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Promise keeping: do we keep our promises?

If he were to run for President, martial arts champion Chuck Norris promised to require Bill Gates and Warren Buffet to pay personally for national comprehensive medical coverage for every American ... or meet him in the Rose Garden (Norris, 2007). A humorous proposition perhaps, but not a promise easily kept. Within the past historic year of campaign rhetoric, specific promises were made. How do we as citizens of this nation perceive political promise making? Do we believe the adage that politicians will say anything to get elected? Several studies have found that past Presidents did indeed convert about 66%-70% of their party's promises into policy (Johnson, 2008). Yet, the broken promises are remembered most often. Repeated gaps between promises and performance create doubt, distrust, and finally, cynicism in the public.

Promise making, promise keeping, and promise managing are full-time challenges for nurses. How often have you told a patient you will be right back with more ice chips? Completed an assessment that was less than thorough? Told your staff you would address the issue of enough IV pumps for the unit ... soon? Delays can be unanticipated and often beyond our control as caregivers and managers, yet it is easy to leave a trail of broken promises and unfulfilled commitments (often not intentionally) just because the words flow easily and casually (Hofmann, 2008). All too often, we lay blame on circumstances or others when we are confronted, and leave it at that. Our personal reputations, the value of our profession, and the credibility of the institution within which we work are based on how well we fulfill our promises to our patients, our colleagues, and ourselves.

Ethical Implications

Promises are verbal or written commitments made to another person or group of people. They are an expressed assurance on which expectation is to be based (Dictionary.com, 2006). They can be explicit, including formal agreements or contracts, and informal agreements, such as a stated intention to do (or not do) something (American College of Healthcare Executives [ACHE], 2006). Promises also can be implicit when they are implied or understood between two parties, though not directly expressed. Philosophers have asserted for centuries that the solemn act of promising provides a bond between the promisor and promisee that normally should be honored (Oakley & Lynch, 2000). It also is regarded highly by those who promote the core ethical values of business. The Josephson Institute of Ethics promotes one of the nation's most widely used character development frameworks based on shared beliefs and consensus values concerning qualities and traits associated with good character (Josephson, 2008). One of the six pillars of character is trustworthiness, which includes reliability or promise keeping. "When we make promises or other commitments that create a legitimate basis for another person to rely on us, we undertake special moral duties; we accept the responsibility of making all reasonable efforts to fulfill our commitments" (Josephson, 2008, p. 1).

A literature review of the topic of promise keeping leads the reader to conclude that its status as a core business value is assured. Yet reality does not always justify this conclusion. Oakley and Lynch (2000) studied over 700 business people and students to test the premise of promise keeping as a core value in the workplace. Their findings indicated that a high proportion of respondents fail to keep their promises in the workplace even when seemingly compelled to do so (the promise is legally enforceable), and even when the importance of religious beliefs in day-to-day business activity was considered. A disturbing number of respondents ranked promise keeping as a low priority in today's workplace. They redefined the work situation in ways that allowed them to refuse to take responsibility for their decisions. Do people keep their promises if there are no implied consequences of legal sanctions? Unfortunately, findings indicated promise keeping is a "phantom ethic" rather than a core value (Oakley & Lynch, 2000, p. 389).

Psychologists claim that many people may not have achieved the stage of cognitive moral development that allows them to keep their promises (Oakley & Lynch, 2000). This has sobering implications for ethical decision making in the workplace and nursing practice. When people make promises or commitments, they create predictable expectations that the promises will be met. Whether the failures are minor or serious, and in spite of good intentions, broken promises cause more harm than good. Promises mean a lot to people because they suggest appreciation, value, and empathy. The effect of broken promises is resentment, undue anxiety, missed opportunities (even lost business), lack of trust in future promises, and a loss of credibility for the one receiving the promises. For the promisor, a chain of guilt and feelings of inadequacy may ensue (Sihera, 2007). The promise can prevent alternative action from being chosen, which means everyone involved loses. Broken promises also give a feeling of false competence to the promisor and can keep that person stuck in a mode of regret and failure. A successful individual tends to value others and keep promises as a way to demonstrate integrity, a key attribute for achievement (Sihera, 2007).

Milton (2002) stated that the concept of fidelity, or faithfulness, adequately describes an "obligation to act in good faith with such actions as keeping promises or vows, fulfilling agreements, maintaining relationships, and fulfilling fiduciary responsibilities" (p. 21). The American Nurses Association (ANA, 2001) Code of Ethics for Nurses serves as the professional framework for nurses to use in ethical analysis and decision making, and establishes the ethical standard for the profession. A host of ethical theories are used to underpin the reasons for decisions about how a nurse ought to act. A fundamental principle that underlies all nursing practice is respect for the inherent worth, dignity, and human rights of every individual. "Nurses are leaders and vigilant advocates for the delivery of dignified and humane care" (ANA, 2001, p. 8), and as such are responsible to act collaboratively with the health care team. This requires mutual trust, recognition, and respect. Making and keeping promises to patients, families, colleagues, and society is an ethical imperative.

Promise Management

According to the ACHE (2006), health care executives have an ethical responsibility to use a systematic, deliberative, and thoughtful approach to decision making when making a promise to a person or group. This statement uses a series of questions to facilitate review of promises. What are the facts regarding the promise? Are there circumstances under which this promise should be revisited? What are the perspectives of the stakeholders affected by the promise? How is the promise going to be communicated and documented? Finally, the policy states that the best decision regarding a new or previous promise will be made when careful reasoning and transparency guide the executive's behavior.

Other members of the nursing profession should feel no differently. No simple ethical recipe exists to guarantee a prompt reduction in broken promises. Changing behavior begins with self-reflection; each person should determine if he or she shows a definite pattern of breaking promises. A pattern suggests the person receiving the promise is not really a priority in the promisor's scheme of things, or is not as valued as other people or activities. It also may indicate the person making the promise is trying to please too many people at once, perhaps to impress others or meet the overloaded expectations of his or her role. Finally, a pattern of broken promises may demonstrate that the promise itself is not perceived as important enough to be kept (Sihera, 2007). Hofmann (2008) described the following guidelines for making, keeping, and managing promises within the health care setting.

1. If you make a significant promise, write it down for yourself immediately. This allows no uncertainty or confusion, and offers a greater capacity for keeping the promise. The action also eliminates unfound assumptions of promises. Give margins of error if necessary for due dates or if unforeseen problems may affect its completion. Suggest nursing staff keep track of promises made to families, patients, and staff for one shift. They will be surprised at the number of promises made in a short period of time.

2. Avoid bad-faith excuses. Interpret your promises fairly and honestly, and don't rationalize noncompliance. Making excuses prevents examining the truth about the situation and taking ownership of the problem. A manager must model the ability to take accountability for any failures; not casting blame on others.

3. Avoid the temptation (even if it is easy, convenient, or expected) to make commitments you cannot keep. Before making a promise, determine if you are willing and able to keep it. Consider unknown or future events that could make promise keeping difficult, undesirable, or impossible. Sometimes, you only can promise to do your best. A delayed but thoughtful "yes" likely means that you can fulfill the promise.

4. Examine carefully how the implicit promises of your profession and institution are being met by your actions or inactions. From the institution's mission statement to the ANA Code of Ethics, these promises exist even though no written contract has been created. Analyze patient satisfaction surveys. Meet with patients and families, listening to their comments about the institution, the responsiveness of the staff, and patient safety issues. Include promise keeping in your staff evaluation criteria.

5. Use role playing in training and educational programs to dramatize the significant consequences for patients, families, and peers of being dependent on the power, authority, and resources of someone who lacks initiative or responsiveness to keep promises inherent in the relationship. Putting yourself in the patient role is a good reminder of the patient's powerlessness and dependence on your word.

6. Team members should communicate with each other and work together to achieve tangible goals that can meet implicit promises given to patients. The goal may be ensuring every patient is visited each hour, hand-offs are smooth, or patients and families have the information and opportunities they need to participate effectively in patient care decisions. These goals also ensure safety and quality care.

Conclusion

Failure to fulfill a promise is not just irritating or disappointing; it can have immediate and long-lasting ramifications for the individual and the institution. Do the vows or obligations you prize as a nurse truly correspond to the values and priorities of your patients? As suggested by Milton (2002), has the profession ethically lost its way in faithfully serving those to whom it has committed its services? Are the patient's priorities, which are almost always the implicit promises of the profession, attended to and not forgotten? Ask yourself if you as a nursing professional are experiencing a decreased emphasis on ethical commitments due to a depersonalization of society, a widespread abandonment of personal ethics, or an increased tolerance of unethical actions (Oakley & Lynch, 2000).

Like integrity, trust is an important but fragile commodity; once compromised, it is very difficult to restore. Each nurse must choose activities or actions needed to remain faithful in the nurse-patient relationship, based on the profession's ethical code and his or her personal philosophy of nursing (Milton, 2002). The nurse manager and other leaders must demonstrate and model promise keeping; holding themselves as well as their staff to this task. Be reliable. Keep your word. Return what you borrow. Pay your debts. Make only promises you can keep. Be loyal. Remember that promise keeping is going beyond what the law requires. It is a responsibility to fulfill your commitments.

References

American College of Healthcare Executives (ACHE). (2006). Ethical policy statement: Promise-making, keeping, and rescinding. Retrieved October 22, 2008, from http://www.ache.org/policy/promise.cfm

American Nurses Association (ANA). (2001). Code of ethics for nurses with interpretive statements. Silver Spring, MD: Author.

Dictionary.com. (2006). Promise. Retrieved December 19, 2008, from http://dictionary. reference.com/browse/promise

Hofmann, P.B. (2008). The myth of promise keeping. Healthcare Executive, 23(5), 48-49.

Johnson, A. (2008). Promises to keep. National Journal Magazine. Retrieved October 31, 2008, from http://www.nationaljournal .com/njmagazine/cs_20080719_4480.php

Josephson, M. (2008). The six pillars of character. Retrieved October 26, 2008, from http://josephsoninstitute.org/MED/MED -2sixpillars.html

Milton, C.L. (2002). Ethical implications for acting faithfully in the nurse-person relationship. Nursing Science Quarterly, 15(21), 21-24.

Norris, C. (2007). If I am elected president. World Net Daily. Retrieved November 2, 2008, from http://www.worldnetdaiiy. com/index.php?pageld=42010

Oakley, E.F., & Lynch, P. (2000). Journal of Business Ethics, 27, 377-392.

Sihera, E. (2007). Why keeping promises is very important. Retrieved October 12, 2008, from http://ezinearticles.com/? Why-Keeping-Promises-Are-Very-Important&id=456238

Dona Dorman, BSN, RN, is an Assistant Clinical Instructor, University of Arkansas for Medical Sciences College of Nursing, Little Rock, AR.

Donna Middaugh, PhD, RN, is Associate Dean for Service and Coordinator for the Nursing Administration Masters Specialty, University of Arkansas for Medical Sciences College of Nursing, Little Rock, AR; and is a MEDSURG Nursing Editorial Board Member.
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Title Annotation:Nursing Management
Author:Dorman, Dona; Middaugh, Donna
Publication:MedSurg Nursing
Geographic Code:1USA
Date:Jan 1, 2009
Words:2147
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