“The world is a dangerous place, not because of those who do evil, but because of those who look on and do nothing” (Einstein, n.d.).

Nurses who speak out against unethical, unlawful, or outdated practices demonstrate moral courage. Florence Nightingale used her talents, education, and political connections to crusade for healthcare reform. Nightingale’s letters portray her as a ‘strong-minded meddler’ who didn’t hesitate to ‘go above’ the physicians she worked with. Nightingale understood that patient safety requires moral courage; she spoke out repeatedly to protect patients. This spirit is still needed in nursing today (Nightingale strength still needed today, 2007).

 

Figure 1. Acronym of CODE

Courage to be moral requires:

Obligations to honor (What is the right thing to do?)

Danger management (What do I need to handle my fear?)

Expression and action (What action do I need to take to maintain my integrity?)

The “C” in the acronym stands for the virtue of courage. The “O” represents nurses’ ethical obligations. “D” stands for danger management, including cognitive strategies for the emotional control necessary for moral courage and overcoming risk aversion. Finally, the “E” speaks to expression and action through the use of assertiveness and negotiation skills. These behaviors enable nurses to recognize their fears but not allow these fears to keep them from serving as an advocate for their patients. Each of these four components of the CODE acronym will be discussed in turn.

“C” for the Virtue of Moral Courage

Courage is one of the four fundamental virtues in the enduring tradition of moral character as identified by Plato (Stanford Encyclopedia of Philosophy, 2007). Figure 2 contains the definition of moral character and other ethical terms used in this article. The other three fundamental virtues are temperance, justice, and wisdom. Moral courage is the ability to deal with the dilemmas inherent between these four virtues, along with an ability to endure distress, and the ability to overcome fear and stand up for one’s values.

Figure 2. Definitions of Ethical Terminology

Moral character - possession of the virtues of temperance, justice, wisdom, and courage (Stanford Encyclopedia of Philosophy, 2007).

Moral courage – individual’s capacity to overcome fear and stand up for his/her core values (Lachman, 2007a)

Moral virtue - performance of repeated acts of virtue (e.g. courage); a habit of practicing virtue (Aristotle, 350 BCE/1998)

Moral wisdom - understood to include moral perception, moral sensitivity, and moral imagination (Lachman, 2009)

Moral perception - ability to observe what is happening from a moral perspective (Lachman, 2009)

Moral sensitivity - ability to incorporate an extensive array of information, take action on it, and respond to individual needs in a moral way (Lachman, 2009)

Moral imagination - ability to reflect on what it might be like to be an individual in this set of circumstances (Lachman, 2009)

Moral integrity - to feel good about oneself in a fundamental way, to perceive oneself as both a professional who does good work and as a person of character who strives to live a moral life (Laabs, 2007)

Ethical competence - ability of a person to analyze and respond to a moral problem, unrestrained by automatic responses and belief/emotional fixations

As far back as 350 BCE, Aristotle discussed the concepts of courage and practical wisdom. Aristotle (350 BCE/1998) believed that the virtue of courage was the balance (mean) between extremes of cowardice and rashness. Therefore, a woman who rushes head first into danger, either because she is blinded by rage or because she is unaware of the hazards that lie ahead is not courageous.

Central to the nurse’s ability to act in a morally courageous manner is the nurse’s knowledge of the situation (wisdom), emotional control (temperance), management of the risk, and ability to address assertively the moral problem (courage). According to Aristotle, courage involves rational control of emotion and passion; a courageous person is expected to have control over fear and other emotional states. Aristotle wrote “He is courageous who endures and fears the right things, for the right motive, in the right manner, and at the right time and who displays confidence in a similar way” (Aristotle 350 BCE/1998).

Given the interdisciplinary nature of healthcare practice, conflict is unavoidable. This conflict occurs, in part, because of the dissimilarity in educational preparation and the differing views the various professions take of the same situation. For example, nurses are trained to view the clinical situation from a holistic perspective, whereas physicians are trained to formulate a differential diagnosis. Nurses must find ways to preserve their professional integrity by demonstrating the moral courage needed to present their point of view.

Inherent in moral courage is the individual’s capacity to overcome fear and stand up for his or her core values (Lachman, 2007a). This demonstration of moral courage can only be understood in the context of the situation. For example, in a clinical situation the nurse may need to object immediately to healthcare providers’ failure to wash their hands before touching a patient.

Central to the nurse’s ability to act in a morally courageous manner is the nurse’s knowledge of the situation (wisdom), emotional control (temperance), management of the risk, and ability to address assertively the moral problem (courage). Only when these virtues are implemented and the nurse’s voice is heard can justice prevail in the clinical situation in which the ‘right thing’ is not being done for the patient (Lachman, 2007b).

The nurse who lacks courage generally knows what to do or say, but does not do so because of lack of self confidence or fear of embarrassment or punishment. Aristotle (350 BCE/1998) was the first known philosopher to speak to the virtue of practical wisdom which is the ability to see clearly how one can best act in the particular circumstances. An individual with practical wisdom has the potential to act well in a wide variety of situations. However, without the courage to speak or act, this practical wisdom goes to waste. The nurse who lacks courage generally knows what to do or say, but does not do so because of lack of self confidence or fear of embarrassment or punishment. These virtues are important concepts in virtue theory.

Virtue theory focuses on the character of the person, in contrast to other theories that focus on the values and beliefs involved in the decision-making method (Bhuyan, 2007). Virtue theory states that if a person is of good moral character (moral virtue), he or she will construct the right decision, apart from the specific decision-making method. Virtue ethics recognizes that conflicts inevitably arise and that the application of moral wisdom is essential for producing a moral outcome (Armstrong, 2006).

A virtue-based approach to moral decision making and moral courage in nursing requires a detailed description of moral wisdom. Moral wisdom consists of three components: moral perception, moral sensitivity, and moral imagination (See Figure 2). The nurses who possess moral perception would see not only the clinical aspects of the situation, but also the morally relevant features and identify both the clinically and morally relevant features involved in the situation. For example, the nurse would see the failing neurological status of the 56-year-old patient and also see the relevance of assuring that an advance directive was in place. Having moral sensitivity is required for moral courage. Possessing moral sensitivity, the nurse would assure that a “Do not resuscitate” (DNR) conversation occurred between the patient and physician and that the conclusion reached during the conversation would be placed on the chart. Moral imagination reflects on what it might be like to be a patient in this set of circumstances. Empathy is a necessary ingredient of moral sensitivity.

With guidance and practice, a nurse can gain confidence in demonstrating moral courage. Although the components of virtue ethics discussed above identify important considerations in assessing a situation, one is often left at the end of an article on virtue ethics with the question of whether the virtues can be taught to nursing students and/or practicing nurses. Lachman (2009) has expressed her belief that behaviors necessary for moral courage can be taught.

“O” for Ethical Obligations

For nurses the obligations to practice in an ethical manner are described in the Nursing Social Policy Statement (ANA, 2003), Code of Ethics for Nurses (ANA, 2001), Guide to the Code of Ethics: Interpretation and Application (Fowler, 2008), and Nursing Scope and Standards (ANA, 2004). These documents provide the foundation for the ethical practice of professional nursing, as they outline the standards from both the 30,000 foot view (the broad view) and from the frontline view of the nurse-patient relationship. Unfortunately, for many nurses the last time they read these documents was in their professional nursing course.

The Nursing Social Policy Statement articulates the larger picture of the ethical obligations of the professional nurse to society. The Nursing Social Policy Statement (ANA, 2003) articulates the larger picture of the ethical obligations of the professional nurse to society. Members of the ANA Congress on Nursing Practice and Economics created the direction and the process for the task force of 11 members who shaped this document between 2001 and 2003. This statement speaks to the trust that society has in the nursing profession because of “the social contract between society and the profession of nursing” (p. 1). The section on self regulation of nursing practice speaks to the importance of “personal accountability for a knowledge base for professional practice” (p. 11).

Nursing Scope and Standards (ANA, 2004) addresses the six standards comprising the nursing process, the foundation for effective patient management. It also outlines the eight standards of professional performance for nurses, including the need for nurses to be life-long learners, to collaborate within the interdisciplinary team, and to work to enhance the quality of nursing practice. In Standard 13 of this document, it is specifically mentioned that “the registered nurse integrates ethical provisions in all areas of practice” (p. 39).

The obligation to demonstrate the virtue of moral courage is operationalized throughout the Code of Ethics for Nurses (ANA, 2001). Nurses witness incidents that breach standards of care and observe behaviors that demonstrate a pattern of poor decision making or skill. Additionally unlawful and unethical behaviors on the part of practicing nurses may be reported on state board websites (Pennsylvania State Board of Nursing, 2009). Nurses who fail to report the above behaviors are held accountable by State Boards of Nursing. Section 3.5 of the Code of Ethics for Nurses (ANA, 2001) discusses the nurse’s responsibility to address questionable practices:

 

The nurse’s primary commitment is to the health, well-being, and safety of the patient across the life span and in all settings in which health care needs are addressed… When the nurse is aware of inappropriate or questionable practice in the provision or denial of health care, concern must be expressed to the person carrying out questionable practice (p. 14).

 

This passage goes on to make it clear that if the problem cannot be resolved through discussion with the perpetrator of the problem, the nurse is obligated to go to an administrator. If the matter is not resolved at the administrative level, the individual is obligated to report to a higher authority within or outside the agency (Lachman, 2008a). Organizations that take their ethical responsibility seriously have a published infrastructure to deal with ethical violations (Lachman, 2008b).

“D” for Danger Management

One danger or hindrance to moral courage is that of ethical incompetence. Ethical competence requires cognitive strategies, including the ability to analyze and thoughtfully respond to a moral problem unrestrained by automatic responses and belief/emotional fixations (Sporrong, Arnetz, Hansson, Westerholm, & Hoglund, 2007). In other words, ethical competence demands emotional control which enhances insight into both the situation and one’s reaction to the situation. Another danger to moral courage is that of risk aversion. Moral courage requires the willingness to take risks that leave one vulnerable to harm or loss. Developing cognitive strategies to promote ethical competence and overcoming risk aversion will be discussed below.

Developing Cognitive Strategies to Promote Ethical Competence

The authors of Crucial Conversation address deliberations about tough issues, which they describe as having three components: (a) differing opinions, (b) high stakes, and (c) strong emotions (Patterson, Grenny, McMillian, & Switzler, 2002). Examples of these conversations include giving physicians feedback about their abusive behavior, talking to a team member who has violated confidentiality, and conversing with a family who is consistently demanding that “everything be done” for an actively dying patient. All of these are potentially problematic situations that require emotional control.

Patterson et al. (2002) explained how individuals can control their emotions and perceptions by developing insight into the stories they craft. This is important because the stories individuals invent from an occurrence, and the associated emotions affect their actions. This storytelling takes place in a flash moment, so individuals often do not even recognize they are doing it. However, in that moment individuals craft a story that defines the situation as their fault or the other person’s fault, and perhaps even leads the individual to feel powerless to change the situation. If nurses are to be in charge of their emotions, they must manage the stories they tell themselves.

Patterson et al. (2002) provided a process for reversing this habitual path nearly all people take. This process begins with observing one’s own behavior and asking if this behavior is going to get the conclusion one desires. More recent authors (Attwood, 2007; McKay, Davis, & Fanning, 2007) have also emphasized the need to change the misrepresentations in the story because these misrepresentations cut short the thinking needed for moral courage. Controlling one’s emotions and one’s stories can be managed by such strategies as cognitive reframing and self-soothing as described below.

Countering worry about the potential negative consequences of an interpersonal interaction with positive thoughts can facilitate moral courage. Danger Management Strategy: Cognitive Reframing. Cognitive reframing is a method by which a person learns to stop his or her negative thought processes and substitute the negative thoughts with more positive self-talk (Attwood, 2007). Countering worry about the potential negative consequences of an interpersonal interaction with positive thoughts can facilitate moral courage. Decatastrophizing is a cognitive reframing strategy in which a person asks “what if” the horrible event does really happen? What would he or she do in response? The magic in this method is that it permits individuals to focus on plans to address the feared situation, helping them to realize they do have the ability to plan for and control, at least to some extent, the potential negative consequences they fear. For example, a nurse in a busy emergency department (ED) could catastrophize the line up of emergency vehicles outside the ED, focusing on how terrible this situation could be. Else she could cognitively reframe the situation by thinking how she could deal with the situation by using the triage skills she learned in Iraq to lessen the negative thoughts regarding this line up of ED vehicles. By so doing, she is managing her emotions and decreasing the dangers of an emotional reaction out of proportion to the real danger of the situation.

Anger and fear are reasonable feelings to have in many challenging situations. Although research has indicated that with practice one can amend these responses (Begley, 2007), nurses who have persuaded themselves to discontinue indulging in responses of anger or fear have found that making this change is not a simple task. Identifying what triggers anger and fear reactions is an important part of learning to control responses toward colleagues, patients, and families, thus increasing one’s ability to demonstrate moral courage in difficult situations.

Danger Management Strategy: Self-Soothing. When self-soothing, one takes planned steps to quiet (self-soothe) oneself while facing a complicated situation that is activating fear (Domar & Dreher, 2001). A quick walk outside to hear, see, smell, and touch nature can provide nurses with a significant reduction in stress, as can touching something soft and comforting. Dombeck and Wells-Moran (2006) have recommended two other strategies for self-soothing, namely venting to a trusted friend and journaling, as effective self-soothing strategies.

Moral integrity involves feeling “good about oneself in a fundamental way, to perceive oneself as both a professional who did good work and as a person of character who strives to live a moral life” (Laabs, 2007, p. 799). Such individuals live out their ideal of moral integrity by telling the truth as they see it. This moral integrity requires the courage to speak out when others might see them as inappropriately crossing a line. For example, an experienced oncology nurse might openly disagree with the attending physician who wants to continue a painful treatment for a patient who has only a 20% chance of survival. The nurse desires to maintain her moral integrity, and therefore musters the moral courage to share the evidence regarding the limited effectiveness of the suggested treatment with the physician and the patient. Recognizing one’s own moral integrity can be a soothing experience.

Overcoming Risk Aversion

...not all risk taking will be successful...[but] regardless of the outcome risk taking carries sizeable emotional rewards. Risk involves the possibility of suffering harm or loss; hence it carries the potential of danger (The Free Dictionary, 2010). Risk-takers are willing to put themselves on the line in various ways, because they judge the outcome will be worth the risk even though they have no assurance this will be the case. When one acknowledges that they have made a patient error or tells somebody they are angry at their humiliating behavior, they are taking a risk. Nurses can overcome risk aversion by recognizing their professional obligations and by increasing their risk tolerance as explained below.

Danger Management Strategy: Recognizing Professional Obligations. One of the ironies of life is that legitimate security requires risk taking (Treasure, 2008), as does professional growth. Self-confidence comes from purposeful development of one’s identity which involves taking risks. Nurses who take risks know that periodic hostile responses are part of the change process. They understand that negative responses from upset patients and/or families may be an expression of their fear or pain.

Warrell (2008) observed that all risk taking involves choice. For example, nurses who are confronted with the violation of a patient’s advance directive by the surrogate decision maker have options. They can ignore the situation or confront the surrogate. However, nurses who have moral courage recognize their professional obligation, outlined in the professional Code of Ethics for Nurses (ANA, 2001) that states, “The role of the surrogate is to make decisions as the patient would, based on the patient’s previously expressed wishes and known values” (p. 8) and act on this obligation. They will work to have a conversation with the surrogate. These nurses recognize that not all risk taking will be successful. If this conversation fails, they know they can demonstrate moral courage by calling an ethics committee consultation. In some situations the surrogate’s preferred behavior may prevail. Even if this happens, however, these nurses will know that they acted in a professionally responsible manner.

Risk tolerance is the extent of uncertainty that a nurse is able to handle in regard to a potentially negative outcome. When nurses minimize their professional obligations, they risk loosing integrity and may spiral into indifference and burnout. When nurses do turn away from a risk of truth telling, they also lose potential rewards and fall short in their development as a person and a professional. In one study less than 10% of physicians, nurses, and other clinicians confronted their colleagues when they skipped standard infection control procedures, or when they saw an individual who was incompetent in practice (VitalSmarts, 2005).

Danger Management Strategy: Developing Risk Tolerance. Risk tolerance is the extent of uncertainty that a nurse is able to handle in regard to a potentially negative outcome. Nurses who are risk avoidant tend to overestimate uncertainties and underestimate the chance of reaching desired outcomes; risk-preference nurses are the opposite (Warrell, 2008). Nurses who are risk adverse often fear looking foolish and subsequently lose opportunities for growth because they are so concerned about losing their self-esteem. It is important for risk-avoidant nurses to remember that regardless of the outcome risk taking carries sizeable emotional rewards. These rewards may well be feelings of pleasure and pride in speaking up, knowing that this patient is safer because of their action taken. Risk-avoiding nurses may punish themselves for losses, rather than turn the experience into a learning experience. Strong preceptors and nurse mangers know the importance of turning even negative outcomes into learning opportunities; they can help risk-avoidant nurses to become risk tolerant.

Moral courage entails feeling the fear and acting anyway. Conversing with nurses who have less emotional attachment to a given situation can help a risk-averse nurse develop a new point of view regarding the reward/risk ratio. A discussion with another nurse might also help a risk-averse nurse to focus on the “worst case scenario” and realize that she would be able to deal with the worst possible outcome. However, if a nurse cannot deal with the worst case outcome, then it is best to not take the risk, but rather refer the issue to someone who can tolerate the risk.

Most people bypass taking risks because they are afraid; yet it is only in novels that heroes are fearless. Moral courage entails feeling the fear and acting anyway. Figure 3 offers steps to overcome fear. These steps may sound simplistic, but when one is experiencing the “fight or flight” response, it is important to keep things simple.

Figure 3. How to Act in Response to the Fear

Identify the risk you want to take

Identify the situational fear you experience

Determine the outcome you want and what you have to do to achieve this outcome

Identify resources accessible to you

Take action

Fear of confrontation allows nurses to be vulnerable to those who take advantage of them. It is important for nurses to remember to enter a confrontation situation with a desired outcome and garner the necessary resources (knowledge, policy, or people) to increase the likelihood of success.

 

“E” for Expression and Action on the Moral Problem

Moral courage involves more than considering one’s professional obligation and thinking about what risk-taking action to take. Strong communication skills, including assertiveness and negotiation, are necessary in situations demanding moral courage. These crucial skills help individuals deal with the hostility, defensiveness, and a variety of other tactics used by people to prevent one from acting in a morally courageous manner.

Expression Management Strategy: Assertiveness

Assertive behavior is an honest, direct, and appropriate expression of one’s thoughts, feelings, or opinions (Lachman, 2009; McClure, 2007). Appropriate expression means the communication occurs at the right place and the right time. The focus in assertiveness is on solving the problem, which often requires asking for a behavior change from another person. Such communication denotes respect for the other person, while not necessarily for the person’s behavior.

The focus in assertiveness is on solving the problem, which often requires asking for a behavior change from another person. There are three problematic situations that prevent assertive action (Babcock & Laschever, 2007). The first is that nurses may not believe that they have the right to speak up. They may believe their gender, culture, or role does not allow for a voice in the circumstance. They may also fail to recognize that their personal behavioral preferences do not match the behaviors expected of professional nurses and that the role of nurse advocate for patients and families must overshadow their personality preference of silence. The second barrier is the anxiety or fear that nurses experience when they do speak up. The self-soothing and cognitive reframing strategies already discussed may be helpful in these situations. Lack of skills is the third barrier. This will be the focus of the remainder of this section on assertiveness.

Skills are easier to enact when a formula or model can be used to guide behavior. The objective of the following formula (See Figure 4) is to propose a model to use that will call for less work in the frontal cortex, which is already managing the danger of speaking (see Figure 4). Using the following straightforward formula can help organize a response: “When you do X, I feel Y because of Z. And what I’d like instead is [request behavior change]” (Lachman, 2009, p. 53).

Figure 4. Four-Part Assertion Message

A nonjudgmental explanation of the behavior to be changed

An admission of the asserter’s feelings

An explanation of the tangible effect of the other person’s behavior on the asserter or someone else

Announcement of the desired behavior change solution you want, or an invitation to problem solve

This formula focuses on the problematic behavior, the assertors’ feeling generated from the behavior, the concrete effect of the behavior, and finally a request for behavior change. A conversation between a nurse and a physician who refuses to discuss the condition of a terminal patient with a family could take this shape:

When you refuse to talk to the family about the patient’s prognosis, I feel upset, because they now believe he will be going home. I would like you to spend time with them and help them understand that this will not happen.

Remember “moral courage is a means to triumph over fear with practical action” (Lachman 2007a, p. 133).

Skill is definitely needed when the nurse receives from the other individual a self-protective retort of defensiveness. Pausing before reacting to a defensive response gives nurses time to self-sooth and not respond in kind. Objectively, nurses can mirror the emotion observed with statements like, “I can see this makes you upset.” It is important to create a conversational space for dialogue with patients and their families (Patterson et al., 2002).

If the individual walks away, nurses need to determine if they will pursue the person and re-assert. Generally the withdrawal is best left unaccompanied at that time. The next time the nurse sees the person, the nurse can move toward them and ask to finish the conversation. Not allowing the concern to die is a subsequent check of the nurse’s moral courage.

Expression Management Strategy: Negotiation

Negotiation is the process of searching for mutually acceptable solutions. During the negotiation process both parties look for common interests and brainstorm to identify options acceptable to both parties. Guidelines for the development and evaluation of options during negotiation include the four steps described in Figure 5.

Figure 5. Developing and Evaluating Options in Negotiation

Ask what proposed alternatives they favor for the solution

State which alternatives look best to you

Distinguish which choices match most closely

Jointly decide on one or more alternatives

The negotiation process begins by first asking what proposed alternatives one person/party favors for the solution. Then the other person/party presents alternatives, focusing first on the options that are most likely to coincide. If there are no options that coincide, then further discussion of options is in order, as perhaps the discussion has slipped into a defense of positions, rather than examination of options. Finally, in negotiation both individuals jointly decide on one or more of the alternatives. Negotiation skill development will fortify the nurse to be better able to handle the stress of the situations that require moral courage.

...it is judicious to know when to individually manage the conflict and when it is prudent to have an important person higher up in the organization intercede for you. Kritek (2002) presents a number of down-to-earth suggestions about negotiating conflicts where some participants are at a disadvantage that others do not acknowledge. She refers to such situations as “uneven tables,” where fair outcomes are uncertain. Kritek encourages individuals to go to the table having already decided they will honor their integrity, because she believes nurses who do so will be alert and committed to advocating for their personal beliefs. Both honesty and consistently holding to moral principles and standards are necessary to be seen as a person of integrity. People with integrity are outspoken, steady in actions, and open about motives. However, since the “pecking order” in an organization can change over time, it is judicious to know when to individually manage the conflict and when it is prudent to have an important person higher up in the organization intercede for you.

The more nurses know about the needs of the other party and/or the needs of the department, the more likely they will be able to successfully negotiate to reach a moral solution (Mayer, 2006). Before entering into negotiations, nurses must also know their own, specific needs and interests so that they know what concessions and compromises they are willing to make. It is important that nurses not begin their negotiations before they plan and organize their approach. The lack of a sound plan will make nurses more liable to react emotionally.

Conclusion

Moral courage is the individual’s capacity to overcome fear and stand up for his or her core values and ethical obligations. Professional obligations are spelled out in the ANA Code of Ethics for Nurses. Armed with an understanding of their obligations, nurses must assess the risks in speaking or acting in ethically charged situations. Sometimes, the risk may be too great and further analysis of the problem is warranted, or a call to the ethics committee is the appropriate action. Danger management is an important aspect of moral courage. Self-soothing and cognitive reframing can help manage danger and control emotional responses in a conflict situation. Although nurses’ personal preferences for conflict avoidance may conflict with their role obligation for patient advocacy, moral courage is required of all nursing professionals. Overcoming risk aversion and developing risk tolerance enhance moral courage. Developing assertiveness and negotiation skills also enable nurses to be morally courageous. Nurses with moral courage understand that there may be undesirable consequences for their actions, yet realize that maintaining a high level of integrity is more important than avoiding these consequences.

Author

Vicki D. Lachman, PhD, MBE, APRN
Email: Vdl22@drexel.edu

Dr. Lachman is an Associate Clinical Professor in Nursing at Drexel University where she teaches ethics to master’s and doctoral students. In 2002 she completed a Master’s in Bioethics (MBE) from the University of Pennsylvania, with a focus on the ethical issues at end-of-life. In 2008 Dr. Lachman was selected to serve on the American Nurses Association Center for Ethics and Human Rights Advisory Board. She also serves on two ethics committees and writes the quarterly Ethics, Policy, and Law Column in the MedSurg Nursing Journal. Dr. Lachman has authored over 100 publications and her second book, Applied Ethics in Nursing, was released at the end of 2005. Her third book, Ethical Challenges in Healthcare: Developing Your Moral Compass, which focuses on the skills and organizational culture necessary for moral courage, was released in June 2009 by Springer Publishing.