Running head: NURSING AND MORAL COURAGE 1

Nursing and Moral Courage

Samantha Ricci-Weller

University of Saint Mary

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Abstract

This article focuses on moral courage, a concept that comprises the action of doing something

that is ethically correct even if there are adverse consequences, and how it applies to nursing.

The nursing field is filled to the brim with ethical dilemmas for its workforce and while some

nurses have no fear in standing up for what they believe is right, there are many nurses who

experience moral distress and choose to ignore their feelings. Moral courage is the key for nurses

who need to confront other medical professionals and take action, even when there might be

professional setbacks. In this article, moral distress and moral courage are defined, the history of

moral courage in nursing is explored, nursing’s relationship with moral courage is shown, how

fear and courage spread is explained, stories of moral courage from nurses who experienced it

are dissected, how fostering moral courage in the workplace affects nurses is inspected, and the

possible consequences of utilizing moral courage are presented.

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Nursing and Moral Courage

Every profession has its tools. Artists have brushes, writers have pencils, farmers have

tractors, but what does a nurse have? They have their education that creates the backbone for

their practice, they have laboratory tests that can guide their treatment, and they have a team of

medical professionals to help them out. But what happens when a team member makes the

wrong call? When the lab results, the education, and the instinct point to a different solution,

what helps a nurse make a stance? Who is going to protect the patient even if there are personal

or professional hindrances? Although nurses have many tools, the most important one is courage.

Nurses face ethical and moral crisis regularly in their line of work and each nurse acts

differently. Because these situations are never black and white, it can be hard to decipher what is

the right thing to do. Nurses see the patient as a whole because they provide direct and contribute

to the total care of a patient. They are often the last line of defense for a patient and when it’s

time to have moral courage, they don’t always come through. If something is the right thing to

do, nurses should do it. Nurses should understand what moral distress is, what moral courage is,

and how they are related. They should take pride in its deep history within nursing. Nurses

should see how indispensable of a skill it is how it relates to nursing. Nurses should be aware of

its power and how it can grow and spread. Nurses should be able to see the essentialness of

courage in their mission to provide complete patient-centered care by hearing stories of courage

from actual nurses. Lastly, nurses should understand the seriousness of the power of moral

courage by looking at its possible aftermath.

Medical teams are composed of highly skilled professionals who are excellent in their

area of expertise. It is when this team comes together that scientific reasoning and ethical

reasoning collide and are intermingled to create the best care plan for the patient as possible.
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However, their fatal flaw is that they are humans. If humans understand what is the right thing to

do, why is it so hard to do it? The first step into harnessing the power of moral courage is to

understand it. First there is the concept of moral distress. It is a very real dilemma in nursing and

is defined as painful or regretful feelings that come from the inability or the apprehensiveness of

not doing what is right (Gallagher 2011). When one feels that they have not given the

appropriate quality of care or failed to advocate for the patient, they experience moral distress.

Although it will not go away entirely, the only way to prevent or becalm moral distress is to have

moral courage. Moral courage is a habit developed when a person thinks and acts ethically with

confidence even when feelings of fear of retribution are present (Gallagher 2011). It isn’t a skill

one is just born with, it takes time and practice to cultivate moral courage. When a person acts

with moral courage when needed, it makes it easier to perform moral courage again. Moral

distress and moral courage do not cancel each other out, but rather balance each other.

Experiencing moral distress is an indicator that moral courage is needing to be utilized.

Even if courage seems difficult to obtain and understand, it is at the root of nursing and

has been for over a century. Florence Nightingale, the benefactor of what nursing is today,

demonstrated this concept when she treated injured soldiers in Crimea and Balaclava even

though her father argued against it (Biography.com 2014). She saw how the men were dying

from how their injuries were being treated and put a stop to it by establishing sanitary

precautions, regular clean dressing changes, and diets that encouraged healing (Biography.com

2014). She saw how her patients were suffering and decided to do something about it.

Nightingale applied this skill with such fortitude that it can still be looked upon as a great

example of courage to this day.

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The medical world in which nurses are a part of is filled with difficult ethical and moral

situations. Sometimes the ability to distinguish what is right and actually doing what is right can

be challenging. When personal beliefs and values come toe-to-toe with other medical

professional’s ideals and opinions, it can be easier to just walk the other way. However, when a

nurse needs to maintain the promise made to their patient and face the other team members head

on, a certain amount of moral courage is needed. To be able to have or use courage, it is a

necessity to understand what courage is. Because courage is such an undeveloped concept in the

world of nursing, it can contain many different aspects and actions in healthcare. Nurses are just

one aspect of a very complex team of individuals whose jobs are to make their patients better and

it is imperative that this team works seamlessly and cohesively. Although this team works as one

singular unit, a nurse must remain an individual identity to maintain a personal relationship with

the patient because they are the advocates for the patient. When a situation arises that makes a

nurse feel that actions taken by the team are inadequate or disadvantageous to the patient, it is a

nurse’s job to support the patient and address the issues with the other caregivers. It is the

boldness and braveness that moral courage gives nurses to be able to address ethical issues and

take action. Courage is what gives nurses the ability to make a choice, speak up, and face a

difficult situation. It allows the nurse to stand by their values and ideals even when it is to a

superior and the risk of adverse outcomes. If nurses understand the fearlessness and the

determination it takes to have moral courage and the idea is fostered in the medical setting, it will

prevent nurses from turning the other cheek to complicated circumstances and allow them to

fight for their patient.

Courage could be considered taking a moralistic chance and this can scare nurses into not

taking action. When tempers are running high in an intense situation and opposing points are
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made, nurses might encounter some resistance or backlash after confronting a fellow healthcare

professional. This causes anxiety and prevents nurses from utilizing this indispensable trait.

Nurses are the last line of defense for patients and if courage is absent when mistakes are made

or certain aspects of a patient’s case are overlooked, the outcomes can be poor. If one nurse feels

that they cannot stand up for their patient, the feelings of fear will spread. However, when a work

environment fosters and encourages its employees to have moral courage and be brave, that

spreads just as well as fear. According to Hawkins and Morse, taking actions that are for the

well-being of the patient lessons their pain and can advance the practice of nursing or a facility,

boost moral awareness, and reduce the worry of values being challenged (2014). Courage is

usually identified after the fact, but it is interwoven into all and affects all aspects of nursing.

As fast as fear can spread, so can courage and it is up to the institution to create the

environment that allows moral courage to grow in all of its employees. Those facilities that chose

to make a change saw some pretty amazing results. In 1983, it was recognized that the

institutions that could thrive in their high stress environment, had low staff turnover, had high

outcomes, had high patient satisfaction, and had low morbidity and mortality rates had instilled

policies and practices that created an environment that encouraged moral courage (LaSala &

Bjarnason 2010). When nurses felt like their thoughts are respected and welcomed, it wasn’t just

the nurses who had better outcomes but the hospitals also received magnate status (LaSala &

Bjarnason 2010). These hospitals put emphasis on creating better relationships and work

conditions for the medical providers and it worked. Taking care of their employees resulted in

people being happier with their jobs, the hospitals getting better statistics, and patients received

the quality of care they needed. To nurture a workplace environment that allows nurses to feel
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the ability to act on their moral distress with moral courage was not only ultimately better for the

nurses, but for the hospital and patients as well.

For the reason that nursing is a serious responsibility, courage can be called for in many

different and heated situations, even if it is not directly or initially realized. When tempers and

emotions are elevated and sensitive, many different outcomes may arise from using courage to

promote a patient’s needs or wants. Deb Spence tells the story of when she felt that the nurses of

a certain unit did not have the necessary skills or knowledge to take care of a seriously ill patient

and how the doctor agreed with her when she methodically created a rationale behind her stance

to not leave the patient on that floor (Spence & Smyth, 2007). In a perfect world, this

cooperation between a nurses and their superiors would work in the best interest of the patient

every time. However, that is not always the case. Liz Smyth follows with her story of how she

refused to inflict unnecessary pain to a patient just because the physician was in a hurry and the

subsequent reprimand and punishment she received (Spence & Smyth, 2007 pp. 44). Despite the

fact that standing up for a patient could lead to a personal set back, it ultimately will lead to

advancement of the nursing practice. It is easily seen in hind sight but can be strived for in the

future.

When discussing moral courage and the rights of patients, it is also important to keep

safety standards and legal implications in mind. Patient safety should come first for all medical

professionals. The goal of standards of care is to keep all patients and caregivers safe no matter

the illness or condition. They outline how to practice compassion and respect for all rights of the

patients and their families. They seek to maximize effectiveness of care and minimize accidents.

Although each patients care plan will be specifically unique to them and their needs, sometimes

we must step away from the clear path that safety standards draw. When this is needed, it should
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always be done with caution and thorough thought. There are also possible legal ramifications

when taking care of a patient away from hospital standards. The legal limitations of nursing are

led by community, state, and federal laws. So if a medical professional was to not only oppose

safety standards, but to also break a law, they could face legal repercussions (Alfaro-LeFevre

2017). It is important to consider as many factors as possible when deciding what is best for the

patient.

This article drew attention to moral distress and moral courage in the nursing field,

explained how courage has been in nursing from the very beginning, explored the relationship

between moral courage and nursing, analyzed how courage and fear can spread, experienced

actual stories of moral courage from nurses, and contemplated the possible aftermath of using

moral courage. The first step to integrating moral courage into one’s own practice or workplace

is to understand that nurses already have courage. It takes courage to be a nurse. It takes courage

to communicate in an unambiguous and commanding way. It takes courage to fight for someone

else even if it might hurt you. It is valued in the nursing community and sought out after. Nurses

should see the meaning behind courage, why it is a building block in the field, and how

important it is in healthcare. It belongs in nursing education and it belongs in professional texts.

Being a nurse without utilizing courage is like being a farmer who collects his crop without his

tractor or a write who refuses to use a pen. Courage is a tool to nursing as brush is a tool to an

artist… essential.
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References

Alfaro-Lefevre, R., RN, MSN, ANEF. (2017). Critical Thinking, Clinical Reasoning, and

Clinical Judgment (6th ed.). Philadelphia, PA: Elsevier.

Biography.com. (Ed.). (2014, July 8). Florence Nightingale Biography. Retrieved from

http://www.biography.com/people/florence-nightingale-9423539

Gallagher, A. (2011). Moral Distress and Moral Courage in Everyday Nursing Practice. Online

Journal Of Issues In Nursing, 16(2), 1. doi:10.3912/OJIN.Vol16No02PPT03

Hawkins, S. F., & Morse, J. (2014). The praxis of courage as a foundation for care. Journal Of

Nursing Scholarship, 46(4), 263-270. doi:10.1111/jnu.1207

LaSala, C., & Bjarnason, D. (2010). Creating workplace environments that support moral

courage. Online Journal Of Issues In Nursing, 15(3), 1.

doi:10.3912/OJIN.Vol15No03Man04

Spence, D., & Smythe, L. (2007). Courage as integral to advancing nursing practice. Nursing

Praxis In New Zealand, 23(2), 43-55. Retrieved from http://www.nursingpraxis.org/

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Appendix

Topic Paper Outline

Paragraph One: Introducing the topic of Moral Courage in Healthcare

Thesis: Nurses should understand what composes courage, how it relates to nursing, and

be able to identify the essentialness of courage in their mission to provide complete and patient-

centered care.

Paragraph Two: Defining important terms

Topic One: Define Moral Distress

Topic Two: Define Moral Courage

Topic Three: Describe the relationship between moral distress and moral courage.

Paragraph Three: History of Courage in Nursing

Topic One: Florence Nightingale

Paragraph Four: Moral Courage in Nursing

Topic One: The ability to speak.

Topic Two: The ability to make choices.

Topic Three: The ability to face challenges.

Paragraph Five: How fear and courage spread.

Topic One: Advocacy for a patient.

Topic Two: Courage and how it relates to outcomes.

Paragraph Six: Evaluating examples of courage in nursing.

Topic One: When courage works

Topic Two: When courage doesn’t work

Topic Three: How courage progresses nursing when nurses have courage.
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Paragraph Seven: Moral Courage in the Workplace

Topic One: Why they should

Topic Two: Results of those who have implanted moral courage

Paragraph Eight: Consequences of Moral Courage

Topic One: Safety Standards

Topic Two: Legal Implications

Paragraph Nine: Wrapping up the essay.