Revista Română de Bioetică, Vol. 11, Nr.4, octombrie – decembrie 2013 [613849]

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Revista Română de Bioetică, Vol. 11, Nr.4, octombrie – decembrie 2013

DUTY ETHICS AND PROFESSIONAL
OBLIGATIONS IMPLEMENTATION
METHODS INSIDE HEALTH UNITS

Mihai Popescu*, Valentin Titus Grigorean**, Ruxandra Diana
Sinescu**, Alexandru -Rares Stoian**,
Crina Julieta Sinescu**

Abstract
The authors present various means of implementing obligation ethics at workplace in the the
medical system. In addition, the study presents the results of a research regarding the perceptions
of nurses over the obligations involved by the contract between the employer and its employees.
A series of behavior norms and types of regulations’ will be mentioned, which target employee
responsibility towards the organization, customer relationships and the law. In addition, we
would like to emphasize the values that lie at the basis of the elaboration and the correct
application of a system of rules and sanctions (specificity, clarity, justice, transparency etc.) The
institutionalization of ethical principles can be done by means o f a contract (written, but also
psychological) between the organization and the employees, by strengthening organizational
commitment, consolidating organizational culture, and improving organizational management.

Keywords: obligations , employees, organiz ation, rule s, sanctions.

Corresponding Author – Valentin Titus Grigorean: [anonimizat]

*Universitatea Pitesti
** UMF Carol Davila Bucuresti

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1. Introduction
Work ethics comprises a larger
perspective, as it is a field of ethi cs
dealing with work morals [5].
Profession al ethics refers to a specific
domain such as the medical profession
ethics. “ Moral o bligation” , “moral
duty”, or “norms” are notions
frequently used at the workplace in
order to describe a person’s duty
towards the employer and society.
How to make employees adopt,
comply with and respect labor
obligations and the associated ethical
standards ? As a result, this article will
debate aspects of implementing the
ethics of duty in healthcare units
through norms, regula tions’ systems
and institutionalizing ethical
principles .

2. Norms and professional duties
The norms of behavior specify the
real, concrete actions and behaviors
inside the healthcare units, w hile
ethical codes present general principles
concerning ethic al actions and
decis ions [19]. Behavior norms
(specific duties) need to be
communicated to employees and
describe such aspects as:
Agreed or obligatory dress code
(specific uniforms in clinics or
departments);
Following orders and instructions
received fr om managers, physicians,
chief -assistants ;
Compl ying with local, regional
and national laws and regulations in
the health system ;
Maintaining the confidentiality of
certain information;
Avoiding conflicts of interests;
Avoiding sexual, age, ethnic, race
and religious discrimination;
Avoiding the abuse of drug or illegal substances;
Refusing unfair advantages;
Reporting illegal or questionable
(whistle -blowing aspects [19]).
All these norms are permanent
requirements in medical units.

3. Systems of r egulations and
labor obligations
Ethics develop rules and
regulations in order to justify certain
actions [12]. Ethical codes present the
objectives, the general values, the
organization’s mission and the rules
that employees need to respect. The
rule is an ex plicit or implicit statement
which intends to define the conditions
for certain behaviors or actions. Rules
state what is often qualified as
“normal”, acceptable or preferable.
Disobeying them can be interpreted as
something ”bad” and ”inconsistent”
[7].
The r ule elaboration process
requires a serious analysis over the
organization’s needs, the relationship
between the rules that have already
been elaborated and those that are
currently being elaborated, as well as
the impact of new rules and regulations
on the efficiency of employees’
activity [8].
Usually, rules are structured in the
following categories:
A. Rules concerning employees’
obligations towards the healthcare unit
where they work ;
B. Rules referring to relations with
patients and the relationshi p with
foreign organizations;
C. Rules concerning attitudes
towards the law [22].
These categories shall be analysed
in the following paragraphs taking into
account the healthcare institutions .
A. Rules concerning employees’

140
obligations towards the organi zation .
Organizations’ codes that should
regulate the member s’ relationships
and behavior in the following reference
frameworks: 1. mandatory provisions
or governmental code (healthcare
laws) ; 2. The authority system,
adherence towards the general purpose
(the leadership structures in healthcare
units) ; 3. the department’s general
purpose; 4. moral/ethical standards; 5.
pro-social behavior; 6. duty towards
the “general wealth of the
organization”; 7. the structure ,
functioning and the attitudes inside the
department; 8. the technical situation
and t echnical requirements of the
department as a whole [6]. This is the
starting point for the framework of
establishing and setting a regulation
system in healthcare units .
In agreement with the provisions of
the La bor Code, the regulation system
(the internal regulation) includes at
least the following categories: 1. Rules
concerning the protection, hygiene and
work security inside the unit; 2. Rules
regarding the respect for no
discrimination and no violation of
dignity; 3. The rights and obligations
of employers and employees; 4. The
procedure to solve individual demands
and a llegations from employees; 5.
Specific rules regading work
discipline; 6. Disciplinary deviations
and sanctions; 7. Rules concerning the
disciplinary procedure; 8. Ways of
applying other specific legal or
contractual dispositions. As far as
hospitals are concerned, great attention
is given to regulating specific work
areas or departments. For instance,
there are specific regulations
concerning the sterilizing department,
the intensive therapy unit , the
operating rooms , clinics, etc . These
regulations clearly establish the attributions/responsibilities of each
category of personnel, the sanctions for
deviations, and conditions for access of
the personnel. Respecting them has the
connotation of a professional debt with
ethical implic ations.
In order to insure coherence and
achieve the intended effects, a system
of regulations needs to fulfill the
following conditions: rules have to
answer the real needs and not be a goal
them selves , they need to be applicable,
coherent, and widely known by all
those involved in the activity of the
organization. They also need to be
associated with a system of sanctions
and rewards valid for all employees. In
informa l structures , some rules or
codes are the cumulated effect of
general opinion and do not include
viable sanctions that could support
their moral power. Unofficial rules
need to be correlated with official rules
to avoid disagreements between the
two. In formal structures , codes
include real sanctions deriving from
the “proper behavior” of the
organization, as a result of experience
and relations. In this case, fear of
punishment takes precedence in front
of the moral factor [6].
B. Rules referring to patien t/ client
relations in healthcare begin with
patient rights and end with a series of
statements generally or particularly
applicable. Concern for patient rights
is a basic feature of quality: care,
respect, self -determination, intimacy,
physical and mental integrity, respect
for moral/religious/philosophical
values, information etc. [14].
On the other hand, patient s also
have to respect and obey a series of
internal rules of the medical unit
during hospital ization [14].
In case of patient deviation from
the healthcare unit rules, a dilemma

141
arises: what to do with them? The
solution is at the half way between the
moral approach and the managerial
perspective . To put it plainly, patient s
cannot be sanctioned if violat ing the
norms, as empathy and understandi ng
should be manifested towards their
condition. The solution is to proceed
with further explanations and
repetitions of the rules and the newer
patients should be asked to respect the
rules in order to maintain their
accommodation facilities in the best
condition. Thus, equilibrium is created,
which works properly by synthesizing
the attitudes of different social actors:
employees, patients, relatives [14].
C. Rules concerning attitudes
towards the law . There are three main
rule categories applicable at th e
workplace: legal, organizational and
ethical. These categories are
intertwined, have reciprocal
connotations, but the attached rewards
are different. In the case of obeying the
laws the rewards are related to
maintaining the status of employee and
the op portunity to benefit the rights
stipulated by labor legislation . In order
to respect organizational rules there
might be opportunities offered by the
management: promotions, financial
benefits, delegations. As far as the
rewards for an ethical behavior are
concerned, the following are usually
intangible : consideration, appreciation,
respect. Lack of respect or violation of
rules is usually associated with
sanctions (mechanisms to encourage
useful actions and to discourage others
associated with loss or tens ions). The
law can suggest physical sanctions and
punishments, while ethical sanctions
act at the level of one’s conscience
and/ or by (sometimes irreparably)
wounding an individual’s reputation.
In the case of violating organizational rules, tangible sanc tions need to be
used (warnings, change of job, salary
penalties etc.) [23]. Provided that the
system works properly, then it is
perceived as a just one. If it is
inconsequently applied, accusations of
ethics breaking (justice) might come
up. Even if sanct ions are applied in
compliance with legal procedures,
dilemmas may arise concerning
sanction initiatives, the number of
penalized employees and the
magnitude of punishments. In order to
make the system worthy of
appreciation, new rules are necessary
(ones not mentioned already in the
Labor Code). Barnard (2003)
suggested that sanctions be associated
with unassumed codes and
responsibilities. Moreover, we feel that
a set of ethical values and the rules of a
progressive discipline system might be
applied:
1. Specificity: sanctions are
established in compliance with the
situations (they are to be applied to all
specified situations, so that there are no
doubts concerning the circumstances
when the rules have been violated),
with the tasks and the organizational
objectives (unaccomplishment of tasks
and objectives is associated with
different sanctions);
2. Clarity: sanctions must be
clearly established so as not to leave
any doubts concerning rule violation;
3. Universalis m: sanctions are to be
applied to all th ose who committed the
negative deed, not selectively;
4. Equity : sanctions have to
correspond to the negative actions;
5. Correctness: the investigation
has to be well done, well documented,
data should be collected from various
sources to make sure that t he
respective rule had really been violated
and to be able to establish correctly the

142
causality;
6. Expediency: sanctions are to be
applied immediately after having
established the causes;
7. Consistency: sanctions are to be
applied in the same manner in s imilar
situations;
8. The right to defense: employee s
should be informed orally or in written
form of their wrong doing and also
about the specific time at disposal to
prepare the defense;
9. Dignity: while organizing the
appeal process, the law should be
respected, the wrong doer should not
be humiliated, the establishing of the
sanction should be followed by
suggestions concerning the
improvement of personal actions and
the employees’ moral rehabilitation;
10. Transparency: the system of
sanctions is kno wn to everyone, some
sanctions are even elaborated through
consultancy with the employees and
the changes effected in the duties,
rules , and sanctions’ system are
publicly announced.

4. The institutionalization
of ethical principles
Each employee should be aware of
and respect the set of explicit or
implicit ethical principles promoted by
the medical institution. Here are some
of the ethical principles derived from
Hippocrat’s Vow, turned into laws in
medical practice, with direct
implications over the r elations with
patients:
The morale and professional
obligation towards patient health
principle: doctors are responsible for
the results of their activity and need to
maintain a balance between the
challenges of science, experiment and
bioethics [26];
The dedication principle: doctors solemnly commit to dedicate their lives
to humanity. Medical practices need to
be harmonized with bioethic al
standards [25];
The respect and the gratitude
principle: doctors respect their
profession and admit to its value to
society. They have the duty to help
patients maintain their self respect and
not fall prey to self -obloqui [18];
The principle of conscience and
dignity: doctors commit to exert their
profession conscientiously and
digni fied, while at the same time
protecti ng patient dignity [15];
Confidentiality principle: doctors
have to keep patients’ secrets even
after their death [11];
The honor principle: doctors have
to keep by all means the honor and the
noble tradition of being a doctor;
The fellowship principle: ea ch
doctor shall treat his /her colleagues as
fellows;
The nondiscrimination principle:
doctors must not allow considerations
such as nationality, race, religion,
policy or social status interfere
between their duty and the patient . All
people have the right to benefit from
healthcare services [24];
The humanity principle: doctors
commit to keeping total respect for
human life from its very beginnings
and even under threat; they shall not
use medical knowledge contrary to
humanity laws. Inside the medical
institution, doctors are bound to protect
patients and healthcare beneficiaries
from abuses [7]. The simple statement
of ethical principles in various activity
contexts does not insure their
promotion and multiplication inside
the medical staff. There are at least
three modalities through which one can
implement ethical principles:
a) Establishing a written as well as

143
a psychological contract between the
organization and the employees;
b) Strengthening organizational
commitment;
c) Consolidating an organizatio nal
culture oriented towards adopting and
manifesting ethical behaviors [22].
(a) Contracts insure individual –
organization compatibility, the
adherence of both parties to formal and
implicit norms of established behavior,
respect of promises and assumed
understandings, contribute to employee
fidelity and constancy and increase
their perfor -mances. They can be
formal , based on calculations and laws,
but also psychological , representing a
moral pact that mobilizes pleople to
accomplish organization goals [28].
Schein (1994) defines the
psychological contract as “a set of
unwritten reciprocal expectations
between employee and organization”.
The emphasis is laid on the reciprocity
of both parties over the mutual
exchange (in terms of interchangeable
obligations , equity, correctness,
efficiency etc.). According to Schein
(1994), the psychological contract (its
specificity, force and effects) depends
on accepting or rejecting
organizational norms . There are two
categories of norms: pivoting
contractual norms /essen tial ones
(adherence to them insures the status
of organization member) and
peripherical norms (desirable, but not
obligatory). The employees’ attitude
towards these norms can take the form
of acceptance or rejection . The
combination of the two variables
results in four situations:
i) the acceptance of pivoting and
peripheral norms leads to conformism ,
a maximally adaptive solution, which
renders total compatibility between the
organization and the employee, in terms of expectations, responsibilities,
bene fits and objectives.
ii) The acceptance of peripheral
norms and the rejection of basic norms
generates submissive rebellion –
employees hide non -comformist
behaviors with regard to basic norms.
iii) The rejection of both categories
of norms creates revol utionary
behaviors , which are associated with
losing the member ship in the
organization.
iv) The acceptance of basic norms
and the rejection of peripherical norms
manifests itself through creative
individualism – an individual’s
concern to achieve organiz ation goals
and manifest its own identity and
creativity to serve the organization’s
goals [21].
From the employee s perspective,
the psychological contract with the
organization develops itself through:
their own perception of reward ing and
treatment (corr ectness, consequency,
consistency, equity), work place
security, opportunities to fully use their
potential, practic ing and develop ing
competences, career expectations, own
influence and implication and the
degree of trust manifested towards the
organizati on. From the
organization/employer perspective, the
contract develops if the employee
shows competence, effort,
conformation, commitment and loyalty
[2, 3] .
(b) Organizational Commitment
(OC) can be defined as the relative
force of employee identification and
involvement in an organization [17].
Research identified three types of OC:
1. affective (reflects the employee s’
emotional attachment to the
organization and their own
identification and involvement in it); 2.
of continuity (the employee s stay in the

144
organization and become involved, by
evaluating the costs implied if leaving
the respective organization); 3.
normative (reflects a feeling of a moral
obligation to remain in the
organization, the belief that this is the
most ethical thing to do) [16].
Strengthening organizational
morale commitment can be done in
several ways: by increasing
organization confidence (through
measures that support employee
equity, security and well -being),
through the establishment of norms of
group functioning and the accept ance
of norms that the very group can
suggest, by creating opportunities for
employees to socialize, by promoting a
positive managerial behavior (work
support, concern for the employee ’s
well-being, support for the
organization and employee ’s prestige,
the opportunity to participate in
decision making, professional
development, solving stressful issues,
eliminating role ambiguities, offering
rewards and benefits, advantageous
retirement proce -dures, offering
feedback (appreciation of good results
and seizin g the need to adjust of
certain actions), by creating the
opportunities to pursue a task from
beginning til the end (while fulfilling it
the employee can grasp the results of
his efforts), by an optimized
stimulation of the one’s personal
importance for th e work place, by
selecting to be members of the
organization of those candidates that
have motivations and personality traits
that make them favourable to adhere to
ethical behaviors and professional
obligations (dilligence, discipline) [27,
13, 4 ]..
(c) The Organizational Culture is
defined as a set of shared norms,
values and beliefs, a combination of concepts such as: symbol, language
ideology, myth and ritual, a set of
basic assumptions that are authentic
enough to be considered valid [20].
The organiza tional culture is in itself a
set of characteristics that the
organization itself values: “a pattern of
fundamental axioms, invented,
discovered or created by a group,
during its extremely adaptive and
internally integrative activities, which
functioned lo ng enough to be
considered valid and on account of that
they are transmitted to new members
as the right way to perceive, think and
feel with regard to certain problems”
[20]. The creation of a n organizational
culture that supports ethic al duty is
done by establishing a system of
norms, rules correlated with values and
beliefs that are reflected in the
managerial discourse, leaders’
behavior, the management of human
resources, organizational processes
(decisions, procedures,
communication), employee educati on
and training and organizational
traditions and rituals.
Healthcare leaders c ould c ontribute
to the creation of an ethical culture by
following some perspectives: create a
just resource distribution!, create
realistic expectations!, reveal the
common pur poses and the shared
accountability!, involve employees and
patiens in ethical decision making!,
identify and solve the conflicts of
interest!, eliminate the „us-versus –
them” attitude!, provide clear standards
of care!, rely always on evidence –
based medici ne to reduce variation in
service delivery!, improve the quality
and reduce uncontrolled variation!,
manag e costs and present the results to
the partners!, educate patients,
employees and public to understand
the healthcare activity and

145
organization!, reso lve ethical issues
that should be learned and used in a
formal way , promote health related
interests of the patients as the
organization ’s primary concern and
motivation!, make other stakeholders,
physicians, payors and gonernment
agencies equal partners in protecting
the intere sts of the patient population!
[10].

5. An empirical study
We have conducted research on
employee perceptions with regard to
the ethics of rights and contract
obligations in the relationship between
the employees and the institutio n. The
survey was conducted on a sample of
100 female nurses, aged between 23 –
57 years old (A= 33.12, SD=10.20), with a work experience in the unit
between 1 and 33 years (A=12.24,
SD=13.18) (M – mean, SD -standard
deviation.)
The research method used was th e
questionnaire investigation, a
questionnaire consisting of 18
statements which the participants had
to answer using the 5 -step Likert scale
( from 1 –” to a very small extent” to
5”to a very large extent”). The
questionnaire items are presented in
Table 1 (items 1, 2, 3, 4, 5, 6, 7, 8, 9,
11 refer to a set of organizational
obligations with regard to their
employees, while items 10, 12, 13, 14,
15, 16, 17, 18 refer to a series of
employee attitudes and perceptions
with regard to their obligations and
empl oyer).

Table 1 . Items, descriptive indicators and correlation coefficients.

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
1. Organization is good
(M=2.05, SD=1.20)
2. There are situations when employees are not
aware of the obligations impo sed by the formal
hierarchy ( M=2.77, SD=1.34) -.23
3. Demands are exactly formulated
(M=2.04, SD=1.18). .28 -.27
4. Employees proved not to be aware of the
demands of their employment charts ( M=2.56,
SD=1.24). -.22 .25 -.17
5. Work performance is compared based on clear
standards (A=3.00, SD=1.21). .16
6. Work space is sufficient enough
(M=2.33, SD=1.21). .19
7. Work environment (background sounds, smells
etc.) is distu rbing (A=2.97, SD=1.43). -.29
8. We have all the necessary technolog y to
complete tasks ( M=3.33, SD=1.31). .18 .17 .16 .20 .31 -.20
9. Conflicts are solved by adopting well understood
and accepted solutions ( M=3.52, SD =1.22). .19 .16 -.33 .16 .17 .20
10. Employees tr y to work as hard as possible
(M=4.29, SD=0.91). .15 -.24 .22
11. Employees’ suggestions are taken into account
(A=2.81, SD=1.29). -.29 -.20. -.20 .25 -.21 -.22 -.30 .23
12. I have to work after schedule (M =2.71,
SD=1.28). .14 -.18
13. I’m thin king of changing my workplace
(M=3.40, SD=1.42). -.21 -.17 .16 .22 .17

146
14. I love coming to work
(M=3.56, SD=1.22). .21 -.25 .23 .20 -.24 .28 .30 .39 -.32
15. Cooperation with other departments is g oing
well
(M=2.33, SD=1.23). .21 .29 -.17 .19 .30 -.18 .23 .24
16. Relationships wit h other team members are
good (M =4.22, SD=1 .09). .39 .19 .19
17. My work demands the most of me ( M=3.79,
SD=1.00). -.20 .34 .16 -.21 -.24 .21 -.32 -.26
18. My work makes me feel personally
accomplished (M =3.60, SD=1.15). -.18 .20 .23 .21 .19
** Kendall correlations, p< 0.01
* Kendall correlatons, p< 0.05

Based on the evaluations of
employees, we could draw the image
of a dynamic, changing and exhausting
organizational environment. Inside this
environment, modifications,
fluctuations or even ambiguities in the
organizational manner, objective
establishment or workspace usage may
occur. These aspects are positively
correlated with the temporary
ambiguities, the increase in the effort
level and the decrease in personal
satisfaction and commitment.
Cooperation inside the team is
positively appreciated and positively
correlated with a good conflict
management, with the employer’s
obligations, contributing thus to
supporting a feeling of professional
fulfilment. Health -related work is
exhau sting to a large extent. The
feeling of work exhaustion is
positively correlated to the workload,
the discomfort produced by the work
environment and the tendency to leave
the organization (on a declamatory
level). Work exhaustion is negatively
correlated with management openness
to employee wishes and with
professional satisfaction (the
management cannot spare the
employees from undergoing some
effort, which decreases their
satisfaction). On the other hand, management takes into account
employee grievances (item 11), when
certain special situations ask for a
change in organization/action plans
and tasks. The above correlations
reveal very clearly the existence of a
psychological contract inside the
healthcare institution (as an aspect of
moral balance): man agement takes into
account employee wishes concerning
the workplace and technological
constraints, along with the exhausting
degree of effort.

6. Conclusions
The permanent balance between
employee and organization obligations
creates the feeling of correc tness both
on a management level, as well as
among the employees.
The practical aims of this research
were the following: to strengthen
organizational culture throughout
rules, regular revision of organizational
principles and also of employment
charts (co rrelated with the deepening
of the employees’ knowledge on
obligations related to tasks and
hierarchy), keeping the management
objective -oriented and clear
performance standards, concern
towards insuring a moral work climate,
where employees know that the ir
efforts are appreciated, compensated

147
through various advantages, such as
management openness to their
suggestions and wishes. Duty ethics
and professional obligations are
implemented by norms, rules,
sanctions, written contracts, mutual
promises, as wel l as by improving the management system, work
environment and organizational
climate. Thus, one can sense the need
to involve experienced specialists in
both organization management and
bioethics [1]

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