As experienced nurses, none of us would dispute the importance of moral courage in health care, particularly as interventions become more complex and inequities in care delivery abound. We are all acutely aware. Yet, in our experiences as nurse educators, we are often challenged to make examples of moral courage among health care providers real enough so that they are meaningful to students. We teach our students about moral distress, as we all know much about the consequences of the dilemmas nurses encounter in ethically challenging situations and moral distress is often discussed in nursing practice. But do we adequately prepare students to have moral courage?
I recently participated in the development of a leadership program in which moral courage was considered an essential topic for nurse leaders. The experience made me think about how we address moral courage in our basic programs - the programs that prepare the nurses who will deliver the most care to the largest number of persons. Do we adequately address moral courage in all of our clinical courses, or is the discussion reserved for special courses in ethics and leadership? Naturally, this question led me to the literature on moral courage among nursing students. I wanted to know what was already known.
Moral courage is an expectation in nursing. Our obligation to society as professional nurses requires that we speak up when we know that care is wrong, unjustified, inequitable, and/or when it counters patient and family wishes. Our obligations to the public are clearly outlined in the American Nurses Association's (2015) Code of Ethics. Moral courage requires nurses to stand up for what is right, despite the risks and the potential consequences. Risks can include stress, anxiety, isolation from colleagues, and even threats of termination of employment (Lachman, Murray, Iseminger, & Ganske, 2012).
Bickhoff and colleagues (2017) published the most recent paper on the topic, and their conclusion is not as positive as we might desire. In their review of 15 studies from 2004 onward, these researchers concluded that we have much work to do to empower students to act in situations that require moral courage. They found that most students, despite feeling a moral obligation to act, lacked the moral courage to intervene or, at a minimum, to speak up when confronted with practice situations that were clearly evidence of poor practice. Students who remained bystanders at the time of the event described the poor practice at a later time. The major themes identified in this research review included just a student, don't rock the boat, fear of consequences, mentor-student relationship, and patient advocate identity.
For all of us as nurse educators, the good news is that there is important information about how we can best prepare our students to demonstrate moral courage. Teaching through case scenarios, including the use of simulation to illustrate the case, is especially effective. Those new to the profession learn from the experiencea of others, and we can script these experiences in care scenarios. It also is important to embed nursing ethics in all nursing clinical courses, rather than as a stand-alone course only.
Students need to understand that they will experience ethical challenges throughout their careers, independent of the context and patient population.Lachman and colleagues (2012) use CODE as a mnemonic for teaching students. C stands for courage, O for obligation to honor, D for danger and danger management, and E for expression, both in word and deed. As nurse faculty, we must embrace these four principles so that we can teach our students to be morally courageous.
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