Moral Courage

Nursing continues to be the most trusted of professions (Norman, 2016, cited in DeSimone 2019). As a profession, nursing cannot separate itself from moral/ethical intent and behavior. Nursing educators therefore have a huge responsibility for building a strong moral and ethical foundation upon which future nurses will build their practice.

Moral courage is the ability to stand up for and practice that which one considers ethical, moral behavior when faced with a dilemma, even if it means going against countervailing pressure to do otherwise. Those with moral courage resolve to “do the right thing” even if it puts them at personal risk of losing employment, isolation from peers and other negative consequences. One should stand up for what is right even if it means standing alone (Murray, 2010). According to former Senator from Maine Margaret Chase Smith: The right way is not always the popular and easy way. Standing for right when it is unpopular is a true test of moral character.

One should not confuse moral courage with moral arrogance or moral certitude. Individual, social, and cultural values may differ, so it is important to have open, respectful communication (Murray, 2010) While the values of honesty, integrity, fairness, compassion and respect seem to be universal, different cultures might prioritize them differently.

Nurses need moral courage to assure quality care and safety of patients, to interact with other healthcare professionals and to advocate for consistent universal care with healthcare and community organizations (Pajakoski, 2021). Moral courage is needed to deal with unethical, unsafe or discriminatory practices (Murray, 2010).

To clarify the elements of moral courage, Numminen et al. (2016) analyzed literature and arrived at these attributes: true presence, moral integrity, responsibility, honesty, advocacy, commitment and perseverance, and personal risk. Antecedents were ethical sensitivity, conscience, and experience. Consequences included personal and professional development and empowerment (Numminen et al., 2016)

Table 2. Critical Checkpoints in using Moral Courage for Ethical Decision Making
Steps	Checkpoint
1	Evaluate the circumstances to establish whether moral courage is needed in the situation
2	Determine what moral values and ethical principles are at risk or in question of being compromised
3	Ascertain what principles need to be expressed and defended in the situation – focus on one or two of the more critical values
4	Consider the possible adverse consequences/risks associated with taking action
5	Assess whether or not the adversity can be endured – determine what support/resources are available
6	Avoid stumbling blocks that might restrain moral courage, such as apprehension or over reflection leading to reasoning oneself out of being morally courageous in the situation
7	Continue to develop moral courage through education, training, and practice

(Adapted from Kidder, 2005)

He further makes us aware of impediments to exercising moral courage:

Table 3. Inhibitors of Moral Courage

Organizational cultures that stifle discussion regarding unethical behaviors and tolerate unethical acts

Willingness to compromise personal and professional standards in order to avoid social isolation from peers or to secure a promotion/favoritism within the organization

Unwillingness to face the tough challenge of addressing unethical behaviors

Indifference to ethical values

Apathy of bystanders who lack the moral courage to take action

Group think that supports a united decision to turn the other way when unethical behaviors are taking place

Tendency to redefine unethical behaviors as acceptable

(Adapted from Kidder, 2005)

Lachman (2010) has written extensively about the virtue of moral courage. To bolster the teaching and ability to act with moral courage, she suggests the following using the acronym CODE:

Courage to be moral requires:
Obligations to honor (What is the right thing to do?)
Danger management (What do I need to handle my fear?)
Expression and action (What action do I need to take to maintain my integrity?)

She discusses strategies for overcoming risk-aversion and fear in order to speak out and “do what’s right.”

Reflections:

Questions and exercises to consider with classmates and/or colleagues:

Courage means overcoming fear - fear of failure, fear of ostracism, fear of being wrong. Identify which aspects of clinical care cause you most fear. What do you do to overcome that fear?
What do you fear most in interpersonal interaction? How do you overcome that fear in order to manage difficult discussions?
Could we say the staff who opposed the openness and kind of care being given on 5B were exhibiting moral courage?

Helpful Resources

Learn How to Cultivate Moral Courage
Blog post by Senior Policy Advisor Liz Stokes for Healthy Nurse Healthy Nation

Moral Courage

Reflections:

Helpful Resources

Recommended Readings & Viewings