Care situations demanding moral courage: Content analysis of nurses’ experiences

Introduction

Nurses encounter ethical problems daily in their work ^1,2 which need to be solved. Identifying ethical problems requires ethical sensitivity ³ as well as knowledge of ethics and laws regulating nursing. ⁴ However, ethical sensitivity and knowledge are not enough. Nurses have to have moral courage to act according to what they see as ethically right, provided the personal values and mores are in accordance with generally accepted values of healthcare.

Moral courage in nursing means defending and acting on the values and principles of professional ethics and related laws, despite any resistance by others or any adverse consequences to oneself. ^4,5 Being a morally courageous nurse and acting with moral courage involves true presence, moral integrity, responsibility, honesty, commitment, advocacy, perseverance, and personal risk-taking by the nurse. ⁵ Moral courage is an important part of nurses’ ethical competence ⁶ and implementing ethical nursing. ^4,5

Recurring and unresolved ethical problems related to care itself, care environment including other healthcare professionals, or patients and their relatives can lead to moral distress. Moral distress can develop as the result of a situation where a healthcare professional feels an ethical duty to act morally right but is unable, due to the external or internal obstacles involved, to act according to his or her morals and professional principles and values. ⁷ Moral distress can have a negative impact on the well-being of nurses themselves and patients alike. Moral distress manifests itself as emotional, behavioral, or physical symptoms such as frustration, guilt, feeling of inadequacy, avoidance of patients, poor sleep patterns, and many physical symptoms. ⁸ It has also been linked to lower job satisfaction and leaving the profession. ⁹

Moral courage has been suggested as a means to relieve moral distress. Studies related to nurses indicate that the nurse’s personal ability to deal with ethical problems had a significant impact on the development of moral courage and on the experience of moral distress. Nurses with moral courage were better able to handle ethical problems and thus experienced less moral distress. ⁷ Nurses’ previous life and work experiences contributed to the development of moral courage as well. ^8,10 Moral courage relieves moral distress thus increasing the nurse’s well-being and commitment to work which contributed to a better patient care. ⁴

Nurses need courage in many different care situations and contexts at all levels of nursing. In previous studies, nurses have described care situations demanding moral courage in relation to physicians, colleagues, patients, and their relatives. ^9–11 In addition, students’ ^12,13 and their supervisors’ ¹⁴ point of view has been described. It is important that nurses have courage to act in situations that threaten patients’ safety or their good care. ⁴ According to a literature review, an environment that supported moral courage, professional self-confidence, ¹⁵ and ethical sensitivity helped nurses to treat patients well. ¹⁶ The sense of responsibility and duty toward patients and their own profession enabled nurses to act courageously. ^8,14,17 However, there were also ethically difficult care situations where nurses or nursing students did not have enough courage to act implying to the role of work environment, atmosphere, or culture of care concerning lack of support for nurses’ courageous action. ^2,9,12,13 There is also lack of research focusing on nursing leaders and healthcare organizations, although their understanding of the nature of situations requiring moral courage is also important. Leaders’ and organization’s support play an important role in the emergence of nurses’ moral courage. ¹⁸ Nevertheless, specific care situations demanding moral courage and nurses’ actions in these situations have not been studied, but have rather been generally referred within other research topic.

The purpose of this study is to describe nurses’ experiences of care situations demanding moral courage, and how they act in these situations. The aim is to gain knowledge of the nature of care situations demanding courage, which can be utilized in nursing education and further research in developing ethical nursing care. The study sought answers to the following questions:

What kind of care situations demand moral courage from nurses?

Method

The study applied qualitative descriptive research design. Situations demanding moral courage were also quantified to describe their prevalence.

The data were collected with an open-ended question included in the questionnaire to collect data for the pilot and validation study of Nurses’ Moral Courage Scale (NMCS_{©Numminen 2017}). NMCS consists of 21 items measuring nurses’ self-assessed level of moral courage within four dimensions, and 10 socio-demographic variables. The development and validation of the scale has been reported elsewhere providing a detailed description of the scale. ¹⁹ In the open-ended question, respondents were asked to describe briefly one example of a care situation demanding moral courage and how they solved it. This study analyzed the answers to the open-ended question.

The target groups were nurses, public health nurses, midwifes, and nurse managers from four different clinical fields in a major university hospital in Finland. The four clinical fields selected for the study were (1) children and adolescents; (2) psychiatry; (3) head and neck center; and (4) operating rooms, intensive care, and pain management. These departments covered a wide variety of nursing units and care environments. Convenience sampling was applied.

The data were collected in May–October 2017. The following eligibility criteria were applied: (1) a registered nurse licensed by National Supervisory Authority for Welfare and Health (www.Valvira.fi), (2) a sufficient command of the Finnish language to be able to complete NMCS, and (3) work presently in one of the four clinical fields.

A total 286 participants provided 611 responses to the open-ended question all included in the analysis. The respondents provided a representative data of situations requiring moral courage. However, the responses were not analyzed according to the clinical areas or care units, but as one group. Sample and data collection are described in more detail elsewhere. ¹⁹

The majority of the respondents were women and their mean age was slightly over 40 years. The average work experience of respondents was 16 years (range 0.2–44.3 years).

Results

Care situations demanding moral courage

The situations demanding moral courage were categorized in seven main domains each containing several subcategories, according to whom the situation occurred and the most frequent situations (Table 1.).

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Table 1.

Care situations demanding moral courage.

Categories	Subcategories
Colleagues (n = 101)	1. Colleague’s unethical action (n = 47)
	2. Disagreements between nurses (n = 19)
	3. Colleague’s malpractice (n = 12)
	4. Colleague is guilty of drug theft (n = 6)
	5. Colleague treats patients violently (n = 5)
	6. Endangering aseptic work (n = 5)
	7. Colleague’s inadequate working condition (n = 5)
	8. Colleague’s lack of professionalism (n = 2)
Physicians (n = 84)	1. Disagreements between nurse and physicians (n = 25)
	2. Physicians’ unethical action (n = 23)
	3. Physicians’ indifferent attitude (n = 13)
	4. Physician is not making a decision on limiting treatment in a hopeless situation (n = 9)
	5. Physician’s lack of professionalism (n = 8)
	6. Physician’s malpractice (n = 5)
	7. Physician’s substance-abuse problem (n = 1)
Patients (n = 34)	1. Caring of demanding patient groups (n = 17)
	2. Interaction with the patient (n = 11)
	3. Use of restrictive measures (n = 6)
Organization (n = 28)	1. Inadequate resources (n = 15)
	2. Bureaucratic practices (n = 13)
Nurses themselves (n = 18)	1. Nurses’ own malpractice (n = 13)
	2. Patient prioritization (n = 3)
	3. Failing students’ internship (n = 1)
	4. Making a child welfare report (n = 1)
Relatives (n = 13)	1. Disagreements between nurse and the parent (n = 10)
	2. Encounter the relatives (n = 3)
Managers (n = 9)	1. Disagreements between nurse and the manager (n = 4)
	2. Manager neglects his or her duties (n = 2)
	3. Manager is guilty of drug theft (n = 2)
	4. Manager is guilty of bullying (n = 1)

n = number of situations described.

Colleagues

Situations occurring with colleagues were mostly concerned with colleague’s unethical action such as neglecting patient’s care, ignoring the rights of the patient, or inappropriate behavior of a colleague, for example, inappropriate treatment of patients or other professionals, disrespectful speech toward a patient, lying to a patient, unethical attitudes toward patients, and bullying by a colleague.

The patient had been in surgery the day before, now we are helping her up. The patient tells me that the pain is awful, colleague is not prepared and is not willing to give the painkiller. (ID391)

The nurse (coworker) treated an Iraqi Kurdistan refugee very disgracefully at care situation several times, e.g. by throwing home care instructions on the patient’s bed in front of the patient without saying nothing or going through it. Interpreter standing on site. (IDp54)

Other situations occurring with colleagues were disagreements between nurses about patient care or practice, colleague’s malpractice, drug theft, inadequate working conditions, lack of professionalism, or colleague treated patients violently or endangered aseptic work.

Physicians

In the situations occurring with physicians, disagreement between the nurse and the physician concerned patient’s treatment and practice, such as disagreements about the patient’s discharge, medication, the patient’s surgery, the patient’s access to information, necessity for examinations, disagreements concerning professional duties between the physician and the nurse, the organization of patient care, and other medical decisions made by the physician.

I clearly disagreed with the doctor about the patient’s ability to cope with home care. (ID446)

The physician prescribes an examination for the patient that I think is useless and causes unnecessary pain and harm in the end of patient’s life. (ID377)

Unethical actions of the physician included neglecting the patient’s treatment, ignoring the rights of the patient, and inappropriate behavior by the physician. Ignoring the rights of the patient meant ignoring the patient’s living will, self-determination, and access to information. It could also mean violation of confidentiality obligation and patient intimacy, or unequal treatment of patients.

Other situations were physicians’ indifferent attitude, hopeless situations where physician was not making a decision on limiting treatment, physician’s lack of professionalism, physician’s malpractice, and physician’s substance abuse.

Patients

Situations occurring with patients related to caring of demanding patient groups, interaction with the patient, and use of restrictive measures. Demanding patient groups in this context referred to aggressive patients, psychiatric patients, and patients with dementia. In the case of aggressive patients, in almost all of the described situations, it was a substance-abuse patient who demanded drugs and behaved threateningly. With psychiatric patients, the situations concerned patient autonomy and professional confidentiality, as well as the decisions about a psychiatric patient. For patients with dementia, situations requiring moral courage were all related to patient autonomy. The interaction with the patient was related to encountering the patient and being genuinely present with the patient, as well as to the unpredictable situation in the discussion with a dying patient.

As a younger nurse, I was working alone in the isolation room with a patient who had dozens of days of treatment behind. He was frightened by the upcoming operation that was planned for him. I talked to the patient and I sat beside the bed many times. I asked if he wanted me to hold his hand. He wanted and I did. An experienced colleague stepped into the room. He wondered loudly what I was doing. I replied that the patient was scared, so I hold his hand. I continued to hold his hand, even though I felt that my action was so unusual in intensive care environment that I was wondering if I did something inappropriate. (ID464)

The use of restrictive measures in the treatment of a patient was generally seen as an ethically difficult situation. Nurses often had to discuss the necessity of restrictive measures and consider the different options. Ambiguous policies on the use of restrictive measures, as well as sudden situations in which the doctor is unavailable, also produce difficulties.

Organization

Situations occurring with the organization patient safety were perceived to be at risk due to inadequate resources or when bureaucratic practices such as organizational pressure on economic efficiency did not support patient-centered care. Nurses needed courage also in situations where organizational practices were perceived to be primarily driven by the interests of the organization rather than the interests of the patient.

I am constantly confronted with situations in which I would only do what my role as a psychiatric nurse basically entails, does not just suffice and not improve the patient’s situation. For the sake of efficiency, I have been instructed that I should only care for the things that belong to my job description and leave the rest untreated, because there is need of a certain amount of tasks to be performed per day. (IDp109)

Nurses themselves

Situations occurring with nurses themselves concerned nurses needing moral courage when reporting their own malpractice.

I forgot for more than two hours to put a medication-related iv hydration into a pause and felt a momentary temptation to keep quiet about it because I was so scared. (ID349)

Moral courage was needed also when the nurse needed to prioritize patients in situations where all patients could not be treated at the same time. Also, failing students’ internship and making a child welfare report were situations demanding moral courage.

Relatives

The situations occurring with relatives were such as disagreements between the nurse and the parent, and when the nurse needed to encounter the relatives.

A child patient (2 years old) suffered from lack of oxygen and was painful. I would have liked to relieve him of the pain and give medicine prescribed by the doctor. The child’s father strongly denied the medication. (ID238)

Managers

In situations occurring with managers, disagreements between the nurse and the manager were related to the organization of patient care, the use of restrictive measures, and the use of resources. Moral courage was also needed in a situation where the manager neglected her or his duties, for example, when she or he acted against the law concerning mental health patients or prohibited a caregiver from making a child protection report.

I have had to ask my manager to comply with the Mental Health law regarding the number of staff on night shift. I refused to break the law myself and I booked an extra person for the night. (ID398)

Other situations occurring with managers were the situations where the manager was guilty of drug theft or of bullying.

Nurses’ actions in care situations demanding moral courage

Nurses’ actions in care situations demanding moral courage were categorized into four main categories and several subcategories (Table 2).

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Table 2.

Nurses’ actions in care situations demanding moral courage.

Categories	Subcategories
Verbal communication (n = 202)	1. Speaking up (n = 61)
	2. Telling the manager (n = 43)
	3. Justification for the statement and stand one’s ground (n = 27)
	4. Discussion with the work community (n = 18)
	5. Telling the physician (n = 11)
	6. Telling the upper level of the organization (n = 11)
	7. Talking with the patient (n = 10)
	8. Admitting the mistake (n = 9)
	9. Speaking for the patient (n = 7)
	10. Talking with the relatives (n = 5)
Immediate action (n = 74)	1. Interrupting of action (n = 21)
	2. Overriding physician (n = 13)
	3. Require action (n = 11)
	4. Defending the patient/relative in care situation (n = 9)
	5. Refusal to act (n = 7)
	6. Acting against bureaucratic practices (n = 7)
	7. Points out action (n = 4)
Written notification (n = 15)	1. Making a patient safety incident report (n = 10)
	2. Reporting to occupational safety and health (n = 3)
	3. Making a child welfare report (n = 2)
Failure to act (n = 8)

n = number of situations described.

The main act was to try to solve the situations through verbal communication such as speaking up, that is, to raise the issue with the person concerned. In most cases, disagreements with a colleague, physician, and manager could be discussed with the person concerned. However, based on the data, it was more difficult to talk to a physician than to a colleague. Some of the nurses tried to resolve the situations by justifying their own statement well and, despite the opposition, they decide to stand their ground.

I have raised this issue with colleagues, so that they could change their own attitudes and pay attention.…It’s harder to talk to the doctors about the issue, but it’s got to be done. (ID319)

I listened to my manager’s accusations and then I calmly explained my reasoning and the treatment of the situation. The last word was still said by my manager, whose last word is usually no. I still stood in my ground. (IDp38)

Some issues were reported to the manager, physician, or the upper level of organization. In most cases, telling the manager was related to situations in which a colleague or physician was found to act wrongly. Physician was told, for example, about medication errors or about child patient’s controlling parents. Upper level of organization was usually reported about inappropriate behavior of a manager or a physician, poor treatment of psychiatric patients, drug abuse problem of a physician, and about a suspicion of a manager’s drug addiction.

Other ways of verbal communication were discussion with the work community, talking with the patient or relatives, and admitting one’s own mistake. Sometimes nurses also speak for the patient, for example, in situations where the patient was afraid or incapable of expressing his or her opinions to the physician. These were often situations where the physician disagrees with the patient.

The doctor’s opinion on the patient’s need for treatment was different than mine or the patients. Instead of leaving it to it, I decided to defend the patient’s opinion.…It was difficult for the patient to express himself to the doctor. (ID432)

The second category was an immediate action, for example, interruption of action. Nurses interrupted the action of another professional when they found it to cause harm or risk to the patient’s good care. The physician’s action was interrupted when nurses felt that the measure was causing suffering to the patient, or if they felt that the doctor did not have enough knowledge to perform the measure. The colleague’s action was interrupted when inappropriate treatment of patients or a clear mistake in the colleague’s action was detected.

I asked the doctor to stop the procedure to control the patient’s pain with a more effective anesthesia. (IDp29)

When I arrived at the patient’s room and saw the nurse to treat patients in a questionable manner, I told him that he would have time to go home (work shift was over). I went on and did everything to make the patient feel safe. (ID231)

In some situations, nurses felt obliged to refuse the action they were asked for. Often, the action was refused on the basis of patient safety or patient’s rights. Correspondingly, there were also situations in which nurses demanded another professional to take action.

I thought the doctor made a radical mistake during the surgery when he left a tissue that could not be left there! The doctor asked for a sewing thread to close the area he was operating but I refused to give it because he had not removed the tissue. (ID44)

In situations where the nurse did not feel that he or she has received a satisfactory solution from the physician, for example, in the case of analgesia, the nurse overrided the physician by speaking to another physician.

Other ways of immediate actions were defending the patient or relative in a care situation, acting against bureaucratic practices or on someone’s wrong action.

The third category was written notification such as reporting of adverse events, reporting to occupational safety and health, and making a child welfare report. A Patient Safety Incident report was made when patient safety was compromised, for example, due to a personal or colleague’s treatment failure.

I made a HaiPro-notification (= reporting danger situations) about the situation. The case was dealt with by a senior physician. (IDp61)

A child welfare report was made in situations where the nurse was concerned about the coping of the family or the child’s welfare in general. Occupational safety and health were reported in cases of bullying.

The fourth category is the situations where nurses failed to act morally courageously. These situations affected the nurses afterward and also caused a sense of guilt.

The situation is still bothering me. I didn’t tell the manager about that because I was afraid of the “revenge” of the instrument nurse. I should have been more determined. (IDp37)

I wondered afterwards what impact it had that I didn’t act. I acted wrong in the situation and I did not show moral courage. (ID79)

However, in general, the nurses felt that they were acting correctly in ethically difficult situations, even if the outcome was not always satisfactory. Often, ethically difficult situations did not have a clear solution that would satisfy all parties involved.

I think I acted right for the patient in the situation, but wrong with the doctor because he got in a bad light in the eyes of the patient. (ID121)

Nurses acted in difficult ethical situations morally courageously for the benefit of the patient, despite the potentially unfavorable consequences for themselves. Guiding principles of the nurses were the ethical principles of nursing such as promoting good patient care, alleviating suffering, and respecting dignity of patients and the sense of responsibility of the nurse. Although nurses acted courageously in most situations sometimes they also failed to do so.

Discussion

Due to significant changes in healthcare over the recent decades in Europe and beyond, health professionals are increasingly facing complex ethical problems in their work. ^7,23 It requires of them ethical competence, and as a part of it, moral courage in resolving these problems. ⁷ In nursing, moral courage is important in implementing ethical nursing care. However, thus far there has been lack of research in this field. This study provided new insights into the nature of care situations demanding moral courage. It is important to better understand these situations in order to promote the identification of these situations and to provide nurses with ways to resolve them and to promote ethically safe and high-quality care.

The findings indicate that there are numerous care situations which demand moral courage and the situations occur with different groups of people, mostly with other healthcare professionals, particularly with colleagues and physicians, but also with patients, relatives, nurses themselves, managers, and organization. Since the gravest problem area is between healthcare professionals, focus should be addressed to development of leadership, positive ethical climates, and improvement of interprofessional discussion culture. ²⁴

The situations with colleagues were mostly related to the unethical behavior, such as inappropriate treatment of others or neglect of patient care which leads to consider the adequacy of basic and continuing ethics education of nurses, collegiality, and discussion culture between colleagues. By improving education and open discussion culture, it would be possible to reduce some of these situations. ^24,25 On the contrary, the respondents have identified these situations well and tried to address the problem indicating their sensitivity to recognize ethically inappropriate behavior. ³

In situations occurring between physicians and nurses, physicians’ indifference was reported clearly more frequently than that between nurses. It was also common that the discussion between the physician and the nurse did not solve the problem. According to earlier literature, nurses feel that they are excluded from ethical decision making. ²⁶ In order to avoid misunderstandings between healthcare professionals, it is important again to emphasize an open culture of ethical dialogue also between different professional groups. ²⁵ And again, violence against the patients was not described at all in relation to physicians which was the case with nurses explained by the fact that physicians do not participate in the same frequency in patients’ daily care situations.

The study provided also new knowledge about situations related to nurses themselves, the managers, and the organizations. In earlier literature, only failing a student’s internship was perceived as a situation demanding moral courage from nurses themselves. ¹⁴ According to our result, the most common type of wrongdoing was related to colleagues and physicians which differs from the study focusing on whistle-blowing where most common type was organization-related. ²⁷ Situations with patients and relatives often concerned encounters with a vulnerable or a dying patient and being truly present, as addressed in earlier literature. ^{9,10,15,16,28,29} The qualitative approach used in this study helps to understand the nature of the situations demanding moral courage from new perspectives and to realize that the phenomenon is widespread.

Situations demanding moral courage were most often resolved through verbal communication by speaking up either with the person concerned or involving the manager, physician, or someone at a higher level of the organization. In earlier literature, nurses’ actions in situations requiring courage have not mentioned the persons involved. ^1,15,30 Mostly, a verbal discussion between professionals could be enough if the ethical dialogue in healthcare were more transparent. ²⁵ Situations were also resolved through immediate action. Nurses dared to interrupt another practitioner immediately in case of evident risk of harm to the patient implying that nurses’ work ethic is based on patient-centered care and patient’s good.

According to our results, nurses’ actions were guided by legislation and ethical principles; the patient’s right to good, high-quality, and safe care; the sense of the nurse’s duty; and the need to take responsibility. Nurses felt obliged to respect the patient’s own will, relieve the patient’s suffering, and treat patients equally and fairly respecting their dignity. Defending patients’ rights and acting as an advocate for the patient was seen as an important duty of the nurse. Furthermore, the feeling of collegiality made the nurse act courageously in situations where unethical action was directed at a colleague. In general, nurses felt that they acted correctly in ethically difficult situations, although the outcome may not always be satisfactory. The results were partly consistent with earlier literature about moral courage which shows that nurses’ ethical sensitivity helps them to treat patients well, ¹⁶ and their ability to put patients’ needs before their own makes them act courageously. ¹⁰ In addition, the sense of duty of the nurse plays a significant role in the appearance of morally courageous action. ^8,14,17

Although nurses acted courageously in most situations, there were also situations where nurses lacked moral courage to act, which has been also reported in previous literature. ^2,8

Strengths and limitations

The four different clinical fields in a university-level hospital represented a wide variety of demanding nursing environments and nursing situations where moral courage is required. Consequently, the findings are applicable to nursing care in hospitals representing the studied clinical fields. The age range and level of experience of the subjects was wide, which also contributes to the transferability of the findings.

However, collecting data from only a single country and hospital may be a limitation because of global differences in healthcare culture and systems. Using convenience sampling could also be considered a limitation in that only certain types of nurses may be selected for the study. However, specific selection criteria and representative group of nurses working in different care contexts reduce the risk of bias. ²³ Based on statistical power analysis, the required sample size for the study was estimated to be sufficient.

Suggestions for further research

Research is needed on the moral courage of physicians and managers, as well as of patients’ and their relatives’ experiences of the care situations demanding courage. Research should also be directed to education and to a wider range of healthcare services including their administration and management to obtain a deeper and more comprehensive understanding of care situations demanding moral courage and educational needs related to it. This could be complemented using various new research designs. International and interdisciplinary research is also necessary to detect differences between care cultures and to bring new perspectives to approach the concept of moral courage.

Conclusion

Care situations demanding moral courage focus on good and safe patient care and the patient’s good is at the center of nurses’ attention. However, the situations needing moral courage were mostly related to the actions of other healthcare professionals, such as colleagues and physicians, and much less to organizations, managers, nurses themselves, and patients and their relatives.

The results from this study may be applied in developing ethical nursing care through nursing education and through further research. Education can be used to increase nurses’ knowledge about care situations demanding moral courage and to encourage them to act courageously when teaching and learning ethical decision making. Education can also help managers to identify situations that demand moral courage and help them to support nursing staff to cope with these situations to ensure good and safe patient care.