Patient advocacy requires nurses to support and protect their patients. Nurses often find themselves in ethically questionable situations that conflict with their personal and professional morals. Sometimes, speaking out for the patient requires 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 violated. This article provides an overview of moral courage, defines important terms, examines barriers to moral courage, discusses strategies for developing moral courage, reviews peer support and organizational cultures that support moral courage, and discusses whistle-blowing.

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 colleagues, 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 challenge 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 action is required. Thus, moral cour­age 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 conflicts 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 experience when her patient advocacy meets resistance or her moral courage is challenged. It also describes effective management strategies to help nurses resolve these problems. Julie, age 45, works in a tele­metry 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 respected 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 question everything Dr. Shoen does for Mr. Yarrow, her agitated semicomatose patient. Susan, in the meantime, speaks to Brenda, a new nurse graduate, about Mr. Yarrow’s apparent need for more sedation. She says she hesitates to ask Dr. Shoen for a sedative order because of her experiences with retaliation in similar circumstances. Brenda, who has studied moral courage at nursing school, finds it disheartening that an experienced 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, assesses him, speaks with Susan and Brenda, and validates their concerns about his care. With Brenda present, Julie talks with Susan about options for speaking up for what she believes is in the patient’s best interest. Julie presents the option of using objective data—namely, the SBAR (Situation-Background-Assessment-Recommendation) technique—to help resolve the situation. She role-plays with Susan how to approach 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 medication, and the patient is comfortable.” Later, Brenda tells Julie she’s grateful she had the opportunity to witness moral courage in action.

Barriers to showing moral courage

All healthcare organizations and professionals have a responsibility to uphold high ethical standards. But not all situations in which nurses advocate for patients turn out the way Susan’s did. Sometimes nurses face obstacles when advocating for patients, and some nurses may try to circumvent morally courageous behavior. Ethics experts have identified several barriers to morally courageous behavior:

• organizational culture, which sets the stage for how individuals respond to unethical behavior. In an organizational culture that eschews the interdisciplinary dialogue crucial to resolving unethical 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 standards if their organization tolerates unethical situations, preferring to avoid the risks of displaying moral courage. What’s more, some nurses may grow more reluctant to face the difficult challenge of confronting 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 behaviors occur, with subsequent loss of independent thinking
• preference for redefining unethical actions as acceptable. For example, 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 mne­monic CODE to help nurses recall the steps to take. (See CODE: The key to taking action in a dilemma by clicking the PDF icon above.)

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 information to determine whether a situation warrants further exploration.

O: Obligations to honor

The “O” in CODE stands for the nurse’s ethical obligation, as outlined in the Code of Ethics for Nurses from the American Nurses Association (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 compromised. Suppose, for example, that Wendy, RN, interprets Dr. Colton’s avoidance of a dying patient’s family 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 ethical 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 courageous? This step requires the use of cognitive approaches for emotional control and risk-aversion management. During this step, explore possible actions and consider adverse consequences associated with those actions. To avoid becoming overwhelmed when deciding how to act, focus on one or two critical values. In Wendy’s case, she focused on the values of autonomy and nonmaleficence. The cognitive reframing method helps a person learn to stop negative thought processes that interfere with effective analysis of a situation. By replacing negative thoughts with positive 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 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 uncertainties 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 expression and action through assertiveness 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 defensively when Wendy approaches him (“The family has been hostile to me since I started treating the patient”), 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, communication is open at all levels, policies and procedures support ethical practice, and leaders practice staff empowerment. Empowerment creates a positive work environment through such structures as professional 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 crucial conversations with all healthcare team members. A crucial conversation 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, demonstrating the crucial conversation Susan needed to initiate with Dr. Shoen to make Mr. Yarrow more comfortable.

Peer support

Nurses can increase their effectiveness 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 effect of putting direct pressure on dissenters not to oppose the group’s views. Peer support helps leaders understand that more than one staff member supports morally courageous action. Even when other colleagues may disagree with a courageous 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 offered Susan her unsolicited support. Suppose, for example, a nurse is asked to get a signed consent form from a patient who’s about to undergo a nonurgent but essential operation (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. She calls the surgeon and expresses reluctance to get consent in this circumstance; the surgeon becomes angry and tells her to “get the consent anyway.” The operating-room nurse also is bothered by this interruption in the schedule, but chooses to support her peer’s courage in advocating for her patient. This additional peer support helps reassure the courageous nurse to continue to “do the right thing” despite clear opposition. In this way, peer support for nurses’ efforts to exhibit moral courage can improve the effectiveness of individual attempts. Nursing environments that foster peer support are highly desirable.

When is whistle-blowing necessary?

If a healthcare organization fails to put in place the necessary mechanisms for internal resolution of patient safety and quality concerns, whistle-blowing may be necessary for patient advocacy. Demonstrating 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. Nursing’s Social Policy Statement from ANA provides additional direction on how nurses should conduct themselves in an ethical and responsible manner toward those they care for. Nurses have a responsibility to report unsafe, unethical, or illegal behaviors to individuals 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 patient’s pain management with Dr. Schoen. However, in situations where internal resources have been exhausted (as when complaints to a compliance hotline and senior administrators go unheeded), whistleblowing becomes a nurse’s ethical obligation. When the organization fails to address unethical conduct, the nurse must go outside the organization for help. Susan collected all the facts and used her internal resources effectively. However, if Dr. Schoen had continued to resist and discount her opinions and the hospital had refused to address the potentially 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 colleagues 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 whistleblowers, staff members who otherwise might be reluctant to be morally 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 by clicking the PDF icon above.) To develop moral sensitivity, nurses must take the time to reflect not only on their personal and professional values but on their moral obligations. They need to become more “present” in the situation to better understand their own perspective and their patients’ situations. Administrators must create and support a culture that fosters moral courage—one with clear policies on conscientious objection, acknowledging and addressing a staff members’ moral distress, and encouraging peer support for the courageous 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 by clicking the PDF icon above.)

Education on moral courage

All healthcare professionals should be educated in demonstrating moral courage in the face of ethical challenges. Although much has been written on nursing intuitiveness, knowing how to demonstrate moral courage and create an organizational culture that fosters empowerment may not be so intuitive. For this reason, educational strategies should be used both in nursing care settings and academia. Nurses must learn the language of ethics, moral reasoning, and moral courage—and how to approach the moral dilemmas they may encounter. Role-playing is one strategy for 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 standards 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 academia, strategies exist to help nurses gain knowledge about ethics—for instance, discussion of a case and application 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 graduate 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 committees that offer consultation and can be called on to provide education. Workshops can be given on specific ethical subjects or case presentations. Nurse managers should play a role in requesting or promoting ethics educational opportunities in the workplace. (See Online resources on moral courage by clicking the PDF icon above.)

Policies related to moral courage

Healthcare organizations need to create policies that support nurses in demonstrating moral courage without fear of reprisal. Policy is imperative to enhancing healthcare workers’ 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 created 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 uphold 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 toward creating environments that value and support moral courage.

Selected references

American Association of Critical-Care Nurses. Ethics in Acute & Critical Care Nursing. 2012. www.aacn.org:88/wd/practice/content/ethicmainpage.pcms?menu=practice. Accessed March 27, 2012.

American Nurses Association. Code of Ethics for Nurses with Interpretive Statements. Author: Silver Spring, Maryland; 2001.

American Nurses Association. Code of Ethics for Nurses with Interpretive Statements. Author: Silver Spring, Maryland; 2001. http://nursingworld.org/MainMenuCategories/EthicsStandards/CodeofEthicsforNurses/Code-of-Ethics-For-Nurses.html Accessed March 27. 2012.

Catlin AJ, Armig C, Volet D, et al. Conscientious objection: a possible nursing response to care at the end of life which is harmful, causes suffering, or torture. Neonatal Netw. 2008;27(2):101-8.

Institute for Healthcare Improvement. SBAR technique for communication: A situational briefing model. 2011. www.ihi.org/knowledge/Pages/Tools/SBARTechniqueforCommunicationASituationalBriefingM odel.aspx. Accessed March 27, 2012.

Hodkinson K. How should a nurse approach truth-telling? A virtue ethics perspective. Nurs Philos. 2008 Oct;9(4):248-56.

Iseminger K, Levitt F, Kirk L. Healing during existential moments: the “art” of nursing presence. Nurs Clin North Am. 2009 Dec:44(4):447-59.

Lachman VD, ed. Applied Ethics in Nursing. New York, NY: Springer; 2006.

Lachman VD. Ethical Challenges in Healthcare: Developing Your Moral Compass. New York, NY: Springer; 2009.

Lachman VD. Moral courage: a virtue in need of development? Medsurg Nurs. 2007 Apr;16(2):131-3.

Laschinger HK, Finegan J, Wilk P. Context matters: the impact of unit leadership and empowerment on nurses’ organizational commitment. J Nurs Adm. 2009 May;39(5):228-35.

Murray JS. Before blowing the whistle, learn to protect yourself. Am Nurs Today. 2007;2(3):40-2.

Murray JS. Moral courage in healthcare: acting ethically even in the presence of risk. OJIN. 2010;15(3):Manuscript 2.

Murray JS. The Paul Revere Freedom to Warn Act: legislation to protect federal whistleblowers from retaliation. Am J Nurs. 2008 Mar;108(3):38-9. doi:10.1097/01.NAJ.0000312253.48872.56.

Patterson K, Grenny J, McMillan R, Switzler A. Crucial Conversations: Tools for Talking When Stakes are High. 2nd ed. New York, NY: McGraw-Hill; 2011.

A clinical professor who teaches ethics, Vicki D. Lachman is also a track coordinator for the Innovation and Intra/Entrepreneurship program in advanced practice nursing at Drexel University in Philadelphia, Pennsylvania. John S. Murray is the director of nursing research, 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. Kathryn M. Ganske is director and associate professor of the Division of Nursing at Shenandoah University in Winchester, Virginia.