Academic nursing leadership in the U.S.: a case study of competition, compromise and moral courage
International Journal for Educational Integrity volume 15, Article number: 8 (2019)
Public, private, non-profit and for-profit nursing education enterprises in the U.S. are competing with one another in a newly complex and volatile educational landscape, placing academic leaders into situations fraught with moral, ethical and legal compromise with few precedents for guidance. This case study provides a richly contextualized narrative exploration of ethical and legal challenges to one leader’s moral courage, a fictionalized exploration drawn from multiple sources over time, to form a composite that is nonetheless firmly rooted in the complexity and competitiveness characteristic of nursing education today. Our purpose is three-fold: 1) to direct the reader to moral and ethical questions that require thoughtful discourse and analysis among current and future academic nursing leaders; 2) to raise the issue of the need for regulations and oversight that reflect the changing realities of today’s increasingly complex and competitive educational arena; and 3) to encourage nursing education leaders to share additional cases that resonate for them, and in so doing, to expand the wellspring of ideas from which we can all draw in becoming more effective and morally courageous leaders.
Public, private, non-profit and for-profit nursing education enterprises in the U.S. are competing with one another in a newly complex and volatile educational landscape, placing academic leaders into situations fraught with moral, ethical and legal compromise with few precedents to guide them (Bellack 2015; National Council of State Boards of Nursing 2016a; Pardue et al. 2018). This landscape includes a proliferation in the number and types of organizations providing nursing education, such as stand-alone for-profit nursing programs, for-profits integrated into allied health schools, nursing education enterprises that blur the lines between for-profit and non-profit, and more familiar nursing education programs that are part of non-profit public and private colleges or universities. Today’s academic nursing landscape also includes a widening expanse of educational approaches--hybrid, online, face-to-face, flipped classrooms, problem-based learning, and high and low-fidelity simulation education. In contrast, national accrediting organizations charged with educational oversight of this vital health profession have changed very little over the past several decades, making it difficult to uncover actual, let alone potential educational concerns (Dickeson 2006; Hooper et al. 2013; National Council of State Boards of Nursing 2016b).
At the center of this fray, academic nursing leaders are making decisions that have major ramifications on educational quality, the bottom-line financial picture of their academic organizations in the short term and, in the long term, the future of the nation’s most trusted profession (American Hospital Association 2018). Yet these same leaders have few sufficiently detailed narratives from which to draw, to better understand how today’s educational volatility threatens both individual and institutional integrity, let alone how best to respond. This case study is a response to that situation. It provides a richly contextualized narrative exploration of ethical and legal challenges to one leader’s moral courage, a fictionalized exploration drawn from multiple sources over time to form a composite that is firmly rooted in the complexity and competitiveness characteristic of nursing education today. Our purpose in presenting this case study is three-fold. First, it directs us to significant moral and ethical questions and issues that require thoughtful discourse and analysis among current and future academic nursing leaders. Second, it highlights the need for regulations and oversight that reflect the changing realities of today’s increasingly complex and competitive educational arena. And third, this case study encourages nursing education leaders to share cases that resonate for them, and in so doing, to expand the wellspring of ideas from which we can all draw in becoming more effective and morally courageous leaders.
Key ideas in this case study include morality, which is defined here as an individual’s own principles regarding right and wrong, the internal behavior guide known as our conscience. Ethics is viewed as more externally focused, referring to rules or principles provided by an external source, such as the Code of Ethics for Nurses (American Nurses Association 2015). Individuals will vary in the extent to which they internalize rules offered by an external source. Closely related to morality and ethics, the idea of moral courage emphasizes acting in accord with one’s conscience, despite the criticism and personal risk that give rise to moral distress. According to a recent analysis of moral courage, its seven core attributes are true presence, moral integrity, responsibility, honesty, advocacy, commitment and perseverance, and personal risk (Numminen et al. 2017).
Case study approach
A review of the literature provided little insight into nursing leadership involvement in actual dilemmas created by the “seismic changes” in contemporary U.S. nursing education, to borrow a descriptor from a recent study of risk taking among academic nursing leaders (Pardue et al. 2018). This is not surprising given the air of confidence expected of leaders; in-depth sharing of their ethical and legal concerns could threaten themselves and their institutions. We were forced instead to examine our own experiences and those around us, and to consider the use of a case study to explore and better understand salient leadership challenges. A case study approach offered several advantages in this exploration. Detailed cases provide a bridge between the world of ideas and conjecture and the world of practice (Kowalski 2012; Merseth 1997). In addition, case studies give readers the chance to grapple with problems that are set in specific, complicated settings that may be characterized by ambiguity and confounding information. As we also know from the classroom, case studies provide an invaluable opportunity to engage in shared problem solving (Fossey and Glover 2006). Finally, a fictional case that is grounded in reality—readers will judge for themselves the one presented here—opens the possibility of exploring challenging situations that would likely remain invisible in real life due to sensitive information.
The literature did provide useful insights into what constitutes a good case for exploring educational leadership. According to one scholar, such a case is “grounded upon some of the stubborn facts that must be faced in real life situations” (Barnes et al. 1994, p. 44). But these are not facts stripped bare of context or complexity, a pared-down version of an event. Indeed, this would not be reality, which more often than not is messy and uncertain. Two experts on the use of case studies in educational leadership list the following four elements as vital to a realistic and useful case: context, complexity, ambiguity, and relevance (Fossey and Crow 2011). Context is intended to provide the readers with all the background information needed to fully appreciate a specific problem and apply creative solutions. Complexity is a major feature of contemporary academic nursing leadership and encourages discussants to respond using multiple perspectives, understanding ambiguity, and thinking in more fluid and less static ways (Crow 2006; Weick 1978). Next, a good case is “full of ambiguity” (Fossey and Crow 2011), which is intended to imbue cases with enough ambiguity to ensure that solutions are not readily apparent; readers may even disagree on what the core issues really are. Last, a good case study presents an important problem with broad implications for readers, encouraging the clarification of personal and professional values and beliefs. The case study that follows was carefully constructed with each of these four elements in mind.
Setting and central character
The setting for this case is AimHighest University, a non-profit, comprehensive urban university with a combined undergraduate and graduate enrollment of 15,000 students. Enrollment is distributed across three campuses. AimHighest aspires to enter the top tier of research universities while at the same time adding two more campuses. To fund the new campuses, each of the eight university schools was charged with doubling enrollment in their school’s professional master’s programs. School administrators were given wide latitude in developing strategies for expanding graduate enrollment. The School of Nursing, with the approval of university leaders, sought to increase enrollment through partnership with a for-profit educational company, BizEd Enterprises. For an eventual share of 50% of graduate tuition revenue from supported programs, BizEd agreed to provide, as their CEO explained, “critical backroom support, including technical assistance, development of infrastructure and personnel services, to scale up enrollment in targeted programs and increase revenue.” “We’ll do whatever it takes to meet your needs,” the CEO emphasized, later adding, “Our name never needs to be mentioned outside AimHighest.”
The central character in this case study, Dr. N, is an experienced academic nursing leader. She is, however, new to AimHighest University and the School of Nursing, having just been recruited based on her experience in helping to elevate other academic nursing organizations over relatively short periods of time. Prior to her hire, Dr. N went through a lengthy interview process, which included three in-person university visits. At the time of her hire, however, she was unaware of nursing’s partnership with BizEd.
The pivotal crisis of Dr. N’s leadership career in academic nursing did not develop suddenly, nor emerge as a single event. Instead, it came to her awareness gradually, after months of exhaustive work sorting through a tangle of programs in advance of visits from national accrediting organizations to the School of Nursing at AimHighest University. The programs spanned two of the three university campuses, employed various teaching modalities and mixed the for-profit enterprise BizEd, which provided both support and leadership functions, with the not-for-profit university. This hybridization was viewed by university administrators as a method of gaining an edge on competitors through rapidly scaling up of nursing enrollments, thereby increasing revenue.
The joining of non-profit and for-profit at AimHighest occurred within a university described by one of Dr. N’s administrative colleagues as “highly risk tolerant.” Administrators were regularly encouraged to be daring in their plans to meet the strategic objectives of becoming an elite, global academic trendsetter while at the same time adding campuses and increasing graduate enrollment and overall revenue. The tension between such competing aims was most apparent for leaders in the university’s eight schools as each tried to balance enrollment and revenue targets with directives to admit more selective undergraduate classes and higher quality PhD students. Undergraduate and doctoral directives specifically targeted indices used for ranking universities nationally and globally by the U.S. News and World Report and were intended to garner both national and international recognition for AimHighest. Amidst the most daring plans proposed, the School of Nursing was focused on especially by university administrators as an ideal unit for expansion, given the steady interest of applicants and demand for graduates.
Leadership chose to disregard the potential problems with these conflicting ideas, particularly as they were to be operationalized in nursing. Within the School of Nursing a proposal was made to dramatically increase admissions into a master’s in nursing administration program that was barely surviving. This was not only intended to make up for more selective and lower undergraduate admissions, but to boost overall school enrollment and finances. At the time of the proposal just three students were enrolled in all the levels of this professional master’s program. The new plan would add an additional 220 enrollees per year. Yet the traditionally low participation in this master’s offering suggested major difficulties with this approach. Difficulties included an ongoing shortage of qualified faculty, significant limitations in essential clinical placements, and most important of all, a lack of qualified applicants with adequate nursing experience and interest in nursing administration. Enter BizEd Enterprises, which dismissed concerns about faculty, placements and student interest or experience. The company promised to solve these issues and, in exchange for the aforementioned portion of tuition dollars, to recruit hundreds of new students each year into the master’s in nursing administration program. This was exactly the kind of revenue-generating plan, in a tuition-driven organization like AimHighest, that university and certain School of Nursing leaders had hoped for.
Bait and switch
The bold new revenue-generating idea became a plan. The plan was summarily launched, approximately a year prior to the hiring of Dr. N. As described in the School of Nursing documents that Dr. N was now reviewing, however, the plan appeared not working and unworkable. Neither the graduate faculty nor the clinical placements were delivered and, as she eventually discovered, prospective students had little interest in or the prerequisite background for this graduate offering. Moreover, Dr. N learned in conversation and through additional written records that leadership realized from the outset that the plan could not work. It would only function as something described in consumer terms as a “bait and switch” scheme. The “bait” in this case was a graduate degree in nursing for individuals who had only a non-nursing degree, while the “switch” occurred with the awarding of a “pass-through” undergraduate nursing credential (an undergraduate degree awarded along one’s primary path to a graduate degree) even as it became clear that earning a graduate degree in this program would not be possible.
Such a plan “technically” allowed administrators to progress toward the goal of doubling graduate enrollment while admitting a more selective or elite undergraduate cohort. This scheme would have collapsed if the individuals involved at different levels had not given their tacit agreement. Nursing faculty raised few questions and provided little resistance since the school seemed to be “doing well,” according to one nursing professor. Indeed, a tangible effect of the influx of students was that funds for faculty development and travel, which were previously cut in a budget tightening move, were restored and eventually increased. Students, too, became complicit. Although some grumbled about not earning a master’s degree, they were appeased by the sought-after credential of Registered Nurse, along with the likelihood of well-paid employment. In addition, BizEd was the sole provider of advising for this “master’s program.” This meant that they were in a key position to help identify “problem students,” as those who raised concerns were called, and to quash concerns with thinly veiled suggestions that such students were unlikely to even complete undergraduate nursing education, let alone the advertised graduate degree.
Accrediting in the dark
National accreditors were none the wiser, despite their own document review and scheduled site visits to the School of Nursing, which included visits to just one of nursing’s three campus locations. Of course, much of what occurred in the accreditation visits revolved around the self-reports provided by the school. The reports from AimHighest’s School of Nursing appeared impeccable and accreditors praised the many successes that were highlighted in the report. They were unaware of any concerns related to the master’s in nursing administration program since potentially damaging information, that is, BizEd-related data, had been omitted.
In their defense, accreditors are generally spread thin. These had just two and a half days to review a myriad of programs spread across campuses within a complex school. Still, Dr. N wondered why none of the site visitors had connected the dramatic increase in graduate enrollment figures to the influx of students in one of the more unlikely offerings—she knew master’s in nursing administration programs typically had low numbers as compared with other master’s specialties such as family nurse practitioner programs. “Attrition” data seemed to have been overlooked or carefully hidden. Such data would have revealed that large numbers of students were failing to progress to the graduate degree for which they had been admitted. Perhaps more remarkable than keeping accreditors at bay from damaging data, Dr. N now thought, was that no one had broken ranks by raising any red flags during site visitor meetings with university and school administrators, faculty and students. The arrangement was a secret with many colluders.
As the pieces of this bait and switch scheme fell into place for Dr. N, her questions became more pointed to those who had set it in motion. She did not, however, consider contacting the accrediting body to correct the excellent accreditation report that the School of Nursing had received. No doubt, had she done so, the school’s accreditation and ability to continue functioning would have been jeopardized. Eventually, Dr. N’s persistent questions and expressions of concern made the master’s in nursing administration scheme the “elephant in the room” whenever she was in meetings with university and school administrators. The mounting tension and the concerns that she was raising were enough to cause a close colleague and administrator to pull Dr. N aside to tell her that she had “better stop turning over so many stones.”
Dr. N recalled the saying that the true test of one’s character is what one does when no one is watching. Accreditors did not seem to be watching, she thought, and her administrative colleagues and supervisors just seemed to want her to stop watching, and questioning. At barely a year into her position she was still a relatively new hire and the bait and switch scheme that was now uncovered predated her. Maybe she could just feign ignorance, she reasoned, when the scheme inevitably was widely exposed. At least, Dr. N believed it inevitable that it would eventually come to the attention of the wider nursing and university community, not to mention accreditors. This belief was highlighted by a comment from university counsel, during an otherwise chance meeting in which Dr. N’s concerns about the bait and switch were met with the blunt observation that “this is a class action suit waiting to happen.” The comment was a final push for Dr. N. Accreditors may have been fooled, but she realized that she could not morally or ethically hide from what she had found. She would need to take more decisive action.
Methodically inclined, even amid what she considered a moral crisis, Dr. N carefully weighed each action open to her. Fortunately, she had a close friend and colleague with whom she could confide and validate the conflicting thoughts and feelings she was having. Her friend agreed that Dr. N could not in good conscience pretend ignorance. She also helped to address the original financial problem at AimHighest by identifying work areas in which Dr. N still had some influence. This included proposing a new, alternate undergraduate program to satisfy at least some of the revenue concerns. Dr. N hoped that such an alternative would convince university and School of Nursing administrators to end graduate nursing’s bait and switch, and act in concert with the morals and ethics that she believed appropriate and legal. Reluctantly, the leadership team agreed to implement the undergraduate program even though such a move would likely be interpreted by college ranking services to mean that AimHighest was becoming less selective at the undergraduate level. The leaders balked, however, at Dr. N’s insistence that this alternate program should be quickly implemented and accompanied by an immediate ending of the deceptive graduate scheme. They equivocated with the moral choices to be made, agreeing to only “a gradual phasing in of the alternate undergraduate offering and an equally gradual phasing out of the program in question.” Moreover, university administrators called for strengthening of ties with BizEd through a contract extension. This felt to Dr. N like a reward to BizEd for its questionable actions, rather than a shift away from questionable behavior.
Although she appreciated her administrative colleague’s concerns about lost revenue and prestige, Dr. N was adamant that the ongoing ethical and legal infractions that underlay the master’s in nursing administration bait and switch required its immediate ending. What ensued was a standoff, with neither Dr. N nor those to whom she reported being willing to budge from their respective positions. Having resolved her personal moral crisis, Dr. N felt that, at best, she had only partially succeeded in resolving the crisis in its professional context. In her moral distress and struggle to find solutions, Dr. N found herself marginalized in the leadership structure. Administrative colleagues with whom she had worked so closely now kept her at a distance and most of her decision-making power was removed. Looking back Dr. N criticized herself for not anticipating this. It is a fact of life, she concluded, that individuals do not cheer those who point out their mistakes, especially ones with such weighty consequences. After all, any of them might have challenged the situation themselves but did not, thereby exposing their own values or lack thereof.
Unable to prevail, Dr. N considered possible remaining efforts. She contemplated continuing her battle with administrative colleagues, internally. But, she reasoned, this would most likely lead to further marginalization and no improvement in what she considered “only a partial fix of the problem.” And though contractual obligations made her termination unlikely, that was not an impossible outcome. She also considered escalating her concerns, taking them beyond AimHighest University and the School of Nursing, becoming an outside whistle-blower. Such actions, however, would have violated one of Dr. N’s core leadership values--to enrich and grow organizations and the individuals within them, rather than to diminish or harm them. After more than a week of soul-searching, Dr. N chose a different path altogether. She carefully crafted a resignation letter that outlined the egregious nature of the problem she had uncovered and the remediation steps that she believed must be taken—an immediate end to the offending program, swift and full implementation of the alternate program she had proposed, and curtailment of the university’s contract with BizEd. She also outlined the obstruction that she had encountered in arguing for and seeking to carry out these steps. Dr. N’s resignation letter was intended as a final emphatic message to university and school administrators to cease actions that, even if they as individuals felt unharmed by moral compromise, she believed tore at the ethical and legal fabric of an otherwise valued academic organization and the profession of nursing.
Some may be impatient with the detail in this case, wanting to “get to the point” as quickly as possible. But it is the complexity of the case, including details that alternately distract from or amplify aspects of the narrative, that make it particularly useful in exploring a values-laden issue. As in real life, Dr. N’s experience of being compromised as a moral agent--a common definition of moral distress (Varcoe et al. 2012)--involved complexity and ambiguity. The resulting uncertainty would have undoubtedly created discomfort for Dr. N, and to the extent the case reflects real tensions in nursing education leadership today, discomfort for readers as well. More than just an irritant, however, such feelings help lead us to compelling questions and issues to be explored.
Continuing from the viewpoint of Dr. N, yet appreciating the larger issues involved, key questions from this case include:
To what extent did Dr. N demonstrate moral courage in her academic leadership role? Could she have done more? Should she have done less?
Although AimHighest University was identified as a non-profit institution, its identity as private or public was unspecified. What difference, if any, might this distinction make?
What are the overall legal liabilities of this case from the viewpoint of a university or School of Nursing administrator who was involved?
“What is the harm here anyway?” is a critique raised with Dr. N by one of her colleagues. Students involved in the bait and switch, it could be argued, were getting just what they wanted and AimHighest and the School of Nursing were receiving much needed tuition revenue. What is the personal and professional risk of following such a path?
Dr. N put her career on the line in this case. Under what circumstances, if any, should other nursing education leaders decide to risk their career? What core values should guide their decision?
What does Dr. N’s experience suggest about the challenges of accreditation of educational organizations during a time of rapidly increasing and complex competition? What are the responsibilities of academic nursing leaders toward accrediting bodies?
What is at stake for nursing education leaders in a risk tolerant versus risk averse college or university?
The educational tensions at the core of this case also compel us to consider ethical frameworks that might offer some guidance in searching for answers to the above questions. To be sure, there are several frameworks that could be brought to bear in cases such as the one presented here. For instance, the social cognitive approach to moral courage (Bandura 2001) would suggest that moral courage is a function of whether Dr. N perceived her actions as an active producer rather than simply a product of an unfolding situation. Corley (2002) seems to take this a step further by identifying a series of mediating factors in ethical dilemmas, which in this case would focus on Dr. N’s level of commitment, sensitivity, autonomy, sense-making, judgment, conflict, competency, and certainty to interpret moral situations. From more of an organizational perspective, virtue theory (Murphy et al. 2007) as applied in some business settings would start with a question: What is the purpose of an enterprise such as AimHighest or BizEd? Virtue would then lie in following a morally sound path to building the overall enterprise.
And yet, none of these theories promises clear answers. Indeed, Varcoe et al. (2012) argue that the lack of theoretical clarity in research involving moral distress and moral courage hinders its application to policy, education and practice. In any event, a case such as this is intended to open a dialogue in search of answers to questions, rather than to offer pat solutions. It will ideally shed light on timely issues that are worthy of further analysis and discussion. For instance, in considering the first question above, one group of leaders may assert that purely from the point of view of moral courage, Dr. N should have blown the whistle loudly, not only internally, but externally too, to accrediting bodies and the community-at-large. But another group might counter that such moral absolutist thinking fails to fully consider the very real situational constraints in this and similar cases. This group could observe that the viability of a valued academic organization was in jeopardy, one that provided considerable good in terms of patient care and scholarship; careers of administrators, faculty and students involved in this scheme were also at risk. This kind of case-driven dialogue underscores what Kennedy (1956) wrote in his classic monograph on leadership: “to decide at which point and on which issue (one) will risk (one’s) career is a difficult and soul-searching decision” (p. 13). It also exemplifies the usefulness of this case and potentially others in suggesting multiple and even conflicting views and conclusions.
Fossey and Glover (2006) emphasize that “the best (educational leadership) cases are not ideologically driven” (p. 9), and thus foster multiple viewpoints. Indeed, authors who set out to describe a case in order to make a single social or political point are likely to become entangled in their own biases and miss important perspectives that form the whole of a more objective, richly drawn case study. This is not to suggest, however, that the only response is to throw up one’s hands in hopeless frustration. Rather, this case highlights that in approaching value-laden problems set in specific, often complicated institutional and cultural settings, various answers may be compelling.
Unfortunately, Dr. N, like many other deans, directors and chairs in nursing, was largely unprepared for her moral dilemma. This was true not only in terms of anticipating such a situation or sorting through the paths of action open to her, but more fundamentally, in understanding what goes into being a morally courageous academic nursing leader. And yet, the increasingly complex and competitive world of nursing education suggests a future in which leaders will face more rather than less ethical and legal challenges like that of Dr. N. Moreover, the choices made by leadership will have ramifications beyond the classroom, affecting nurses’ moral decision-making within and outside of schools and potentially influencing the credibility of an entire profession. One need only look to professions such as journalism, the clergy, and the judiciary, to see how growing doubts about trustworthiness have undermined public confidence in these professions (McCarthy 2018).
Grappling with case studies such as Dr. N’s and analyzing paths toward resolution holds promise for helping leaders to effectively meet the leadership challenges of a volatile educational landscape. Of course, this presumes a readiness to engage in one’s own reflective process, identifying core personal and professional values and beliefs and sharing these with colleagues. Neglecting to do this inner and interpersonal work threatens a kind of moral ambiguity that will leave academic nursing leaders unprepared to effectively confront significant moral crises in themselves and their organizations. Nurses in general have been encouraged to engage in similar self-examination in anticipation of their role as direct care providers. “Encounters with the deepest, truest part of (our)selves” (Bagay, 2012, p. 130) is how one nurse describes the process of self-reflection and values clarification. The authors argue that this process needs to be expanded beyond the clinical setting to involve nurses’ work in leading nursing programs, schools and colleges.
Returning one last moment to Dr. N, we can assume that time diminished some of the more unpleasant memories of her leadership crisis. With renewed optimism and some trepidation, we can imagine that she eventually went on to lead other academic organizations. Her optimism would have been tempered, however, by the understanding that academic nursing leadership was not simply about doing good, an idealized image formed in her earliest nursing education; it could also be fiercely political and competitive, with ample temptation to find easy paths. Unknown is the extent to which her fuller understanding of leadership became a stimulus for Dr. N to better prepare herself for more challenges ahead, or to help mentor new leaders, or to share her insights with colleagues at professional meetings and in educational leadership journals.
More than a century ago, another nursing education leader, Laura Beecroft, bemoaned the lack of ethical guidelines and other rules for heads of nursing programs across the United States. At the conclusion of her talk to the Fifteenth Annual Convention of the American Society of Superintendents of Training Schools for Nurses, she chided, “let every superintendent teach ethics in her school and at the same time practice ethics herself” (Beecroft 1910, p. 57). What ensued was a lively discussion of the situations that Miss Beecroft shared, ending without clear agreement. Presumably, though, discussants left with a better idea of some of the ethical challenges before them, and potentially useful and ethically sound responses. The case presented here suggests no less a need than in Miss Beecroft’s era for dialogue related to ethics and contemporary leadership in nursing education. It directs us to questions and issues that require thoughtful discourse and analysis among current and future academic nursing leaders, including the need for ethical and policy guidelines that effectively respond to new forms of educational and administrative challenges. The case of Dr. N should also encourage other leaders to share cases that resonate for them, and in so doing, to expand the wellspring of ideas from which we can all draw in becoming more effective and morally courageous leaders.
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Olson, T., Walsh, E. Academic nursing leadership in the U.S.: a case study of competition, compromise and moral courage. Int J Educ Integr 15, 8 (2019). https://doi.org/10.1007/s40979-019-0048-y