Background: Nurses encounter complex ethical dilemmas in everyday nursing care. It is important for nurses to have moral courage to act in these situations which threaten patients’ safety or their good care. However, there is lack of research of moral courage. Purpose: This study describes nurses’ experiences of care situations demanding moral courage and their actions in these situations. Method: A qualitative descriptive research design was applied. The data were collected with an open-ended question in the questionnaire used in validation (...) of the Nurses’ Moral Courage Scale. The sample consisted of 286 nurses from four different clinical fields in a major university hospital in Finland, providing a total of 611 answers. Data were analyzed using inductive content analysis. Ethical considerations: The study followed the commonly recognized principles of good scientific practice. The use of data was authorized by the developer of the instrument, the data collector, and the participating hospital. Ethical approval was obtained from the university ethics committee. Findings: Nurses acted morally courageously in most situations but sometimes they failed to do so. Although situations demanding moral courage varied, they could be categorized into seven main domains relating to colleagues, physicians, patients, relatives, nurses themselves, managers, and organizations. Nurses acted in the situations in different ways. The main acts in solving the situations were verbal communication or immediate action, such as interrupting of action. Conclusion: Care situations demanding moral courage focus on good and safe patient care and the patient’s good is at the center of attention. The situations are mostly related to the activities of other healthcare professionals. Findings may be applied in developing ethical nursing care through basic and continuing nursing education. Research is needed on the moral courage of physicians and managers, as well as on patients’ and their relatives’ experiences of care situations demanding moral courage. (shrink)

Background:Moral distress, moral sensitivity, and moral courage among healthcare professionals have been explored considerably in recent years. However, there is a paucity of studies exploring these topics among baccalaureate nursing students.Aim/objective:The purpose of this study was to explore the relationship between and among moral distress, moral sensitivity, and moral courage of undergraduate baccalaureate nursing students.Research design:The research employed a descriptive-correlational design to explore the relationships between and among moral distress, moral sensitivity, and moral courage of undergraduate nursing students.Participants and research (...) context:A total of 293 baccalaureate Filipino nursing students who have been exposed to various clinical areas participated in the study.Ethical considerations:Institutional review board approval was sought prior to the conduct of the study. Self-determination was assured and anonymity and confidentiality were guaranteed to all participants.Findings:Results indicate that a majority of the nursing students in the clinical areas encounter morally distressing situations that compromise quality patient care. However, despite the fact that they want to do what is in the best interest of their patients, their perception of being the inexperienced among the healthcare team drives the majority of them to ignore morally distressing situations to avoid conflict and confrontation. Another interesting finding is that 79.20% of the respondents hardly consider quitting the nursing profession even if they frequently encounter morally distressing situations. Analysis also shows associations between moral distress intensity and frequency ( r = 0.13, p < 0.05) and moral distress intensity and moral sensitivity ( r = 0.25, p < 0.05). The dimensions of moral courage are also related to both moral distress and moral sensitivity.Conclusion:Results of the study imply that moral distress is a reality among all healthcare professionals including nursing students and requires more consideration by nurse educators. (shrink)

Scholars have shown renewed interest in the construct of courage. Recent studies have explored its theoretical underpinnings and measurement. Yet courage is generally discussed in its broad form to include physical, psychological, and moral features. To understand a more practical form of moral courage, research is needed to uncover how ethical challenges are effectively managed in organizational settings. We argue that professional moral courage (PMC) is a managerial competency. To describe it and derive items for scale development, we studied managers (...) in the U.S. military and examined prior work on moral courage. Two methods were used to measure PMC producing a five dimensional scale that organized under a single second-order factor, which we termed overall PMC. The five dimensions are moral agency, multiple values, endurance of threats, going beyond compliance, and moral goals. Convergent and discriminant validity are analyzed by use of confirmatory factor analysis procedures. We conclude by presenting a framework for proactive organizational ethics, which reflects how to support PMC as a management practice. (shrink)

The factors preventing registered nurses from failing students in practice are multifaceted and have attracted much debate over recent years. However, writers rarely focus on what is needed to fail an incompetent pre-registration nursing student in their final placement. This hermeneutic study explored the mentor experience of failing a pre-registration nursing student in their final placement. A total of 19 mentors were recruited from 7 different healthcare organisations in both inner city and rural locations in the southeast of England. Participants (...) took part in individual reflective interviews about their experience of failing a pre-registration nursing student in their final placement. These experiences were interpreted through a hermeneutic discovery of meaning. The new horizon of understanding which developed as a result of this research is framed within the context of moral stress, moral integrity and moral residue with the overall synthesis being that these mentors’ stories presented a new horizon of moral courage. (shrink)

Background: In recent years, operating theatre nurse students’ education focused on ethics, basic values and protecting and promoting the patients' dignity in perioperative practice. Health professionals are frequently confronted with ethical issues that can impact on patient’s care during surgery. Objective: The objective of this study was to present what operating theatre nursing students perceived and interpreted as undignified caring in perioperative practice. Research design: The study has a descriptive design with a hermeneutic approach. Data were collected using Flanagan’s critical (...) incident technique. Participants and research context: Operating theatre nurse students from Sweden and Norway participated and collected data in 2011, after education in ethics and dignity. Data consisting of 47 written stories and the text were analysed with hermeneutical text interpretation. Ethical considerations: The study was approved by the Karlstad University's Research Ethics Committee. Findings: The findings show careless behaviour and humiliating actions among health professionals. Health professionals commit careless acts by rendering the patient invisible, ignoring the patient’s worry and pain and treating the patient as an object. They also humiliate the patient when speaking in negative terms about the patient’s body, and certain health professionals blame the patients for the situation they are in. Health professionals lack the willingness and courage to protect the patient’s dignity in perioperative practice. Discussion: In the discussion, we have illuminated how professional ethics may be threatened by more pragmatic and utilitarian arguments contained in regulations and transplant act. Conclusion: The findings reveal that patients were exposed to unnecessary suffering; furthermore, the operating theatre nurse students suffered an inner ethical conflict due to the undignified caring situations they had witnessed. (shrink)

It is argued that dignity can be considered both subjectively, taking into account individual differences and idiosyncrasies, and objectively, as the foundation of human rights. Dignity can and should also be explored as both an other-regarding and a self-regarding value: respect for the dignity of others and respect for one’s own personal and professional dignity. These two values appear to be inextricably linked. Aristotle’s doctrine of the mean enables nurses to reflect on the appropriate degree of respect for the dignity (...) of others and of respect for themselves. To develop an understanding of the rationale for and the significance and implications of dignity in health care practice, a view of human nature is proposed that implies vulnerability and fallibility, and that urges that an ethic of aspiration is embraced. Anonymized vignettes are included to illustrate points about the everyday nature of dignity. (shrink)

Background: Moral courage is required at all levels of nursing. However, there is a need for development of instruments to measure nurses’ moral courage. Objectives: The objective of this study is to develop a scale to measure nurses’ self-assessed moral courage, to evaluate the scale’s psychometric properties, and to briefly describe the current level of nurses’ self-assessed moral courage and associated socio-demographic factors. Research design: In this methodological study, non-experimental, cross-sectional exploratory design was applied. The data were collected using Nurses’ (...) Moral Courage Scale and analysed statistically. Participants and research context: The data were collected from a convenience sample of 482 nurses from four different clinical fields in a major university hospital in Finland for the final testing of the scale. The pilot comprised a convenience sample of 129 nurses. Ethical considerations: The study followed good scientific inquiry guidelines. Ethical approval was obtained from the university ethics committee and permission to conduct the study from the participating hospital. Findings: Psychometric evaluation showed that the 4-sub-scale, 21-item Nurses’ Moral Courage Scale demonstrates good reliability and validity at its current state of development showing a good level of internal consistency for a new scale, the internal consistency values ranging from 0.73 to 0.82 for sub-scales and 0.93 for the total scale, thus well exceeding the recommended Cronbach’s alpha value of >0.7. Principal component analysis and confirmatory factor analysis supported the theoretical construct of Nurses’ Moral Courage Scale. Face validity and expert panel assessments markedly contributed to the relevance of items in establishing content validity. Discussion and conclusion: Nurses’ Moral Courage Scale provides a new generic instrument intended for measuring nurses’ self-assessed moral courage. Recognizing the importance of moral courage as a part of nurses’ moral competence and its assessment offers possibilities to develop interventions and educational programs for enhancement of moral courage. Research should focus on further validation measures of Nurses’ Moral Courage Scale in international contexts. (shrink)

Background: Nursing as an ethical practice requires courage to be moral, taking tough stands for what is right, and living by one’s moral values. Nurses need moral courage in all areas and at all levels of nursing. Along with new interest in virtue ethics in healthcare, interest in moral courage as a virtue and a valued element of human morality has increased. Nevertheless, what the concept of moral courage means in nursing contexts remains ambiguous. Objective: This article is an analysis (...) of the concept of moral courage in nursing. Design: Rodgers’ evolutionary method of concept analysis provided the framework to conduct the analysis. Data sources: The literature search was carried out in September 2015 in six databases: PubMed, CINAHL, Scopus, Web of Science, PsycINFO, and The Philosopher’s Index. The following key words were used: “moral” OR “ethical” AND “courage” OR “strength” AND “nurs*” with no time limit. After applying inclusion and exclusion criteria, 31 studies were included in the final analysis. Ethical considerations: This study was conducted according to good scientific guidelines. Results: Seven core attributes of moral courage were identified: true presence, moral integrity, responsibility, honesty, advocacy, commitment and perseverance, and personal risk. Antecedents were ethical sensitivity, conscience, and experience. Consequences included personal and professional development and empowerment. Discussion and conclusion: This preliminary clarification warrants further exploring through theoretical and philosophical literature, expert opinions, and empirical research to gain validity and reliability for its application in nursing practice. (shrink)

Background: Most undergraduate midwifery curricula comprise ethics courses to strengthen the moral competences of future midwives. By contrast, surprisingly little is known about the specific moral competences considered to be relevant for midwifery practice. Describing these competences not only depends on generic assumptions about the moral nature of midwifery practice but also reflects which issues practitioners themselves classify as moral. Objective: The goal of this study was to gain insight into the ethical issues midwives encounter in their daily work, the (...) key competences and resources they consider indispensable to understand and deal with them, and to assess phenomena linked to moral distress. Methods: We conducted individual semi-structured interviews with eight midwives and two other health professionals, varying in terms of years of experience and work setting. Interview transcripts were analyzed in an interdisciplinary research group, following thematic analysis. Ethical considerations: This study was not subject to approval according to the Swiss Law on Research with Humans. Participants were informed about the study goals and gave written informed consent prior to participation. Results: External constraints limiting the midwife’s and the patient’s autonomy and resulting interpersonal conflicts were found to be the most relevant ethical issues encountered in clinical practice and were most often associated with moral distress. These conflicts often arise in the context of medical interventions midwives consider as not appropriate and situations in which less experienced midwives in particular observe a lack of both interprofessional communication and trust in their professional competence. Ethical issues related to late abortions or prenatal diagnostics and selective abortions were also frequently addressed, but many midwives involved had learned to cope with them. Discussion: In the light of the ethical issues and factors contributing to phenomena of moral distress, an empirically grounded profile of moral competences is drafted. Curricular implications in the light of possible adaptations within undergraduate midwifery education are critically discussed. (shrink)

Background: As moral action could help nurses reduce moral distress, it is necessary to carry out qualitative research to present the experiences in which nurses apply moral action. Aim: To describe and analyze the phronesis applied by nurses in the face of moral distress. Research design: The research participants were invited to participate in in-depth interviews. The research materials were based on the stories described by the research participants and recorded by means of first-person narrative. Narrative analysis was applied to (...) interpret the nurses’ phronesis. Participants: Twenty-seven nurses from Taiwan. Ethical considerations: The Institutional Review Board of the Kaohsiung Medical University Hospital in Taiwan confirmed that this study passed the research ethical review. Findings: According to the narrative analysis results, the phenomenon of moral distress contains difficulty, action, and idea transformation. The difficulty is the source of moral distress, action is the practice of moral courage, and idea transformation is the nurse’s emotional movement. Action and idea transformation are collectively called phronesis in this study. Discussion: Moral distress refers to a state of suffering caused by situations in which nurses cannot carry out their ethical intentions. Phronesis is the process through which nurses take actions and relocate the subjects and is an ethical way to find relief from moral distress. Starting with empathy and respectful attitudes arising from self-reflection, nurses may be helped to get relief from the suffering of moral distress. Conclusion: Phronesis can help nurses positively face the emotional strain of moral distress. This article puts forward a narrative method to complete the four steps of phronesis: write about the care experience, identify the difficulties in the stories, seek the possibility of action, and form a new care attitude, which could help nurses learn to reduce their moral distress. (shrink)

Background: Homeless persons in the United States have disproportionately high rates of illness, injury, and mortality and tend to believe that the quality of their end-of-life care will be poor. No studies were found as to whether nurses or nursing students require moral courage to help homeless persons or members of any other demographic complete advance directives. Research hypothesis: We hypothesized that baccalaureate nursing students require moral courage to help homeless persons complete advance directives. Moral courage was defined as a (...) trait of a person or an action that overcomes fears or other challenges to achieve something of great moral worth. Research design: The hypothesis was investigated through a qualitative descriptive study. Aside from the pre-selection of a single variable to study (i.e. moral courage), our investigation was a naturalistic inquiry with narrative hues insofar as it attended to specific words and phrases in the data that were associated with that variable. Participants and research context: A total of 15 baccalaureate nursing students at a public university in the United States responded to questionnaires that sought to elicit fears and other challenges that they both expected to experience and actually experienced while helping homeless persons complete advance directives at a local, non-profit service agency. Ethical considerations: The study was approved by the Internal Review Board of the authors’ university, and each participant signed an informed consent form, which stated that the study involved no reasonably foreseeable risks and that participation was voluntary. Findings: Before meeting with homeless persons, participants reported that they expected to experience two fears and a challenge: fear of behaving in ways that a homeless person would deem inappropriate, fear of discussing a homeless person’s dying and death, and the challenge of adequately conveying the advance directive’s meaning and accurately recording a homeless person’s end-of-life wishes. In contrast, after their meetings with homeless persons, relatively few participants reported having encountered those obstacles. So, while participants required moral courage to assist homeless persons with advance directives, they required greater moral courage as they anticipated their meetings than during those meetings. Discussion: Our study breaks new ground at the intersection of nursing, moral courage, and advance directives. It might also have important implications for how to improve the training that US nursing students receive before they provide this service. Conclusion: Our results cannot be generalized, but portions of our approach are likely to be transferable to similar social contexts. For example, because homeless persons are misunderstood and marginalized throughout the United States, our design for training nursing students to provide this service is also likely to be useful across the United States. Internationally, however, it is not yet known whether our participants’ fears and the challenge they faced are also experienced by those who assist homeless persons or members of other vulnerable populations in documenting healthcare wishes. (shrink)