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...