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Overview and Summary: Moral Courage Amid Moral Distress: Strategies for Action

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Karen Iseminger, PhD, RN, FNP

Citation: Iseminger, K., (September 30, 2010) "Overview and Summary: Moral Courage Amid Moral Distress: Strategies for Action" OJIN: The Online Journal of Issues in Nursing Vol. 15, No. 3, Overview and Summary.

DOI: 10.3912/OJIN.Vol15No03ManOS

Nursing care today is provided in very complex environments. This complexity can lead to moral distress and the need to demonstrate moral courage. Moral courage involves the willingness to speak out and do that which is right in the face of forces that would lead a person to act in some other way. The articles in this topic offer readers comprehensive insights into nurses’ moral distress and their moral courage. The articles address moral distress and moral courage from a broad perspective ranging from that of bedside nursing and creating a therapeutic milieu, to nursing leadership and administration, to nursing education, providing along the way foundational concepts requisite to understanding moral courage.

In “Understanding and Addressing Moral Distress” Epstein and Delgado provide a very helpful overview for understanding and addressing moral distress. They begin their discussion by describing the phenomenon using case scenarios and projecting nurses' experiential responses to these realistic examples. Next they provide a historical overview of scholarly publications that address moral distress, ranging from the foundational work of Jameton in 1984 through today’s increasingly developed analyses of this topic. They identify sources of moral distress, such as futile care, communication issues, inadequate staffing, inadequate pain relief, and false hope; and they offer ways in which we can recognize the symptoms of moral distress.

Epstein and Delgado include a poignant discussion regarding moral residue and the resultant crescendo effect. Moral residue is the long-lasting effect of unresolved moral distress that alters our perception of self; it crescendos in a way that does not allow this effect to return to baseline. Instead, with each subsequent distressing event a cumulative effect causes symptoms to be exacerbated. These authors conclude their discussion by advocating for a moral distress consult service to assist in addressing these threats to one’s moral integrity. Such a service could foster strategies to reduce moral distress and encourage the taking of action steps, such as speaking up, being deliberate, being accountable, building support networks, focusing on change, participating in moral distress education, making moral distress an interdisciplinary concern, finding root causes, developing policies, and initiating workshops.

In their article “Creating Workplace Environments that Support Moral Courage” LaSala and Bjarnason challenge readers to reflect upon their moral responsibility for creating a milieu that supports moral courage, a milieu in which ethical nursing practices can take place. In this very stirring article, the authors note that building a base of nursing competence decreases moral distress. This increased competence helps nurses to be morally responsible, more adept at recognizing and responding to situations in which they find unethical practices or inferior patient care. This finely tuned competence develops an “ethic of care,” moral reasoning, and heightened moral judgment, which together foster shared decision making and encourage all team members to assume moral responsibility for the consequences of their actions.

LaSala and Bjarnason build on moral courage definitions by advancing the discussions to include organizational factors which stimulate moral courage. Organizations can develop their mission, vision, and values in such a way that an actualization of moral courage arises in all disciplines. In addition, this actualization which is so essential for a therapeutic organizational milieu breaks down barriers to communication. Features of a therapeutic organizational milieu include a “just culture” (fairness in every action) and leadership development that recognizes the delicate balance between process techniques and the personal characteristics requisite for ethical nursing leadership. When nursing leadership embraces heightened communication, empowers autonomous nursing practice, and advocates for patients, nurses can be transformed toward a focus on moral courage and bedside safety.

In the article “Strategies Necessary for Moral Courage” Lachman offers precise definitions for moral character, moral courage, moral virtue, moral wisdom, moral perceptions, moral sensitivity, moral imagination, moral integrity, and ethical competence that are easy for the practicing nurses to learn. She also shares strategies, which when employed together heighten the virtue of moral courage. Her model for moral courage is represented by the acronym “C.O.D.E..” In this model C represents courage, O reminds nurses of their ethical obligations, D represents danger management, and E reflects expression. This model guides nurses as they strive to develop the assertiveness and the negotiation skills necessary to advocate for their patients. She also provides a very interesting historical analysis of practical wisdom.

Building upon this framework, Lachman encourages the development of cognitive strategies that promote ethical competence. She encourages cognitive reframing which assists individuals to stop negative thought processes and promote positive self talk. This reframing is essential to the implementation of moral courage on an everyday basis. She champions the notions of overcoming risk aversion and realizing professional obligations; developing a tolerance for risk; and most importantly moving into actions that address moral concerns. These actions employ negotiation strategies that look for proposed alternatives, distinguish choices that closely match the values of the participants, and decide on appropriate alternative actions.

John Murray adds to the body of knowledge on moral courage by giving concrete, historical examples of ethical fitness that increase the provider’s level of courage in their daily organizational activities in his article “Moral Courage in Healthcare: Acting Ethically Even in the Presence of Risk.” It is a formative article about the personal characteristics of nurses who attempt to act out their ethical principles in situations that can pose significant risks to their career or to their position, or in situations that might interfere with their relationships in the workplace.

Murray also provides a provocative discussion on issues related to moral courage that are applicable for all professionals. He encourages readers to be aware of moral arrogance and moral certitude. Arrogant epistemologists believe that their moral stand is the only valid one; moral certitude represents the notion that a firm belief is based on an inner conviction that is very resistant to challenges to one’s position. Toward that end, Murray explains why the code of ethics for nurses addresses the distinction between public and private morals. He offers valuable resources available in professional articles, textbooks, and on the Internet to assist nurses to develop moral courage and provides tables that depict representative check points for ethical decision making and moral courage inhibitors. He has highlighted the critical need for healthcare professionals who understand the importance of moral courage in the workplace and who are willing to take action when ethical values are being compromised.

In the article “Moral Courage for Nurse Leaders” Cole Edmonson provides resources to lessen moral distress in nursing leadership. Although the majority of the articles in this topic deal with moral distress and moral courage among caregivers, this article provides insight into the moral distress seen among nursing leaders, distress which can arise from sources different from the moral distress seen at the bedside. The nursing leader’s responsibility is to create a culture that supports acts of courage of nursing. Because of nursing leaders’ added responsibilities to the organization, they experience not only distress similar to that of bedside caregivers but also distress that is unique to their leadership roles. For example, a unique feature of nursing leadership is that these leaders work on professional teams that include non-clinicians who may have a limited understanding of the provision of direct patient care. This requires the nursing leader to translate the work of nursing into familiar terms for these colleagues and to paint for them a picture that describes the work of providing patient care.

Edmonson discusses the four A’s framework from the American Association of Critical Care Nurses, which has been a standard framework, one foundational to much of the work describing nurses’ moral distress, and now for the development of moral courage. The author encourages the use of sacred spaces to develop a community for nursing leaders that provides a haven where they can become re-energized. In these havens they can learn from each other through honest communication and skill development. Edmonson concludes with recommendations for practice and research intended to help nursing leaders to flourish in their role of champions for moral courage.

In “Moral Distress in Academia” Kathryn Ganske parallels the moral distress and moral courage discussions presented in the previous articles and builds upon these notions as they are seen in the field of nursing academia. She discusses some unique issues related to moral distress, such as dishonesty, cheating, plagiarism, grade inflation, and incivility. She offers antidotal examples of students who barely skim the passing point in every class, yet who are passed onto other classes because of administrative demands to pass students. The cost of academic education and the resultant significant debt that students experience causes pressure to pass students so as to avoid burdening them with additional financial debt.

Ganske also describes the relationship between ethical climate and moral distress. She notes the unique features of an academia milieu where such distress can sometimes be rampant. She encourages the adaptation of instruments used in clinical practice for use in educational settings, and recommends additional research to understand the nuances of moral distress and the development of moral courage in the academic environment.

These introductory articles present encouraging directions to help readers embrace the concept of moral courage and stand up for patients’ existential needs. They describe both individual and organizational factors to consider in the quest for maintaining a healthy work environment by establishing a morally courageous work force.

The journal editors invite you to share your response to this OJIN topic addressing Moral Distress and Moral Courage either by writing a Letter to the Editor or by submitting a manuscript that will further the discussion of this topic which has been initiated by these introductory articles.


Karen Iseminger, PhD, RN, FNP

Dr. Iseminger is the Director of Ethics Integration for St. Vincent Health in Indianapolis, IN. As Director, Karen is responsible for coordinating ethics resources and activities, which include the provision of consultative services to St. Vincent Health clinicians, patients, families, and those involved in leadership positions. She also serves on the American Nurses Association Ethics Advisory Board.

She has been a Nurse Practitioner for more than twenty years, working most recently as the Assistant Director of Quality of Life for Community Cancer Care in Indianapolis (IN), providing psychiatric support for oncology patients. Previous academic appointments have included serving as Professor of Nursing at Anderson University (near Indianapolis) and Associate Professor of Nursing at the University of Indianapolis (IN). She has also authored numerous professional articles and book chapters.

Dr.Iseminger earned her BSN at Ball State University and her MSN at Indiana University-Purdue University at Indianapolis. She went on to complete her Doctorate of Philosophy from State University of New York at Buffalo, and her post-doctorate in Pediatric Management & Residency at Northern Kentucky University. Additionally, she holds a post-doctoral certification as a Philosophical Counselor.

© 2010 OJIN: The Online Journal of Issues in Nursing
Article published September 30, 2010