nursing profession and health care organizat ions. 
 
 
2.5 VALUES AND ETHICS IN HEALTH CARE ORGANIZATIONS 
Health care organiz a tions require the ethical managem e n t , of self, 
professional, organiz at ional, patient and public  interests and values 
(Young, 2003; Weber, 2000). Llewell y n (2007) explains that health care 
leaders who have ethics as the core of their values, will ensure that they 
meet their social contracts and et hic al obligations to society, 
communities and patients, employees , and the health care professions. 
Ethical health care managem ent practice therefore involves more than 
clinica l , profess i o n a l and personal ethics and valu es, but also foc us on 
 30
the provision of care, the needs of citizens and the employ ment of 
people (Weber, 2000). 
Values have been defined as “...relatively indepe n d e n t human creati o n s 
that are used to guide, evaluate and justify human action” (Sarvimarki & 
Sandelin Benko, 2001, p.  131). Values have the power offer ration a l 
explanations for human activities (S arvimarki & Sandeli n Benk o, 2001).  
Since professi o n s represen t one of sever al sets of competin g group 
value premises and ideologies that may transcend organiz ational 
values, there is a possibility of ambi valent values relationships at the 
organizational level (Bullis, 1993).  Wells (1999) describes that the 
impact of managerialism on the NHS has been to draw clinicia ns into 
the management life of the organiza t i o n and inevitab l y has an impact on 
professional values and inte rpro f e s s i o n a l relation s h i p s .  
 
It seems possible that ther e has been a change in the tradition al self-image, 
perceptions, values and roles of individual health  professio n a ls . . . M o r e o v e r , 
health care professionals may find themselves in a position of role and value 
ambiguit y , caught between meeting manageria l targets and continui n g to 
function within the parameters of their clinical tradition s. This may lead them to 
act in ways which are aimed at managing their cons equent anxieties rather than 
carrying out the tasks envis ioned by se nior managers and polic y makers... it is 
plain that such an importan t shift in focus and autonomy has affected the cultur e 
and philosoph y of the various profess io n s , including nursing, within the NHS. 
(Wells, 1999, p59-60). 
 
 
So what are the val ues of health professionals and health care 
organizations? To an extent, public  sect or management values of 
efficiency and effectiveness in resour ce utilizatio n have alread y been 
identified. Alongside this soc ial res ponsibility, fiscal prudence, out comes 
focus and accountability have also been noted.  
 
In a triangulated study set in Irel and, Car ney (2006) identified eleven 
key values (some positive and some negative) active in the health care 
 31
organization that wer e held by bot h health care clinic i a n s and non 
clinical managers. Excelle nce in patient care was the highest ranked 
value ident ified in this study (Car ney, 2006). Values driven, the second 
highest ranked value identified by the st udy, concerns trust, integrity, 
caring, loy alty, compassion, just ice, quality, advocacy and dignity 
(Carney, 2006). The third ranked va lue was managerial receptiveness - 
identified as a caring and suppor tive approach by senior managers 
resulting in staff feeling valued for their contributions (Carney, 2006). 
Organizational dependability,  as an identified valu e, indicated that a 
strong public ethos was active in t he context (Carney, 2006). The value 
of equity in care deliv er y highlights accessibility and timely care deliv ery 
(Carney, 2006).  Negative values identif ied by the study include: lack of 
peer cohes ion, power groupings, lack of manager i a l recepti v e n e s s and 
lack of organizational dependability (Carney, 2006). 
 
The values of health care organizations may be explicitly stated, for 
example, in formal communications ei ther within the or ganization or to 
the public and communities whom t hey serve. A search of New 
Zealand’s 21 District Health Board webs ite s found that at least seven 
(Auckland, Counties Manukau, Waitemat a, Bay of Plenty, Hawkes Bay, 
Hutt Valley , and Southland) shared thei r values on their websit e, or 
were at least easily accessible to the public via this medium. An array of 
values were set out on these webs ites and inc l uded: Openness, 
Integrity, Compassion, Customer Focus, Respect, Supporting Wellness, 
Patients Come First, Serving Our Community, Helping Each Other, Best 
Practice, Taking Responsibility, Striving to Improve, Working Together 
With Passion Energy and Commitment, Can-do by Leading, Innovating 
and Acting Courageously, Trust, Striving for Excellence, Making a 
Difference, Teamwork, Learning (Mohiotanga/Wairuatanga), Caring 
(Manaakitanga), Professionalism, Flexibility, Innovation, Responsibility, 
Partnership, Collaboration, Accountability, Effectiveness and 
 32
Acknowledging Cultural Values (Mana Atūa / Mana Tūpuna / Mana 
Whenua/ Mana Tangata). 
 
Despite the somewhat curs ory, if not distant appr oach to identifying the 
values of these healt h care organizatio n s , it is at least possib le to point 
out some valid feature s. Firstly, asi de from reference to accountab ility, 
responsibility, effectiveness, and colla boration, these values do not tend 
to indicate a market place model or ientation. Rather, they suggest a 
humanistic organizational model, linked to the needs and culture of their 
workforce and community, in particular Maori cultur e and com m unity. 
This is not to suggest that these health care organizations are without 
focus on their fisca l responsib ilities, sinc e there were undo u btedly 
references to ensuring financial accoun t a b i l i t y in some missio n 
statements on the websit es. Instead, these values, publicly declared, 
demonstrate shared commitments to health care deliv ery by all 
members of the health care organization. 
 
In the opinion of Faithfull and Hunt (2005) the values of nursing are: 
 
[T]hose basic assumptions about what is of value in the prac tice and profession 
of nursing: what is of fundamen t a l importance in nursing. Together they 
cons tit u t e the organiz a t i o na l culture of nursing . Values are guiding princip l es , 
often implicit, that inform perceptions a nd standard s of what is right, or wrong, 
appropr i a t e or inapprop r ia t e , worthy or unworthy, acceptab le or unacceptable in 
our behavior, important or less important. Values may be individual or collective 
or both; they embrace ethical values , but are somewhat wider (p.441 ). 
 
Emerging values in professional  nursing have been identified as: 
respect for human dignity, cultural and sexual differences and choices; 
continuity and trust in caring relations hips; organizational openness; 
nursing role flexibility ; enhanced pr ofessional autonomy; timeliness; 
working with uncertai n t y ; and therapeu t i c support (Faithfu l l & Hunt, 
2005). 
 33
Professional nursing values may also  be located wit hin statements of 
professional practice, codes of ethics and conduct. The International 
Code of Ethics for Nurses (Inter national Counc il of Nurses, 2006a) 
encompass es values of the nursing pr ofession which include: caring, 
maintai n i n g human rights, family and communi t y respect , social 
responsibility for the health and soci al needs of the public, responsibility 
and account a b i l i t y for practic e , co mpetence and continual learning, 
sustaining and protec ting the envir on m e n t from polluti o n , maintai n i n g 
patient confidentialit y, alongs ide managing and implementing 
acceptable standards of clinic al, management, research and education 
in nursing.   
The Code of Conduct for Nurses estab lished by the Nursing Council of 
New Zealand (2005) likewis e embrac es core professiona l nursing 
values. Using a framework of principl es, the code specifies: that nurses 
must be legally compliant in terms  of registration, competence and 
practice; that nurses act ethically and maintain standards of practice 
inclu ding requis ite nursing knowledge and skill; that nurses respect the 
rights of patient s / c l i e n t s ,  including the patients indiv i duality, right to 
informed consent and culturally safe  practice; and finally that nurses 
justify public trust and confidenc e, such as ensuring that duty of care 
has been met (Nursing Counc il of New Zealand, 2005) . 
Bioethic al principles underpinning healt h professional pr actice are also 
an important expression of  the values of health professions. Autonomy, 
beneficenc e, nonmaleficence, self-determination, veracity, justice, and 
fidelity, create an ethica l framework for health professionals inc l uding 
nursing (Shirey, 2005; Johns t one, 2004).  Autonomy and self-
determination reflect the acknowled gemen t of a person’s indiv idual 
choices which stem from personal values and beliefs (Shirey, 2005; 
Johnsto n e , 2004). Nonmale f i c e n c e ex presses the imperative that we 
should do no harm in our health care endeavors by ensuring that error 
is reduced and adequate staffing is pr ovided to ensure vigilance in 
 34
nursing practice (Shirey, 2005; Johns tone, 2004). Beneficence, is the 
obligation to do good in our caring work and ensuring that others are 
engaged in doing good in society and  work als o (Shirey, 2005; 
Johnstone, 2004). Veracity represents the value of telling the truth to 
patients and colleagues, as well as  not deceiving others, values 
considered fundamental to ethica l relationships (Shirey, 2005; 
Johnsto n e , 2004). “Justic e refers to t he fair and equitable distribu tion of 
benefits and burdens in society” (Shirey, 2005, p.61). This principle may 
also be identified in  manageme n t behavior to in corporate truthfulness 
and respec t (Shirey, 2005). Fidelity refl ects the value of faithfulness to 
ones commitments and in all nursing, this is to patients and the nursing 
profession (Shirey, 2005). 
It is not necessarily the case therefor e, that profession al nursing values, 
which include ethical values, are at  odds with those of the health care 
organization. Indeed many appear to be shared, such as respect, 
flexibility, responsibilit y, teamwork and best practice. It is also possible 
that the professional nursing values identifi ed here are shaped by and 
are responsive to contemporary health  care climates that emphasize 
social res ponsibility; in particula r the pruden t use of resour c e s for 
meetin g the health care needs of whole communi t i e s . Yet a conundru m 
remains evident; the needs of individu a l patients or the needs of patient 
collectiv es such as diagnostic or nursing service bounded collectives, 
which clinical and managing nurses pursue, may be subsumed in the 
broader efforts and purposes of health care organizat ions, requir ed to 
meet the health needs of whole pop ulations within significantly 
controlled fiscal limits. Nurses may become frustrated and exhausted 
because the organizat ional contexts in whic h they practise may make it 
difficult to fulfill their ideals of good patient care (Gastmas, 1998). It is a 
conundrum that manifests as ethical conflict for health professionals, 
and most importan t l y for the purposes of this re searc h , nurse manager s . 
 
 35
2.6 ETHICAL CONFLICT FOR HEALTH PROFESSIONALS AND 
NURSING 
Because of their dual professional and organizatio nal roles, health care 
professionals are at gr eat risk of experiencing ethica l confli c t (Gaudi n e 
& Thorne, 2000; Gaudine & Beaton, 2002). Increas ed responsib ility for 
the allocation of scare resources has  in particular, spawned a raft of 
dilemmas for health care professionals  in management positions in their 
attempts to balance the financ ial and human aspects of service deliver y 
(Lemieux-Charles & Hall, 1997) . New instit utional arrangements arising 
from reformin g health care systems also place these clinical managers 
in situations or circumstances w here their broader pr ofessional and 
organizational commitments conflict wit h those of their clinic al peers 
whose practice is affected by their dec isions (Lemieux-Charles & Hall, 
1997). Individu a l health care managers ma y feel that they are required 
to make ethically difficult decisio ns alone, and “...without support from 
the organization, may become def ensive and isolated” (Lemieux-
Charles & Hall, 1997, p.59). 
 
Ethical (moral) conflic t for health care prof essionals  has been defined 
as: 
 “...a situation involving a clash of values within the practitioner, among 
prac titioners, and/or  between practition e r s and patients , conc er nin g what was 
the morally right action to take, or as a situation in whic h the duties and 
obligations of health professionals were unclear” (Redman & Fry, 2000,p.362). 
 
Ethical conflict may also occur between the health professional and the 
health care organization, where their re spect i v e values differ, or where 
some mutually shared values take precedent over other values 
(Llewellyn, 2007; Gaudine & Beaton, 2002). 
 
Faced wit h the constant array of  ethical conflict, health care 
professionals can burn-out from the stress of tryi ng to do the right thing 
the right way, and may be cons umed wit h a downwar d spiral of defeat 
 36
by the pressures and burdens of ethica l conf licts (Rodney & Starzomski, 
1993; Gaudine & Thorne, 2000, Llew el l y n , 2007). Other possib l e 
consequences of ethical conflic t include: moral dilemmas (when an 
indiv idual sees more than one right  thing to do); moral unc ertainty 
(when an individual is uncertain of which moral principle to apply); and 
moral distress (when an individual k nows the right thing to do but is 
prevented from doing so) (Jameton,  1993, cited in: Corley, 2002; 
Kalvemark, Hoglund, Hansson, We sterhold & Arnetz, 2004;  Corley, 
Minick, Els wick & Jac obs, 2005) . Mo ral dis t ress for nurses has been 
further defined as: 
 
[P]ainful feelings and/or psycho logical di sequi l i br i u m that occurs when nurses 
are conscio us of the morally appropr ia t e ac tion a situati o n require s , but cannot 
carry out that action becaus e of instituti o n a l iz e d obstac l es : lack of time, lack of 
supervis o r y support, exercise of medical power , institutional polic y or legal limits 
(Jameton, 1984, cited in Corley, 2002, pg 637). 
 
 
Some of the possible outcomes of moral distress include: impacts on 
the patient such as increased discomf o r t or sufferin g , impacts on the 
health prof essional such as resi gnat i o n , burn-out and loss from the 
profession, and impacts on the organiza t i o n such as loss of reputati o n 
or accreditation, and difficulty in recr uiting nursing staff (Corley, 2002).  
 
Sund in-Hu ard and Fahy (1998) utilized interpretive research methods to 
study the relations hips between moral distress, nursing advocacy and 
burnout in nurses. They found that when clinical nurses attempted to 
advocate for patients in morally troubli ng situations, their experience of 
moral distress was heightened, and wit h this the risk of professional 
retribution and burnout  (S undin- Huard & Fahy, 1998).  
 
In a series of opinion based articles  focused on limited health care 
resources and its relationship to moral distress, Arlen (2001, 2001a, 
 37
2 0 0 2 , and 2004) draws attenti o n to  the pervas iveness of the 
phenomenon of moral distress in nursi ng and its relationship to scant 
resources and the burgeoning problem  of nursing shortages. Arlen 
proposes that resource restricti ons and nur sing shortages have caused 
nurses to question whether patients are receiving quality care and 
whether patient s are the first priorit y (Arlen, 2001a). Nurses increasingly 
see themselves as ineffective advoc at e s for their patient s and feel 
paralyzed by their situation (Arl en, 2001a). Moreover nurses are 
concerned about how others are maki ng decisions that nurses should 
be making and the subsequent lack of cont rol that they have over their 
practice (Arlen, 2001b) . 
 
Nurse Managers’ Ethical Conflict with Their Health Care Organizations 
Whilst the significance of nurse m anagers’ ethical conflict wit h their 
health car e organiz ations is ack nowledged, it is has not been 
particularly well researched and is  an area of nursing administ r a t i o n 
practice that had remained largely silent until the mid 1990’s (Brosnan & 
Roper, 1997; Gaudine and Beaton, 2002). Knowledge of the issues and 
the experience of this pr oblem are essential in or der to “...wor k towards 
the resolution of ethical conflicts and towards the mitigation of negative 
outcomes for nurse managers , thei r organiza t i o n s and the nursing 
profession” (Gaudine & B eaton , 2002, p. 19).   
 
A Canadian based study of nurse m anagers ethical conflict with their 
health car e organizations (Gaudine & Beaton, 2002) provides the 
theoretical and methodological foundat i o n s for the present research 
project and is disc uss ed in some detail presently. The literature search 
noted in the introduction of this c hapter yielded several articles of 
releva n c e to the topic, most of which are introduc e d and disc usse d 
here. 
 
 38
Literature reporting both theory and re sear c h of ethica l confli c t and 
dilemmas as it impacts on decisi on making and clinical car e for 
practising clinical nurses (e.g. staff nurses) was identifi ed in the search  
(Butz, Redman & Fry, 1998; Gaudi ne & Thorne, 2000; Redman & Fry, 
1996; Red m an & Fry, 2000; Red m an & Hill, 1997; Red m an, Hill & Fry, 
1997; Red m an, Hill & Fry, 1998; Sandman & Nordmark, 2006; Von 
Post, 1996; Wagner & Ronen, 1996). The search also produc ed one 
research report on ethical conflic t in a multidisc i p l i n a r y setting 
(Kalvemark, Hoglund, Hansson, We sterholm & Arnetz, 2004), and one 
research report regarding ethical conflic t experienced by nurses 
conducting utilization reviews in m anaged care practice (Bell, 200 3). 
 
In a systematic review of five studies  concerning clinical nurses’ ethical 
conflicts, Redman and Fr y (2000) sought to capt ure the characte r , 
similarities and differences in the experienc e of ethical conflict, as well 
as resolutions and themes of ethical conflict. The major character of 
ethical conflict identified by this  review was disagree m e n t with the 
quality of medical care provided to patients (Redman & Fry, 2000). 
There were identif i a b l e differe n c e s in the foc us of ethic al conflict arising 
from the different clinical spec ialty services in which studies were set, 
e.g. nephrology, rehabilitation, pedi atri c s (Redman & Fry, 2000). For 
example, pediatric nurse practiti oners described the most dominant 
ethical conflic t as child/p a r e n t / p r a c t ioner relationships, particularly in 
pursuit of protection of the chil d’s rights (Redman & Fry, 2000). In 
contrast, rehabilitation nurses experienced ethical co nflic t in relatio n to 
over and under-treatment of  patients. The major them es identifi e d in the 
review were: harm/goo d of life-pro l onging aggressive t herapies;  and 
inadequacy of resources for care (Redman & Fry, 2000). In their 
conclus ion, Redman and Fry (2000) point out that there was wide 
variation between pr ofessional, cor porate and societal definitions of 
adequacy of care. 
 
 39
One key Canadian study located by t he literature search, investigated 
ethical conf licts which practising clin ica l nurs es had with their employi n g 
organizations and professional associ ations (Gaudine & Thorne, 2000). 
The major themes of ethical conflic t revea led in this qualitative study 
were: safety and the quality of pat ien t care; the value of human 
resource s ; and ineffect i v e or inappr opriate actions (Gaudine & Thorne, 
2000). This researc h reports that nur ses perceiv e d their employe r s as 
more interested in balancing thei r budgets than the welfare of patients 
(Gaudine & Thorne, 2000). The participant s in this study also descri b e d 
that nursing was not a valued human resource in the healt h care 
organization when compared with m edicine (Gaudine & Thorne, 2000). 
 
Other studies and literature revealed by the literat u r e search explore d 
challenges to nursing values, ethi ca l dilemm a s , moral proble m s and 
uncertainty in clinical nursing prac tice more generally (Gastmas, 1998; 
Nathanie l , 2006; Woods, 1997; Wurz bach 1999). Further research and 
literature has examined et hical activism, assertiveness, virtue ethics, 
and enactment of ethics in clinic al practice (Arries , 2005; Doane, Pauly, 
Brown and McPherson, 2004; Dodd, Jansson, Br own-Saltzman, Shirk & 
Wunch, 2004; Peter, Lerch Lunardi & Macfarlane, 2004; Varcoe, Doane, 
Pauly, Rodney, Storch, Mahoney, et al., 2000). 
 
Peter, Lerch Lunardi, and Macfarlane (2004) conducte d a review of 18 
studies inv olving ethic al dilemmas and c onflict in nursing practice , whic h 
identified that nurses resisted in situatio n s where they experien c e d 
ethical conflicts in relation to the ac tions of other health professionals, 
however there were also instances  wher e they did not.  Where the 
nurse did not, it was reasoned as a pos sible result of internaliz ed 
oppressi o n (Peter et al., 2004) . Acts  of nursing resistance such as 
challe n g i n g and confr onting decision-makers, were evidence of 
important ethical acti on and exercise of power, which contracts to 
passivity and silenc e (Peter et al., 2004). 
 40
 
In a grounded theory study of experi enced registered nurses in New 
Zealand, Woods (1997) explor ed ev eryday moral decision making in 
clinical practice. Findings from this study revealed the core variable of 
‘maintaining a nursing ethic’ whic h is intrinsic and enduring throughout a 
nurse’s career (Woods, 1997). This nursing ethic arises form 
antecedent s such a moral development, upbringing and social 
experience which guide moral decision making (Woods, 1997). This 
researcher also concluded that context, alongs ide individual shared 
perceptions of moral events infl uen c e the degree to which nurs es will 
become inv olved in ethical situations (Woods, 1997). 
 
Nathaniel (2006) also undertook a grounded theory study in the US, 
exploring nurses’ struggles with mora lly troubli n g patient situati o n s . The 
substan t i v e grounde d theory of moral re ckoning arising from this study 
highlights that moral distress is a narro w concept that fails to explain the 
long-term and ongoing proces ses that  nurses may exper ienc e from 
morally troubling patient care situat i o n s (Nathan i e l , 2006). In summary , 
the grounded theory of moral reckoning proposes that: 
 
After a novice period, the nurse experien c e s a stage of ease in whic h ther e is 
comfor t in the workplace and congrue nc e of interna l and externa l values . 
Unexpe cted ly, a situational bind occurs in  which the nurse’s core beliefs come 
into irreconc i la b l e conflic t with externa l forces . This compels the nurse into the 
stage of resolut i o n , in whic h he or sh e either gives up or makes a stand. The 
nurse then moves into the stage of reflecti o n in whic h he or she lives with the 
cons equences and iter atively examines beliefs, values, and action s. The nurse 
tries to make sens e of experiences through remembering, telling the story and 
examining conflicts (Nathaniel, 2006, p. 419). 
 
 
The meaning of ethics and the enactment of ethical practice in nursing 
have also been explored through nursi ng research (Doane et al., 2004; 
Varcoe et al., 2004). The latter of these studies found that: 
 41
 
Being a moral agent and enacting moral agency involved working within a 
shifting moral context; working in-between their own identities and values and 
those of the organiza t i o ns in which they worked; and working in-betw ee n 
compet i n g values and interes t s . They describ ed a proc ess fraugh t with 
profes s io n a l strugg l e and deep perso na l st ruggle as they sought to sustain their 
identity as moral agents by doing what they saw as good while contextual forces 
cons trained their ability to choose and act in ways they deemed ethical (Varcoe 
et al., 2004, pg 319). 
 
 
In a survey of 175 nurses in t he United States, engagement in ethical 
activis m (trying to make hospita l s more receptive to nurses’ participation 
in ethics deliberations ) and ethical a ssertiveness (participation in ethics 
deliberation even when not formally inv ited) was found to be strongly 
influenc ed by existing organizational re cept ivity to nursing inv olv ement 
and ethics training (Dodd et al., 2004). The se researchers conclude that 
nurse leaders must ensure receptiv ity of clinical nurses’ ethical 
concerns, and that ethical adv oc acy is encouraged (Dodd et al., 2004). 
 
A recent approach to the res olution  of moral dilemmas in nursing 
practice was offered by Arries ( 2005) who describes the applic ation of 
virtue ethic s in clinical nursing pr actice. Bas ed on Aristotelian though t , 
virtue ethics places emphasis on the character and dispos ition of the 
moral agent, in contrast to emphasis on duties, rules or principles 
approac h e s (Arries , 2005). The virtues applica b l e to the nurse as a 
moral agent include: reflection, empat hy, fair ness, honesty, dedication, 
responsibility, trustworthiness, integrity, discernment, compassion and 
conscien t i o u s n e s s (Arries, 2005). Armed with these virtuous 
characteristics, the nurse as a moral agent is able to provide a more 
holistic analysis of moral dilem m as in nursing , which in turn facilit a t e 
flexible and creative solutions to an array of ethical conundrums in 
nursing (Arries, 2005). 
 
 42
Literature arising from the sear ch that concer ned nurse managers, 
including exec utive, mid-level and clinical nurse manager s, was 
particularly limited and mainly opini on in nature. For nursing executives, 
failure to provide services of the highest quality due to economic 
constraints determined by the organiza tion, was the most consistently 
identified and import ant ethical issue identified in a sur vey conduc ted by 
Cooper, Frank, Gouty and Hans en (2002). Whilst no particular solution 
to this dilemma was proffered by these authors, they  nonetheles s stress 
that education and prepar ation of those dealing wit h ethical dilemmas in 
the health care organization is a central concern (Cooper et al., 2002).  
 
In contrast, Shirey (2005) identifies numerous strategies that nursing 
leaders (infers all nurses in leadershi p roles) may pursue to promote an 
ethical climate for nursing practice that ensures congruen c e between 
caring nur sing and caring organization al missions. For example, one 
strategy proposed is engagement and reflection by the nursing 
leadership team as to how an organization’s mission interfaces with 
nursing (Shirey , 2005). Another strat egy suggested is the establis hment 
of a leadership training program in  ethics, with em phas is on ethical 
decision making from the perspecti ve of the organizations caring 
mission (Shirey, 2005). In Shirey’s opinion nursing leaders must 
undertake these strategies to ens ure  the fostering of employee morale, 
organizational commit m ent, engaged nurses  and their retent i o n in the 
workforce (2005). 
 
Dissatis f a c t i o n with their nurs e managers and percept ions of 
abandonment of basic nursing va lues by nurse managers was a 
perspective of practising clinic al nurses identified in the literature 
(Kellen, Oberle, Girard & Falkenb erg, 2004; Gaudine & Thorne, 2000). 
Whether these perceptions are a re flection of an actual change of the 
nurse manage r s value system , or mi sunder s t a n d i n g of how the nurse 
managers values are being lived is an area of debate, since the nurse 
 43
manager may be charged wit h fiscal stewardship and for ensuring 
public health care dollars are utiliz ed to the best advan tage, along side 
their core professional val ues (Kellen , et al., 2004). 
 
Identification and analys i s of values confli c t for nurse managers was 
undertaken in a sur vey of 75 Israeli nurse managers (Hendel & 
Steinman, 2002). This research proj ect explored three differen t value 
sets applicable to nurse managers in a changing health care 
environment: personal, professional a nd organizational values. One of 
the core findings from this study is  that personal values (e.g., power, 
wealth and respect) and professional values (e.g. patient centere d care) 
rated much higher than organizational  values (e.g., competi t i o n , risk-
taking and status) (Hendel & St einma n , 2002). Arguabl y these 
organizational values are private se ctor for profit based values as 
opposed to public sector not for profit values. Nonetheles s and 
according to these researchers, education efforts are paramount to 
ensuring that nurse managers int erna lize organizational valu es (Hendel 
& Steinman, 2002). 
 
Foundational study 
Gaudine and Beaton (2002) undertook a qualitativ e descrip t i v e st udy of 
nurse managers’ ethical conflict and values differe n c e s with the ir health 
care organization and pr ofessional ass ociati ons (Gaudine & Beaton, 
2000). Interviews were conducted with 15 nurse managers utiliz ing a 
semi-structured interview guide which ask e d for descriptions of ethical 
conflict with their health care organiza t i o n and professional 
associa t i o n s , factors that eased or  worse ned ethical conflict and the 
personal outcomes of ethic al c onflict. Even though they sought 
descriptions concerning ethic al conf lic t with both the nurse manager s ’ 
health car e organiz a tions and professi onal assoc iations, their report 
does not explic itly set out nor compare findings from both these 
relation s h i p s . Indeed this research ing duo mostly found that their 
 44
participants had no et hical conflicts wit h their professional assoc i ations 
(Gaudine & Beaton, 2002). 
 
The findings from Gaudine and Beat on’s research, establish four 
themes of ethical conf lict between nurse managers and their health care 
organizations. The theme of voicelessness was related to lack of 
collaboration, invisibi lity, hiring nurse managers who would ‘toe the 
party line’, and exc l usion from dec is ion making in the hea lth care 
organization (Gaudine & B eaton, 2002). The theme of where to spend 
the money , reflected differences in the mi ssion and values of the health 
care organization and the nurse manager, exemplified by budget cuts in 
staff develo p m e n t (Gaudi n e & B eaton, 2002). The theme of the rights of 
the individual versus the needs of the organization , concerned the 
valuing of indiv idual rights, and the feeling of being caught between 
divergent needs (G audine & Beaton, 2002). Unjust practices on the part 
of senior administration and/or the organization represent descriptions 
such as unfair promot ions and terminations, unfair workloads, and the 
organizatio n failin g to act even when aware of a problem (Gaudine & 
Beaton, 2002). 
 
Factors that eased or mitigated et hical conflict are summarized as 
support, problem-solving and growth, and  refocusing (Gaudine & 
Beaton, 2002). Support was received by other nurse managers , hospital 
administ r a t o r s , ethics committe e s , st aff nurses, family and the public 
(Gaudine & Beaton, 2002). Problem solving and growth was 
summarized as occurring with those who had provided support. 
Refocusing described the experience of hope, focusing on personal 
goals and high qualit y care, and on positiv es to arise from the conflict 
(Gaudine & Beaton, 2002). 
 
Factors that worsened the experience of ethical conflict were significant 
and are summarized by the res earchers under four headings: fallout 
 45
from decisions the nurse manager did not agree with, inability to resolve 
ethical conflict, situational factors and  factors relating to the nurse 
manager (Gaudine & Beaton, 2002). Fallout was related for exam ple, to 
poor or unsafe patient care and increas e d complai n t s about nursing 
care. Inability to resolve ethical conflict concerned an inab ility to speak 
out or act and to make the needs of nursing understood (Gaudine & 
Beaton, 2002). Situational factors included fear of escalation if the nurse 
manager spoke out, poor communicati on because of the organizat ion’s 
size and the opinions of physicians mo re valued than those of nurses. 
Factors relating to the nurse manager concerned needing mentors, 
uncertainty about wha t is right, and i nab ility to inform their nursin g staff 
of efforts to resolve issues of concern to them (Gaudine & Beaton, 
2002). 
 
The outcomes of ethical conflicts for nurse managers personally wer e 
identif i e d as: negative feelings, turnover, and learning to remain silent 
(Gaudine & Beaton, 2002). Negative feelings included frustrat i o n , anger, 
fear, stress, burnout , lonelin e s s , demoralization, powerlessnes s and 
lack of fulfill m e n t . Turnover was reflect e d in loss from the profess i o n 
and position. Learning to remain silent is as it suggests, an oppressive 
and detrimental outcome for the nur se manager and the health care 
organiza t i o n . 
 
In summary , the researc h e r s comment that the theme of voicelessness 
had disturbing implic ations for hospi ta l s wishing to attract and retain 
excellent nurses in m anagement and bed-side ro les, since, being 
voiceless, goes against nursing val ues of collaborat ion and inc l usion 
(Gaudine & Beaton, 2002).  Dis tress, frustration and wanting to resign 
as a common outcome with their partici pants similarly raises concerns 
regarding stability and re cruitment of the nurse manager wor k force 
(Gaudine & Beaton, 2002).  
 
 46
The values identified and at issue in  Gaudine and Beaton’ s (2002) study 
are summarized as: 
 
[P]roviding quality care, or doing what is  best for each client, family or staff 
member , and the fair treatmen t of nurse s and nurse manage r s in the work place . 
These values reflect the ethical principl es of beneficen ce and non-malifecen ce – 
or the moral imperatives to do good to others and to not caus e harm to others ... 
and justic e . The nurse mangers describe d their hospita l ’ s values, in contras t , as 
balancin g their budgets and protec ti n g their legal pos ition (Gaudine & Beaton, 
2002, p. 29). 
 
 
The researchers conclude that if qua lity nur sing care is to be provided 
hospitals and nurse managers need to  understand each others values 
and perspectives (Gaudine & Beat on, 2002).  To do so, these 
research e r s advocate for workshop s whic h bring nurse managers, direct 
care nurses, administrators and boar d members together in order to 
share pers pectives and to com bi ne with organizational reform that 
ensures decision mak i ng process es are more visible and structured in a 
way that allows all parties a vo ice and respect (Gaudine & Beaton, 
2002). 
 
 
2.7 LITERATURE REVIEW SUMMARY AND RATIONALE FOR STUDY 
Underpinned by a marked political ideological shift from egalitar ianism 
to neoliber alism, the first part of this review has outline d the context and 
processes of rapid a nd broad economic and polit ic al reform in New 
Zealand from 1980 to 1999. Transcend ing public policy and structure, 
neoliberalis m has in it s wake transformed social policie s and structures 
to fundamentally alter the organizations, objectives, processes and 
values of New Zealand’s health care system.  
 
Manifestations of neoliberalis m in  the institutional context, public 
management theories applied in New Zeal and’s public institutions, such 
 47
as agency, public choice and new pub lic management , along with their 
politic al and economic objectives and activiti e s , spawned repeated 
restruct u r i n g of the health sector  in New Zealan d between 1984 and 
2001. New public management theory or managerialism in the healt h 
sector, both in New Zealand and other  countries, has had and continues 
to have a marked impact on health care  organizations . Derived from the 
entrepreneurial context of  the privat e sector , managerialism focuses on 
outputs, effectiveness, efficiency, social responsibility and fiscal 
prudence in the utiliz ation of  public health resources. Managerialism in 
the health sector has not however been without signific ant criticism. 
 
As the largest and most visible pr ofession in health care, nursing has 
been greatly affecte d by reform and managerialism. Profe ssiona l 
nursing in New Zealand  as elsewhe r e in the globe has been 
restructured several times in the last two decades with a number of 
conseque n c e s . Nursing leadersh i p structur es at all lev els of healt h care 
organizations have been weak ened, and at times completely abolished, 
resulting in a threatened and vulner a b l e profess i o n . The quality of 
nursing care has been eroded and patient s have suffered the affects to 
their health by way of poor healt h care outcomes. Nurses have been 
personally affected by reform, includi ng ill health, injury and burnout, to 
such an extent that there is now a global nursing shortage. Nurses who 
remain in health care service, and those yet to come, practic e in a 
context fraught with tensi on between the values of their profession and 
the values of the health care  organization charged with fiscal 
accountability and stewardship for health  resource utiliz ation. It is a 
context that renders nurses  and in particular nurse managers, 
vulnerable to ethical conf licts as they strive to provide the care they and 
their profession believ es is right and necessary for their patients.  
 
Ethical conflict arises from values  differences or clashes between the 
health prof essional and health care organiza t i o n , and may have a 
 48
number of implications for both pa tients and nurses. Whilst patients may 
experience increased discomfort or suffering as a consequence of poor 
care, impacts on the health professional include resignation, burn out 
and loss fr om the profession pr imarily  as a consequence of suffering 
moral distress. A review of the lit erature on ethical conflict in the nursing 
revealed both empiric al and theoreti cal ins ights that primarily focused 
on the experience of ethical conflic t and moral distres s for clinica l 
practising nurses. One study was loc ated which explored ethical 
conflicts which clinic al practisi ng nurses have wit h their employing 
organizations, and only one study  to address the concept and 
experience of nurse managers’ ethica l conflicts with their health care 
organiza t i o n s .  
 
The study by Gaudine and Beaton (2002) revealed that nurse 
managers’ experienc e ethical conf lict as one that  renders them 
voicele s s in their attempt s to determine how best to meet the  
competing needs of indivi dual pat ients and the hea lth care organiz ation. 
It was also an experience that may result in unjust practices on the part 
of the health care organizat ion such as unfair workloa d s and 
terminations (Gaudine & Beaton, 2002) . Factors that mitigate d this 
experie n c e for the nurse manager include support fr om other nurse 
manager s , hospita l ethics commi ttees and the nurse managers’ 
families.  Factors which made the exper ie nc e of ethical conflict for nurse 
managers worse inc l ude fallout from  unsafe nursing care, and an 
inab ility to resolve sit uations. The out come s of ethical conflict revealed 
by this study included negative feelings, turnover and being silenced. 
Key values at issue and identified in  this research concerned the quality 
of patient care and fair tr eatment of nur sing staff. 
 
Rationale for the present study 
Contemporary emphasis in  the management of health services toward 
efficiency and effectiveness in public healt h resource utilizatio n situates 
 49
nurse managers in an inevit able context of values tension. This context 
creates risk of the experience and negative consequences of ethical 
conflict for nurse managers, patient s , nursing staff and health care 
organizations. This chapter has rev ealed that whilst the concept and 
problem of ethical conf lict is underst o o d , it has not been well resear ched 
from the perspective of nurse manager s ; with only one qualitat i v e study 
found in the literature s earch that particularl y addresses the phenomena 
from this view point (Gaudine & Beaton, 2002).  
 
When little is known of a parti cular phenomena and experience, 
qualitative descriptive studi es ass ist in defining and conceptualiz in g that 
experience, as well as describing di mensions and variations of that 
experience (Polit & Tatano Beck, 2006). Replication studies in the 
quantitative research paradigm are of central importan c e for the 
verification or refutation of results or finding s of some prior study (Ellis, 
1994; Page & Meyer, 2000; Polit & Ta tano Beck, 2006; Bryman & Bell, 
2003). Replication als o under sc o r e s the desire to check on cultura l or 
ideo logic al bias on the part of the researcher (Ellis, 1994) as well as 
providing the substance for systemat ic and meta-analysis (Eden, 2002). 
Whilst the usefulnes s of replication st udies in qualitative research is 
almost ignored by the literature, per haps on the basis of subjectivity in 
findings and severe limitations of generaliz ability of findings, this study 
is concer ned with knowing and und erstanding more about real 
experiences others have encount ered, and others have researched, but 
clearly to a very limited degree. Indeed Gaudine and Beaton adv ise that 
“...future research could exam ine ethical conflict as experienced by 
nurse managers wor king in other setting s ” (2002, p.32). At the very 
least, there will be broad points of  contras t and compari s o n between the 
findings of the two studies from which refinement of concepts may 
proceed. It may also, from the perspec tive of triangulation in research, 
be usefully considered a second s ource of informa n t s from whic h 
 50
conclus ions may be drawn regar ding the knowledge and findings 
generated (Bryman & Bell, 2003;  Polit & Tat ano Beck, 2006). 
 
The research presented in this report is thus aimed at building on and 
enhanc ing knowledge of the experi ence of nurse manager’s ethical 
conflict with their health care organizations , in a New Zealand context. 
As previously noted by Gaudine and Bea t on (2002) knowledge and 
understanding of t he phenomenon is essential to  resolution of ethical 
conflict s and mitigati n g its negative  cons equences. In contrast to the 
foundation study, this research did not  seek to describe the experience 
of ethica l confli c t that nurse m anagers’ had with their professional 
associations, since the participant s in this earlier study, mostly 
experienced no ethical conflict wit h their professional assoc i ations 
(Gaudine & Beaton, 2002).  
 51
                                     CHAPTER 3 – METHOD 
 
The purpose of this research is to build and enhanc e knowledge and 
understanding of the exper ience of nurse managers’ et hical conflict with 
their health care organiza t i o n s . In order to achieve this purpos e, this 
study seek s rich desc r iptions, them es and patterns of the experience, 
and to do so by replicating the qual itative descriptive approach of the 
study by Gaudine and Beaton (2002). Consistent with these research 
purposes, this chapter presents the methodological underpinnings, 
participant recruitment and selection,  data collectio n and analysis for the 
study. It also sets out important ethical procedures and consider ations, 
as well as an outline of the estab lis hment of research rigour for the 
study.   Some brief critici s m s are made of the methods used in the 
foundation study, and as a consequenc e the adapted methods for 
analyz ing qualitative descriptive data for the current study are set out.  
 
 
3.1 METHODOLOGICAL UNDERPINNINGS  
This study followed the qualitat ive descrip t i v e approac h to res earc h 
utilize d by Gaudine and Beaton (2002) . Qualitative research seeks to 
contribute to “...a better understanding of social realities and to draw 
attention to processes, meaning patte rns and structural features” (Flick, 
von Cardoff & Steinke, 2004, p.3). De scriptive research “...sets out to 
describe a phenomenon or event as it  exists without manipulation or 
control of any element involved  in the phenomenon or event under 
study” (Page & Mey er, 2000, p.22).  Description draws upon the 
ordinary vocabulary of people to c onvey ideas about things, people and 
places, inc l uding what is, or was going  on, as well as what people are 
involv ed in, and or do (Strauss & Corbin, 1998).  
 
It has been noted that some qualitative research reports do not identify 
a specific research tradition suc h as ethnography, phenomenolo gy or 
 52
ethnology within whic h the study is located (Polit & Tatano Beck, 2006; 
Thomas, 2003, 2006) . Gaudine and Beat on (2002) likewise, do not 
situate their study wit hin a particula r research traditio n . Instead, they 
refer only briefly to the use of selected aspects of grounded theory 
methods in both their data collection and analys is, emphasizing that 
“...events and feelings are best described by the person who has 
experie n c e d them” (Gaudin e  & Beaton, 2002, p.19). 
Three key criticisms of the foundation study methods and report are 
noted here. Firstly, the publis hed repor t of Gaudine and Beaton’s (2002) 
study provide s limited rationa l e fo r the influence and methods of 
grounded theory. Secondly, experts and proponents of grounded theory 
may consider the tacit inference to  the methodology and methods in the 
report, a slur on the strengths and va lue of the grounded theory. Finally, 
the emphasis on thematic findings in Gaudine and Beaton’s (2002) 
study and report is incons is t e n t  with grounded theory methods and 
presentation of findings.  
Consequently, this study has applie d a general induc t ive approach to 
qualita t i v e data analysi s (Thomas ,  2003, 2006). This approac h to 
qualitative data analy sis provides a convenient and les s complex means 
of condens ing large amounts of raw data for many research purposes 
where ther e is no u nderpin n i n g research tradition (Thomas, 2003; 
2006). This method enables the establ ishment of clear links between 
research objectives and findings derived from raw data with focus on 
presentation and desc r iption of the most import a n t categories (Thomas, 
2006). Whilst most similar to grounded theory methods, the general 
inductive method does not  explicitly separate the coding process into 
open and axial coding (Thomas, 2006).  The key steps and processes 
of the general inductive approach are: close reading of the text and 
immersion in the data; coding of  transcripts for recurring topics, 
processe s , substanc e and themes; creation and sorting of codes into 
clusters and categories; revis ion,  integr a t i o n and refine m e n t of 
 53
categories; and relating categories  and themes to one another 
(Thomas , 2003, 2006).  Fi ndings from data analysis using this method 
are inev itably shaped by the ex perie n c e s and ass umpt i o n s of the 
researcher, and decis ions regarding what  are more or less important in 
the data (Thomas, 2006).  
 
3.2 PARTICIPANT RECRUITMENT AND SELECTION 
Gaudine and Beaton utilize d a conv enie nce sample of 15 nurse 
managers in an eastern Canadian prov ince to inform their study 
(Gaudine & Beaton, 2002). In  contrast the current  research utilized a 
mixture of convenienc e and  purposive sam pling, with a resultant eight 
nurse managers recruited. Whilst convenience sampling involves the 
selection of the most readily av ailable persons, purposive sampling 
involv es selection bas ed on judgment  on who will be most informative 
(Polit & Tatano Beck, 2006).  
 
Two key methods were utiliz ed to re cruit partici p a n t s . In the first 
instance, recruitment involv ed pr of essional networking, which inv olved 
advertising the resear ch by way of an electronic notice on the website of 
the College of Nurs es Aotearoa. Prospec t i v e particip a n t s responde d 
directly to the researcher via this method. The second method utiliz ed 
invitations to participat e in the res ear ch that were distributed by mail-out 
with the assistance of the Nursing Council of New Zealand. Around 75 
registered nurses across several regi ons whose job classification was 
nursing management or admin istration were sent research invitations, 
directly from the Nursing Council of New Zealand, ensuring that the 
process maintained the priv acy of  the poss ib l e recrui t s . Again, 
participants responded directly to the researcher. A copy of the 
invitations distributed via these methods and two different nursing 
organizations are set out in Appendices I and II.  
 
 54
The uptake and response to the invitations was particularly slow. Over 
an eight month period (including net work advertising, and invitation 
mail-outs), only 11 responses were re ceived by the researcher.  Thus, 
three respondents were not rec r uited or selected because they did not 
fit the selection criteria, or they chose not to parti cipate in the study at a 
later stage. Despite the much lesser num ber of recruits from that of the 
foundation study, the interviews and subsequent transcripts rendered an 
extremely large and rich data source that proved ample for the study’s 
purpose. 
 
Each respondent to invitations was sent a copy of the research 
information sheet (Appendix III). At times, respon d e n t s automa t i c a l l y 
followed up with a tentat ive agreement to participat e in the research, at 
other times the research e r foll owed up by phone ca ll or email to 
determine what their decision was in regard to participation. These 
potential participants were provi ded with an opportunity for more 
detailed elaboration and di scus s ion of the study with the researcher 
prior to seeking their written informe d consent . When the respond e n t s 
had made the decis ion to partici p a t e in the study, they were ask ed to 
complete a written consent form (Appendix IV). 
 
In their publishe d report, Gaudi ne and Beaton (2002) have not made 
explic it their criterion fo r selection of participants, other than noting that 
selecti o n of partici p a n t s was bas ed on convenience. In the present 
study, the criteria for se lecti o n were three fold: 
 
• Current registration with the Nursing Counc il of New Zealand 
• Current practising certificate issued by the Nursing Council of 
New Zea la nd 
• At least one year of experie nc e as a nursing manager in a 
primary, secondary or tertiary health care organization in the last 
five years within the Ne w Zealand health sector 
 55
The term and professional title ‘Nurs e Manager’ was not central to a 
participant’s selection into the res earch. Indeed many of the participants 
did not actually have the prof essional title ‘Nurse Manager’. The 
particip a n t s and the research e r approac hed the term functionally, rather 
than specifically. By func tional applic ation is meant  that the participants 
all had professional responsibilitie s that involved the management of 
nursing services and practices. Any im plic ations of the functional use of 
the term Nurse Manager have been noted in the final chapter of this 
repor t . 
 
 
3.3 DATA COLLECTION 
Two methods of data collection were ut ilize d in this study; a biogr aph i c a l 
data collecti o n form and semi-str uctured audiotaped personal 
intervie w s . It is evident from Gaudi n e and Beaton s ’ (2002) report that 
data was collected from their participants regarding age, gender, 
professional experience, qualifications, and areas  of nursing practice 
and charact e r i s t i c s of their health  care organizations. They do not 
however, identify how this infor m ati on was collected. For the purposes 
of the present study, a biographical data collectio n form was distributed 
to participants who had consented to the study (Appendix V). The 
purpose was to elic it a broad understanding of the participants  
biographic al and prof essional characteri stics. The findings from a very 
general analysis of the information provided by participants on these 
forms are summarized and set out here. 
 
At the time of their interviews, all the particip a n t s in this study were 
practising as nurse managers, across fi ve differ e n t Distri c t Health Board 
regions in New Zealand, and seven di fferent employing health care 
organizations. Three of the partici p a n t s were prac ticing in the pr imary 
health sector, whilst the other five  were employed in the secondary 
health sector. Two of the partici pants were engaged as clinical nurse 
 56
m a n a g e r s , two in profess i o n a l nu rsing dev elopment management, one 
in operatio n s manageme n t, and three in senior nursing adminis t r a t i o n 
positions in their health care or ganizations . The participant’s specialty 
areas of nursing practic e , includi n g that of past nurs ing manag em e n t 
roles, were: eldercar e, primary heal th, emergency, cardiac, general 
medical and surgical, and mental health. Two of the participants in this 
study were over 50 years of age, with the remaining six aged between 
41-50 year s. All but one of the par ticipants was female. The mean 
number of years experien c e as a nurse manager was 8 years and one 
month. The total number of nursing management positions each 
participant had held varied significantly from one to nine pos itions. One 
of the participants had a tertiary  education bas ed qualification of 
Registered Comprehensive Nur se, whilst all others commenced their 
professional lives as Registered General and Obst etric Nurses from 
hospital based educat ion.  All bu t two participants had completed post 
registration qualifications  inc ludin g bachelor ’ s degrees, certific a t e s or 
diplomas in nursing, health science, or business. At least two of the 
participants held masters degrees. Th ree of the participants were 
engaged in tertiary study towards dipl oma or masters le vel qualific ations 
at the time of their interviews. 
 
Interviews are the most common se lf-rep o r t in g method of gatherin g data 
in qualitative research (Polit & Tatano Beck, 2006). Semi-structured 
interviews are “...used when researc hers have a list of topics of broad 
questions that must be addressed in an interview” (Polit & Tatano Beck, 
2006, p. 291). The interview schedule (list of pre-determined questions 
to be ans wered) ensures a measure of consistency in par t icipant 
interviews as well as a measure of focus in the ensuing dialogu e 
(Bryman & Bell, 2003). However , this inter view method als o pr ovides 
signific ant leeway in how the partici p a n t s reply and indeed how the 
researcher may clarify, probe or ex plore particular or general responses 
(Bryman & Bell, 2003). The interview guide utilized in this st udy is 
 57
exactly the same as that utiliz ed by Gaudin e and Beat on (2002) and is 
present e d in Appendi x VI. 
 
The interviews were conducted in locations of convenience to the 
participant where priv acy was able to  be carefully maintaine d. Prior to 
commencing the interview, some  time was spent ensuring the 
participants comfort and confidence in the process. It was also an 
important opportunity to review the purpose of the research, the 
participants understanding of the proce ss and to check through consent 
forms. The interviews in this study varied significantly in length from 45-
120 minut es, dependant on the length of  participants’ responses to 
questions, and the number of examples t hat they were able to provide. 
 
All intervie ws bega n by askin g par ticipants to describe any ethical 
conflict they have or have had with their health care organiz ations. 
Ethical conflict was defined in the interview schedule and again at the 
start of the interview as  any situation where the nurse manager’s values 
differed from those of the or ganization and the nurse manager 
experienced conflict as a result (Gaudine & Beaton, 2002). Particip a n t s 
were then asked to describe fact ors that eased and worsened the 
ethical conflict they had described.  The final question posed concerned 
the description of outcomes of the ethical conflict. Whilst Gaudine and 
Beaton (2002) focused this on personal out comes, in the present study 
this quest ion was posed to incl ude personal, professional or 
organizational outcomes. The purpose in doing so was to identify a 
fuller range of pos sible inter action consequences and outcomes 
between the nurse manager and the health care organiz ation.  
 
The audiot aped interviews were transcr ibed verbatim by the researcher 
as soon as practicable following their conduct . The transcr i p t s were 
carefully checked for possible identifiers (such as nam es or places) that 
were deleted or replaced with terms  that ensured anonymity of the 
 58
participant. Each transcript was then s ent to the participant for review.  
This practical procedure enabled t he participants to ensure that the 
transcripts accurately reflected thei r dialogu e and meaning s , as well as 
providin g an opportun i t y for them to ensure that their anonymit y was 
maintain e d in the transcri p t s . 
 
 
3.4 DATA ANALYSIS  
Gaudine and Beaton  (2002) utilized the follo wing techniqu es in the 
analys is of data for their study: 
 
• First-level coding – review of transcripts according to the areas 
covered by the interview guide 
• Second-lev el coding – identific ation of themes and categories 
• Exploration of the data for patterns 
• Step-wise replicat i o n where each researcher separately 
analyzed data then cross check ed their emergent categories, 
themes and interpretation 
 
In comparison there are several poi nts of difference in data analysis 
between this project and the foundation study. Firstl y , this projec t 
involv ed only one rather than two resear chers as was the case in 
Gaudine and Beaton’ s (2002) st udy, and it was theref ore not pos sible to 
use step-wis e replicat i o n . Secondly, the int erview schedule was not 
engaged in data analysis until refinement, comparison and relating 
categori e s , and the presenta t i o n of findings. Finally, and has already 
been ment ioned, a general inductiv e approach for qualitat i v e data 
analys is has been ut iliz ed to guide the steps and processes of data 
analys is. 
 
Alongside the general in ductive approach to qualit ativ e data analysis, 
research supervis i o n provided important guidance throughout the 
 59
analytic pr ocess. The steps and proces ses in dat a analys is for this 
study are as follows: 
 
• The first step of data analys is involved a pr ocess of immersion 
in the data through listening to eac h interview recording several 
times then reading and rereading of transcripts in order to become 
completely familiar wit h them, as well as gaining an understandin g 
of recurring events, topi cs, themes and processe s . 
• The second step inv olved coding of transcripts for recurring 
events, topics, themes and proc esses. This cod ing process 
resulted in over 500 codes that  were transcri b e d (cut and pasted 
electronically) onto separate cards with identi f i e r s (e.g. A/6/18 – 
participant/page/code number) used to  link the code to the exac t 
source of text from which the code was derived.  
• The third step involv ed sorting the code s into 20 different 
clusters or categories , by way of comparing and cont rasting the 
codes and their related transcript. The clust ers were then labeled, 
with key dimensions a nd properties memoed.  
• In the fourth step, the categor ies were also then compared and 
contrasted and as a consequence a ll but two of the categories 
were integrated. This integrat i o n of categor i e s was based on 
consideration of the purposes of the research as well as the 
different questions in the interview schedul e .  This proc ess resulte d 
in the emergence of 6 key conc ept ual categories. The integration 
into conceptual categories inv olv ed moving, or conceptualizing up 
from, and abstracting the clusters into a larger and cohesiv e 
conceptual whole.  
• Once these concept ual catego ries had emerged, they were 
labeled, with dimens ions, them es and relations hips to other 
categories memoed.  
 
 60
Two types of memos were used to  support and progress data analysis. 
The first type, coding memos, were primarily concerne d with iden tifying 
the dimens ions and themes of cat egories. The second type of memo 
concerned the research and analytic  process as a whole. These 
memos, which wer e kept in a resear cher diary , facilitate d the 
identification of ideas and hunches r egarding what the participants were 
experienc ing as well as identifyi ng relationships and patterns between 
codes and categori e s . Memos were  thus an important part of 
remembering and understanding why and how codes and cate gori e s 
developed and play ed a si gnificant role in moving and abstracting up 
from the data. These memos also hel ped to check on researcher biases 
during the analytic process. 
 
 
3.5 ESTABLISHING RESEARCH RIGOUR 
The framework for this brief discussi on on the establis hment of research 
rigour is that proposed by Lincoln and Guba (1989). The criteria of this 
framework address credibility , dependability confirmabilit y and 
transferability in the research process.  
 
Credib ility or confiden ce in the trut h of the data and interpretations has 
been addressed by two methods; prolonged engagement and member 
checking. This study has not been undertaken quickly , and indeed the 
collection of data as previously noted, occurred over  an eight month 
period. The analys is of data was al so a lengthy process with several 
phases which built on eac h other in terms of t he robus tness and clarity 
of analytic technique.  Participants we re asked to check their intervie w 
transcripts once transcription was complet ed, and thus provided the 
opportunity for feedback at this time. This process ensured that the 
participant was able to reflect on the questions asked and answers 
given during their interviews, and any misinter p r e t a t i o n whether by the 
researcher or the participant, was abl e to be identified and rectified. A 
 61
second member checking process was engaged which asked two of the 
participants to review analytic fi ndings. In both member checking 
processes the participants’ feedba c k was in agreem e n t with the 
transcripts and data analysis presented. 
 
Depen dability and confirmability of t he research has been address ed by 
ensuring that all materials arising from the study hav e and will continue 
to be available to the research super visors and assess ors at completion 
of the study. Dependability and confirmability have als o been supported 
by way of the processes of research supervision. 
 
The criterion of transferability refe rs to the “...extent to which the 
findings from the data c an be transferred to other settings or groups and 
is thus similar to the concept of generaliz ability” (Polit & Tatano Beck, 
2006, p336). In the pres ent study, transferability has been promoted by 
ensuring concise and accurate det ail of partici p a n t samplin g and 
selection as well as concise and accurate description of the data 
analys is process. 
 
 
3.6 ETHICAL CONSIDERATIONS AND ACTIVITIES 
Prior to undertaking the researc h a human ethics app lication was made 
including the submis sion of all per tinent documentation to the Massey 
University Human Ethics Com m itt ee in March 2006. This process 
required that the res earcher be cognizant and compliant with the Code 
of Ethical Conduct for Research, Teaching and Evaluations Involvin g 
Human Participants (Massey University, 2005). Approval for the study 
was receiv ed in May 2006 from the Massey Universit y Human Ethics 
Committee:  Southern A,  Application 06/17.  
 
Two other important ethical matters  were considered and addres sed in 
the ethics approval and research conduct process ; the possibl e 
 62
psychological effects that reliving the ethical conflic t experience may 
have on the participant, and the possibi lity that the dial ogue revealed 
incidents with possible legal implicat ions . Both of these matters were 
raised and address e d with the partici pants in the information sheet. 
Sensitiv ity to any display of dist ress or anguish during intervie w was 
acknowledged and responded to appropriat ely. None of the participants 
demonstrated the need for or requested further psychological 
counseling. No dialogue raised legal concer n; had this occurred it would 
have been addressed consistent with the procedures set out in the 
study informat i o n sheet. 
 63
CHAPTER 4 - DATA ANALYSIS  
 
The object ive of this chapter is to present the findings from data 
analys is. This is achieved through presentation and discussion of a 
framework of key conceptual cat egor ies, their dimensions and themes 
and relationships to one another, al ong with select ions of int erview 
transcript. The six key conceptual ca tegories of the framework are: The 
Health Care Organization, Nursing Management Advocacy, Isolation, 
Support, the Bottom Line, and Being and Becoming Nursing Leaders . 
The presentation and discussion of  the first conceptual category, The 
Health Care Organization does not include transcrip t excerpts , since the 
majority of the data it represents were one or two words, and to an 
extent are identifiable in the remai nder of the presentat ion. The chapter 
concludes with a brief summary of the data analysis.   
 
Presentation of findings in this chapter is also supported by the 
diagrammatic representation of the fram ework offered in Figure 1.  Each 
of the key conceptual categories ar ising from data anal ys is is found 
within the diagram, which includes the dimensions  and themes inherent 
in each cat egory. The Health Care Organization is conc eptualiz ed in the 
diagram as a broken line that depi cts the openness of the health care 
organization to its health system env iro n m e n t and aspect s of that 
environment such as other health or ganizat ions, other people in health 
care organizations, health policy and br oader health system processes.  
The large arrows in the diagr am, demonstrate direction and 
relation s h i p s between categori e s . For example, the experienc e of 
Nursing Management Advocacy is influenc ed by both the experiences 
of Isolation and Support and the conceptual categor y and exper ience of 
the Bottom Line is a result of all three of these other categories in the 
framewo r k .  Experienc e of the Bottom Line leads to Being and Becoming 
Nursing Leaders. 
 
 64
4.1 THE HEALTH CARE ORGANIZATION 
The analys is of data reveale d that t he health care organization was not 
merely an employer, or inv olvi ng exec utive management - although 
these two entities and descriptions were  evident. Rather, the health care 
organization was people, positions, structures, systems, processes and 
culture. Moreover these dimensi ons and experienc es crossed the 
boundaries of individual health care or ganizations to other healt h care 
organizations, into the community  and its representatives, and in 
relatio n to Governm e n t , particu lar policy and funding systems and 
processes. 
 
The experie n c e of ethical conflic t also occ urred with particular people, 
such as immediate managers, se rvice managers or general managers 
(most non-clin i c a l ) and at other time s executive managers such as Chief 
Executive and Chief Operating Office rs. The health care organization 
was also revealed as other nur ses and nurse managers, including 
professional nursing l eaders and Directors of Nursing. At times the 
health care organiz ation was medical or clinical directors. Most 
frequently the health care organiz ation was referred to as managers or 
general managers or the structure of managers, at times phrased 
merely as “they”. One of the more distinctive structures of the healt h 
care organization was governance bas ed, including District Health 
Boards (DHB’s), and primary health  organiza t i o n s (PHO’s) Boards. 
 
The health care organization was also portrayed by participants as a 
culture, including: a cult ure of bully ing, the cult ure of medicine, and the 
culture of primary and se condary health services. Lastly and particularly 
a result of having part icipants who pr acticed in primary health care, the 
health care organization was des cribed as a business or firm concern e d 
with financial sustainability. 
 
 
 65
 
 
 
Conceptual Category
The Bottom Line
Dimension
Links values clash, conflict and outcomes
Themes
Challenge and Confrontation
The Nurse Managers Bottom-Line
The Health Care Organizations Bottom-Line
Conceptual
Category
Nursing
Management
Advocacy
Dimensions
Duality and Fusion of Values
Themes
Advocacy
Valuing professional nursing
Quality nursing practice
Quality patient care
Valuing teams
Safety
Conceptual
Category
Being 
and Becoming
Nursing Leaders
Dimension
Transformation
Themes
Reflection
Learning
Growth
Motivation
Counting the Costs
Conceptual  Category
Isolation
Dimensions
The experience of ethical conflict and
the nurse managers role
Themes
Silencing
Isolation 
Barriers
Invisibility
Conceptual
Category
Support
Dimensions
The experience of ethical conflict and
the nurse managers role
Themes
Perso nal
Professional
Organizational
Figure 1. Framework of analytic findings: conceptual categories, themes, 
dimensions & relationships. 
 
The health care organization was al so des cribed and experienced as a 
complex weave of systems and proc esses. Examples of this less 
tangible and less personal dimension of the health care organiza t i o n 
include : human resourc e , perform ance mana gement, f unding, planning, 
decision-making and risk managem ent systems and processes. 
Descriptions also included nursing educ ation and professional nursing 
development systems and processe s within and between dif f erent 
health care organiz a t i o n s . 
4.2 NURSING MANAGEMENT ADVOCACY 
 66
The key conceptual category of Nursing Management Advocacy is 
central to the many and varied descr ip t i o n s that parti cipants shared in 
their interv i e w s , when asked to de scri b e their experi e n c e s of ethica l 
conflict wit h their health care organizations. Nursing Management 
Advocacy has the im portant dimensi on of both duality and fusion of 
nursing and management values in the participants’ descriptions, whic h 
did not nec essarily repr esent polemic values stances between the nurse 
manager and the health care organization.   Rather, that at times the 
descriptions also portrayed the nurse  manager experiencing a fus ion of 
nursing and management va lues in their perspec t i v e s , roles and 
activities. For example the participants experienced ethical conflict when 
the organiz ation did not live up to t heir stated and agr eed upon values. 
Describing this experience as ‘c ognitive dissonance’, one of the 
participants portrayed the ways in  whic h they had encountered 
managers who did not demonstrate empathy or compassion for their 
staff: 
 
I think that cognitive dissonance comes up hugely for me as well as the 
organization...I guess there is, the dissonance for me is when management, 
some managers, have, they espouse the nice words, they talk about it, they use 
the latest lingo, but they don’t walk the talk. Okay, so they don’t, they don’t then 
act on it, they are last minute and reactive in their own style. They don’t really 
demonstrate empathy and compassion for the people they are working with, so 
people loose trust and respect, because they can’t see the process. They know 
what is required and it’s even covered in our collective agreement for nurses, 
this is how we will manage change, and its like a breech of all of 
that.(H/5/14&16). 
 
 
The fusion of values in descriptions  was also evident when participants 
recognized the broad er objectives, pr ioritie s and resp onsib ilities of the 
health car e organiz a tion. For exam ple, Participant H expres sed an 
awareness of the different demands influencing general managers and 
their actions, by describing: 
 67
                
So I think, generally the people directly above me have been going in a line with 
me, but they often get pushed off the line. Then they have always explained to me 
why they have changed direction. I think the level above is just not aware of 
where the line is. (H/12/28). 
 
In the following discussion, the par ticipant demonstrates a sympathetic 
understanding of the issues and val ues inherent in managing health 
care organizations in the primary care sector and their ability to function 
financially: 
 
I think the fact that its always been a private business, its really difficult, and I 
have to say I have some sympathy for GP’s,  they’re running a business at the 
end of the day. They are not running a charity, and to have the government 
come along and say actually no we’re not going to let you do that is a bit hard for 
them too. And I can see the down side of that, if I were running a business I 
would get pretty hacked off with them if they told me I couldn’t charge more if I 
though my time was worth it. But at the same time you can’t have your cake and 
eat it. You can’t get money from the government and charge the patient. So you 
have to meet somewhere in the middle. (B/16/42). 
 
 
The theme of advocacy involved feeli ng, observing and identifying, then 
communicating or wor king with the health care organization regarding 
problems, issues, dilemmas, bug- bear s, and circumstances that 
challenged their values. For example,  advocacy involv ed activities such 
as, raising issues, asking ques tions, lobbying, influencing, reporting 
problems, escalating, speaking out, sending emails, confronting, 
challenging, pushing for,  writing memos and fighting for what they 
believed was the right thing for the health care organization  t o do, or 
concerning what they believed wa s wrong.  Advocacy is clearly yet 
differently expressed in each of the following three trans c r i p t extra c t s . In 
the first example Participant D dem onstrates the way in whic h they 
utilize d their nursing manageme nt posit ion to advocate for chan ge and 
 68
improvement in the nursing service. The second example involves a 
manager practising in primary health care, and is a very general but 
importan t statemen t of nursing values. The third example concerned the 
participant’s involvem ent in restructur ing of a clinic al service where beds 
numbers were being reduced. 
 
Where I can improve things or have the potential to improve things ...for 
professional peers, and the patients themselves, and I am lucky enough to be in 
a position where I can work towards speaking out or improving the processes 
that are currently in our organization which are causing their conflict. (D10/26). 
 
I think, being an advocate for the patient. I think that that is what nursing is all 
about, and I think when you stray away from that and become employed by GP’s  
or anybody else, you can loose sight of the fact that that is what you are actually 
there for. In fact we had a panel of nurses talking to nursing students recently, 
and we were talking about getting political and being strong, being 
knowledgeable about what is happening in nursing. One of the nurses pointed 
out that if you are a strong advocate for the patient you can actually be a strong 
advocate in other areas, and you can actually be strong politically, so I think it all 
starts with being a really strong advocate. (B/14/36-37). 
 
And, despite advocacy in which I tried very hard behind the scenes to try and 
change the direction that this conversation was going, the paper went out and 
everyone just went into chaos in the teams that were being dispersed. (G/1/4). 
 
 
The other themes of the category are indicative of the core functions of 
the nurse manager’s professional role  and values. Valuing professional 
nursing, describe s the nurse manager’ s activ e pursuit and development 
of the roles, responsibilities, an d respect for the broad and specific 
contribution of professi onal nursing in their health  care organiz a t i o n s , as 
the organiz ation in turn pursues its health service objectives.  
 
One of the ones that I still get conflict with the organization, is the valuing of 
nursing. Primarily where it shows up to me most is in the horizontal violence, 
bullying sort of field. (H/8/18). 
 69
 What happened with the professional development program conflict was that 
briefly we all came together, we put aside our PHO differences and we worked 
on a very professional, development level...and I don’t think we have to ask our 
PHO’s permission to get together. I think we can get together and actually talk 
about professional development in our own time if necessary. (B/17/44-45). 
 
 
Valuing pr ofessional nursing was al so encapsulated in des criptions 
where the nurse managers enhanc ed professional behaviour s and 
culture wit hin their own nursing t eams. For example, Participant F 
described members of t he nursing team lacked real interest in the 
elderly patients for whom they cared,  and then change to this attitude in 
the facility: 
 
In the, when I first started here, I started as the RN and I noticed that, how can I 
put this nicely, that my colleagues were just kind of looking for a job, they would 
do the minimum, I was on from Monday to Friday, and you wouldn’t believe the 
stuff that got left for me, because they weren’t really interested in old people. 
That’s changed now, um, we are, the RN’s that were have got on, have got here 
now all want to make a difference. (F/8/16). 
 
 
Other examples of the value of t he nursing profession are expres sed in 
the following two transcript extracts. Whilst the first example very 
broadly concerns the struggles associated with lac k of respect for 
professional nursing within the health care organization, the second 
reflects the ways in which reso urce allocation dec isions, in particular 
decisions regarding the funding of pr ofessional development for nurses, 
made at a governance level, have im plications for the nursing 
profession.  
 
I think there is something deeper there, which is actually nurses being seen as 
hand-maidens and being told what to do by somebody, and if its not a doctor 
telling you what to do, its somebody else, it may be a CEO who wants to tell you 
 70
what to do. I think there is an element of nursing not being seen as respected or 
owning its own professional development.(B14/35). 
 
[T]he worst thing the parliament, well the government ever did, was take away 
that nurse subsidy, because that was the only capped money we had within a 
primary care setting to say you have to pay these nurses this much, or this 
bucket of money, even if they had kept the whole practice nurse subsidy in a 
bucket, we could have then have a voice to say we know you have got $40,000 
in there for education. (E/13/28). 
 
 
This latter participant also went on to describe the promotion of 
professional nursing, as changing the culture of health care to one that 
is led by nurses, in c ontrast to a med ic ally dr iven culture of health 
services. This example is not only about a nurse manager advoc ating 
for professional nursing, but also de scribe s their congruen c e with this 
value. 
 
Its all about culture, its about the culture of secondary, the culture of primary, the 
culture of medicalized health care, the culture of nurse-led health care. Now in 
our organization I developed, and I say I,  because I did, and  then with the help 
of an every increasing expanding team, developed a nurse led culture and it 
worked really effectively, And people are starting to recognize this.(E/22/47). 
 
 
The term quality is used to describe both nursing practice and patient 
care, since the descriptions reflec ted responding to the communities 
health needs, the pursuit of evid ence based practice, and improv ement 
in standards of nursing care and prac tice. Advocating for quality nursing 
practice was expressed by all of t he participants through their pursuit of 
the appropriately qualif ied and educated nursing staff, special i z e d 
nursing staff and enough nursing staff to  meet the needs of patients in 
their care. All of these issues conc erning the quality of nursing practice 
were a significant and persistent caus e of ethical conflict for participants 
as they shared their experiences in  their interv i e w s .  One exampl e 
 71
provided by participant A, concer ned needing nurse s who wer e skilled 
in the care of mental health pati ents in acute general settings and then 
advocating for this over an extended period of time. 
 
But the nursing of these patients per se is not often as good as it should be. 
Often there are just no comprehensive nurses around. If they ask for a psych 
special we will try and get a comprehensive nurse or a psych nurse....I have 
been trying to do something about that for a long time. I’ve probably still got 
some of the emails I’ve sent.(A/15/34). 
 
 
Quality nursing practic e also involved thinking and acting strategically in 
nursing resource development. The nurse manager’s advocacy in this 
regard may be about convincing or proving to the health care 
organization that nursing resource use and development was essential. 
The followi n g extract capture s t he nurse managers’ ongoing adv ocacy 
for the development of the nursing team they were responsible for. 
 
As a nurse manager and leader I often had the problem of having to prove that a 
certain strategy was best in the long run even though in the short term it may 
cost. Often non-clinical people are managing nurses and do not understand 
some of the thinking behind strategies such as staff retention. The concept that 
‘a nurse is a nurse is a nurse’ was often the feeling you got from managers who 
were not nurses. Thus strategies to improve retention and seniority of staff were 
often seen as increasing cost rather than increasing value. The need to pay for 
staff overtime and extra resourcing to prevent staff turnover and training costs 
was an example. (H/5/11). 
 
 
Quality patient care, whilst closely aligned to that of quality nursing 
practice, has as its focus what is  right and what is necessa r y for 
meeting the health care needs of the patient . For exam ple , Partici p a n t A 
describes the inappropriate use of unt rained health care assistants for 
care of mental health patients:  
 
 72
They have basically gained their experience by osmosis really, they have no 
training but they have been exposed to a fair lot of mental health patients...its 
wrong, its wrong. (A/17/41). 
 
When asked why they believed that the issue was ethical, they replied: 
 
Well it’s a human right, that’s what it states in the booklet that they get, that they 
get the right care, in the right time in the appropriate place by the appropriately 
qualified people. (A/17/42). 
 
 
The quality of patient care also concerned advocacy for the best care 
deliv ery models. For example, after describing the pitfalls of one nursing 
model, the particip a n t then desc r ibe s adv ocacy for a better model of 
care delivery where the focus was more on the providing better qualit y 
care for the patient than the organizations drive for efficiency in nursing 
resource use. 
 
Would they like to go to a primary nursing model, and there was also strong 
support to go to a primary nursing model. There are a number of other questions 
that were asked in that proposal but the submissions for those two areas have 
given us an impetus to change the way things occur. So we have this 
opportunity to bring in a primary nursing model which will increase the number of 
RN FTE and reduce the number of health care assistant FTE. (D/4/11). 
 
 
Advocating for quality patient care was also pursued by the nurse 
manager with other member s of the nursing team. For exam ple, the 
following dialogue demons trates reciprocal ex chang e s between nurses, 
concerni n g quality patient fo cused care delivery systems. 
 
I did a presentation to them yesterday and I said you people I think, don’t quite 
realize the effort of living in this community...The girl today I was working with 
she said, you really overrate that transport problem, its not an issue.. and I said 
to her go back through your notes, and this poor guy had about six appointments 
 73
in two weeks. I have said to people, being sick in places like this is a full-time 
occupation ... and at the end of the day most of them are ineffective, they don’t 
make any difference to the health outcomes. So yeah, I push for taking it back to 
the people, you know.(E/21/45). 
 
 
One of the unique exampl es described, involved re-development and 
re-design of a health service. The particip a n t ’ s descript i o n in the 
following piece of transcript alludes to lac k of focus on patient and 
community needs and the poss ible effects of service redevelopment 
and redesign on the community as a w hole. Importantly this example 
also demonstrates the value of holisti c health care inherent in nursing, 
as well as evidenc ing the participant’s  intens ive process of advocacy to 
retain services that were belie ve d most appropr i a t e for communi t y 
health needs. 
 
The continuing care residents are all locally born and bred people....their families 
live there, they had spent time there in the past in their younger days and the 
families wanted them to come back, and all these families had put in money and 
time into the community and hospital, all the equipment was donated by these 
people. So it meant that somebody who had been there for more than one 
generation, in their 80’s was suddenly going to be uprooted,  and just shipped of 
because the DHB did not see that - money-wise, that was not going to work for 
them. They did not care about socio-economic factors for the community, 
because apart from uprooting these poor people and shipping them away from 
their families...it meant that ... people would have lost their jobs directly as a 
result. So, I had a huge problem with it...for the next year....we fought the DHB 
...to retain the services. (C/2/4-6). 
 
 
I n another of the unique ex ample s , evidenc e based clinica l practic e as it 
contributes to quality patient care was at the heart of the participants’ 
advocacy. Multiple values sets are identifiable in this description. 
 
The ethical conflict for me was when I realized that the pediatrician was 
prescribing Ritalin for children, because the parents wanted that for their child, 
 74
and yet he would actually document that there was no clinical rationale for the 
Ritalin. That was a huge dilemma for me...There are clear guidelines as to how 
Ritalin should be prescribed and what it should be prescribed for and the 
clinician had documented that it had no clinical rationale, but the parents had 
requested it.(D/13/38) 
 
 
The them e of valuing teams was express e d along a number of 
dimensions including nursing, c linic a l (multidisciplinary), and 
organizational teams. Under va l u i n g the role of t eams in the health care 
organization were a source of ethi cal conflict for the nurse manager and 
included the way in which change woul d affect not only individual team 
members, but also the benefit s of teams to ac hieving healt h care 
manageme n t goals. 
 
I guess what I felt, just in relation to that team stuff, is that people don’t often 
value that teams working well together can make huge benefits to the 
management team. They make things happen that would normally not be 
achievable, not just a series of individuals that come to work - its that whole 
team spirit, that whole culture that makes things work. And, I felt that 
management was seeing this as just people that could be dispersed anywhere, 
and they weren’t giving value and respect to the people. But I also felt that there 
was this whole stuff - the dollars have to be managed in a pretty straightforward 
way- and this isn’t just like a closing of a factory; there are people attached, and 
patients  attached, and a  whole raft of reasons.(G/3/9-10). 
 
 
Valuing teams also involves the in clus ion or engagement of teams in 
decision-making.  In this particular example the participant relates 
teamwork to extant guidel ines in the health care organiz at i o n , as well as 
specifying the risks that failure to include and engage teams has for the 
health care organiza t i o n . 
 
So I have huge ethical dilemmas when decisions are made, I can see what’s 
needed to be achieved, but the way they go about the decisions leaves the 
organization very vulnerable... For me there are very clear guidelines about how 
 75
this should be happening. If a problem exists you sit down with the people 
involved and you say we have got a problem, lets think about some options and 
solutions, so that everyone is feeling as if, along the way, right from the very 
beginning they understand what is happening.(G/4/14). 
 
 
The theme of safety, concerned the sa fety of patients and staff, as well 
as legal safety. When standards of care are compromised bec ause of 
lack of resource s , or poor clin ical decision-making, systems and 
processes, the health care organizati o n s patients and staff are not safe. 
These processes in turn heighten legal risks for the health care 
organization. There were many exam pl e s from the interv i e w s that 
concerned the fundamental theme of safety, and most often linked to 
lack of app ropriately skilled clin ic al nursing resource s , but also unsafe 
clinical equipment. The followin g three selecti o n s of dialogu e 
demonstrate how participants raised sa fety concerns and the pos sible 
consequences of lack of safety for patients, nurses and the health care 
organiza t i o n . 
 
 
And therefore we had to keep the organization safe in terms of HR process, go 
through a lengthy process of managing this person and basically giving her the 
opportunity to upskill, to relearn what was basic care in a lot of ways and still 
keep the patient safe, was my side of things. That was quite a conflict because I 
new that any period, or very quickly I learnt that any period that she was 
involved in patient care which was unsupervised, she was likely to do something 
that was dangerous.(H/1/2). 
 
We had one standing hoist, that was, I considered, to be dangerous, and 
because it didn’t look it, the advice that I got was that it didn’t matter which sling 
you used, they could still slip out of it. So I took it out of operation and I went to 
my manager, and she was in agreement, she said right were going to get a new 
one, and the word came back from the Board, no you can’t. (A/1/1). 
 
There is an issue that keeps recurring and has recurred since I’ve been with the 
organization in a variety of roles. I have seen it written from nursing staff on the 
 76
floor ... it’s an issue and it’s around the safe staffing and the use of unregulated 
care givers. So it’s a resourcing issue, it’s definitely to do with both the level and 
number of registered nurses on the floor and the skill mix. (D/11/2). 
 
 
 
4.3 ISOLATION 
The conceptual category of Isolation emerged from data analysis as a 
key and important intervening influence on the process of Nursing 
Management Advocacy. Four themes were id entified: silenc ing, 
isolation, barrier s and invis ibility. 
 
Participant s described experiences which silenc ed their advocacy, and 
in particular different of forms and channels of communicatio n such as 
emails , memos, report s , meetin g s and represen t a t i o n s to the health 
care organiz a t i o n . Si lencing was inherent in  both the nurse managers 
own behav iors when managing an et hica l conflict and organiz a tional 
response to the nurse manager’s advocacy.   
 
It was interesting one of the nurses said the other day... she said she didn’t want 
any secrets anymore. And I thought, yeah right, when is the next one going to 
happen. So there is a lack of understanding from some of the staff as well, which 
makes it really, really difficult. They knew that things were going on, but they 
didn’t know what. So there were a lot of secrets, I did have a lot of secrets from 
them, because I wasn’t able to tell them. And it was just this comment that one 
of the nurses made the other day and I thought that it really is interesting, that 
they know that there are secrets, and what makes it hard is that they don’t 
understand that they are secrets and I can’t  talk to them about it. (C/8/39-40). 
Before the next general meeting, a couple of the general managers were talking 
to me, they didn’t say anything specific, but from a couple of the general 
managers, I got the distinct impression, that I needed to keep my mouth shut, 
you know shut up or think about whether you like your home as much as you 
thought you did. (C/3/15). 
 
It was really hard. I guess there are some things that happen, that you can’t say a 
lot. But there is a difference between not saying things and lying about it.(C/4/23). 
 77
  
The participants also experienced silenc ing in the context of bullying, or 
horizontal violence. The two examples  of horizontal violence pr ovided 
by the particip a n t s in this study in cluded a specific conflict event and a 
more general and ongoing experience of bully ing involving medical 
professionals and a nursing team. In the extract which follows, 
concerning care that wa s not based on clinical ev idenc e, the participant 
was silenc ed by an immediate manager  and more specifically by a 
medical member of the clinical team  which they exper ienced by way of 
person a l threat . 
 
And I took it to my manager who basically told me that because there was 
trouble recruiting medical staff that thank you for sharing it, but, it would probably 
be something that would be left alone and not dealt with. However it was 
addressed with the pediatrician, so A) I was identified, and B) the pediatrician 
was informed of my concerns and personally came to my office and threatened 
me after hours when I was working late one night.(D/12/33-34). 
 
 
The theme of invisibility concer ned where participants were actively 
addressing situations where there were values clashes and ethical 
conflict, but doing so in ways or ci rcumstances wher e they were not 
always seen by their colleagues , both nursing and management. 
Practising invisibly, by way of quiet influenc e, is possibly also indicative 
of not wishing to be seen to be in support of nursing.  
 
Behind the scenes is not a negative context so much. A lot of people work 
behind the scenes. A lot of nursing is done behind the scenes. Because the 
caring quiet moment is not always something in front, that everybody is visible... 
It just means there is a lot more one on one stuff. There is a lot more quiet 
influence. (G/26/74). 
 
 78
It doesn’t mean I don’t say anything, but you may not see the forum in which I 
deal with it. I will deal with it at different levels on different days all the time, and I 
never let go. It’s just, it may not be confrontation. (G/30/89). 
 
 
Using a metaphor based on how one mi ght surreptitiously influ ence 
their husband, Participant C descr ibes the invisible hand of an 
advocate: 
 
I have to perhaps sew the seed so that people think it’s actually their idea...like 
you do with your husband, sew the seed, they think it’s their idea and then it’s all 
fine. And you do have to do that a bit with your bosses I think, make them think 
that they’re really clever. (B/5/17). 
 
 
Barriers between the participants and t he health care organization as an 
employer, between participants and professional groups or 
departments, and between different  health care organizations 
contributed to the participant’s isol ation. For example, one partic ipant 
described how their news letter to nursing colleagues in dif f erent 
practices of a PHO was stopped prior to  its distribution by their practice 
manager .  
 
And it is really difficult being micro-managed . We had an example this week, I 
advertised something in our weekly bulletin to the practices, and I worded it very 
carefully, and I didn’t want to rock any boats and I passed it by somebody else, 
and reworded it and it didn’t go out,  it was stopped at the gate. I thought gosh I 
thought she had better things to do with her time than read what I had put in the 
weekly newsletter. Obviously not. (B/18/48). 
 
Employmen t barriers were clearly felt and experienced by participants. 
In the process of advocating and c hallenging the planning of a service 
restructure at the governance level of the organization, including the 
Director of Nursing at this level,  the participant expressed on three 
occasions the risk to their employment with the health care organization. 
 79
 
 I thought my job was sitting on the line with a lot of this. (C/3/13) 
 
 I know my job was on the line several times, because I did go to the line   with 
what I had said to people,(C/4/22). 
 
And I also felt that they are never going to give me a job...because I’m too much 
of a stirrer.(C/5/22). 
 
 
Another of the participant ’s des cribed that reporting signific ant events 
arising during the course of their work, such as the consequenc es of 
inappropriate nursing resource allo cation was about sending mes sages 
to the “hierarchy” (A/8/15). This implicit ly express es organiz ational 
structure and culture as a barrier to their advocacy. Lack of structure in 
contrast , may in turn result in an inabilit y to advoc ate,  although it is 
evident that this does not inhibit nurse s from actually raising the issue of 
lack of struct u r e .  
 
We have a body of nurses who feel very disempowered in our organization 
because they have been silenced through the lack of nursing structure, and they 
are quite vocal about that. (D/9/22). 
 
 
Organizational structure was expe rienced by the nurse manager as a 
cultural norm with specific behavio rs aim ed at helping keep things 
secret, although clearly not unnot iced. Talking generally about 
relation s h i p s in their health care organizations participant F explains: 
 
Well I got on quite well with our last service manager, we had these quite nasty 
discussions at times, but looking back it wasn’t a very happy place here. Just 
because things seemed to be secret...Because the service manager, the general 
manager and the board member, would come here, and close themselves off in 
the office there. And I would be told “Do not disturb us, nobody is to disturb us”. 
Okay, so they would stay in there for most of the day, poke sandwiches at them 
now and again, um and then they would go away, and there would be absolutely 
 80
no idea what they were doing, but I knew that they were making decisions about 
the budget.(F/13/23). 
 
 
Isolation evolved from data analysis as  its own theme, either perceived 
by the nurse manager or exercised by  the health care organizat ion in 
response to ethical conflict or  as a consequence of it.   
 
A lot of the nurses sort of disappeared, it is probably my imagination, but walking 
down the corridor...I felt that people would see me coming and duck into a door 
somewhere. They probably didn’t, but it felt like that.(C/6/33). 
 
Health is really patch protective and it doesn’t matter where you are really 
because its always the same... so  we were all in our little offices being told by 
our CEO’s to keep our heads down keep out mouths shut and it will all blow 
over.(B/4/13-14). 
 
 
The conceptual category of Isolation therefore describes experiences 
that impact on the process and substanc e of Nursing Management 
Advocacy and on the role more general l y . It is poignan t l y summari z e d , 
including the risks to employm ent in the following extract. 
 
For me personally, yes there are risks, we have a culture of bullying in our 
organization, and if you speak out you are silenced, through any number of 
means and one of them could be that your job is disestablished. I’m not naïve 
enough to believe that it’s the only organization that does that either, I’ve seen 
that occur, and yes that’s definitely a possibility... But if it happens, it happens, 
and I will deal with that, so the risk is loss of income really.(D/10/2-28). 
 
4.4 SUPPORT 
The conceptual category of Support similarly, influenc es the experienc e 
of Nursing Management Advocacy and is readily identif ied as the result 
of the interview schedule that ask ed the participants to describe those 
factors which made the conflict easier. Support was described as an 
 81
influenc e not only on the nurse managers ability to advocate, but also 
on the performance of the nur se managers role generally.  
 
The major sources and forms of suppor t for nurse managers were 
persona l and profess i o n a l . Family me mbers and friends were identified 
as a key resource people for the par tici p a n t s , particu l a r l y when the 
nurse manager struggled with the emot ional burdens or indeed physical 
illness aris ing from their experience of ethical conflict .  When asked 
what made two partic ular examples of ethic al conflict easier, Participant 
C and Participant D replied: 
 
I’ve been thinking about that, and I can’t, I guess the only thing I can think of that 
made it easier, was the support of my husband and the chair of the community 
group... The staff were scared to say anything; they didn’t know what was really 
going on.(C/7/37-38). 
 
My husband went through that with me and he still brings it up a lot about how 
much support he had to give me at the time. My children also went through that 
with me. (D/16/44). 
 
 
P r o f e s s i o n a l support, primaril y from other nurse managers, was sought, 
at times given and received by par ticipants in order to gain other 
perspectives, or supervision of m anageme n t activiti e s , or to show a 
united approach to an ethical conflict. This dimension of professional 
support is reflected in the first extract to follow, whic h involv ed several 
nurse managers across different health care organizations in the 
primary health sect or. It was al so described more broadly by 
participants , and as the second exam ple demonstrates, in terms of 
coaching .  
 
We then as Nurse Mangers  sent letters of support to her bosses outlining what 
had been said at the meeting, that we felt quite clear that there was no bullying 
 82
happening at the meeting, and that this was a joint decision between all of us 
and what we actually wanted.(B/2/6). 
 
I can think of two professional leaders primarily, that have really coached me to 
develop, and that made a huge difference. Because again they had a bigger 
picture, they understood some of the things I didn’t at that stage understand, and 
probably still don’t. But they coached me to be able to achieve what I wanted to 
do within the system. Where that professional leadership has not been available 
it’s been much harder to learn.(H/6/14).  
 
 
T h e theme of organiz at i o n a l support has two key dimensions. Firstly, 
the health care organization may, in a specific circ umstance or in a 
broad sens e, support the nurse manager in the midst or aftermath of 
ethical conflic t . Secondl y , organiz a t i o n a l suppor t also re flects when the 
participants support others in the organization:  
 
When the manager told him that she had ordered one, he laughed, and just said 
well good for you, but don’t do it again....Yes, it would have stopped dead if she 
hadn’t been supportive. And I would have been left absolutely outraged, 
because I had been let in.(F/2/5). 
 
When the nurses get into that sort of predicament, they’re frightened, they’re 
scared. They don’t know how they are going to cope and basically what you do 
is use your good communication skills and put out other options, and then help 
them to choose the right mode of how they are going to work for the rest of the 
night.(A/4/8). 
 
 
Perhaps in irony, this final slice of  transcript describes a circumstance 
that has already been introduced, wher e one participant nurse manager, 
advocat i n g for quality patient care, s pecific ally the appropriate use of 
medication, was bullied by a m edical team member, then was 
unsupported by an immedi a t e general manager , yet in the aftermath 
was supported by the health care organization to relocate els ewhere 
within the organization. 
 83
 
No the organization was extremely supportive of my decision, but personally I 
think that part of that was because I was a very outspoken person and I think 
another part of it was they had identified the strengths of me professionally and 
that’s why they put me in there in the first place and so they did look after me 
afterwards. They seconded me to a position until I felt I could see something 
else in the organization that I wanted to go to. So I did feel supported by the 
organization post event. (D/15/42). 
 
 
 
4.5 THE BOTTOM LINE 
The conceptual category of the Bottom Line has three themes that 
overlap: confronting and challenging, the health care organization and 
the nurse manager . The theme of c onfrontation and c hallenge is about 
heightened advocacy or a focal point of ethical conflict. At the end of the 
day, ultim ate choices and mor al pos itions were felt, express ed and 
responded to in reciprocal fashion. In terms of its relations hip to the 
other conc eptual categories and to t he ques tions asked of participants, 
this category has the dimens ion of linking values clash and ethical 
conflict to outcomes . The Bottom Line describes and represents both 
reflexiv e and at times inevitable soci al interac t i o n s and experie n c e s of 
ethical conf lict. 
 
I really left my previous position because at the end of the day I think I was 
fooling myself that I was making a difference for the nurses. At the end of the 
day I had to actually wake up to the fact that the health, where I was working 
was the epitome of the constant, we were perpetuating the continuum of health 
disparity.(E/26/58). 
 
There are some things you can fight and some things you can’t. So sometimes 
what I will do is give a context to things, like I will think, is this the battle or is this 
the war? So sometimes it is absolutely essential that I fight this one, this is 
absolutely bottom line and I will not let some things go. (G/9/30). 
 
 
 84
Challenge and confro ntation by or of the health care organiz ation’s 
fiscal bottom line may be particularly di rect and acute; as  one participant 
described “quite terse and difficult” (G/4/12). Yet at other times the 
descriptions tended to express fis cal restraint as an inevitability that was 
unchangeable by the nurse manager. 
 
 
At least at the end of the day you have done everything in your power. I mean in 
the health care systems of today, I don’t expect it’s anywhere different in the 
world, certainly in Australia they have got the same sort of things. Fiscally as 
well as what is going to happen in the future, I don’t know. I think at the end of 
the day nurse mangers, again, can only go as far as their budget will allow 
them.(A/8/6). 
 
        Again it’s a monetary thing; they just don’t want to pay. (A/15/35).  
 
 
The Bottom Line was not only about fisc al restraint and the limited 
resources of the health care organiza tion, but also about  the relative 
respect that the health care organi zation had for professional nursing 
which is consistent with the theme of valuing profes sional nursing that 
has already been presented. Some dialogu e expressed intense 
exchanges between the nurse m anager and the health care 
organization, as well as poss ible changes as a consequence of the 
nurse manager’s advocacy for the profession. For exam ple both 
particip a n t D and H described their experiences of challenging the 
organization in relation to the value of the nursing profession as follows: 
 
The Chief Executive Officer stated at a staff briefing that he would like to 
introduce more senior professional leadership nursing roles; however, he has 
not got the funding to do that. I challenged him in that briefing, that if they know 
it’s the right thing to do, how can they afford not to do it, financially? And he did 
grin and say that’s a very good question. (D/25/61). 
 
 85
The conflict for me comes, when that individual happens to be a medical 
professional, that the reverse tends to happen, and the organization tries [to] 
quiet it rather than take it through a process and I find that quite frustrating. So 
much so, to the degree I have heard one manager say that the medical staff are 
too important to risk losing. I have to say that was challenged. But that is 
certainly the impression you get when it comes to bullying. I have seen it a 
number of times now, and I have escalated medical bullying to as high as I 
possibly could. (H/8/19/20). 
 
 
Where the nurse manager could no longer tolerate values inc ongruence 
and clashes with the health care or ganization, and the position which 
the health care organization had taken,  it was evident that the nurse 
manger would or may leav e their nursing manageme n t position s in 
response. It was als o evident that the health care organiza t i o n s bottom-
line did in fact occasio n a l l y change , someti m e s as a result of the nurse 
managers’ advocacy, as the examples below will show. Import a n t ly, this 
concept highlights reciprocal social proces ses that pivot around values 
clashes. 
 
 
I think the way I cope with it is I have decided I have the ultimate choice. Which 
is I can move on. So basically no matter what an organization asks  of me I can 
choose to accept it and meet the challenge, or I can walk away if I believe its  an 
unreasonable ask. If I think there are things I can do and I’m supported to 
change things then fine. When it becomes from my perspective an organization 
saying they are not going to change, and I don’t think it’s acceptable, then my 
perspective is I can’t support the organization, therefore I can’t work with the 
organization. (H/15/34/35). 
 
And, probably the thing that did change the mind of the managers was, A) a 
commitment that we would try and hold the beds as much as we could, in terms 
of closing of beds, but also that we needed those side rooms, for the patients 
that needed side rooms, and we used that clinical ethical consumer focused 
route, but also infection control, and a whole lot of other dimensions to defend it 
and that stood. (G/2/7). 
 
 86
This year for the first time we have got a decent amount for, in the budget, for 
resources, for education. Yeah, because, the service  manager feels that they 
are actually changing the way they are thinking, that they can’t concentrate on, 
solely on the bottom line, or they can, but its going to be a smaller bottom 
line.(F/23/36). 
 
I guess, you know I have made a big change to leave an organization a number 
of years ago, because I couldn’t work with the values of the organization. I think 
you reach a certain point in your leadership role where you have to work in an 
organization where the values are consistent with your own; otherwise you just 
can’t work in that organization. And I made that decision having been part of 
very big picture leadership decisions that had been made, and I felt more and 
more uncomfortable about the money that was being spent to create a vision, 
the lack of kind of connectedness to the community and what was really offered 
to the community, and also the way in which people were being talked about in 
terms of widgets.(G/14-15/43-44). 
 
 
 
4.6 BEING AND BECOMING NURSING LEADERS 
This conceptual category describes  a transform a t i o n dimens io n , and 
various elements evident in transfo rmation, as it relates to the 
experience of and outcomes for ethica l conf lict for nurse managers. The 
transformation of nurse managers to nurse leaders is not a blunt 
instrument, nor is it about different roles or levels of nursing pr actice. 
Rather , Being and Becoming Nursing Leaders is an evolving career 
long process where reflection, learni ng , growth, motivati o n and counting 
the costs of nursing leadership ar e experienced. One of the early 
memos written by the researcher during data analysis provided a vision 
of nursing professional s who were on different  roads of the same 
journey of moral and prof ess i o n a l develop m e n t :  
 
A couple of things have spru ng to  mind listening to all the 
tapes and reading all the transcripts together. First of all, 
everyone is on a different road, but on the same journey. 
 87
Secondly, they have all changed over time and experience, 
not just from their nursing mana gement roles, but also from 
their clinical nursing experiences, and in particular when they 
were engaged in moral dilemmas . (Researc h e r di ary memo - 
May, 2007) . 
 
 
Whilst it was evident that some of t he participants identified distinctions 
between the terms nurse manager and nur se leader, a constant factor 
was the way in whic h their nursing career s and experience of ethical 
conflicts had contribut ed to their dev elopm e n t as nursing leaders. In the 
following extract the participant has described an ethic al conflict and its 
meaning and influenc e simultaneously.  
 
Yes, I think if there was one example when I was thinking through what you 
might ask me there was one clinical ethical conflict when I was very early on as 
a professional. When I was working permanent night shift on an area, there was 
a doctor whose practise I didn’t feel comfortable with, and I had been to 
management and said I felt this person was not following things up and was 
neglectful. There was this one patient, a young chap, he deteriorated on my shift 
and then the next day I came on and still nobody had really done anything about 
it. On the third day I came in early, because I felt something was wrong, and 
went in and he was on the verge of arresting and dying. And I was then left with 
this huge dilemma as to what to do. I had already notified management and they 
had done nothing about it in terms of my concerns about this doctors’ safety, 
and, they didn’t want to deal with it.  I was at such a dilemma as to what to do, I 
nearly left nursing at that time. (G/13/37). 
 
 
The first theme in this conceptual cat egory is that of reflection on the 
experience of ethical conflict. 
 
I felt quite undermined; I actually went away and thought why am I doing this 
job?....because if I don’t have a remit to actually go and make these decisions 
on behalf of the nurses, then what am I employed to do? It really makes you sit 
 88
down and think, what is my job? And that happens quite a lot in health and I 
have certainly faced that quite a lot in my life.(B/4/15). 
 
...twelve months from removing myself from the team, to me stating okay I’m 
ready for another role, these are the sorts of roles I’m interested in...huge 
damage, in terms of self doubt really, about whether I could have done things 
differently, which I probably could have...there was an awful lot of reflection on 
my part. (D/16/43). 
 
 
Reflection can also pr ovide a foundat ion for career motivation and moral 
develop m e n t . Motivat i o n was therefo r e not confine d to being a nurse 
manager, but also has its origins from  earlier parts of nursing careers. 
 
I made an active decision to stay because I thought if I am a relatively strong 
person in terms of my beliefs about things if I can’t deal with it, how on earth 
would my colleagues deal with it. I needed to stay so I can change it. And that’s 
been, I made an active decision to stay because I was on the verge of going. If 
managements not prepared to deal with poor practice that actually kills patients 
then how can I work in an organization in a profession that doesn’t feel like it can 
make a difference? And so I actively changed it, and what I changed, I went 
back onto that same ward as a charge person, and actively created the 
opportunity, where people could speak out about poor practice.(G/1/-38). 
 
 
Learning from their experiences of  ethical conflict was a repeated 
express ion of these participants; indeed “ there is no etiquette book that 
tells you how to manage these circumstances” (G/12/35). Learning 
other managers, important  process e s , techniq u e s , lessons , and about 
themselves is an im port a n t part of Being and Becoming Nursing 
Leaders. 
 
A positive might be that you learn to work the system. And that you actually 
learn to be subtle in your approach. I’m a very direct person and that does not 
go down generally very well. I find it difficult to couch things in nice round soft 
terms and tend to go to the heart of the matter. (B/5/16-17) 
 89
 It was about; it was more about learning individuals, and learning how to speak 
in a way that they wanted to hear things. It was more about learning how to read 
other peoples styles and use those styles to get what you wanted. (H/6/13). 
 
I think any nurse who’s looking to go forwards in their career, obviously we all 
learn from experience, and part of the reflective thinking is to reflect on an 
experience and learn from it...So I learnt from every experience. (E/4/7). 
 
 
Where there was learning, whether from an ethical conflict or the role of 
nurse manager more generally, there was als o identificat ion by 
participants of their personal and professional growth. 
 
 As I’ve said, I’ve actually grown with this job. (F/23/35). 
 
I learnt a hell of a lot out of it, I’ve grown as a person and more confident in what 
I do. When I’m not really stressed out and I can see the trees out there...I’ve got 
a lot of confidence now, and its made me also think about nursing and 
management and where do I want to go with it, its made me look at my career 
and future more clearly too. (C/5/29). 
 
 I mean I still get very emotional about it. But would I do it again, absolutely. 
Would I do it slightly differently? Possibly. I’ve learnt from what I went through, 
and hindsight is a wonderful thing. Would I hope it to change the outcome? No. 
No I wouldn’t. I think I make better decisions because of what I have been 
through and hopefully so would of that doctor. (D/18/50). 
 
 
The final theme describes the proc ess and experienc e of counting the 
costs of nursing leaders hip. The participants paid the cost of detrime n t 
to their health and well-being includi ng stress and burnout, as well as 
physical and psychological pain.   
 
One of the struggles is you’re fighting on the inside and your fighting on the 
outside. I have said to a lot of people, there is only so much time you can do 
that...because you do burn out. (B/19/51). 
 
 90
I can actually see an awful lot of wins from the pain that I went through with that 
team.(D/18/49) 
 
That I hadn’t realized the difficulty, the constant weight on my shoulders, you 
know its like,  because every minute of the day was in an advocacy role because 
they were, they were, such a disparate group, and they just needed such strong 
advocacy.(E/16/36). 
 
 
Nonetheles s, the participants were awar e of the costs they paid for their 
efforts as nursing adv ocates and leaders. 
 
Because there is a cost to leadership. The cost of leadership is massive and I 
think, people don’t always realize it, they think its exciting to be a leader. It is, but 
I think it’s also, there is a cost. (G/19/58).  
 
Now, I lost power, relationships, kudos, respect, dignity, everything within that 
whole group... So, even though they might have thought that it was unjustified, 
they were beholden to stay supportive to their colleague, which I could 
understand, I didn’t like, but I had an understanding of them and I can 
understand where they are coming from.(E/6-7/12-13). 
 
I guess the one thing that I am really aware of and we have already touched on 
it is that there is a personal cost. I think particularly for nurses, I can’t speak for 
non-nursing. (H/13/31). 
 
 
Despite the costs, the participants descr ibed persistence in their nursing 
manageme n t careers, at times in the same health care organization that 
had caused them a degree of pain: 
 
Part of my healing for me, was that I decided to go back into mental health in a 
different role...and I felt I needed to do that for my healing and I think it was very 
worth while. (D/16/45). 
I just sort of realized how lonely my job is....I know that I m not liked down their 
now, by the senior managers.... And I thought if that is what its like at that 
level, then I don’t want to be at that level. I want to be where I am, even though 
 91
it’s hard and it does what it does to you, I prefer that to being up there . 
(C/8/40/41 ). 
 
I guess its this thing again I feel that I have an opportunity because of the 
position I hold in the organization, and one of the projects that I have been 
tasked with is designing a primary care model. I see that as an opportunity and 
in there I will be able to make the statement about how patient care is utilized. 
They may not listen to what I have to say, but I have the opportunity to put the 
case forward, bringing in all of those issues that I have mentioned. (D/26/63). 
 
 
 
4.7 SUMMARY OF DATA ANALYSIS 
W h i l s t for the most part the Health Care Organization was experi e n c e d 
and described as par ticular management personnel, in particular roles, 
it also enc ompas s e s manageme n t struct ures such as general, clinical, 
governanc e and nur sing. As well, the Health Care Organization was 
described as systems and processes, including policy making, decision-
making and funding systems and proc es ses. The participants also 
experienced conflict with the profit  based business dimensions, as well 
as cultural dimensions of the health care organization, such as bully ing 
and medic alization.  
 
The conc eptual category of Nursing Management Advocacy describes 
the experience of nurse manager’s ethical conflict with their health care 
organizations through its integrati on of a variety of conceptual, 
descrip t i v e and themati c finding s . The partici p a n t s in this study 
described both duality and fusi on of nursing and health care 
organization values. Their descriptions and experiences of ethical 
conflict concerne d either unique circ umstances, or were part of the 
everyday activities and responsibi lities of their nurs ing management 
roles. Nurse manager s identified and then advocated for quality nursing 
and patient care, the value of teams, the value of professional nursing 
and safety in the health care or ganization. This conceptual category 
 92
also fuses the particular values which clas hed with those of the healt h 
care organization and the role components of nurse managers. 
 
The conceptual category of Isolation e n c a p s u l a t e s the major factors that 
worsened the exper ience of ethical conf lict for these participants. 
Isolation concerns the themes and proce sse s of silencing, inv isib ility, 
isolation and barriers that impeded,  and weakened the ability of the 
nurse manager to advocate and prac t i c e accor d i n g to  their nursi n g 
values. In contrast, the conceptual category of Support describes those 
factors that improved the nurse manager ’s experience of ethical conflict 
with their health car e organiz a tion.  The key sources and for m s of 
support which the particip a n t s exper ienced were personal, profes siona l 
and organizational. 
 
The Bottom Line is a conceptual category wh ich involved the pro cesses 
of challenging and confront ing, either the nurse manager ’ s or the health 
care organization’s stance on a parti cular or broad ethical conflict. It 
also describes when the nurse manager  established their personal and 
professional bottom-line about an ethica l conflict, or context of ethical 
conflict, from which they might decide to leave the organization, or stay 
and work with it in order to try and im prov e it. Lastly, this conc eptual 
category describes cir cumstances when the bottom line position that the 
health organiz a t i o n took, was not actually the bo ttom line, and there was 
change or the possibility of change as a consequenc e of the challenge 
and advoc acy that the nurse manager undertoo k . 
 
Being and Becoming Nursing Leaders c o n c e p t u a l i z e s career long 
experiences of ethical conflict in nursing, as well as the outcomes of 
ethical conflic t describ e d by the particip a n t s . The themes of reflect i o n , 
motivation, growth and learning describe how nurse managers changed 
from their experience. Counting the costs of nursing leadership reflects 
the negativ e outcomes of their experi ences, including the detriment to 
 93
personal health and well-being, as well as the negative impact on their 
professional standing and respec t. 
 94
CHAPTER 5 – DISCUSSION  
 
The objective of this chapter is to  provide a comprehensive disc ussion 
of the findings from data analysis highlighting the ways in whic h this 
qualitat i v e descript i v e study, enhanc es or challenges existing 
knowledge and understandi ng of the experience of nurse managers ’ 
ethical conflict with their health ca re organizations. To achiev e this 
objective, the chapter reviews of each of the key concep t u a l catego r i e s , 
their themes and dimensions, provid ing comparison and contrast with 
the descriptive findings from th e foundation study by Gaudine and 
Beaton (2002). This chapter will al so explore dat a analys is findings 
alongs ide other key and relevant aspec ts of the literat ure presented in 
Chapter 2, and any ne w literatu r e salient to the discuss ion.  In particular 
this chapter will situate the study and its findings within the framewor k of 
reform that has marked implicat i ons on health care management, and 
the ways in which reform has impacted on the values of health care 
services and the ethical conflict  which nurs e managers’ experience. 
 
 
5.1 THE HEALTH CARE ORGANIZATION 
There is no comparat ive analytic finding in Gaudine and Beaton’s 
(2002) research to the ke y conceptual category of the  Health Care 
Organization. This may simply be because Gaudine and Beaton 
analyzed their data based on assumpti ons regarding who or what was 
the health care organization, or narrowed their coding and data analysis 
in such a way as to exc lude this conceptual finding. Nonetheles s , the 
present study identifi e s that the health care or ganization with whom and 
which nurs e manager s experienced ethica l confli c t is for the most part, 
concerned with non-clinic al general management personnel and 
structures. This finding is consist ent  with many aspect s of the literature 
that alluded to the dominant ro le that non-clin ical managers and 
management values now play in health care services (for example see, 
 95
Gower et al, 2003; Wells, 1999). Howe v er, medical staff, other nurses 
and nurse managers, such as the Director of Nursing, is also the health 
care organization with which the nurse manager experienced values 
clashes and ethical conflict. This finding suggests not only that the 
experience is truly values driven, but  also that the experience is about 
more than a clinic ian ve rsus management phenomenon. 
 
The identification of et hi cal conflict with gov ernanc e structures may well 
be a product of health system design in  New Zealand, where structures 
such as the Ministry of Health, DHB’s and PHO Boards oversee and 
influenc e health service delivery strategies and funding decisions on 
behalf of patient populati o n s . I ndividual nurse managers may not 
address these dimensions of the health care organization on an 
interpersonal professional  level. There is a c onsequent emphasis on the 
effectiveness of nursing exec utiv es and nursing organizations that work 
at these broader levels, to bring the values of nursing to the forefront on 
behalf of their nursing colleagues and pr ofession.   Perhaps most 
importantly, this finding highlights that individually, nurs e manager s may 
be persistently frustrated in their effo rts to ensure quality health services 
and nursing care, bec ause of the organi z at i o n a l distan c e from decisi o n 
or policy-making structure and process.  
 
Arguably this description also reflects  the devoluti o n and influenc e of 
public choice theory in health system management , as outlined in 
Chapter 2. For example the separation of int ere sts groups, like nur sing, 
from policy and fiscal decision makers such as the Ministry of Health, 
DHB’s or PHO Boar ds. To do so ensur es that decisions are apolitical 
and unfettered by the perspectives and needs of clin ical groups or 
professi o n s . Conseque n t l y , nurs e manager s experience, although may 
not always recognize, that broad fiscal decisions are designed to be 
beyond their influence as individua l professionals within the health 
syste m .  
 96
Nurse managers’ may also exper ience ethic al conflict with the systems, 
processes and culture of the Health Care Organization, and because of 
this, it may render the experienc e one where the nurse manager is 
unaware or unsure of what to address in order to find resolution. For 
example, when the values clash and ethical conflict concerns a culture 
of medical bully ing, it requires cultural and behavioral change in the 
Health Care Organization , and not merely interpersonal address and 
change. It seems that even though a healt h care organization might 
espouse the values of respect and t eamwork in their employees, they 
may not in some instances be ac tua l i z e d via inte rp r o f e s si o n a l 
relat io n s h ip s . 
 
Organizational culture relates to the assumptions, values, attitudes, and belie fs 
that are shared among significant groups within an organization...culture is 
conc er n ed with the common and accepted ways of doing things within an 
organiza t i o n as well as the shared ways of thinking about and making sense of 
an organization that percolate among it s member s (Davi es , Manni o n , Jaco bs , 
Powell & Marshall, 2007, p.47). 
 
 
The relationship bet ween organizati onal culture an d organizational 
performance, in particular senior management team culture in health 
care, was investigat ed by Davies, Mannion, Jacobs, Powell and 
Marshall (2007). This study found that  there was a strong correla t i o n 
between the dominant culture of an organization and its performance 
and more specifically t hat those aspects of performance valued by the 
dominant culture are those aspects at which an organization excels 
(Davies et al., 2007). Hence, if health  care organizations value medicine 
over nursing and endorse medica l bullies, the organizations 
performance may well reflect the exal ted attrition of nurses from its 
service s . Likewis e , if a health car e organization values more greatly the 
need to stay within tight fiscal constrai n t s , in contra s t to growing quality 
and effectiveness, they may well succeed. However this may be at 
 97
greater cost in the l ong term, arising from the constant demand to 
recruit new nurses who may invariabl y leave that organization. It is a 
conundrum that is validated by a severe world wide shortage of nurses 
(International Counc il of Nurs es, 2006; Buchanan & Calman, 2006; 
Heinz, 2004). 
 
At the very least, this conceptual category has demonst rated that the 
experience of nurse managers’ ethica l conflict with their healt h care 
organizations may be deeply and system atically entrenc hed in health 
care organizational culture and design along with hum an and 
professi o n a l relation s h i p s , which ar e in constant ethical tension. 
Furthermore, it is not difficult to posit  that this tension is devolve d from 
the whole of New Zealand’s health  care system and its complex quarter 
century of reform which has focus ed on reducing the burden of health 
care spending on the fiscal resour ces of the state. 
 
 
5.2 NURSING MANAGEMENT ADVOCACY  
There is no thematic comparison to duality and fus ion of values in 
Gaudine and Beaton’s ( 2002) findings, however their report does list 
that “...hospitals stated values (e.g . integrity; consultation) ar e not 
upheld by administration an d board” (p. 22). It may be a consequ e n c e of 
that study’s participant s providing only descriptions of values differences 
and clashes. Or, alternatively, it may be a consequenc e of more intense 
socialization to the health care  organization’s values and the 
expectation that they will be m anifested and practised in the New 
Zealand context.  
 
This dimension rais es concerns about how nurse managers may 
effectively balanc e competing values. For example, how may a nurse 
manager ensure that they remain wit hin their ward or service budgets 
and be fisc ally responsible, whils t at  the same time ensuring appr opriate 
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clinical nursing education to ens ur e the appropriate quality of nursing 
practice? Where a nurse manager r educes education for nurses in his 
or her service, it may appear to the nursin g teams they lead, that they 
have forsake n their basic nursing va lues. This perception, introduced 
and discus s e d in Chapter 2 (Kellen et al, 2004) is partly a produc t of the 
different contextually driven ethi cal frameworks which inform nurse 
managers and practis ing clinic al nurses, such as staff nurses. Kellen, et 
al (2004) propose that staff nurse s and nurse managers therefore need 
to engage in learning and dialogue about thei r differ i n g ethica l 
obligations and perspectives, and how  the se influenc e their dec isions 
and actions. Whilst this strategy may not completely abrogate the 
tension s that exist, it may go some way in reassuring clinical nur ses of 
their nurse managers’ values. 
 
Likewise this dimension also highli ghts whether and how the health care 
organization ensures that its practi ce is values congruent – how it 
ensures that it ‘walks the talk’ of  teamwork, collabor ation and patient 
focus, for example. As with the different ethical perspec t i v e s and 
obligations of staff nurses and nurse managers noted above, general 
managers and CEO’s may unquestiona bly have dif f erent and even 
broader values to appease. However not  all the values clashes at this 
level of the health car e organiza t i o n are concerned with the alloc ation of 
scarce resources. As this research has  demonstrated, failure to consult, 
or failure to respect the contrib u t i ons of different professional groups 
and teams in health care organizations, is equally concerned with 
respectful and inc lusive decision-making process, rather than a  mere 
monetary decision.  
 
The theme of advocacy is an im portant  one, which transcended much of 
the participants’ interviews. Whilst there is no comparat i v e theme to 
advocacy in the foundation study, one example of the outco m es of 
ethical conflict in Gaudine and Beat on ’ s (2002) rep ort includ e d when 
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nurse managers spok e out. Indeed the major theme of voicelessness 
which aros e from Gaudine and Beaton’ s (2002) res earch , tends to reflect 
an opposit e experience to the theme of advocacy . That the nurse 
managers in this study engaged in strong advocac y for their values, 
suggests that they found such positions morally and personally 
prefera b l e and tolerab l e in their re lati o n s with other staff. Again in 
contrast to the perception that  nurse managers had abandone d basic 
nursing values (Kellen, et al, 2004), the theme of advocacy and other 
findings in the present study such as invisi b i l i t y , sugges t that they may 
not have.  
 
Advocacy involves standing up for what one believes in, for self or for 
others (Allen, 1990), and in nursing is  a process most commonly aimed 
at promoting client independence and autonomy (McGrath, Holewa & 
McGrath, 2006). The nursing advocat e role “...is to become actively 
involv ed in representing the patient  to others in the health care 
environment” (McGrath, et al., 2006,  p395). Yet as previous ly noted in 
the review of the liter ature, advocacy may carry with it the risk of 
professional retribut ion and burnout for nurses (Sundin-Huard & Fahy, 
1998).  
 
There are also some similarities bet ween the theme of advocacy in this 
study, to the concepts of ethical activis m , assertiveness, ethical 
resistance and the enactment of ethical practice in nursing, that were 
introduced in the literature review (D odd et al., 2004; Peter et al., 2004).  
The finding of Nursing Management Advocacy a r i s i n g from this study 
reinfor c e s the inheren c y in the nursi ng prof ess i o n to speak out, stand up 
and resist things that they perceive or believe are morally wrong. In 
doing so however, nurse managers may be taking employment and 
profess i o n a l risks that make them extreme l y vulnera b l e , whilst at the 
same time contribu t i n g to their mora l development as nursing leaders. 
 
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Valuing professional nursi ng, and advocating for suc h, may be a result 
of the ways in which the nursing prof ession has struggled to maintain its 
integrity and effectiveness throughout rapid reform, repeated 
restructuring and its aftermath in Ne w Zealand. This study found that 
nurse managers advocated for professional nursing for a variety of 
reasons, such as providing innovative and effective care delivery in 
developing primary health care services or in response to medical 
bully ing. This theme also concer ned the professional developm ent of 
clinical nurses, and ens uring the appropr iate pr ofessional attitude in 
nursing teams in order to deliver the right care to the pa tient at the right 
time. This strong focus on conflicts concerning the val ue of the nursing 
profession is also evident in G audine and Beaton’s (2002) work for 
example , “...sev e r a l partici p a n t s be lieved that adminis trators did not 
want to understand nurses and did not  intend to act on nurses’ needs” 
(p23) and also in that st udy’s theme of voicelessness whic h identified 
that nursing is not val ued or understood. Si milarl y , the study by Gaudine 
and Thorne (2000) identifi e d that practi sing clinical nurses experienced 
an underv aluing of nursing by the health care organization when 
compared to the medical profession. 
 
This study has identified that advoc ating for professional nursing was 
also one of the social responses to medical bully ing.  Yet it was also 
evidenc ed in this study that the health care organization might choose 
to ignore medical bully ing behav iors and culture towards nursing. Whilst 
there is no particular evidence of  medical bullying in Gaudine and 
Beaton’ s (2002) report, they do identify that opi nions of physicians are 
more valued than those of nurses in the theme of situational factors 
which wors en ethical conflicts. The f oundati o n study also identifi e d that 
the organization may fail to act even when aware of problems in the 
theme of unjust practices on the part of senior administration and or the 
organization.  
 
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There is certainly awareness of the prev alence of bully ing in health care 
organizations both in medicine and nur sing specifically (Field, 2003; 
Hutchinson, Vickers, Jackson & Wilkes, 2006; Lewis , 2006; Randle, 
2003).  Bullying behav ior in organizations  is describ e d as a detaile d and 
complex issue that has been linked to  the concept of  oppressed group 
behavio r (Hutchi n s o n et al., 2006) with bullies being highly articulate, 
and mostly aware of what they ar e doing (Lewis, 2006). The most 
probable reason for bully ing behavior is  that it is learned within the 
workplace and with this the reinfo rcement of the dominant norms of 
bully ing behavior in the organiz ational  workplace, particularly healt h 
care organizations (Hutchinson et al., 2006; Lewis, 2006).  Needham 
(2003) likewise suggests t hat bullyin g in the workpla c e occurs because 
“...leadership and management of the organization is allowing it to 
happen” (pg, 18). 
 
This analyt ic finding therefore hi ghlights the dominan ce, and particular 
bully ing behaviors of the dominance of the medical pr ofession in health 
care, as well as portraying the social cons equences of this dominance 
for the nurse managers who experi ence it. Introduced in Chapter 2, 
Carryer (2001) identified that pr ofessional nursing and its potent i a l 
contribution to healt h care ha s been neatly appr opriated by both 
medical resistance to autonomous nur sing practice, and the systematic 
erosion of clinical nur sing leadership wrought by managerialism. 
Consequ e n t l y , the experie n c e of bu lly ing of nursing managers that is 
featured in this study may be the resu lt of the complex interplay of a 
vulnerable and oppr essed prof ession  practicing wit hin a culture of 
health care that reinforces the do minance of medicin e and of generic 
managem e n t practic e s . 
 
It may also be argued, that nursing and indeed medicine represent the 
professi o n a l i s a t i o n and institutionalization of healt h care, in contra s t to 
indiv idual, family or community  driven health car e. Perhaps the 
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undervaluing of the nursi ng profession is a means by which the health 
care organiza t i o n , and to an extent the healt h care system as a whole, 
sets one profession against anot her; enabling one seemingly powerful 
and influential group (medicine) to dom inate the other seemingly less 
powerful group (nursing), avoiding recognition of the dominanc e of 
managerialsim culture altogether . This  phenomenon shifts emphasis, 
knowingly or otherwise, fr om publicly funded profe ssional health care, to 
personally responsible hea lth care  by way of disease or illness 
prevention for which indivi d u a l societ y member s ta ke responsibility. To 
do so would undoubtedly contribute to cost containment in the public 
funding of health economies.  
 
Some of the confli c t ex perie n c e d by partici p a n t s in the foundation study 
described the health care organizations  failure to value quality nursing 
practic e (Gaudin e & Beaton, 2002). Given the evidenc e outline d in the 
literature that links the quality of nursing practice with patient outcomes 
(for example, Aiken, Cla rke & Sloane, 2000) it is therefore not surprising 
that the nurse managers in the current study described rigorous pursuit 
of this value. A manifestation of the ethical principle of beneficence, 
quality nursing practice is an im perative for nursing managers who 
would be accountable for when the nur sing care delivered in their 
respective services is not of an  appropriate quality, and poor patient 
outcomes result.   
 
Emphasis on the value of quality nursing practice ident ified in this study 
could be considered a manifestation the tension betw een egalitarianism 
and neoliberalism, and the ways in which this tension devolves to the 
health care organization and ser vice level. Nurses and nurse managers 
may therefore be seen to embody t he inher ent tensions between limited 
resources and achiev ing quality nur sing practice; doing as much as 
possible within a limited budget. At l east as far as the descript i o n s in 
this study have revealed, when this tension is no longer personally or 
 103
professionally accept able to individual nurse managers, the Bottom Line 
may be experienced. 
 
Advocati n g for quality patient care  extends the nurse managers’  
experience of ethical conflict, beyond nursing pr actice, to other 
professions and the health care organi zatio ns’ activities as a complex 
whole, for example when redes igning a health servic e. It also places 
patient and community health needs central to the activities of the 
organization and is an im portant nursing value. This  finding is indicative 
of nationa l policy direc t ives which lin k healt h care servi c e activity more 
closely wit h the health needs of t he patients and communities . That 
nurse manager’s experience conflict based on advoc ating for quality of 
patient care reveals a broader l ens on the organization and a strong 
socialization to health policy and qualit y management practices. 
Gaudine and Beaton (2002) refer similarly to the sacrificing of quality , in 
the theme of where to spend the money , for example when nurse 
managers sacrifice qualit y patient care when there are ins ufficient 
resources to achieve it. Patient and com m unity stakeholders may be 
surprised and disappointed by decisions which healt h care 
organizations make that may ultimately  lower the quality of patient care 
they receive. Yet another layer of va lues and ethical frameworks is at 
play; those of patients and community at  lar ge. It might at least ease the 
experience of ethical conflict for t he nurse manager, if not raise public 
awaren e s s , if the Chief Execut i v e Offi ce r , or Board Chairm a n , has made 
public and demons t r a t e s accoun t a b i l i t y for decis ions at this lev e l, that 
may ultimately impact on or reduce the quality of patient care.   
 
The theme of valuin g teams and advocati n g for them demonstr a t e s 
nurse managers understandi n g of teams as a key socia l struct u r e 
necessary for meeting the objectives of the health care organization. 
When teams and their members are not  valued by the healt h care 
organization, it may not achieve its full potentia l as well as result in the 
 104
loss of valuable people and knowledge to the health care organiz ation. 
Failure to value teams in health care  organiz ations is also contradictory 
to the stated emphasis it received in the health care organiz ational 
values outlined in the literature revi ew . It is thus unders t a n d a b l e that the 
nurse manager not only values teams and what teams can do, but also 
the process of engaging them in rele vant decision-making processes in 
the health care organization. There is no equivalent them atic finding or 
substantive description to valu ing teams in Gaudine and Beaton’s 
(2002) findings and report. 
 
Likewise, there is no equivalent in t he foundat i o n study of the theme of 
safety; however there is referenc e to uns afe patient care in Gaudine 
and Beaton’s (2002) list of factors t hat worsen nurse managers’ ethical 
conflict wit h their health care organiza tions . There is also reference in 
their theme of rights of the individual vers us needs of the organization 
which favors the legal position of the health care organization over 
indiv idual employees (Gaudine & Beaton, 2002) . This theme, safety, is 
a reflection of the do no harm ethical princ i ple of nonmaleficenc e which 
underscores health care professional pr actice. In many respects nurse 
managers have no choice but to advocat e for safe practice and patient 
care – their professional ethics an d legal res ponsib ilities demand it.  
 
Currie and Watterson (2007) explain t hat patient safety is a prominent 
issue in health care services in the Unit ed Kingdom. In particular, 
nurses in the United Kingdom st ress how inappropriate nursing 
workloads effects patient safety (Curri e & Watters o n , 2007) and as 
presented in Chapter 2, this problem has a direct relationship to patient 
outcomes alongs ide staff satisfaction and morale. Nurses who work at 
the ‘sharp end’ or caring interface, are more capable of articulating the 
challenges in delivering safe patient care (Currie & Watterson, 2007). 
Improving the safety of patients receiv ing health care requires a cultural 
 105
change in the health care organiz ation that includes the prioritization of 
safety over efficiency (C urrie & Watterson, 2007).  
 
Likewise, the most recent multiemplo y e r contrac t for registe r e d nurses 
and midwives in New Zealand, emphas iz es the requirement for safe 
staffing and healthy workplaces , and a number of activities designed to 
achieve this requirement (New Z ealand Nurses Organization, 2007).  
The finding of advocating for safety ar ising from this study is therefor e a 
confirmation of the role that nurse managers play in pursuing safety, for 
nursing st aff in particular, in thei r working env ironm e n t s and in the 
broader context of the health care organizat ion. 
 
 
5.3 ISOLATION  
Isolation is an important social experience for nurse managers, whic h 
contrasts to the expectation that  health care organizations foster 
openness, collaborat ion and respect for its member’s opin ions and 
contributions. It is also evidenc e t hat patient focused and professional 
nursing values may not find their way into the decision- making 
processes of the healt h care organiza t i o n . Moreover , the study findings 
allude to deliberate isolation practi ces on the part of the health care 
organization, almost as if it was im portant to prohibit  the nurse manager 
from participating in decision-making.  
 
A possible microcosm of public choice  theory, this conceptual category 
is an important va lidation of Gaudine and Be aton’s (2002) research 
finding of learning to remain silent . Isolating the nurs e manager thus 
isolates the values for which they  stand and in so doing may mean that 
the health care organization is not in touch with the patients’ health care 
needs, and the nurses who must meet these needs.  The exper ience of 
Isolation described in this study may al so be a consequence of reform 
 106
activities where restructuring of health care organizations has removed 
vital nursing leadership structures. 
 
Employment as a barrier is highli ghted in Gaudin e and Beaton’s (2002) 
study and report which is entitled ‘Employed to go against ones values : 
Nurse managers’ acc ounts of ethical conflict with their organizations’. 
As the title suggest s, the nurse managers in the foundation study 
reported practice that was incons ist ent with their values , whereas in the 
present study, nurse managers practic ed consistent with their values, 
but did so with cogniz ance of the em ployment risks and isolation. Whilst 
the participants in the present  study did not experience voicelessness , a 
theme in the foundation study, their advocac y may have been silence d 
and in a sense made voiceless and isolated as a result. The theme of 
invis ibility in the present study is also similar to Gaudine and Beaton’s 
(2002) finding that nurse managers ma y be hired to be both invisible 
and ‘toe the party line’.  
 
The conceptu a l finding of Isolation aris ing from this study, sheds light on 
the social dimensions of employ m ent; including that  nurse managers 
may self impose isolatio n , for exampl e by keeping secrets or invisible 
practice. Participants were awar e that they were taking risks in their 
advocacy which could have detrimen t a l  consequenc es such as job loss. 
Isolation when managing ethic al c onflicts , both by the health care 
organization and self imposed was noted in the literature review to be a 
possible consequenc e of ethical c onflict when the manager was not 
supported (Lemieux-Charles & Hall, 1997). 
 
Isolation is a critical finding aris ing fr om this study that describes a 
social reality and experience related to reform of the health care system 
that may contribute to burn-out and loss of nurse managers not only 
from the health care organization but also the profession. Perha ps too, 
the experience of Isolation is a symptom of workplace bully ing. 
 107
There is a responsibility to be s hared amongst nursing leaders and their 
general management and medical counter parts to ensure that nurse 
managers are not isolated in their work, and that their contribution is 
valued. As highlighted by Gaudine and Beaton (2002) bringing nurse 
managers, nurses, board members and other administrators together is 
important  action required to ens ure that decision mak i ng process es are 
more visible , and structu r e d in a way that allows all pa rties a voic e and 
respect. Failure to do so not only risks the loss of valuable nursing 
professi o n a l s , but also risks mi ssing ess ential com m unications about 
the implications of decisions and  change on nursing practice and the 
patient . 
 
 
5.4 SUPPORT  
The major factor which made the expe rience of ethical conflict easier for 
the nurse manager was Support .  This factor was re levant not only in 
relation to the ethical conflicts themse lv e s , but also in relation to the 
nurse managers’ role performance gener ally. The key forms of support 
identifi e d from data analy sis were family, professi o n a l and 
organiz a t i o n a l . If family members are assumi n g or needin g to assume 
such a supportive role, it indicates how much the experience of ethical 
conflict and the nurse manager s’ job, impact on their social life. Whilst it 
is understandable that family support o ccurs, it is perhaps a burden that 
is not justifiable. Therefore nur se manager s do not necessarily leave 
ethical conflict work issues at work  and the result may be that it 
consumes far more of the nurse  managers’ personal energy than it 
deserves which in turn may result in an unhealthy work-life imbalance 
and burn-out. 
 
Consistent with the recommendations from the study by Thorpe and Loo 
(2003), that it is essential for nu rse managers to maintain a healthy 
professional and personal life bal ance, this finding has two key 
 108
implications. Firstly that relianc e on t he support of family may be a result 
of lack of support from others, such as nursing collea gues. Secondly, it 
suggests that nurse managers have assumed positions that have 
unsustainable workloads, and hence r equire s careful conside r a t i o n of 
whether this will result not only in  an ineffective nurse manager, but a 
deeply overburdened nursing professional who may inv ariably bur n-out 
and give up their work. 
 
It is pleasing to identif y within this  study, that other nurse managers and 
the health care organization may be supp ortive in the midst or in the 
aftermath of ethical conflict. Although support may not negate the 
experiences and consequences of Isolation in its totality, this findin g 
suggests a degree of understanding , and need to provide nurse 
managers with professional su ppor t in the face of, and in the aftermath 
of ethical conflict. The findings from  Gaudine and Beat on’s (2002) study 
like wise identify the theme of support as a key factor which mitigates 
ethical conf lict.  
 
One of the aims of this study wa s to identify what may be done to 
reduce the outcomes of ethical conflict for nurse managers. This 
research finding has clearly identified that provision of support is a key 
factor in reducing burn-out and attr ition of nurse managers. Alongside 
this, stronger nursing leadership st ructures and performance will enable 
the values of the profession to manife s t in the key system s and 
processes which impact  on the services which nurse managers accept 
immediate responsibility for.  
 
 
5.5 THE BOTTOM LINE  
Other than pointing out an example that nurse managers’ wor k with a 
limited am ount of money, and that one of the outcomes of ethical 
conflict may be that nurse manager s leav e their jobs, there is no 
 109
comparative theme to t he conceptual category of the Bottom Line  in the 
foundation study (Gaudine and Beat on, 2002). The bottom line is a 
metaphor which in business and accountancy parlance conc erns an 
organizations sustainable financ ia l performance (Pav a, 2007; Waddock 
& Graves, 1997). The term and its focu s on financial performance has 
more recently been expanded to ‘the triple bottom line’ which includes 
social and environmental performanc e (an organizations people and the 
planet) in order to achieve market or business sustainability  (Li-Chin & 
Taylor, 2007; Norman & MacDonald, 2004; Pava, 2007; Wadd ock & 
Graves, 1997).  
 
The Bottom Line experience revealed in the current study, reflects as a 
starting point, the presence and c hallenge for nurse managers’ of 
financial sustainability in t heir health care organizations. Howev er, if the 
major factor driving health care organi z a t i o n s is financi a l sustain a b i l i t y , 
this study has shown that a consequenc e may be that it does not 
sustain its nurses and nursing m anag ers. Secondly, from the 
perspective that nursing contributes to achieving health servic e goals 
and improved healt h outcomes for populations, this finding also 
demonstrations that the health ca re organ i z a t i o n may not meet the 
social needs of t he patients and community they serve.  
 
Financ ial sustainab ilit y cannot therefor e be the ultimate measure or 
yardstick of performance for health care organiza t i o n s ; a triple bottom-
line framework is undoubtedly essential, at a funding, policy, 
organizational and service level. New Zealand’s public health system 
may well be free to its citizens, but  the quality of services that is 
provided may not nec essarily be of an acc eptable standard within the 
communities of the health professi ons and patient s. Indeed in the 
opinion of the present Chief Executive Officer of Counties Manukau 
District Health Board, “...managing t he quality of care  of the acute 
patient, is more importan t that  the bottom line” (Martin, 2008).  
 110
 
Use of the bottom line metaphor in  some of the participants’ 
descriptions is surely and indication of the way in which the language of 
neoliberalis m and business has transcended the social and professional 
dialogue of health care organiz ations . Whether it is was being used 
rhetorically or factually by the par ticipants in this st udy cannot be 
shown. Notwithstandi n g , continue d emphasis on polic ies of cost 
constraint in New Zealand’s health sector, has been clearly revealed in 
the social experiences portrayed by the participants in this study.  
 
Professional nursing is founded on the values of human caring and 
morality, clinica l exce llenc e and co mpete n c e , as well as soc ial and 
community responsibility. Yet this  concept ual category demonstrates 
that nurse manager s may experienc e a profes s i o n a l contex t and 
relationships that are deeply troublin g and ethically conflicting. On the 
one hand they endeavor to function with  financial lim itat ions and ensure 
that they have utiliz ed their resource s efficiently and ar e accounta ble for 
this. On the other hand, to do so may invariably lead to circumstances 
where the quality of nursing prac tice and  patient care is not saf e or is 
not of a standard necessary to meet patient needs effectively. In this 
study therefore, the bo ttom line has also bec ome a social experience. 
 
The descriptions capt ured by this category provide an indication that 
when nurse manager s can not tolerate their experie n c e s of ethical 
conflict that they would leave the organi zation. This is also an im portant 
indic ation that moral distress was evi dent in the experiences that were 
provided, as well as validat i o n that ethical conflic t may have the 
consequence of loss of nurses fr om the organization. This finding 
reinforces the need for health car e or ganiz ations to actively address the 
impact that ethical conflict has on indiv iduals such as nurse managers. 
 
 
 111
5.6 BEING AND BECOMING NURSING LEADERS  
Gaudine and Beaton (2002)  highlight learning as a factor which 
mitigates ethical conflict, and ident ify turnover, burnout and negative 
feelings as possible outcomes to  their experien c e . Even though 
participants in the present study were enabled to describe the outcomes 
of ethical conflict as it pertained to  patients, staff and the health care 
organiz a t i o n , they did not directl y  do so and tended to focus on the 
personal and professional outcome s for themselves. This may be 
attribu t a b l e to lack of compreh e n s i ve knowledge of wh at these br oader 
outcome s sets might actuall y be, or re lated to fear that revealing these 
matters was not appropri a t e .  
 
The five key themes of this categor y – reflection, learning, motivation, 
growth and counting the costs of nursing leader s h i p have a 
transformational dimension that concerns not merely nursing 
management, but also career long expe rience of the moral dimensions 
of nursing practice. Because of this , the category implies that ethic a l 
conflict changes and develops nurs es; from nurses, to managers and to 
leaders in their profession. Analogous ly, the study by Woods (1997), 
pointed out enduring career  long ethical develop m e n t in nurses, and 
Nathaniel (2006) similarly identifies that moral distress is a long term 
and ongoing process which traverses m any stages of nurses’ careers.  
 
The costs of nursing leadersh ip identified in this study included physical, 
and psychological costs and have a consistency with the concept of 
moral distress. Gaudine and Beaton (2002 ) similarly identified that their 
participants experienc ed moral distress.   As previously explored by 
Arlen (2001, 2001a, 2002, 2004), moral distress is pervasive in nursing. 
The vital message from this finding is  that nurse managers suffer on a 
personal level for their patient s, professi o n and st aff. Whether this 
experie n c e is recogni z e d or underst ood by health care organiz ations is 
a matter that may only be addressed by further strong advocac y from 
 112
the profession, alongs ide conc erted effo rts on the part of the health care 
organization to mitigate the caus es and ens ure provision of support for 
those who experienc e it. This c onceptual category, and the earlier 
finding that at times the health care or ganizations bottom line did 
change, highlights that  nurse managers who ar e transformed into 
nursing leaders by ethical conflict, may also ethically transform the 
health care organizations in whic h they practice.  
 
At least a decade ago, Soffarel i and Brown (1998) explained that 
professional nursing required more than competent, organiz ing, rational 
nursing managers to survive in the r apidly changing world of health 
care. Rather, what was required,  in their opinion, was nursing 
leadership and nursing le ader s, able to transform health services 
through a focus on empowering people (Soffarelli & Brown, 1998). The 
nurse leader of the new millenn i u m would need to focus on people and 
valuing those people, challenging the status quo, and demonstrating 
high ly ethical behavior (Sofare lli & Bro w n, 1998).  Thus, alt houg h 
manageme nt skills such as plan ning and control are important, it is 
nursing leadership which will shape th e future of health care. This 
conceptual category attests not only to these proposi t i o n s , but also 
challenges managerialism and the notion that m anagement is a function 
that is the same regardless of the organiz ation or persons to which it 
relates (Wells, 1999). 
 113
CHAPTER 6 - CONCLUSIONS AND IMPLICATIONS 
 
 
I wish to conclud e this thesis in the manner in whic h it began in the 
introductory chapter; by writing in the first person, and by responding to 
the questions that I pondered from my experience as a nurse manager 
in New Zealand, namely:  
 
• Why was there so much confli c t in nursing manageme n t and 
was it always a question of fiscal limits? 
• Were the organization’s values  consistent with professional 
nursing? 
• Why did I not feel suppor ted and who should have been 
supporting me in my nursing management role? 
 
As well, I will set out what I believe are the key research, education, 
nursing management and health  care organization implications from this 
study. 
 
 
The Study and its Findings 
My own experience as a nurs e manager in New Zealan d was an 
important motivation for this research . In this study I have inves t igated 
nurse managers’ ethical conflicts wit h their health care organiz ations, 
and have done so by rep licating a qualitative and desc r iptive Canadian 
study (Gaudine & Beaton,  2002). My investigat ion of the social 
experience of eight New Zealand nur se managers was aimed at gaining 
a deeper understanding of  and enhanc e existi n g bu t limited knowledge 
of values differences or clashe s between nurse managers’ and their 
health care organiz a t i o n s that result in ethical conflict.  
 
Nurse managers experience et hical c onflict because of the duality of 
professional and organiza tional values that their roles encompass. It 
 114
h a s also identif i e d that nurse  managers are immersed in a 
contemporary context with fiscal lim its and management practices and 
objecti v e s which challen g e and at time s defeat both of these valu e sets. 
The participants in this study revealed  that the values whic h underpin 
their ethic al conflicts with the heal th car e organiz a tion concern: the 
valuing of their nursing profession; the need for and pursuit of quality in 
nursing practice; the pursuit of qualit y patient care; the valuing of teams 
in the health care organiz a t i o n ; and safety. I can attest to the 
importan c e of and pursuit of these values in my own practic e and the 
persist e n t feeling that I was no t valued by my nursing manag ement 
colleagues and general managers. 
 
This study has also revealed that whilst the values of nurse managers 
and health care organiza t i o n s do diffe r and clash in some respects, they 
may also be shared. Thus, when the health care organization does not 
practice according to its values, nurse managers respond by advo cating 
for those shared values. As I reflec t again on my experience, I can now 
identify the failure of the health care organiz ation to act in congruence 
with its stated values. Rather, they  had become very much rhetoric. 
 
Because nurse managers are advocates who are strongly influ enced by 
professional values, it brings them int o conf lict with a number of 
dimensions and people in the health care organization such as non-
clinical managers, other health care professionals such as medicine, 
other nurses, as well as the le ss tangible systems, processes and 
culture of the organiz at ion. The advocacy proce ss may be impaired by 
the isolatio n which nurs e managers’ experience.  At times the nurse 
managers’ isolation may be a consequenc e of organ iz ational structure, 
and cultur e , or it may be a deliberate soc ial res pons e to a situation, 
such as failure by the health care organization to include the nurse 
manager in importa n t or relevan t decis ion-making. When experiencing 
ethical conflict , nurse managers need and sometime s receive support 
 115
from their families, friends, other  nurses and nurse managers or non-
clin i c a l managers . Support is an importa n t factor which mitiga t e s or 
improves the experience of et hica l conflict which nurse managers 
encounte r . I know now that I was sever ely isolated in my nursing 
management work and did not receiv e the support that I needed from 
my colleagues, both nur sing and general management. 
 
When confronting and challenging the health car e organiz ations’ 
bottom-lines, such as fiscal limits,  professiona l group preferences or 
inappropriate processes of decis ion making, the nurse manager may in 
turn encoun t e r their own botto m line. As a consequ e n c e nurse 
managers may leave their jobs for other nursing work, or other health 
care organizations. I see now that  I also left my first nursing 
management role for all these reasons  and that this experience has 
been shared by other nurse managers. 
 
A continuation of moral experiences  throughout their careers, values 
clashes and ethical conflict transforms nurse managers to nurse 
leaders, who may in turn have an impac t on the ethical life of the health 
care organization. Nursing managem ent advocacy should theref ore be 
seen is an important if not vital contribution to the ethical dev elopment 
of the healt h care organization; givi ng subs tan c e and expecta t i o n to the 
values which the health care organization espouses. 
 
It is evident that some of the nurse managers in this study described 
experiences consistent with the conc ep t of moral distre s s , for exampl e 
when they experienced physical and psych ological suf f ering, barriers to 
their participation in decision making, or social is olation in their roles . 
Certainly not all of nursing management ethical conflict issues may be 
easily or effectively resolved, however the ability to raise the issues and 
advocate in a meaningful way, with strong support  from colleagues, is 
necessary in order to prevent nurse managers suffering the 
 116
c o n s e q u e n c e s of moral distress . In my  own way, despite leaving my first 
nursing management role, undertaking this research is part of my own 
professional and pers onal ethical transfor m a t i o n . 
 
Research Limitations and Implications 
R e c o g n i z i n g that the strengt h s of qualit at i v e research rest in the 
identificatio n of meaning, insight and conce ptual deve l opment, I was still 
somewhat disappointed that eight month s of recruiting endeavors only 
provided eight participants for this resear ch. I have considered that 
perhaps even though anony mity wa s assured for prospective 
participants , given the findings in this study, there were risks in 
‘revealing’, that other prospective participants were not prepared to 
take.  Further possible reasons for the low number of participants might 
be that nurse managers are generally too busy to participate, or they 
would prefer not to dwell on that which already causes them great 
anxiety and that they cannot fix. It may also be the case that many 
prospec t i v e nurse manager s do not expe rience ethical conflict or do not 
recognize that this is the case. No netheless, the findings from this 
research coupled with many key similari ties to the descriptive findings in 
Gaudine and Beaton’s (2002) study, and multiple insights identified in 
the literature review, mean that so me conceptual generalis ability is 
appropriate, particularly concerning the values at issue, alongside the 
themes of advocacy, is olatio n , and support.  
 
I have noted in Chapter 3 that the term nurse manager was used 
functionally in the recrui t m e n t proces s , rather th at in a role or title 
specific manner. Bec ause nurse manager s work at differe n t structu r a l 
and influential levels of health care organizations, it may have 
implications for the findings from this research. For example, nurse 
managers practice in different clinic al, operational or strategic levels, 
and there may be different experienc es for those who are perhaps 
practicing further up the nursing m anageme n t hierarch y . In this regard 
 117
f u t u r e researc h could examine and c ontrast the experiences of ethical 
conflict that nurse managers hav e when they are situated at different 
hierarchical levels of the health care organization, or have diff erent 
levels of fiscal account ability. 
 
Other future research implicated by this study is an examination of the 
health car e organiz a tions infrastruc ture, with a view to iden tifying 
communications, decision-making and support mechanisms or barriers 
for nurse managers . Another area fo r future resear c h is nursin g 
managers in primary health car e. T here were three managers in this 
study who practiced in primary health ca re, and it is relevant to consider 
how this different health sector context implicates nurse managers’ 
experie n c e s of ethical conflic t . Future  research could also examine the 
extent to which health care organizations act ually ‘wa lk their value s talk’ 
or whether espoused values are simp ly rhetoric and not practised.  
 
Since bully ing of nurs e manager s in the health care organization was 
highlighted by this study, in partic ular by their medical counterparts, 
there is undoubtedly a need to invest igate this experience and its 
prevalence more closely. In particula r future research should examine 
bully ing and its relationship to the experi e n c e of ethica l confli c t and 
moral distress in health care organizati o n s . Future research could als o 
explore power group culture and behavio rs in health care organiz ations 
and the possible experiences of oppressi on in different professional or 
organizational groupings more specifically. 
 
Education 
Health serv ice managers who do not or iginate from a clinical profession, 
have much to learn in regard to heal th professional values, inc luding 
how and why these ar e mani fest and critical to an effective health care 
organization. In a ver y real sens e,  the nurs e manager s’ descriptions in 
this study gave context to values in health care manageme n t . Clinical 
 118
p r o f e s s i o n a l manage r s , such as nurse managers, also need to learn 
that perhaps their general ma nagement peers lack knowledge and 
understanding of the values   upon which clinicians practice. General 
Managers may themselves be unabl e to influenc e improvements 
beyond the scopes of their fiscal resour ces. The implications of this 
however, rest unequiv ocally at a health  system funding and policy level.  
 
I am conscious that nursing has it s own share of nurses who bully, 
however, there is als o further organiza t i o n a l learning needed to address 
organizational culture and its relations hip to the social experience of 
bully ing.  Education, which has as its focus, respect between and 
amongst professional groups is a vital st ep, necess ary for achieving 
substantive change in a culture of bullying which may be present and 
very destructive in health care organizations. 
 
I have considered why it may be that health care organizations may not 
act in congrue n c e with their stat es val ues . Firstl y , it ma y be an individu a l 
problem of lack of knowledge of these values; consequently education 
is implic ated. Secondly, it may be a problem of implementation. In this 
regard, the learning is perhaps about  how a health care organization 
manifests or operationaliz es its val ues. Some learning needs to be 
contextu a l i z e d in order for it to make sense to a learner. Finally, it may 
be an issue of chosen ignoranc e. This thesis itself perhaps will provide 
a valuable learning tool to address this. 
 
Nursing Management Implications 
This study has helped to identify that  values clashes and ethical conflict 
may well be an inevit able occurrenc e in nursing management practice 
and perhaps answer s the question of why I personally experienced so 
much conflict in my own nursing management role. A key implication for 
nurse managers, is not to feel as though it is a personal and negative 
experience. Rather that  the experience is part of an organization wide 
 119
ethical dev elopment process, withi n whic h the nurse managers play an 
important role in the development of an ethically sound health care 
organiz a t i o n . The second major implica t i o n for nursing managem e n t 
practice is the need to enhance peer and pr ofe ssional support for nurse 
managers, for example by ensuring t hat nurse managers are able to 
articulate their values and ethical conflict experiences with other nurse 
managers , includin g other more s enior nursing managers. A third 
nursing management implication and closel y related to the second is the 
need to evaluate nursing and general management infrastructure for 
elements that may exac erbate the experience of isolation. Nurse 
managers with appropriate and effective support wi ll have some of the 
effects of ethical conflict mitigated.  
 
Health Care Organization Implications 
Rather than silenc ing nur se managers who advocate,  or placing barriers 
in the way of their participation in dec ision-making, health care 
organizations must recogniz e that nurse managers’ represent the 
values of quality nursing practic e and patient care and safety. These 
views and values are essential to the achievement of the health care 
organizations objectives. This is not  to say that others do not bring 
these view points forward, but to em phasize that nursing is driven by its 
patient focused values, and to ignore them is to risk ignoring patient 
needs. 
 
Since this study has described that nurse managers may play a critical 
role in the ethical dev elopment and soundne s s of health care service s , 
there is a need to evaluat e organiza t i o n a l structur e and cultur e, and the 
ways in which these may impair nur sing management advocacy. Failure 
to do so may result in the cont inued and unnec essary attrition of 
valuable nursing leaders from the health care organization and 
profession as well as the values which they demonstr ate the willingness 
and ability to represent. 
 120
                                         APPENDICES 
 
 
 
        Appendix I:     Invitation to particip ate in research distributed 
                         by the Nurs ing Council of New Zealand   
        Appendix II:    Invitation to partic ipate in researched listed 
                        on College of Nurses Aotearoa website  
Appendix III:  Research Information Sheet  
Appendix IV:  Participant Consent Form  
        Appendix V:   Biogra phical & Professional Data Collection Form                   
Appendix VI:  Interview Schedule 
 121
                                                 APPENDIX I 
 
                          DEPARTMENT O  
 Privat e Bag 11 222 
 Palmers t o n Nort h 
 Ne w Ze aland 
 Telepho n e : 64 6 356 9099 
 Facsim i l e : 64 6 350 5661 
 
AN INVITATION TO PARTICIPATE IN RESEARCH - 
NURSE MANAGE RS’ ETHICAL CONF LICT WITH THEIR HEALT H 
CARE ORGANIZATIONS 
 
DEAR COLLEAGUE, 
• It is my pleasure to invite you to participate in this qualitative research, 
concerning Nurse Managers’ ethical conf lict with their health care 
organizations. My name is Linda Chalmer s, and I am a RGON currently 
studyin g for a Master in Management (Health Service Management) at 
Massey University; this research pr oject fulfils part of this degree. 
 
• The resear c h aims at gener ating inc r eased knowledge and 
understanding of the phenom enon that is of im portance to Nurse 
Managers, the nursing profession,  and other key healt h care 
stakeho l d e r s . 
 
• Approximately 15 participants will be selected for the project who will 
be registered nurses with the Nursing Council of New Zealand, hold a 
current practising certif icate and have at least one years experience as 
a Nurse Manager (or analogous title) in  the last 5 year s within the New 
Zealand health sector. 
 
• Collection of data is by way of completion of a brief written 
questionnaire and per sonal tape recor ded interview. The next round of 
interviews will be conducted from July to October 2006. 
 
• Should you wish to have further in formation regarding the research, or 
you wish to participate, please phone or email the researcher Linda 
Chalmers: Email: l.chalmers@inspire.net.nz  Phone: (09) 276 5844. 
 
• Ethics appr oval – this project has been reviewed and approved by the 
Massey University Human Ethics Co mmittee Southern A: Application 
06/17. If you have any concerns about the conduct of this research, 
please con t act Dr Joh n O’Ne ill, Chai r, Mas sey Univer sity Human Ethics 
Committee:  Southern A, telephone (06) 350 5799 x 8635, email 
humanethicssoutha@massey.ac.nz . 
 
• This invitat ion as been sent with the kind assistance of the Nur sing 
Counc il of New Zealand; no personal information or contact details have 
been revealed to the researcher in this undertaking. 
 122
APPENDIX II 
 
                                                                                                                                 Priv ate Bag 11 222 
                                                                                                                                 Pal mers t o n Nor th 
                                                                                                                                 New Zealan d . 
Teleph o n e : 64 6 356 9099 x2777                                                                            Tel epho n e : 64 6 35 6 9 099 
Facsim i l e : 64 6 350 5661                                                                                         Fac s imi l e : 646  350 5661                                                
 
AN INVITATION TO PARTICIPATE IN RESEARCH - 
NURSE MANAGE RS’ ETHICAL CONF LICT WITH THEIR HEALT H 
CARE ORGANIZATIONS 
DEA R COLLEAGUE, 
• It is my pleasure to invite you to participate in this qualitative research, 
concerning Nurse Managers’ ethical conf lict with their health care 
organizations. My name is Linda Chalmer s, and I am a RGON currently 
studyin g part time for a Master  in Management (Health Service 
Managem e n t ) at Massey Univers i t y ; this researc h project fulfils part of 
this degree . 
 
• The resear c h aims at gener ating inc r eased knowledge and 
understanding of the phenom enon that is of im portance to Nurse 
Managers, the nursing profession,  and other key healt h care 
stakeho l d e r s . 
 
• Up to 15 participants will be se lected for the project who will be 
registered nurses wit h the Nursing Council of New Zealand, hold a 
current practising certif icate and have at least one years experience as 
a Nurse Manager (or analogous title) in  the last 5 year s within the New 
Zealand health sector. 
 
• Collection of data is by way of completion of a brief written 
questio n n a i r e and persona l tape recor de d intervi e w , the second round 
of which will be conduc ted from September to December 2006. 
 
• Should you wish to have further in formation regarding the research, or 
you wish to participate, please phone or email the researcher Linda 
Chalmers: Email: l.chalmers@inspire.net.nz  Phone: (09) 276 5844. 
 
• Ethics appr oval – this project has been reviewed and approved by the 
Massey University Human Ethics Co mmittee Southern A: Application 
06/17. If you have any concerns about the conduct of this research, 
please con t act Dr Joh n O’Ne ill, Chai r, Mas sey Univer sity Human Ethics 
Committee:  Southern A, telephone (06) 350 5799 x 8635, email 
humanethicssoutha@massey.ac.nz . 
 
• This invitat ion as been establis hed on this webs ite with the kind 
assistance of the College of Nur ses Aotear oa; no personal infor m ation 
or contact details have been reveal ed to the researcher in this 
undertaking. The College of Nurses  Aotearo a is not a part of the 
research project other than to assist with recruitm e n t . 
 123
APPENDIX III   
 
         Private Bag 11 222                                                          
                                                                Pal mers t o n North 
                                                                                                                      New Zealan d                                                                               
New Ze alan d .                                                                                                Telepho n e : 64 6 356  90 99 
                                                                                                                      Facsimi l e : 6 46 350 566 1 
                                                                                                                 
 
NURSE MANAGERS’ ETHICAL CONFLICT WITH THEIR HEALTH 
CARE ORGANIZATIONS RESEARCH PROJECT 
 
INFORMATION SHEET 
 
Researcher Introduction 
T h a n k you for your interest in this propos e d resear c h projec t . I am Linda 
Chalmers, a Registered General & Ob stetric Nurse who is currentl y a 
full time tertiary student completi ng a Master of Management (Healt h 
Service Management) through the Depar tment of Management, College 
of Business , Massey Universi t y .  
 
This qualitative research project ai ms at describ i n g the experie n c e s of 
Nurse Managers’ et hical conflict with their health care organizations, 
and replicates a study undertaken in C anada in 2002. The findings from 
this research will facilitate growth  in both knowle dge and understandin g 
of the phenomenon that is of im portance not only for the nursing 
profession but to other stakehol ders in the health sector. 
 
P a r t i c i p a n t Recruitm e n t 
Participant s have been recruited wit h the support and assistance of two 
professi o n a l nursing bodies in New Zealand. Approximately 15 
participants will be selected for study who will meet the following criteria: 
• Current registration with the Nursing Counc il of New Zealand 
• Current practising certificate issued by the Nursing Council of New 
Zealand 
• At least 1 year experience as  a nursing manager in a primary, 
secondary or tertiary health care organization 
 
Whilst there may be benefits for you associated with reflections on 
ethical nursing management  practi c e , it may be possib l e that you 
experience some psy chological distre ss arising from your recollections 
and reflections of ethical conflict. If this occurs, then measures will be 
suggested to help you to cope with this distress. 
 
Participant s should be aware that t he disc losure of information during 
interviews that relates to an illeg al or unla wful act, may under certain 
circums t a n c e s be subject to refe rral to the appropriate legal or 
disciplinary entity. 
 
 124
Should you choose to be a partici pant in this research you may be 
reimbursed for the reasonable cost of travel whic h you incur to attend 
the research interviews. 
 
Project Procedures 
• You will be invited to complete a brief written bio graphica l and 
profession al questio nnaire tha t will gat her information requ ired to 
broadly describe the biograph ic al and prof essional ch aracteristics of the 
study group.  
• You will be invited to attend a personal interview with me lasting 
approximately 60-90 minutes. The inte rvie w will be tape recorded . The 
key questio ns that you will be ask ed dur ing the intervie w will inclu de: 
 
i) Describe any ethical conflict yo u have had with your health care 
organization in your role as a Nurse Manager. 
ii) Describe the factors that eased the conflict. 
iii) Describe the factors that worsened the conflict. 
iv) Describe the personal, profe ssional and organizational outcomes 
resultin g from that conflict . 
 
• The tape recording of our interview will later be transcr i b e d to written 
form by myself. This transcript will be posted to you for verification prior 
to data analysis. 
• All data gathered from interviews or  the written quest ionnaire will be 
treated with confiden t i a l i t y . Each partic ip a n t will be referred to 
throughout the project by pseudonym or  letter. Your name and any 
other identifiable data or materials will not be availa ble to anyone other 
than the researcher and the resear ch supervisors identified below. 
• A summary of the research will be m ade available to you at the end of 
the study. 
• A masters thesis will be written fr om the completed research and may 
be followed by academic papers, articles or conference materials. 
• Data or materials arising from the study will be maintained by the 
researcher in a sec u re place thr oughout the duration of the research 
project. Once the project is comple ted, research tapes  will be returned 
to you should you desire or will be securel y stored alongsi d e all other 
researc h materia l s arising from data  collect i o n and analysi s for a period 
of five years by the Department  of Management, Massey University 
Palmerston North. After this peri od these materials will be des t royed 
following usual research protocols. 
 
P a r t i c i p a n t s Rights 
You are under no obligation to accept this invitation. If you decide to 
participate, you have the right to: 
• Decline to answer any particular question 
• Withdraw from the study 
• Ask any questions about the study at any time during participation 
 125
• Provide inf ormation on the underst anding that your name will not be 
used unles s you give permission to the researcher 
• Be given access to a summary of  the project findings when it is 
concluded 
• Ask for the audio tape to be turned o ff at any time during the interview 
 
 
Thank you for your interes t in this researc h project and for taking the 
time to read this informa t i o n sheet. If you would lik e to take part in this 
research, or you would like to discuss your participation in more detail, 
please contact me by phone or email at  first instance using the following 
contact details: 
Linda M Chalmers 
Ph (09) 276 5844 
Email: l.chalmers@inspire.net.nz 
 
S h o u l d you need to, you may also cont act the following res earch 
supervi s o r s : 
• Dr Craig Prichard (Senior Lecturer) 
      Departm ent of Management  
      Ph (06) 3569099 Ext 2244 
• Dr Denise Wilson (Senior Lectu rer in Nursing/Albany Campus 
      Co-ordin a t o r ) 
School of Health Sciences 
           Ph (09) 414 0800 Ext 9070 
 
Ethics Approval 
This projec t has been reviewed an ap proved by the Massey Univ ersi t y 
Human Ethics Committee:  Southern A,  Application 06/17. If you have 
any concerns about the conduct of this research , please contact Dr 
John O’Neill, Chair, Massey Univ ersity Human Ethics Committee:  
Southern A, telephone (06) 350 5799 x 8635, email 
humanethicssoutha@massey.ac.nz . 
 
 126
  
APPENDIX IV 
                                                                                  
DEPARTMENT OF MANAGEME 
 Privat e Bag 11 222 
 Palmers t o n Nort h 
 Ne w Ze aland 
 Telepho n e : 64 6 356 
9099 Facsi m i l e : 64 6 350 5661 
 
  
 
NURSE MANAGE RS’ ETHICAL CO NFLICT WITH THEIR  
HEALTH CARE ORGANIZATIONS 
 
PARTICIP ANT CONSENT FORM 
This cons ent form will be held for a period  of five (5) years by the Department of 
Managemen t, College of Busine ss, Massey Univer sity, Palmerston North. 
 
 
 
I have read the Information Sheet and have had the details of the study 
explain e d to me. My  questions have been answer ed to my satisfaction, 
and I understand that I may ask fu rther questio n s at any time. 
 
I agree/do not agree to the in terview being audio taped. 
 
I wish/do not wish to have my tapes returned to me. 
 
I am aware that disclosure of information during interviews that relates 
to an illegal or unlawful act, may under  certain circumstances be subject 
to referral to the appropriate legal or disciplinary entity. 
 
I agree to participate in this study  under the conditions set out in the 
Informa t i o n Sheet. 
 
 
Signature: ……………………………………………. 
Date:… … … … … … … … … … . . 
 
Full Name – printed: 
…………………………………………………………………… 
 
 
 
 
 
 
 127
APPENDIX V 
 
 P r i v a t e Bag 11 222 
 Palmers t o n Nort h 
 Ne w Ze aland 
 Telepho n e : 64 6 356 
9099 Facsi m i l e : 64 6 350 5661. 
 
  
Nurse Man agers Ethical  Confli ct with their 
 Health Care Organizations 
 Biographical and Professional Data of Research Participants 
 
Dear Research Participant, 
Thank you for volunteering to participate in this research project and for 
providing me with your written informed consent to do so. Please 
complete the following biographical and professional data collection 
form, and return to the researcher on the day of your personal interview. 
The information will be utilized to broadly describe the biographical and 
professional characteristics of the group of participants under study. 
Please be assured that any unique characteristics that my identify you 
or your employer will not be included in data analysis, the research 
report or any other research publication. If you have any questions or 
concerns about this data collection form or any other aspect of the 
research please do not hesitate to contact me.  
 
Thank you. 
 
 
 
Linda M Chalmers. 
 
 
(Please complete the form using a biro). 
1. Title of your current nursing position and area of practice: 
.................................................................................................  
(position will not be reported). 
 
2.  Gender: (please specify).............................. 
 
3.  Age (tick ; one box): Under 30 years  …       31 - 40 years  …       
 41- 50 years  …      Over 51 years    …   
 
4.  Nursing Qualification(s) (tick;  one or more boxes):  
 RGON    …                  R Comp Nurse    …                Diploma of Nursing       
…                                    Bachelor of Nursing     …      Other (please 
specify)……………………………… 
 
 
 128
5. Other completed tertiary qualifications (tick;  one or more boxes): 
Bachelors Degree             …   (please specify 
type)………………………… 
Post graduate certificate   …   (please specify 
type)………………………… 
Post graduate diploma      …   (please specify 
type)………………………… 
Masters Degree                …   (please specify 
type)………………………... 
Other       (please specify)................................................ 
 
6. Please specify any tertiary qualifications that you are currently 
enrolled in and working towards......................................................... 
 
7.  How many years in total have you practiced as a registered nurse 
(tick;  one box): 
 Under 5 years     …              6-10 years      …                    11-15 years    
…                 
 16-20 years        …              21-25 years    …                    26-30 years     
… 
 31-35 years       …               36-40 years     …                  Over 40 years  
… 
 
8.  Please list the Nurse Manager positions you have held, including any 
currently held, the areas of nursing practice of those positions, and how 
long you have held or had held that position (e.g. - Charge Nurse 
Manager, Critical Care, 3 years 6 months; Team Leader, Medical 
Nursing, 2 years)( you need only specify your  last 3 different Nurse 
Manager positions):  
 i) Title:..................................Area of practice:......................Years 
held:...... 
ii) Title:..................................Area of practice:......................Years 
held:...... 
iii)Title:..................................Area of practice:.......................Years 
held:..... 
  
9.  Please specify the total number of years experience you have as a 
Nurse Manager:............        
 
 129
                               APPENDIX VI   
 
Private Bag 11 222                                                                                 Private Bag 11 222 
 Palmers t o n Nort h 
 Ne w Ze aland 
 Telepho n e : 64 6 356 9099 
 Facsim i l e : 64 6 350 5661 
 
  
 
  
 
 
NURSE MANAGE RS ETHICAL CO NFLICT WITH THEIR  
HEALTH CARE ORGANIZATIONS 
 
INTERVIE W SCHEDULE 
 
Participant s will be interviewed ut iliz ing a semi-structured and an open-
ended method based on the following four questions: 
 
1).Describe any ethical conflict y ou have or have had with your health 
care organization in your role as a Nurse Manager. 
2) Describe the factors that eased the conflict. 
3) Describe the factors that worsened the conflict. 
4) Describe the personal, profe ssional and organizational outcomes 
resultin g from that conflict . 
 
The definition of ethical conflict pr ovided for participants if required will 
be: 
• Any situation where the nurse managers’ val ues differed from or 
clashed with those of the health care organization and the nurse 
manager experienced conf lict as a result (Gaudine & Beaton, 2002). 
 
Gaudine, A. P., & Beaton, M.R. (2002). Employed to go agains t one’s 
values: Nurse managers’ accounts of ethical conflict with their 
organizations. Canadian Journal of Nursing Research, 34, (2):17-34 . 
 130
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