24 American Nurse Today Volume 7, Number 5 www.AmericanNurseToday.com
PATIENT ADVOCACY requires nurses to support and protect their patients. Nurses often find themselves in ethically ques- tionable situations that conflict with their personal and profes- sional morals. Sometimes, speaking out for the patient re- quires them to demonstrate moral courage—for instance, in the face of conflicting loyalties, in highly charged conflict situations, or when the patient’s rights are being violat- ed. This article provides an overview of moral courage, defines important terms, examines barriers to moral courage, discusses strategies for de- veloping moral courage, reviews peer support and organizational cul- tures that support moral courage, and discusses whistleblowing.
Defining key terms Moral courage is the willingness to stand up for and act according to one’s ethical beliefs when moral principles are threatened, regardless of the perceived or actual risks (such as stress, anxiety, isolation from col- leagues, or threats to employment). Moral distress occurs when nurses feel powerless to act after witnessing improper behavior, if organizational constraints make doing the right thing difficult or impossible. Ultimately, these situations chal-
lenge one’s sense of virtue, which involves acting in accordance with one’s moral and ethical principles. Moral courage is a virtue and needs to be developed (as does emotional intelligence) to determine when ac- tion is required. Thus, moral cour- age is linked to virtue ethics, which emphasizes the role of character rather than doing one’s duty to bring about good consequences.
Virtue ethics appreciates that con- flicts occur and that more than just moral wisdom is needed to ensure a moral outcome.
Case scenario: Susan’s dilemma The following scenario illustrates the moral distress a nurse may experi- ence when her patient advocacy meets resistance or her moral cour- age is challenged. It also describes
effective management strategies to help nurses resolve these problems. Julie, age 45, works in a teleme- try unit at a university medical center. A registered nurse (RN) for 20 years, she is now a charge nurse on the 7 A.M.-to- 7 P.M. shift. She has an in-depth understanding of the goings-on at her hospital and is highly re-
spected by her peers. This weekend, Julie is busy as
usual when Dr. Shoen, an attending physician, tells her she’s unhappy with Susan, a staff nurse. According to Dr. Shoen, Susan seems to ques- tion everything Dr. Shoen does for Mr. Yarrow, her agitated semico- matose patient. Susan, in the meantime, speaks
to Brenda, a new nurse graduate, about Mr. Yarrow’s apparent need for more sedation. She says she hes- itates to ask Dr. Shoen for a sedative order because of her experiences with retaliation in similar circum- stances. Brenda, who has studied moral courage at nursing school, finds it disheartening that an experi- enced nurse like Susan seems to lack the courage to speak her mind about a patient’s care because she fears negative consequences. She recognizes that Susan’s concern over her patient needs to be elevated, and finds Julie to tell her Susan might need help. After Brenda speaks with Julie,
Julie enters Mr. Yarrow’s room, as- sesses him, speaks with Susan and Brenda, and validates their concerns about his care. With Brenda pres- ent, Julie talks with Susan about op- tions for speaking up for what she believes is in the patient’s best inter- est. Julie presents the option of us- ing objective data—namely, the
DOING THE RIGHT THING: Pathways to moral courage
Learn how to prepare yourself for the ethical and moral dilemmas you’re likely to encounter in the workplace.
LEARNING OBJECTIVES 1. Define moral courage.
2. Identify barriers to demonstrating moral courage.
3. Discuss strategies for developing moral courage.
The authors and planners of this CNE activity have disclosed no relevant financial relationships with any commercial companies pertaining to this activ- ity. See the last page of the article to learn how to earn CE credit.
CE 1.6 contact
hours
By Vicki D. Lachman, PhD, APRN, MBE, FAAN; John S. Murray, PhD, RN, CPNP, CS, FAAN; Karen Iseminger, PhD, FNP; and Kathryn M. Ganske, PhD, RN
www.AmericanNurseToday.com May 2012 American Nurse Today 25
SBAR (Situation-Background-Assess- ment-Recommendation) technique— to help resolve the situation. She role-plays with Susan how to ap- proach team members when she has a concern about patient care, and suggests she use the technique with Dr. Shoen. Taking Julie’s advice, Susan
speaks to Dr. Shoen. An hour later, she tells Julie, “It’s always been hard for me to step forward and say something when I know a patient should be getting better care. But the technique you showed me helped me present the facts to Dr. Shoen in a professional way without making her feel threatened. Now she understands the need for med- ication, and the patient is comfort- able.” Later, Brenda tells Julie she’s grateful she had the opportunity to witness moral courage in action.
Barriers to showingmoral courage All healthcare organizations and pro- fessionals have a responsibility to up- hold high ethical standards. But not all situations in which nurses advo- cate for patients turn out the way Su- san’s did. Sometimes nurses face ob- stacles when advocating for patients, and some nurses may try to circum- vent morally courageous behavior. Ethics experts have identified
several barriers to morally coura- geous behavior: • organizational culture, which sets the stage for how individuals re- spond to unethical behavior. In an organizational culture that es- chews the interdisciplinary dia- logue crucial to resolving unethi- cal behavior or that disregards unethical actions, staff may shy away from morally courageous behavior. Also, some nurses may be willing to compromise their personal and professional stan- dards if their organization tolerates unethical situations, preferring to avoid the risks of displaying moral courage. What’s more, some nurs- es may grow more reluctant to
face the difficult challenge of con- fronting unethical behaviors.
• lack of concern by colleagues who don’t have the moral courage to take action
• groupthink, in which individuals collectively decide to look the other way when unethical behav- iors occur, with subsequent loss of independent thinking
• preference for redefining unethical actions as acceptable. For exam- ple, a nurse observes, but pretends not to see, two nurses repeatedly documenting narcotic wastage by cosigning each other’s name.
CODE: An aid to demonstrating moral courage Remembering what actions to take when you face a moral dilemma can be emotionally and cognitively difficult. Vicki Lachman, a coauthor of this article, developed the mne- monic CODE to help nurses recall the steps to take. (See CODE: The key to taking action in a dilemma.)
C: Courage The first step is to critically evaluate the situation to determine whether moral courage is needed to address it. Morally courageous people know how to use affective and objective in- formation to determine whether a sit- uation warrants further exploration.
O: Obligations to honor The “O” in CODE stands for the nurse’s ethical obligation, as out- lined in the Code of Ethics for Nurs- es from the American Nurses Asso- ciation (ANA). When caught in a moral dilemma, you should self- impose a purposeful time-out for reflection to help determine what
moral values and ethical principles are at risk or are being compro- mised. Suppose, for example, that Wendy, RN, interprets Dr. Colton’s avoidance of a dying patient’s fami- ly as a lack of compassion. During a time-out, she comes to see that by avoiding delivering bad news to the family, Dr. Colton is dishonoring the patient’s autonomy. She decides to approach the situation from an ethi- cal stance and avoid a judgmental communication. She considers: What’s the right thing to do? What principles need to be expressed and defended in this situation?
D: Danger management The “D” in CODE stands for danger: What do you need to do to manage your fear of being morally coura- geous? This step requires the use of cognitive approaches for emotional control and risk-aversion manage- ment. During this step, explore pos- sible actions and consider adverse consequences associated with those actions. To avoid becoming over- whelmed when deciding how to act, focus on one or two critical val- ues. In Wendy’s case, she focused on the values of autonomy and nonmaleficence. The cognitive re- framing method helps a person learn to stop negative thought processes that interfere with effec- tive analysis of a situation. By re- placing negative thoughts with posi- tive self-talk, you can focus on viewing the situation clearly. Equally important, strive to avoid
stumbling blocks that might impede moral courage, such as apprehension or overreflection; these responses might make you “reason” yourself out of the risk of taking morally
CODE: The key to taking action in a dilemma When you face a moral dilemma, use the CODE mnemonic to help you recall what steps to take. C Courage: Determine if moral courage is needed to address the situation. O Obligations to honor: Take a time-out to reflect on your ethical obligations and
determine what moral values or ethical principles are at risk in the situation. D Dangermanagement: Use cognitive approaches to handle your fear and risk
aversion. E Expression: Express your beliefs and take action through assertiveness.
26 American Nurse Today Volume 7, Number 5 www.AmericanNurseToday.com
courageous action. If Wendy uses positive self-talk (“I can approach Dr. Colton and support the family by discussing with him how to deliver the bad news”), she’s more likely to take morally courageous action than she would if she used negative self- talk (“He’ll never listen to me”). Self-soothing is another way to
promote risk taking. Risk-avoidant nurses tend to overvalue uncertain- ties and undervalue the chance of reaching a desired outcome. Risk- preference nurses do the opposite. To self-soothe, use deep-breathing and other techniques that reduce physiologic arousal of fear.
E: Expression The “E” in CODE denotes expres- sion and action through assertive- ness and negotiation skills. Knowing one’s obligations and demonstrating specific behaviors can enable you to move past your fear and serve as an effective patient advocate, as Susan did in our case scenario. To avoid blocks to exercising moral courage, nurses need to develop moral courage through education and practice, and to use the tools they learn in making everyday decisions. This helps them develop morally courageous behaviors even before an ethical dilemma occurs. The negative assertion technique
is one example of a tool that nurses can use. If Dr. Colton responds de- fensively when Wendy approaches him (“The family has been hostile to me since I started treating the pa- tient”), she should first state which part of his response she agrees with, and then tell him which part she disagrees with. So she might say, “You’re right. The family has been hostile to you in the past. But we still have the ethical obligation to keep communicating about their mother’s deteriorating condition.”
Organizational cultures that support moral courage In an organization whose culture supports moral courage, communi-
cation is open at all levels, policies and procedures support ethical practice, and leaders practice staff empowerment. Empowerment cre- ates a positive work environment through such structures as profes- sional practice models and shared governance, as well as participation in ethics committees. Leaders must ensure these structures are used to make individual and organizational accountability expected behaviors. In organizations that advocate
accountability, managers must have the moral courage to generate cru- cial conversations with all health- care team members. A crucial con- versation is a discussion between two or more people where the stakes are high, opinions vary, and emotions run strong. For example, Julie, the charge nurse in our case scenario, role-modeled the needed communication to resolve Susan’s conflict with Dr. Shoen, demonstrat- ing the crucial conversation Susan needed to initiate with Dr. Shoen to make Mr. Yarrow more comfortable.
Peer support Nurses can increase their effective- ness as change agents by using peer support when they need to exercise
moral courage for patient advocacy. Interventions to protect patient safety and improve the quality of care and health outcomes are enhanced when morally courageous nurses elicit peer support for advocacy endeavors. This helps combat the groupthink ef- fect of putting direct pressure on dis- senters not to oppose the group’s views. Peer support helps leaders understand that more than one staff member supports morally coura- geous action. Even when other col- leagues may disagree with a coura- geous nurse who speaks up for a cause, nurses should be expected to support their peers’ right to address tough issues and problematic clinical situations. In our case scenario, Brenda sought peer support from Julie in handling the conflict and of- fered Susan her unsolicited support. Suppose, for example, a nurse is
asked to get a signed consent form from a patient who’s about to un- dergo a nonurgent but essential op- eration (such as open reduction or internal fixation of the femur). But based on her assessment, the nurse determines the patient is cognitively impaired (which is an acute change) and has no family members who could care for her postoperatively.
Wanted: More research on moral courage Some research on moral distress exists, but little of it addresses moral courage. What we know about moral courage is mostly anecdotal, based on the experiences of those who’ve encountered unethical behaviors and used moral courage to ad- dress and attempt to resolve their distress.
To develop the science of moral courage, research is needed to explore: • nurses’ experiences with moral courage—especially nurses who’ve been consci-
entious objectors or whistleblowers • characteristics of nurses who show moral courage, indicated by standing up for
ethical beliefs, confronting an ethical issue head on, and speaking out and do- ing the right thing even when others don’t
• effects of moral courage on healthcare delivery • factors that promote and inhibit moral courage • effectiveness of various strategies and frameworks for developing and sustain-
ing moral courage.
Tremendous opportunities exist to develop empirically supported interventions related to moral courage. Interventions used to date have been based on personal observations and experiences, and these remain untested. We need to advance the scientific knowledge base of moral courage and develop and test interventions to help nurses demonstrate resolve when confronted with ethical dilemmas. Toward this end, research programs related to ethics must receive adequate funding.
www.AmericanNurseToday.com May 2012 American Nurse Today 27
She calls the surgeon and expresses reluctance to get consent in this cir- cumstance; the surgeon becomes an- gry and tells her to “get the consent anyway.” The operating-room nurse also is bothered by this interruption in the schedule, but chooses to sup- port her peer’s courage in advocat- ing for her patient. This additional peer support helps reassure the courageous nurse to continue to “do the right thing” despite clear opposi- tion. In this way, peer support for nurses’ efforts to exhibit moral courage can improve the effective- ness of individual attempts. Nursing environments that foster peer sup- port are highly desirable.
When is whistleblowing necessary? If a healthcare organization fails to put in place the necessary mecha- nisms for internal resolution of pa- tient safety and quality concerns, whistleblowing may be necessary for patient advocacy. Demonstrat- ing moral courage means taking personal and professional risks; every nurse should understand this. But nurses also need to recognize their responsibility to uphold the ethical principles that guide nurses’ professional behavior, as outlined in the ANA Code of Ethics. Nurs- ing’s Social Policy Statement from ANA provides additional direction on how nurses should conduct themselves in an ethical and re- sponsible manner toward those they care for. Nurses have a re- sponsibility to report unsafe, uneth- ical, or illegal behaviors to individu- als within an organization who are in a position to stop these behaviors. In Susan’s case, she was able to
obtain the help she needed from a manager (Julie) to address her pa- tient’s pain management with Dr. Schoen. However, in situations where internal resources have been exhausted (as when complaints to a compliance hotline and senior ad- ministrators go unheeded), whistle- blowing becomes a nurse’s ethical
obligation. When the organization fails to address unethical conduct, the nurse must go outside the organ- ization for help. Susan collected all the facts and used her internal re- sources effectively. However, if Dr. Schoen had continued to resist and discount her opinions and the hospi- tal had refused to address the poten- tially ineffective pain management, Susan would have been obligated to complain to the medical board and possibly consider resigning and seeking employment elsewhere. Nurses must play a pivotal role in
promoting ethical environments— those where they and their col- leagues believe they can be morally courageous and come forward with their concerns. In ethical workplaces with protection policies and a clear means for addressing concerns, where colleagues support whistle- blowers, staff members who other- wise might be reluctant to be moral- ly courageous feel more empowered to speak up.
Recommendations for practice, education, research, and policy Nurses need to identify scenarios where they should demonstrate moral courage. Depending on the individual nurse’s role, these may include clinical, education, research, or policy scenarios. (See Wanted: More research on moral courage.) To develop moral sensitivity, nurs-
es must take the time to reflect not only on their personal and profes- sional values but on their moral obli- gations. They need to become more “present” in the situation to better un- derstand their own perspective and their patients’ situations. Administra- tors must create and support a culture that fosters moral courage—one with clear policies on conscientious objec- tion, acknowledging and addressing a staff members’ moral distress, and en- couraging peer support for the coura- geous nurse. Furthermore, bedside nurses and nursing administrators should use ethical decision-making practices to resolve value-based conflicts that lead to moral distress. (See Conscientious objection.)
Education on moral courage All healthcare professionals should be educated in demonstrating moral courage in the face of ethical chal- lenges. Although much has been written on nursing intuitiveness, knowing how to demonstrate moral courage and create an organization- al culture that fosters empowerment may not be so intuitive. For this rea- son, educational strategies should be used both in nursing care set- tings and academia. Nurses must learn the language of ethics, moral reasoning, and moral courage—and how to approach the moral dilem- mas they may encounter. Role-playing is one strategy for
Conscientious objection When you find yourself in circumstances that exceed your moral limits or jeopard- ize your professional standards, you have both the right and obligation to express your conscientious objection. Conscientious objection has been associated mainly with the military but is gaining more attention in health care.
A healthcare worker may express conscientious objection by abstaining from offering certain types of care to which he or she has moral objections. For example, in our case scenario, Susan recognized the need to speak up when she perceived the plan of care for her patient lacked appropriate sedation. She believed the plan was morally objectionable because it violated beneficence (an action to benefit the patient). Believing her patient’s well-being was in jeopardy, she didn’t yield to the physician’s preference.
Some healthcare organizations have policies related to conscientious objection for medical personnel. To familiarize yourself with these guidelines, see the American Nurses Association’s Code of Ethics for Nurses, Provision 5.4: Preservation of integrity.
28 American Nurse Today Volume 7, Number 5 www.AmericanNurseToday.com
learning new behaviors in difficult situations. This technique places nurses in dialogue pairs where they play out a scenario they’re given— for instance, a difficult but necessary conversation about maintaining stan- dards rather than cutting corners, or how to approach senior personnel or physicians when concerned about a patient’s plan of care. This can make nurses better equipped to demonstrate moral courage when difficult situations arise. In both the workplace and acade-
mia, strategies exist to help nurses gain knowledge about ethics—for in- stance, discussion of a case and appli- cation of Code of Ethics provisions to the case; also, use of simulation with a standardized patient experiencing a violation of privacy or autonomy. Nursing educational curricula include ethics in both baccalaureate and grad- uate programs. Many schools have in- depth courses that give students time to learn the language of ethics and ethical reasoning, which helps in day- to-day practice. Nurses who think they lack the tools to handle difficult situations in daily practice can tap into webinars, nursing literature, and other continuing-education offerings. Also, most hospitals have ethics com- mittees that offer consultation and can be called on to provide educa- tion. Workshops can be given on specific ethical subjects or case pre- sentations. Nurse managers should play a role in requesting or promot- ing ethics educational opportunities in the workplace. (See Online re- sources on moral courage.)
Policies related to moral courage Healthcare organizations need to create policies that support nurses in demonstrating moral courage with- out fear of reprisal. Policy is impera- tive to enhancing healthcare work- ers’ ability to respond appropriately to unethical behaviors. All nurses should become staunch advocates of creating and implementing such policies. Leaders must recognize the importance of moral courage.
Support moral courage The dynamic changes in health care over the past few decades have cre- ated increasingly complex moral and ethical dilemmas, some of which call on nurses to demonstrate moral courage. Addressing such dilemmas and acting appropriately are never easy. But nurses are accountable for providing the best possible patient care. Advocating for a patient’s best interest can pose challenges and risks, but nurses must resolve to up- hold their ethical obligations. The increasing number of publications on moral courage underscores the need for an ongoing conversation among nurses in all roles and across all settings to commit to working to- ward creating environments that val- ue and support moral courage. �
Selected references American Nurses Association. Code of Ethics for Nurses with Interpretive Statements. Au- thor: Silver Spring, Maryland; 2001. http://
nursingworld.org/MainMenuCategories/Ethic sStandards/CodeofEthicsforNurses/Code-of- Ethics.pdf. Accessed March 27. 2012.
American Nurses Association. Nursing’s Social Policy Statement: The Essence of the Profession. (3rd ed.) Author; Silver Spring, Maryland; 2010.
Lachman VD, ed. Applied Ethics in Nursing. New York, NY: Springer; 2006.
Lachman VD. Moral courage: a virtue in need of development? Medsurg Nurs. 2007 Apr;16(2):131-3.
Murray JS. Moral courage in healthcare: act- ing ethically even in the presence of risk. OJIN. 2010;15(3):Manuscript 2.
Visit www.AmericanNurseToday.com/Archives .aspx for a complete list of selected references.
A clinical professor who teaches ethics, Vicki D. Lach- man is also a track coordinator for the Innovation and Intra/Entrepreneurship program in advanced practice nursing at Drexel University in Philadelphia, Pennsyl- vania. John S. Murray is the director of nursing re- search, Surgical Programs/Emergency Department, at Children’s Hospital Boston in Boston, Massachusetts. Karen Iseminger is director of ethics at St. Vincent Health in Indianapolis, Indiana. KathrynM. Ganske is director and associate professor of the Division of Nurs- ing at Shenandoah University inWinchester, Virginia.
Online resources on moral courage To learn more about moral courage, visit the following websites.
American Nurses Association Center for Ethics & Human Rights (short definitions of ethical principles and theories)
www.nursingworld.org/MainMenuCategories/EthicsStandards/Resources/ Ethics-Definitions.pdf
American Nurses Association Code of Ethics for Nurses www.nursingworld.org/MainMenuCategories/ EthicsStandards/Codeof
EthicsforNurses.aspx
American Society for Bioethics & Humanities www.asbh.org
Foundation for Moral Courage www.moralcourage.org
Institute for Global Ethics www.globalethics.org
Moral Courage Amid Moral Distress: Strategies for Action (The Online Journal of Issues in Nursing)
http://nursingworld.org/MainMenuCategories/ANAMarketplace/ANA Periodicals/OJIN/JournalTopics/Moral-Courage-Amid-Moral-Distress.aspx
Moral Courage Project www.moralcourage.com
Nursing Social Policy Statement www.nursesbooks.org/Main-Menu/Foundation/Foundation-of-Nursing-
Package.aspx
www.AmericanNurseToday.com May 2012 American Nurse Today 29
Please mark the correct answer online.
1. Willingness to stand up for and act according to one’s ethical beliefs when moral principles are threatened, regardless of the perceived or actual risks, is known as:
a. standard. b. virtue. c. moral distress. d. moral courage.
2. Situations that threaten a person’s moral or ethical principles may challenge one’s sense of:
a. standard. b. virtue. c. moral distress. d. moral courage.
3. Rather than emphasizing doing one’s duty to bring about good consequences, virtue ethics emphasizes the role of:
a. principles. b. character. c. standards. d. courage.
4. Individuals collectively deciding to look the other way when unethical behaviors occur is called:
a. moral distress. b. moral courage. c. group analysis. d. groupthink.
5. One characteristic of an organizational culture that supports morally courageous behavior is:
a. redefining unethical actions. b. groupthink. c. group analysis. d. interdisciplinary dialogue.
6. The first step to take when facing a moral dilemma is to:
a. determine if moral courage is needed to address the situation.
b. reflect on what ethical principles are at risk.
c. use cognitive approaches to handle your fear and risk aversion.
d. express your beliefs and take action through assertiveness and negotiation skills.
7. Danger management refers to: a. determining if moral courage is needed
to address the situation. b. taking a time-out to reflect on your
ethical obligations and determine what moral values or ethical principles are at risk.
c. using cognitive approaches to handle your fear and risk aversion.
d. expressing your beliefs and taking action through assertiveness and negotiation skills.
8. When caught in a moral dilemma, taking a time-out allows you to:
a. reflect on your obligation to show moral courage.
b. reflect on your ethical obligation. c. manage your danger. d. manage your actions.
9. An example of a strategy for cognitive reframing that nurses can use to help manage the fear of being morally courageous is:
a. positive self-talk. b. overreflection. c. deep breathing. d. autonomy.
10. One nurse states, “The charge nurse is always late and doesn’t care what we think.” The second nurse responds, “You’re right. The charge nurse is usually late. But I don’t think that means she doesn’t care about our input.”This exchange is an example of:
a. overreflection. b. positive self-talk. c. negative assertion. d. positive assertion.
11. A dialogue between two or more people where the stakes are high, opinions vary, and emotions run strong is called:
a. a crucial conversation. b. a crucial exchange. c. a negative assertion. d. a positive assertion.
12. If an organization fails to resolve a situation that puts patients at risk, the nurse may have to:
a. go against Nursing’s Social Policy Statement.
b. go against the ANA Code of Ethics. c. become a whistleblower. d. drop her complaint.
13. Which statement about moral courage and education is correct?
a. Ethics education should be reserved for graduate school education.
b. Role playing is not a valuable tool for education about moral courage.
c. An ethics committee can provide education and consultation.
d. Policies should be avoided because they constrain decision making.
14. A nurse decides to abstain from providing care that she or he objects to on a moral basis. This action is called:
a. conscientious objection. b. CODE analysis. c. moral distress. d. virtue ethics.
POST-TEST • Doing the right thing: Pathways to moral courage Earn contact hour credit online at www.americannursetoday.com/ContinuingEducation.aspx (ANT120501)
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PURPOSE/GOAL To provide the information nurses need to act with moral courage
LEARNING OBJECTIVES 1. Define moral courage. 2. Identify barriers to demonstrating moral courage. 3. Discuss strategies for developing moral courage.
