Building an Ethical Practice: Culture, Leadership and Resilience in Eye Care

Ethical culture as an organisational concept has been well-researched historically in business settings but only more recently in the healthcare professions.^{1, 2, 3} Studies and literature highlighting the pressures that unethical organisational behaviours can place on the health and wellbeing of practitioners in the eye care professions have only recently garnered greater attention.^{4, 5, 6, 7}

Insights into the consequences of organisational pressures placed on eye care professionals have revealed numerous cases of dissatisfaction, increased stress levels and burnout, which in turn can lead to negative health consequences for the public they serve.^{5, 7}

Several approaches have been suggested in an attempt to mitigate the effects of stress and subsequent cases of burnout amongst health professionals.^{2, 4, 7} The most evident approach would be the reduction of the top-down organisational pressure which often places profit motives at the forefront of business decisions. In a capitalist society, however, where healthcare is being increasingly commodified, a blanket approach such as this is not only an extremely naive pipedream but decidedly impractical and highly unlikely to be engaged. Other approaches, perhaps driven from the ground up, need to be explored if realistic positive ethical changes are to be achieved in the healthcare professions.

If healthcare practices and organisations are to uphold and strengthen their moral standards and maintain public trust in their integrity, including values of empathy, compassion, and professionalism, then it is imperative that attention be directed toward the ethicality or otherwise of the prevailing organisational cultures that exist in those professions.

There are several systematic tools professions can utilise to curtail the emergence or potential continuance of unethical practices. This article looks at the concept of an ethical culture and the roles that ethical leadership and ethical resilience have to play in helping to shape that culture in eye care practices.

Ethical culture

Ethical culture can be referred to as the principles of right and wrong in an organisational context.³ These principles create an environment wherein the (un)ethical behaviours of managers and employees can be explained and predicted.³ Conscious actions are required by an organisation's leadership to foster the emergence and continued application of desired ethical norms.^{3, 8}

Research shows that organisations or practices with a strong positive ethical culture will have numerous competitive advantages irrespective of the industry or profession.^{3, 6, 9} Ethical organisations tend to attract talented and innovative people and instil a greater sense of pride among their employees.³ Ethical practices build organisational trust and promote workplace security and employee productivity.³ Financially, a positive ethical culture can lead to significant value for an organisation.³

Conversely, a negative ethical culture can have deleterious effects not only on employees but on the organisation as a whole.^{5, 6} Clinician burnout resulting from negative organisational cultures has received significant research of late.^{6, 7, 8} Employees who consistently have to juggle between their values and those of their organisation are particularly susceptible to stressful situations and the potential engagement in morally questionable behaviours. One such behaviour, labelled unethical pro-organisational behaviour (UPOB), refers to unethical actions that are engaged in to further the interests of the organisation.¹ Employees who engage in UPOB seek to enhance their own professional or organisational standing by promoting their employer's interests, but do so in an unethical manner.¹ This behaviour deviates from societal values and norms and may occur with or without the knowledge of higher management or the organisational leadership.^{1, 6}

Discussion will now turn to two factors that can mediate and impact the ethical culture of an organisation: ethical leadership and ethical resilience.

Ethical leadership

An ethical leader is one who, through teaching and modelling, fosters the practice of proper ethical decisions and actions in those under their leadership.^{6, 8} This type of leadership provides standards and clarity of purpose to employees when encountering difficult ethical decisions that may arise from their normal daily activities or from higher managerial directives.^{6, 8} Good ethical leadership acts as a buffer against unethical organisational practices.

Social learning theory suggests that ethical leaders can influence the moral behaviour of society and individuals by modelling values such as sincerity, reliability and moral obligation.⁸ Ethical leaders encourage knowledge-sharing and instil a sense of trust, which has been shown to influence job satisfaction and employee engagement at work.⁸

To reduce ethical strain in an organisation, ethical leaders should facilitate, prioritise and enable the means with which employees can act in accordance with ethical expectations. For example, an ethical leader may encourage employees to read and sign an ethical policy document that highlights ways in which to deal with ethically difficult circumstances at work. Role play of specific scenarios with corresponding group discussion could also be enacted.

In an eye care setting in particular, an ethical leader may periodically remind employees of the overriding moral purpose to provide quality eye care, of the need to place patients' eye health requirements before those of profitability, and provide examples with desired resolutions.

The actions of an ethical leader can act to decrease the moral stress experienced by employees. When employees have a clear idea of what the ethical expectations of their role entail, they are less likely to suffer stressful effects when they encounter potentially problematic ethical situations.³

Ethical resilience

In a workplace setting, ethical resilience, also known as ethical efficacy, relates to an employee's ability to deal with the ethical dilemmas and strain they encounter as a result of their work demands and/or organisational pressures.^{3, 6, 10} Ethical stress arises when the demands and expectations of an environment exceed an individual's coping resources.^{3, 10} Lower levels of ethical resilience can lead to both psychological and physical health problems due to an employee's lack of ability to adequately deal with these ethical pressures.⁶ Employee health problems often lead to a decrease in work performance, which in turn adversely affects the organisation.⁶

For individuals working in an organisation, one of the main sources of ethical strain arises from a lack of consistency between an employee's ethical values and those of their employer.⁹ Social psychologists refer to this conflict in values as cognitive dissonance, a theory which explains that it is a human trait for individuals to aspire to behave in ways that are consistent with their beliefs.⁹ Thus, employees who encounter more situations that challenge their ethical resilience will be at greater risk of stress, burnout and/or enacting unethical behaviours.⁵

Organisations may test employees' ethical resilience through their control over promotions, bonuses and job security, for example.⁹ Furthermore, employees may also see colleagues being rewarded for morally questionable behaviours and view these behaviours as necessary for praise or advancement.⁹

Suggestions

So how can we improve ethical culture in the eye care professions? How can we encourage ethical leadership and improve ethical resilience among practitioners?

Organisations need to provide the means and leadership to reduce uncertainty when employees are faced with ethical issues.³ Policies and procedures that clearly set out expected ethical norms should be readily accessible in every organisation and reinforced by an ethical leadership.

How do you identify an ethical leader, or how do you foster one? According to Junaidi, ethical leaders "make just and reasonable decisions and define success in terms of both the results and the methods used to accomplish them".⁸ Ethical leaders are a strong tool for organisational success and competitive advantage. Identifying or employing such a leader may prove to be difficult but ultimately worthwhile. To avoid potential inherent bias, organisations may be best served seeking external aid for this endeavour. There are numerous companies and educational tools that exist to assist in this.

Ethical resilience, and the recognition and strengthening of it in individuals, is an equally difficult yet important enterprise. Dzau states that the "health system cannot sustain current rates of clinician burnout and continue to deliver safe, high-quality care".⁵ People are not born with an innate sense of right or wrong. This has to be nurtured over time and requires sustained effort.¹¹ Therefore an organisation that has a genuine interest in its employees' health and productivity (which in turn enhances organisational success) will invest time and resources into developing, enabling and supporting its employees to make their ethical decisions in a more moderated and agreeable manner.^{3, 11}

Conclusion

Individuals and organisations have to make ethical decisions on a daily basis. Eye care professionals and their employers need to establish and enact strong moral codes in order to deliver the highest quality care for the public they serve. Without constant vigilance, eye care professions may subconsciously risk neglecting the underlying ethical values of primary healthcare and subsequently lose public trust.

One conspicuous observation is that, as a profession, we have to acknowledge that there may be a problem in the first place. We can't fix something that we cannot or do not wish to see.

Every decision we make matters.

_{This article was first published online by mivision on 3 July 2026, and is republished with permission.}