THE MORAL CASCADE MODEL: THE INTERSECTION BETWEEN LEADERS' MORAL DECISION MAKING AND

THE MORAL CASCADE MODEL:
THE INTERSECTION BETWEEN LEADERS'
MORAL DECISION MAKING AND
ORGANIZATIONAL VIRTUOUSNESS
JUDITH COHEN, PHD, RN
PROFESSOR
COLLEGE OF NURSING & HEALTH SCIENCES
BETTY RAMBUR, PHD,RN
PROFESSOR
COLLEGE OF NURSING & HEALTH SCIENCES
JILL MATTUCK TARULE, EDD
PROFESSOR
COLLEGE OF EDUCATION & SOCIAL SERVICES
CAROL VALLETT, EDD
RESEARCH ASSOCIATE PROFESSOR
COLLEGE OF EDUCATION & SOCIAL SERVICES
Context and Assumptions
 Moral distress occurs at the interface of the
individual and the organization
 Organizations shape individuals as the individuals
shape the organization
Gaps in Existing Knowledge
 Little evidence based research on individual/organizational
interaction.
 Research establishes moral distress but does not address
when there is a positive outcome for the individual and
organization.
 Methodological challenges including examining
individual/organization interaction, complex moral reallife decision making, and assessing thought processes
regarding moral action/decision making.
Major Points and Rationale
 An Interactive Dialectic Among
 individual

experience and moral decision-making
virtuousness of the employing organization.
Moral Stress
 Cascades via two pathways
Moral distress and its sequelae,
moral residue and negative
organizational outcomes


Moral eustress with corresponding moral and organizational
enhancement
The Moral Cascade Theory

Theory created first (Rambur, Vallett, Cohen,& Tarule,
2010)

Scholarly Influences include
 Moral Development (Kohlberg, 1984; Gilligan, 1982)
 Positive Psychology (Seligman & Csikszentmihalyi,
2000)
 Virtuous Organizations (Cameron, 2003; Dutton,
Glynn, & Spreitzer, 2006)
 Stress (Selye, 1974; Csikszentmihalyi, 1990 )
Testing the Model
Health care and Higher education institutions
Interview of 10
Leaders
Triangulation of
Data
Defining Issues
Test (Rest et al,
(1999)
Positive Practices Survey
(Cameron, Mora,
Leutscher, & Calarco,
2011)
Research Questions
 What themes emerge that illuminate the nature and
quality of moral distress and eustress?
 Can both moral distress and moral eustress be
further differentiated by an individual’s cognitive
moral developmental stage?
 Does an institution’s virtuousness profile correlate
with how workers’ respond to moral stress?
Data from interview
 Two forms of analysis
 Grounded
theory approach identifying
themes
 ‘Mapping’
leaders’ narrative about their
decisions on the Cascade
Interview themes
 Eustress & distress may emerge during the same
decision making narrative
 How the leader views the organization and his or her
role in it influences how moral stress is experienced.
 The decisions varied significantly between the two
organizations:


Health care – quality patient care vs economics and efficiency
Higher education – personnel and student progression
decisions, i.e., tenure, dismissing a student
Stated and unstated organization
(espoused/enacted)
 Both provide context & content for decisions
 Alignment of individual with both can create a positive
context for decision making
 Most frequently expressed stated vs unstated = service
mission vs. resources & efficiency (shifting corporate
expectations)
 Healthcare:

Patient care vs “money talks in this institution”.
 Higher education:

“Why are we here.. To really provide the best service we can for the
students…[or] to fill all the beds and to fill all the seats in the classroom”
Mapping the Cascade
 Moral Identity, moral prehension, moral at-tension
organizational
effects
 Moral stress
 Moral certainty
 Intention to act
Moral Transaction
Effect of action
Eustress and/or distress
Moral identity, prehension, attention create focus &
readiness for engaging a moral decision
 Moral identity = moral compass
Can stand in conflict with institutional position
“ I expect people to treat me how I would want to treat them and to be
upfront.”

 Moral prehension - awareness beginning

“it (a care decision) made the hair stand on the back of my neck”
 Moral attention (at-tension)

Prompts for attention = power, safety issues, right vs good for the
organization, anger
Cascade to Action
moral stress - certainty – intention to act
 Moral stress

“Moral struggles are really interesting.
They engage the heart as well as the
intellect”.
 Moral Certainty


“I don’t think that I can say that I am
absolutely sure before I have my intention to
act. “
Awareness of the issue
Dawning sense of needing to pay attention

Disputed: certainty vs ‘satisfizing’ in higher
education (not life and death)
Certainty vs “a balancing act of competing
values”
Moral Line in the sand


“This is going totally against my moral beliefs.” And
not acting on that distress. I think that’s what I’ve
learned. When I feel like my morals are being
pushed or threatened that if mine are being
threatened then a lot of other people’s are being
threatened too. And if I’m in the position where I
can impact that for the patients and nurses that I am
there to represent, then that’s my moral responsibility.
 Intention to act



(
“Do you stay in this or do you get out? Does
this cross my personal moral line? “



Preparing: imagining ideal, possible actions,
or outcome
Role of dialogue/relationships in gaining new
perspectives, “checking it out”
Weighing alternatives and potential
impact(s)
Mapping the Cascade
 Moral Identity, moral prehension, moral at-tension
organizational
effects
 Moral stress
 Moral certainty
 Intention to act
Moral Transaction
Effect of action
Eustress and/or distress
Moral Eustress
Moral
Transaction
Positive
Organizational
Outcomes
Moral
Eustress
Individual
Moral
Enhancement
Act
Effective
 Call a meeting –communication to
Moral
transaction
Often dependent
upon moral
courage, despite
awareness of
risk, action is
taken with
resulting impact
on both the
individual and
organization.





share perspectives/understanding
Write a business plan envisioning
new modes of operation
Dismiss someone
Engage others and/or the
opposition, negotiating new vision
with others, seeking out resources
Compromise
Quit (“it was for moral reasons and just that
feeling of being out of alignment with the
corporate culture that caused me to vacate the for
profit sector and move into an environment where
it was much more about the individuals and the
greater good),
 “So, it’s been pretty successful…a
Act effective
Judged as effective by
addressing the problem,
meeting needs of many.
patient satisfier and a staff
satisfier…it took a lot of buy in..
And there’s been a lot of work in
the organization…just getting the
right group together and doing
the communications made a huge
difference and then the
satisfaction’s just been
tremendous for everybody
involved”.
Melinda , pg 6
Moral
Eustress
The institution , despite
challenges, changes
practices , which feels
like support to the
leader and like the
solution has moved the
unit to “a good place.”,
i.e. Positive
Organizational
Outcomes
“I get an awful lot of support and
it’s not easy business. You know,
just everything: delivering safe
care, quality care, and all that sort
of stuff under the pressure of all the
regulatory agencies…it’s been a lot
of hard work but, you know, I’m
really pleased with where the unit’s
at. And if I left today I’d feel like
it’s in a good place.”
Melinda, pg 42
Moral Distress
Moral
Transaction
Negative
Organizational
Outcomes
Moral
Distress
Moral
Residue
Act
Ineffective
Moral Distress
 Thwarted


By a more powerful colleague/boss
By organizational ‘rules’, .e.g. tenure
“I felt angry. I just feel at times that we are not looking at patients
as people, but as statistics. But really that this person was a
mother and a sister, and a daughter at one time and we are losing
sight of that.”
Brenda. P. 2
 More moral distress in health care than higher ed.



Power structure: relation between nurses and doctors
More likely to occur in institutional structures in which there is
assigned responsibility without accompanying authority
Proximity to patients within life/death contexts
Act
Ineffective
Thwarted from doing
what the leader knows
is the right thing to do
Frustration
distress
 Emotional distress vs moral
distress
 Emotional distress always
accompanies moral distress but
not visa versa
Emotional distress
I felt very good of what I accomplished. I felt leaving was the right
thing, but it was very sad for me. It was just like leaving this
dysfunctional home. You know that’s always a sad thing to have
to do, but it was the right thing to do. So that’s why I, you know, I
felt like this relief when I finally made that decision, “Yes. This is
the right thing to do.”
Karen, pg. 19
I mean it – it hurts, I think its – its tough because I think
that it’s – you know, I use the word agony very intentionally
when I’m talking about some of these decisions.
Don pg.3
Leaders’ moral developmental stage
 Two thirds of the leaders interviewed were at the
highest moral stage
 Further analysis is needed to establish if this
measure appears to have explanatory power about
leader’s decisions.
Positive Practices Survey
 29 items, 7 point Likert scale
 6 Factors






Caring
Compassionate support
Forgiveness
Inspiration
Meaning
Respect, integrity, and gratitude
 Administered online to 50 randomly selected employees from
each organization
 17 respondents from each organization, phone follow up with
additional 5 non-respondents from each organization
 44% overall response rate
Positive Practices Survey
 No significant differences between respondents and non-
respondents
 Comparing organizations
 No significant differences on all scales
 Forgiveness was very close to being significant different with Healthcare scoring
noticeably lower on this scale
 Small sample size did hamper power to detect 1 pt differences

Higher ed: impressive agreement on institutional mission & trust in
consensus as a decision making strategy.

Healthcare: multiple layers of authority & a significant conflict between
mission of patient care vs measured efficiency, efficacy and economic
outcomes
Some preliminary conclusions
 Moral eustress is significantly under studied.
 Moral distress and eustress may occur in the same moral
decision.
 Moral decisions engage and are influenced by the
individual, the unit and, where relevant, the larger
organization.
 Moral distress is currently defined and applied in health
care settings, almost exclusively. This pilot suggests it
can effectively illuminate moral decision making in other
settings as well.
 The Cascade provides a model for preparing future
leaders so they become skilled in identifying aspects of a
decision making process.
Questions to pursue
 Does the size and complexity of the organization
impact leaders’ moral decision making process and
outcome?
 Are decisions that deal with life and death
circumstances more likely to produce moral distress?
 Does institutional mission coherence inoculate
against moral distress?
Works cited

Cameron, K. S. (2003). Organizational Virtuousness and Performance. In
K. S. Cameron, J. E. Dutton & R. E. Quinn
(Eds.), Positive
organizational scholarship (pp. 48-65). San Francisco: Berrett-Koehler.
 Cameron, K., Mora, C., Leutscher, T.,& Calarco, M. (2011).Effects
of Positive Practices on Organizational Effectiveness. The
Journal of Applied Behavioral Science ,47, 266-308.
 Cohen, J., Tarule, J., Vallett, C., & Rambur, B. (2011). Stress and
the Workplace: Theories and Models of Organizational Stress.
InV. H. Rice (Ed). Handbook of stress, coping, and
health.
Thousand Oaks, CA: Sage Publications (in press).
 Czentmihalyi, M. (1990). Flow: The psychology of optimal
experience. New York, NY: Harper and Row.
 Dutton, J., Glynn, M. A., & Spreitzer, G. (2006). Positive
Organizational Scholarship. In J. H. Greenhaus & G. A.
Callanan (Eds.), Encyclopedia for career development: Sage
Publications.

, J., Vallett, C., & Rambur, B. (2011). Stress and the Workplace: Theories and Models of Organizational Stress. InV. H. Rice (Ed). Handbook of stress, coping,
and health. Thousand Oaks, CA: Sage Publications (in press).
Works cited (continued)
 Gilligan, C. (1982). In a different voice: Psychological theory and
women's
development. Cambridge, MA.: Harvard University Press.
 Kohlberg, L. (1984) The psychology of moral development. NY: Harper
 Rambur, B. A., Vallett, C., Cohen, J. A., & Tarule, J. M. (2010). The moral
cascade: Distress, eustress, and the virtuous organization. Journal of
Organizational Moral Psychology, 1(1), 1-14.
https://www.novapublishers.com/catalog/product_info.php?products_id=24686
 Rest, J., Narvacz, D., Bebeau, M. J., & Thoma, S. J. (1999). Postconventional
moral thinking: A neo-Kohlbergian approach. Mahway, N.J.: Erlbaum.
 Seligman & Csikszentmihalyi, M. (2000). Positive Psychology. American
Psychologist, 55, 5-14
 Seyle, H. (1974). Stress without distress. Philidelphia, PA: Lippincott.