The impact of institutional ethics on academic health sciences library leadership : a survey of academic health sciences library directors

Ethical behavior in libraries goes beyond service to users. Academic health sciences library directors may need to adhere to the ethical guidelines and rules of their institutions. Does the unique environment of an academic health center imply different ethical considerations? Do the ethical policies of institutions affect these library leaders? Do their personal ethical considerations have an impact as well? In December 2013, a survey regarding the impact of institutional ethics was sent to the director members of the Association of Academic Health Sciences Libraries. The objective was to determine the impact of institutional ethics on these leaders, whether through personal conviction or institutional imperative.


INTRODUCTION
In 2010, former Medical Library Association (MLA) President Mary L. Ryan, AHIP, FMLA, asked in an editorial published in the Journal of the Medical Library Association, "Does It Really Matter Who's Paying for Dinner?" [1].For health sciences librarians, that editorial summarized many of the ethical challenges facing our association, our profession, our institu tions, and us.The editorial aptly noted that many of the challenges overlap, and lines between and among ethical issues and decisions can be blurred.
Terms such as conflict of interest, values, and professionalism are often used interchangeably in discussions surrounding ethics.Searching "definition of ethics" on Google yields a definition stating that ethics are "moral principles that govern a person's or group's behavior" [2], Synonyms include values, moral code, ideals, principles, standards, virtues, conscience, and other interrelated concepts.The definition provided through Google also contains a very interesting graphical representation of use of the word "ethics" over time.This representation was done using the Google Ngram Viewer, which graphs word or phrase usage.The "ethics" graph shows a more than 1,000% increase in the occurrence and usage of the word from 1800 to 2008 [2].In question 5 of the survey conducted for this article, over 57% of respondents indicated that within the last 5 years, there had been an increased emphasis on ethics in their institutions (Table 1).
Major professional library organizations such as the American Library Association, the American Associ ation of Law Libraries, and MLA have published codes of ethics or ethical principles [3][4][5].These codes tend to focus, according to Barsh and Lisewski, "nearly exclusively on how these key values relate to librarians' roles as information specialists, and primarily on the library's role in service to patrons" [6].Espousing concepts of confidentiality, personal neutrality, privacy, quality, and equity of access, the wording is often outward facing.In contrast, MLA's Code of Ethics for Health Sciences Librarianship has a section titled "Self," with two items focused beyond the concept of ethical service to users.The first item relates to "developing and maintaining professional excellence."The second section states, "The health sciences librarian shall be alert to and adhere to his or her institution's code of ethics and its conflict of interest, disclosure, and gift policies" [5].
This second statement has relevance and bears further reflection because academic health sciences libraries and their leaders are not only governed by their professions' ethics, but also operate within academic health centers.Encouraged by the Associ ation of American Medical Colleges (AAMC) and the National Institutes of Health, academic health centers have adopted ethics and conflict-of-interest policies and standards as public and political scrutiny of corporate influence, particularly of research, has increased [7,8].Thus, these large, complex institu tions often have well-articulated codes of conduct and ethics applying to administrators and faculty.Many state institutions of higher education also require adherence to state-level ethics and to con flict-of-interest policies for elected and public offi cials [9].
What is the intersection and impact of these policies on academic health sciences libraries and library directors?As leaders in these institutions, what are their thoughts about ethics?Have academic health sciences library directors acknowledged and adopted these policies?Are they accountable for supporting and complying with these policies?What methods do they use to do that?Do they have a responsibility for modeling ethical behavior and encouraging the same in the library staff?Querying the Association of Academic Health Sciences Libraries (AAHSL) direc tors regarding these questions accomplished two things.First, these questions revealed if academic health sciences library directors are expected or even required to know about, support, and adhere to institutional ethical guidelines or rules.Second, directors' thoughts and convictions regarding person al accountability and responsibility as leaders were examined.A third, less obvious issue is raised: the ethics of being a leader, perhaps creating a pause for introspection and reflection on the topic.

T a b le 1
Questionnaire on institutional impacts on ethics and ethical leadership

METHODS
AAHSL <http: / / www.aahsl.org>represents libraries in institutions with allopathic medical schools that are AAMC members.In early December of 2013, a survey of twelve questions, reviewed and approved by the Institutional Review Board for the Social and Behav ioral Sciences at the University of Virginia, was distributed through the "Directors Only" email discus sion list to the directors of AAHSL libraries.A reminder to complete the survey by early January was sent in mid-December.Directors were invited to participate in a survey to determine the extent to which institutional ethics played a role in the work of academic health sciences library directors.Directors were advised not to include any information regarding individuals or institutions that could be used to make assumptions of identity even though some of the questions had open-ended responses.All responses were voluntary, and the results would be kept anonymous.
The questions provided directors an opportunity to share their knowledge and awareness of ethics as related to their leadership, understanding of institu tional requirements, personal revelations regarding ethics and ethical situations, knowledge transfer to library staff, and needs for future information on the topic.Seven of the twelve questions offered opportu nities for additional comments on the questions.The questions were developed to focus on five broad themes: the importance of ethics to the work of an academic health sciences library director, communi cation of institutional ethics to staff, personal ethical conflicts, institutional ethical challenges, and the most important aspects of ethics in academic health sciences leadership.Comments were analyzed by frequency, and comments were tagged or categorized into the broad themes examined.

RESULTS
At the time of the survey, 169 people were on the AAHSL Director list.Fifty-six responses were re ceived for a response rate of a little over 33%.Questions, response frequencies, and numbers of comments are shown in Table 1.The comments from all questions were aggregated, reviewed, analyzed, and grouped according to the themes mentioned above.

Importance of ethics
One hundred percent of the directors believed ethics were important to their work as a director (Table 1).Of the 30 comments made in this category, 60% (18) were tagged as relating to trust and integrity.The second largest category, representing 20% (6), were tagged as role modeling.Sample comments include: "Ethics effect [sic] everything-moral, expenses, interstaff relationships to name a few." "Leadership requires trust and there can be no trust without ethical behavior." "Ethics are a foundation of our services.If we have ethic [sic] policies in place, employees don't have to guess, they know how to respond.""As one's ethics has an effect on all areas of one's life, one's work life is no different.""Being able to sleep at night and look others in the eye with a clear conscience is very important to me." "Sets example for others.Establishes trust and credibility for the library director and library staff with others outside the library." "I believe directors model the behavior they want in their organizations.There is so much change happening, we need some 'true north' in figuring out approaches and choices.Considering the ethics is an important piece of that.""Ethics are critical for anyone in a leadership position, because (1) our roles as leaders give us considerable authority (financial, organizational, etc.) so there are many potential opportunities for ethical dilemmas; (2) we have considerable influence, especially with those who report to us, so ethical lapses on our parts can have serious consequences for other people as our own institutions; and (3) as leaders, we are models for others in the organization, so our behavior must be above reproach."

Communication of institutional ethics
As institutional and library leaders, academic health sciences library directors have responsibility for conveying institutional ethics rules to staff.When queried regarding methods for conveying institu tional ethics policies to staff, 71% of the respondents cited institutional or campus communications, train ing, and policies.A smaller percentage (17%) commented on library or departmentally focused communications and training.Interestingly, 6% commented that ethics policies at their institutions pertained only to faculty and that their librarians were excluded from the policies since they did not have faculty status.Several comments indicated multiple points of contact regarding conveying institutional ethical rules and expected behaviors, which included both institutional channels as well as reinforcement at the library.Samples of comments include: "Email notifications from the campus.Campus publica tions.Rules about accepting meals, gifts, etc., are conveyed before conferences, meetings, etc." "All professional/academic staff must fill out a report of external professional activities, which raises awareness.We also have guidelines on what we may accept from vendors, etc. Supervisors work with individuals to ensure rules are followed.""All faculty, along with staff who have control over business decisions/purchasing, are required to sign detailed conflict of interest [COI] statements...Those who have responsibility for grant funding must complete training and additional COI forms.I am also required to personally submit a detailed report annually.""I remind them of the policy annually, and we're all required to complete forms for outside employment, gifts, etc., annually.""I have meetings with librarians and senior managers to discuss ethics.""We have a list of Guiding Principals [sic] one of which is Represent the Library's ethic of honesty, integrity, and trust.This ethic is brought up on a regular basis."

Personal ethical conflicts
Question 9 focused specifically on whether or not directors had ever felt conflicted in their own behaviors or decision making.Answers to this question were almost evenly split, and 18% answered that they were not sure.There were 13 comments about this question, most of which fell into the categories of vendor relations (30%), personnel issues (30%), licensed resources (15%), and other (15%).Directors provided specific examples of where these conflicts had occurred.These examples included: "Many times, but it depends on how you define ethics.I've been conflicted about providing truthful references for employees/former employees, about the ethics of allocating resources to staff for travel, etc." "Have faced only minor decisions rather than challenges.Things like whether to disclose something told in confi dence to others who should know, whether to reveal the name of someone when discussing a tricky situation, etc." "Nothing major, but as a director, I have lots of vendors offering to take me to lunch or dinner, especially at conferences.In general I don't accept but pay for my own meals to avoid any idea that I can be bought.""I have discussed the ethics of being 'wined and dined' by vendors with my faculty and staff.Some are not happy that they cannot take meals or other perks from vendors, and that they cannot have objects at work with vendor names on them, etc." "One area that confounds me is the lack of clarity in our eresource licenses and also copyright principles.""There have been situations where I felt pretty confident about what needed to be done but I had to do some educating so that others understood."

Institutional ethical challenges
Sixty-one percent of the directors said they had been affected by a lack of ethical behavior on the part of someone else (Table 1).There were 10 comments for question 10, 40% of which were categorized as having to do with integrity and trust.Other categories, with 1 comment each, included confidentiality, vendor rela tions, and financial issues.These comments reflected the day-to-day challenges in the library and the complex nature of institutional politics and culture.Comments also illustrated observations of unethical behavior that was beyond the control of the library director.One commenter expressed incredulity at university library colleagues' lack of ethical behavior, citing observations of university library staff accept ing gifts and dinners from vendors.
"I am always shocked when someone doesn't have the same ethical or moral compass as I do.Just this past year I was faced with a situation where someone at a higher level used his authority to attempt to get library staff reassigned to him...Quite frankly it was the most fatiguing, wearing and discouraging thing I have ever professionally experienced.I had to believe that telling the truth would win in the end.""I have observed people in leadership treating others without civility, which to me is an ethics problem.I have also observed people in leadership allowing their friends to have a level of access that does not correlate with their positions on the org chart.""Librarians discussing details of reference requests anec dotally.Residents discussing patient conditions in a casual setting were they could be overheard.""Watching our main campus librarians being taken out to lunch (or dinner) while we were in the midst of a huge contract negotiation.Their flippant attitude about it NOT being a problem when discussing about a $500,000 contract and that they deserved it, somewhat stunned me." "I have seen employees try to finagle expense reports or time off.I have also seen embezzlement and unorthodox purchasing decisions.Anything within my control-I have corrected."

Most important aspects of ethical leadership
Analysis of comments on the most important aspect of ethical leadership for academic health sciences library leaders revealed 2 major themes for the responses.Fifty-six percent of the respondents com mented on trust and integrity, and 36% focused on role modeling.This open-ended question led to over 40 comments.The remaining 8% fell into other categories.This question illustrated deep commit ments to personal and professional ethics.The comments suggested an understanding of the power and influence held by a director as a leader and role model and of the responsibility entrusted to each library leader.Some comments also illustrated the direct connection academic health sciences library leaders felt with the missions of their institutions and health care.
"Being honest and treating others with respect and fairness would be my number one goal.""Living with myself is probably the most important, but as a leader, as I said above, library staff must have trust that the director will act ethically.""It's hard to pick just one area, so I'll go with the one that I think can be the most damaging when ignored.We need to be acutely aware about the power we hold, especially power over others who report to us.We need to be sure to treat those over whom we have power in a way that is civil, respectful, and completely honorable in every way.It isn't about being nice, it's about not abusing personal power, even accidentally.""In the health sciences, ethical leadership is important because influence can affect the lives and health of those entrusted to our care.Each person on a health sciences campus has a responsibility to act at the highest level of ethical behavior.""Treating individuals fairly and without bias.That does not mean you treat everyone the same, but that you have

DISCUSSION
The objective of this survey was to determine the impact of institutional ethics rules on leaders of academic health sciences libraries.Certain questions specifically asked about increased institutional em phasis on ethics, institutional ethics statements, policies, and ethics training.These questions were straightforward.In some institutions, ethics policies only applied to administrators and faculty.Does this mean library directors and staff are exempt from these institutions' ethical policies and behavior?Are only faculty expected to be ethical?Analysis of the comments showed ethics seem to be foundational, underpinning the work of academic health sciences directors.One respondent wondered whether questioning ethics was even valid.
A few comments were made regarding the inter pretation and application of institutional ethics in general academic libraries.Is there a difference in ethical considerations between these two types of libraries?Differences in the culture, mission, and business models might account for the differences between a solely academic community and an academic health center.In an academic health care environment, the focus is often on revenue generation and cost recovery, and the "business" is supported by clinical care and research.Perhaps there is a greater emphasis on and awareness of conflict-of-interest issues, especially if patient care or quality research is compromised.
Surveys such as this raise additional questions and illuminate other areas for discussion.Throughout the survey, the directors responded strongly regarding the importance of ethical leadership and overwhelmingly felt they were ethical people.Since there was not 100% participation by the AAHSL directors, perhaps many directors do not feel that ethics are a concern.Or perhaps it could be inferred from the comments that ethics are both a personal and foundational issue, one that is fundamental to "standard operating procedure" and central to the way they function as directors.
In response to question 11, "Do you believe you would benefit from learning more about the ethics of leadership?," more than 60% of the respondents answered "yes" or "yes, very much."The responses to this question and insights from the comments indicated interest in the topic and could inform directions for further education and programming regarding issues and impacts of ethical behavior in academic leadership roles.While AAHSL does not have continuing education courses similar to those of MLA, there is programming at its annual meeting.There might be an opportunity to develop program ming or frame a discussion around the topic of personal and institutional leadership ethics.
An additional survey could be considered.Ques tions could include strategies for conveying ethical standards to staff.Are ethical standards for a director the same as those for a library staff member?Is there anyone who could or should accept dinners from a vendor?How about pens or canvas bags?What are the consequences of unethical behavior?Are there ethical leadership differences between what academic health sciences librarians and their academic col leagues consider appropriate ethical behavior?What are the differences in these environments?Another important component could be scenarios rating ethical situations, on a scale measuring ethical severity, and allowing commentary.A second survey could provide additional information regarding be liefs about acceptable ethical behavior and could explore many different nuances and directions.

CONCLUSION AND IMPLICATIONS
This survey revealed that academic health sciences library director respondents considered themselves fundamentally ethical people.A need to be personally ethical and serve as a role model was expressed along with a responsibility for creating a workplace that supports ethical behavior.Considering the health care environment in which these directors work, this is to be expected, as institutions of this type have focused more and more on ethics in the education, research, and clinical enterprises.As leaders in these enterpris es, library directors would be expected to adhere to the same ethical standards as those of other institu tional leaders.This survey is a starting point for more in-depth future discussions.
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The impact of institutional ethics reasons you can clearly communicate about why differences may exist.""Adhering to ethical standards both with library staff, with peers, and with administrators, no matter what.It provides a solid example for others.""Talk the talk and walk the walk.The fakers can be spotted virtually and 10 ft.away."