Moral Courage – what is it and why do nurses need it?

Researching and discussing moral courage has become a strong focus of my nursing career.  I have previously written about my personal experiences which have motivated me to take this path, as well as how I believe moral courage can help drive culture change.  Over the next few months, I will be posting a series of blogs on moral courage and sharing the results of some of the research I have completed as part of my honours and PhD (which I started this year).

Today, I thought it would be good to talk about the term ‘moral courage’, what it means and (briefly) why it is so important to nursing.  Let’s start with a definition.  Sam Manekshaw defined moral courage as “the ability to distinguish right from wrong and having so distinguished it, be prepared to say so, irrespective of the views held by your superiors or subordinates and of consequences to yourself.”  In simple terms, it is doing what you believe is the right thing, despite the risk of negative consequences.  Morally courageous individuals believe that upholding their core values is worth exposing themselves to repercussions such as social ostracising, embarrassment or loss of employment.

Moral courage needs to be distinguished from physical courage.  Putting yourself at risk of physical harm to help others or for a greater purpose, such as those who serve in our armed forces or a parent protecting a child from an attack, requires physical courage.  The consequences of the action, which may even include death, are limited to a physical injury.

In situations where moral courage is required, the consequences are not physical. They could include though, putting a friend offside or losing the friendship entirely, being excluded from social or work groups, or even being fired.  At the time of taking action it is often difficult to predict what the actual consequences will be, their severity and how long they will last.

A great example is the 1968 Olympics when Tommie Smith and John Carlos gave what was referred to as the ‘black power salute’ during their medal presentation to bring attention to the plight of African-Americans in the US.  The Australian with them, Peter Norman, after discussions with Smith and Carlos, wore a pin that supported their cause.  This action did not put them in immediate physical danger.  It did however have other consequences, including being booed by the crowd as they left the stadium.  Smith and Carlos were both kicked out of the Olympic village and when they returned home, were ostracised by the US sporting community.  Time magazine described their action as ‘Angrier, nastier, uglier’ and they were both subjected to abuse and death threats.  Norman also faced backlash for his part and was heavily criticised by the Australian media. (Side note – In 2012, Australia formally apologized to Norman, with one MP telling Parliament that Norman’s gesture “was a moment of heroism and humility that advanced international awareness for racial inequality.”)

There are also situations that require a mixture of physical and moral courage. For example, the protestors in China’s Tiananmen Square in 1989.  The protestors were clearly in physical danger – they were shot at and others arrested and then executed. There were also unknown other consequences – would their families be penalised? Would they be ostracised by the community when they returned home? Would they be fired if their employers found out?  Many protesters faced these ramifications, which while not causing physical injury, had a large negative impact on their lives. 

How does this relate to nursing?  Moral courage is seen as a critical virtue for nurses and crucial to safe and professional practice.  It is no secret that patients get hurt when receiving health care.  According to WHO, one in ten patients are harmed whilst receiving health care and 43 MILLION patient safety incidents happen every year around the world.  Nurses are one of the most vital safety points for their patients.  Virginia Henderson said, “we are the mouthpiece for those too weak or withdrawn to speak” and this is where moral courage becomes so important.  It is moral courage which gives us the will and determination to speak up when something is not right.  When we witness ethical misconduct, are pressured to conform with unsafe practices or are asked to perform a task unsupervised that we don’t feel competent doing, moral courage allows us to face our fears, weather the consequences and say something. 

While above I have focused on why moral courage is essential for patient safety, it is also crucial for our own safety.  Some of the biggest issues we are facing in nursing – bullying or horizontal violence, safe workloads/ patient to nurse ratios, increasing violence from patients and/or their families – these all require us to speak out and advocate for ourselves. Moral courage helps us do this and not accept unacceptable working conditions.

Now let’s put this into context using a straight-forward example.  Imagine it is the first time working on a new ward and you sign out a Schedule 8 med with a colleague. When you leave the med room to give it to the patient, the other nurse says, ‘you go and give it, we don’t worry about both going on this ward’.  You know what the correct action is – both nurses to the bedside and administer/witness together – so what do you do?  Moral courage helps you to speak up and say, ‘actually I would like you to come with me if you don’t mind’ (or something similar).  But what are the consequences for this action? It could be nothing – colleague says, ‘sure no problem’ and goes with you. It could be positive – colleague says ‘you’re right we should both go, thanks’. It could also be negative. It could result in being belittled – ‘oh you’re just new and don’t know how it works’ – or being berated – ‘just get on with it would you, I don’t have time to hold your hand’ – or being bullied – ‘are you too stupid to be able to do it by yourself’.  It could also then have a longer-term impact – colleagues avoiding doing S8s with you again, or being ostracised on the ward etc.  The point is, at the time of the action, you do not know what response you will get but you do know what the right action to take is, and this is why it takes moral courage to speak up in the first place.

Moral courage lets us speak up and take action even when there might be negative consequences, or when we do not know what the consequences will be. It helps us advocate for our patients. It helps us advocate for our colleagues. It helps us stand up for ourselves. It can help us change the culture, not only of our work place, but the nursing profession.  This is why I am passionate about moral courage and teaching nurses and nursing students how to build their moral courage and use it. Nurses make up more than half of the health work force.  So, if we can demonstrate moral courage and support our colleagues when they do as well, imagine the positive impact we could have on health care.

(If you would like to read the full literature review with references, the published journal article can be found at – Collegian article )

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