Healthy Nurse, Healthy Nation™ Blog - Learn How To Cultivate Moral Courage
Director of ANA's Center for Ethics and Human Rights, Liz Stokes, PhD, JD, MA, RN, explains why moral courage is important for nurses and how to cultivate it.
As nurses, not only do we care for our patients on a daily basis, but we also have to advocate for them, especially when they can’t do so for themselves. That’s where moral courage comes into play. While moral distress refers to uncomfortable feelings that arise when we’re unable to do what we believe is right for our patients, moral courage involves the willingness to speak up and overcome that feeling of powerlessness.
Moral courage in action
You’ve probably heard of Alex Wubbels, the head nurse at the University of Utah Hospital’s burn unit. A video of her refusing to let a Salt Lake City police detective draw blood from a badly injured patient while he was unconscious was released in September.
“She’s a perfect example of moral courage. She spoke up, had the moral courage to say ‘no, I'm advocating for my patient, and I will not let you violate my patient’s rights,’” says ANA’s Senior Policy Advisor Liz Stokes, JD, MA, RN.
Stokes explains that even though the outcome of Wubbels’ actions was not favorable at the time – the detective shouted at her, shoved her, and forced her into handcuffs – public perception of her actions has been overwhelmingly supportive. After all, the story has already increased awareness of the importance of patients’ rights and the rights of the healthcare workers who care for them.
Since moral courage can take different forms, here are some other real-life examples:
- An anonymous Navy nurse exerted his ethical right to discontinue forcibly feeding a detainee in Guantanamo Bay. He defied military orders because it was a violation of his code of ethics. Despite threats from the military that he’d be dismissed and lose his benefits, after an investigation, he was able to keep his military status.
- Krista Shalda, a North Carolina nurse, called the police after multiple reports that a nursing assistant had sexually assaulted residents in her workplace. When Shalda reported the concerns to her supervisor, she was encouraged not to notify the police. Shalda called the police and reported the incidents even though her job was at stake. The nursing assistant was found guilty and convicted.
- Even Stokes herself recalls a situation where she had to draw upon her own moral courage early in her nursing career. A suspected rapist was going into cardiac arrest and needed CPR. None of her colleagues were initiating CPR, so Stokes began it herself and then others followed suit. Their combined efforts saved his life. Stokes didn’t know his backstory at the time, but even if she did, “your first priority is to provide care to your patient without judgment,” she says.
Barriers prevent nurses from acting morally courageous
Even when something doesn’t feel right – or when we want to take action on an issue – sometimes we don’t speak up because we fear the repercussions. “Nurses may be scared they'll be fired, demoted, or reprimanded in some way. They may also worry about being bullied by their co-workers. Moral courage is overcoming these fears and speaking up for the patient’s best interest,” says Stokes.
How to develop moral courage
In order to display moral courage, the ethical awareness and sensitivity to analyze and respond to a moral problem. Nurses must commit to act in an ethical manner as well as follow the profession’s code of ethics.
“Nurses need to learn to identify, strengthen, and develop their self-efficacy. They need to recognize their value to patients and to the entire health care operation,” says Stokes.
Vicki D. Lachman, PhD, MBE, APRN, FAAN, created a framework that nurses can use to exhibit moral courage and resilience in the face of ethical challenges. The acronym for it is “C.O.D.E.”
Courage to be moral requires:
- Obligations to honor: What is the right thing to do?
- Danger to manage: What do I need to handle my fear and uncertainty?
- Expression and action: What action is needed to meet my obligations to the patient and to maintain my integrity?
How hospitals can support the moral courage of their nurses
It’s in a hospital’s best interest to have a staff that is adept in moral courage and moral resilience. When the nursing community doesn’t have that, they’re likely to experience moral distress, which can lead to burnout or compassion fatigue, and even nurses leaving the organization or profession altogether. “The cost of nursing turnover ranges, but it's in the thousands of dollars and is very costly for hospitals,” says Stokes.
Hospitals and organizations can take the following steps to circumvent that:
- Incorporate programs that develop the moral courage and resilience of the staff.
- Develop nurses’ ethical confidence through continuing education programs or nurse residency programs.
- Create an environment where nurses feel safe to speak up.
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American Nurses Association. (2015). Code of Ethics for Nurses with Interpretive Statements. Retrieved August 02, 2017, from http://www.nursingworld.org/codeofethics
Hawkins, D. (2017, September 02). ‘This is crazy,’ sobs Utah hospital nurse as cop roughs her up, arrests her for doing her job. Retrieved September 11, 2017, from https://www.washingtonpost.com/news/morning-mix/wp/2017/09/01/this-is-crazy-sobs-utah-hospital-nurse-as-cop-roughs-her-up-arrests-her-for-doing-her-job/?utm_term=.d64a3e296c18