Moral Courage

I’ve recently gone back to Uni and begun a research project looking at demonstrations of moral courage by undergraduate nursing students. This led me to reflect on a time when, as a student, I failed my patient.

It was my very first placement and I was beyond excited, but also very nervous, having never done any type of nursing before. During the first week, I was caring for a lovely older lady, who I’ll call Mary. Mary had fractured her humerus a few days earlier and on this morning, I had been asked to help her shower and dress.

During the process, I noticed Mary was flinching, grimacing and groaning. I did my best to minimise the movement of her injured arm, but unfortunately I was still causing her discomfort. When we finished, I got Mary settled in a chair, her arm nicely supported, but it was very obvious she was still in a significant amount of pain. I did as my lecturers had taught me; I conducted a pain assessment and after seeing Mary had some PRN (when required) analgesia charted that had yet to be given, asked if she would like me to see if she could have some pain relief. Mary gratefully said she would.

I found my supervising nurse, and told her what I had observed, Mary’s reported pain levels and asked if we could give her the PRN medication. The nurse told me that Mary was due for paracetamol at midday and could wait. This is the point where I let myself and my patient down.

I didn’t speak up. I didn’t ask why we couldn’t give the PRN medication. I didn’t point out that it was still only 10am and two hours is a long time to wait for pain relief. I didn’t say that leaving a patient in obvious pain went against the (limited) education I had so far received, as well as my own personal morals and ethics. I didn’t question her decision at all, even though I had doubts about how correct it was. Instead, I apologised to Mary and told her she would have to wait. The sad smile she gave me, and the look of resignation in her eyes, was just heartbreaking.

Now there may have been a reason why the nurse didn’t want to give Mary that PRN medication, she never took the time to explain her decision to me. However, even now as a registered nurse and looking back, I can’t figure out what that reason would have been. I do know that pain is consistently undertreated in elderly patients. I do know that high levels of acute pain hamper the body’s healing process. I do know that pain is a cause of delirium in the elderly. I do know that if she was my patient today, I wouldn’t hesitate to give her the analgesia.

This experience had a profound impact on me and my nursing career. This was the experience that made me vow that I wouldn’t be silent again. In all my future placements and now as an RN, I speak up and put advocating for my patient above all else. This isn’t always easy, especially when I was a student nurse, and even now as an early career RN. I’ve had to learn different ways of approaching different personalities, and diplomacy and tact are essential. The focus is always clarification, not confrontation.

However, my inexperience, in a way, has been my most useful tool, allowing me to phrase my questions as a simple ‘why’. ‘Why’ is a powerful word and my university drilled into me its’ importance with every assignment asking me to give my rationales for decisions, every essay asking for evidence-based treatments, every tutor who taught me not to accept ‘that’s the way we’ve always done it’. If I had had the courage to ask the nurse on that first prac ‘why’, maybe Mary wouldn’t have been left suffering.

Speaking up is hard, that’s undeniable. However, moral courage is a muscle that all nurses need to develop, and that starts as a student. When I am supervising students now, I begin the day telling them, if you don’t understand or agree with what I am doing, just ask. I’m happy to give them my ‘why’. To the other nurses who supervise students, I hope that you would all encourage this as well and remember courage is “also what it takes to sit down and listen” (Winston Churchill).

To the students out there, be mindful that how you ask your questions, and the attitude they are asked with, will go a long way in determining how your nurse responds. Always be respectful and approach the situation open-minded and willing to learn and please don’t use the line “but the Uni told me to do it this way”. Tell me ‘why’ it can or should be done differently.

There is a quote by Robert Kennedy which has always resonated with me and when I start to doubt whether I have the courage to speak up, I try to remember it.

“Few men are willing to brave the disapproval of their fellows, the censure of their colleagues, the wrath of their society. Moral courage is a rarer commodity than bravery in battle or great intelligence. Yet it is the one essential, vital quality for those who seek to change a world which yields most painfully to change.”

At the end of the day, I would rather look silly or even be yelled at for asking a question, rather than my patients not receive the best care possible. My ego will survive the bruising, and to me and to the all Marys out there, it’s worth it.

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