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Letter to the Editor

Strengthening Moral Courage Among Nurse Leaders

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Cole Edmonson, DNP, RN, FACHE, NEA-BC

Abstract

Moral distress among practicing nurses is frequently discussed in the nursing literature, along with well-developed recommendations for increasing moral courage in practicing nurses. Implementing these recommendations depends on nurse leaders being morally fit to lead and to create an environment in which moral courage actions can emerge. The literature is lacking pertaining to nurse leaders’ preparation to lead in a morally courageous and transformational manner in our current corporate environments and hierarchies of healthcare. In this article, the author reviews the literature addressing moral distress and moral courage among direct care nurses; describes the development of an intervention to strengthen the moral courage of nurse leaders; reports a study that involved implementing this intervention; presents the findings of this study; evaluates the effectiveness of the intervention; and discusses the findings in terms of lessons learned and future directions. He concludes with a call for healthcare leaders to demonstrate moral courage and create environments that promote morally courageous acts that enable nurses to remain centered on the patients, families, and communities we serve.

Citation: Edmonson. C., (February 17, 2015) "Strengthening Moral Courage Among Nurse Leaders" OJIN: The Online Journal of Issues in Nursing Vol. 20 No. 2.

DOI: 10.3912/OJIN.Vol20No02PPT01

Keywords: Moral courage, moral distress, moral residue, virtue ethics, ethical conflict, nurse leaders, mentoring, practice recommendation, innovation

Moral distress in nursing is a common theme related to the work of practicing nurses... Moral distress in nursing is a common theme related to the work of practicing nurses; it is well described in the literature, along with fully formed recommendations for increasing moral courage in professional nurses. However, these recommendations depend on nurse leaders being morally fit both to lead and to create an environment for morally courageous actions to emerge. Lacking in the nursing literature are articles that describe nurse leaders’ preparation to lead in a morally courageous and transformational manner in today’s corporate environments and hierarchies of healthcare.

In this article, I will review the literature addressing moral distress and moral courage in direct care nurses; describe the development of an intervention to strengthen moral courage among nurse leaders; report on a study that implemented this intervention; present the findings of the study; and evaluate the effectiveness of this intervention. I will also discuss the findings in terms of lessons learned along with future directions and conclude with a call for healthcare leaders to demonstrate moral courage and create environments that promote morally courageous acts that keep nurses centered on the patients, families, and communities we serve.

Review of the Literature

A review of the literature using the CINAHL database found literature related to nurse leaders experiencing moral distress or demonstrating moral courage to be lacking. However, the nursing literature is replete with discussions of moral distress and moral courage among direct care nurses, along with recommendations on strengthening moral courage in this population. It is interesting to note that the concept of moral courage among leaders in general is discussed in the psychology literature (Elpern, Covert, & Kleinpell, 2005Sekerka & Bagozzi, 2007); yet there is no evidence of such discussions in the nursing literature. 

Insights related to moral courage among direct care nurses can be translated, however, to the nurse leader, when considered in the broader scope of the nurse leader role in the acute care clinical environment. The experience of moral distress in clinical nurses is generally believed to occur when a nurse is faced with a situation in which, the ‘right’ actions are known to the nurse, but the nurse does not act due to external forces present in the situation (Corley, 2002; Elperin et al., 2005; Ganz & Berkovitz, 2011; Jameton, 1984; Ohrn, Rutberg, & Nilsen 2011; Rainer, 2014; Rashotte, 2004; Repenshek, 2009; Rushton, 2008; Wilson, Goettemoeller, Bevan, & McCord, 2013).

External forces that provide context for the inaction related to moral courage include job structures, social hierarchies, organization hierarchies, resources, technology, competition, and the growing demand for healthcare. External forces that provide context for the inaction related to moral courage include job structures, social hierarchies, organization hierarchies, resources, technology, competition, and the growing demand for healthcare (Corley, 2002; Jameton, 1984; Mohr & Horton-Deutsch, 2001; Nathaniel, 2006; Wilson et al., 2013). Singularly and combined, these forces represent realities of modern day nurses’ practice environment that have the potential to overwhelm nurses’ coping mechanisms and directly relate to moral paralysis (i.e., the inability to act on a moral violation in distressing situations due to fear of consequences).

A systematic review of how direct care professional nurses experience moral distress in hospital environments supported prior findings that morally distressed nurses suffer from biological, emotional, and moral stress (Rittenmeyer & Huffman, 2009). Reactions to moral distress included anger, loneliness, depression, guilt, powerlessness, anxiety and even emotional withdrawal. One effect of moral distress on the organization and healthcare system is that of nurses leaving the stressful situation for a less stressful environment (turnover). Prolonged moral distress without action to relieve the distress may result in negative feelings toward self and/or the offending source (organization, physicians, peers, patients or families). Self-hatred, low self-esteem, burnout, hardening or jading can develop in nurses who experience prolonged exposure to unrelieved moral distress (Corley, 2002; Ganz & Berkovitz, 2011; Hart, 2005; Levi, Thomas, Green, Rentmeester, & Geneviva, 2004; Repenshek, 2009; Rushton, 2008).

One effect of moral distress on the organization and healthcare system is that of nurses leaving the stressful situation for a less stressful environment (turnover). Nurses may also displace negative feelings or actions toward the offending source through horizontal violence, bullying, job dissatisfaction, lack of focus on primary work or disruptive behavior (Edmonson & Allard, 2013; Elperin, et al., 2005; Levi et al., 2004; Repenshek, 2009; Rushton, 2008). The result of organizationally focused negativity by the nurse may create a toxic work environment that yields loss of productivity, high turnover rates, high vacancy rates and distractions from patient care that create patient safety issues (Beumer, 2008; Corley, Minick, Elswick, & Jacobs, 2005; Hart, 2005; & Houghtaling, 2012).

Rittenmeyer and Huffman (2009) also described secondary findings of organizational constraint and culpability in their systematic review. Organizational constraints included limited finances (resources), poor staffing patterns, and weak policies. These constraints result in organizational culpability for nurses who feel unrelieved distress because they could not advocate effectively for their own or their patients’ well-being.

Prolonged exposure to moral distress that is unrelieved by acts of moral courage may result in moral fatigue and moral residue (i.e., the build-up over time of unrelieved moral distress)(Carroll, 1991; Grady et al., 2008; Jones & Ryan, 1997; Lang, 2008; Pijl-Zieber et al. 2008; Sekerka & Bagozzi, 2007; Sekerka, Bagozzi, & Charnigo, 2009). Organizational leaders need to recognize the need for an environment conducive to moral acts through a balanced, safe, and open forum for discussion. Discussions may include internal/external influencing factors, participant/observer emotions, a learning environment, a strong ethics foundation, and an environment where courageous acts are encouraged, recognized, and rewarded.

Self-regulation and external-approval needs significantly influence the moral decision-making process and ultimately the morally courageous action or inaction by the nurse (Granitz, 2003; Houghtaling, 2012; Jones & Ryan, 1997; Rotter, 1966; Sekerka & Bagozzi, 2007). These influential areas in moral decision making need to be further explored, continually practiced, and increasingly recognized to contour the environment for courageous acts to occur by individuals.

Because moral courage and moral distress discussions, as related to the nurse leader, could not be found in the literature, existing literature focusing on direct care nurses has been translated into an intervention to promote moral courage. This intervention translates findings from the direct-care nurse literature to the nurse leader.

My goal in this work has been to strengthen the moral courage of nurse leaders, identify factors that would increase their ability to act courageously in morally distressing situations, and decrease their moral distress. To achieve this goal, I worked to synthesize the literature related to moral distress, identify the environmental and cultural factors that promote courageous acts of nurse managers, develop an intervention to strengthen moral courage in nurse managers, and improve the internal and external conditions that promote morally courageous acts, as described below.

Development of the Nurse Leader Moral Courage Intervention

This intervention was designed to increase the acts of moral courage in nurse leaders, to decrease or alleviate moral distress, and ultimately to prevent moral residue. It emerged through evidence translation from the literature describing direct-care nurses’ experiences with moral distress and the most effective interventions to relieve this distress.  

First, evidence translation revealed a need to measure nurse leaders’ experience of moral distress, including type, duration and outcomes, along with nurse leaders’ view of self as a moral leader. Because no tool could be found to measure moral distress among nurse leaders, the Professional Moral Courage Scale (PMCS) by Sekekra and Bagozzi (2007) was selected to evaluate leaders’ self-described view of their own moral courage. The PMCS scale was developed by these two authors based on previous work related to moral courage and a study of managers in the military. The five-dimensional scale was validated using single-factor order to measure overall PMC. The scale, which assesses overall PMC, measures five dimensions (themes), including Moral Goals, Multiple Values, Enduring of Threats, Going Above and Beyond Compliance, and Moral Agency. The authors reported convergent and discriminant validity that was analyzed by use of confirmatory factor analysis procedures (Sekekra & Bagozzi, 2007).

...evidence translation revealed the need for a model to bolster nurse leaders’ ability to act in a morally courageous manner. Second, evidence translation revealed the need for a model to bolster nurse leaders’ ability to act in a morally courageous manner. A model was sought to recognize and address the differences in the two domains in which nurse leaders work, specifically nursing and leadership. The model chosen, Lachman’s CODE (Courage, Obligations, Danger, Expression) model (2007), was the best fit because it focused on recognizing (a) the moral situation, (b) the distress felt by the involved nurse leader, (c) the obligation to address it, (d) the control of one’s emotions, (e) risk assessment, (f) peer consultation and (g) outcome evaluation for learning.

The third area to emerge from evidence translation was the need for ethics education and training to increase the likelihood of recognizing, analyzing, and acting in a morally distressing situation. A course was developed based on virtue ethics within a framework of the Balance Experiential Inquiry (BEI) model (Sekerka, Godwin, & Charnigo, 2009). BEI is based on the concepts of appreciative inquiry and diagnostic deficit for a balanced approach to build on strengths and decrease deficits. BEI incorporates the andragogical philosophy of adult learning, in which participants who experience an ethical dilemma reflect on the experience, reason abstractly about the experience, and then act and experiment with newly acquired behaviors (Sekerka, Godwin, & Charnigo, 2010).

The moral compass work by Kiel and Lennik (2005) was also incorporated into the class content to represent a powerful metaphor that could more easily be remembered by attendees and to provide direction, in a time of doubt, regarding the right thing to do. The concepts of virtue ethics and moral compass share many complimentary themes, ideas, and action direction, specifically the concept of knowing one’s self in terms of characteristics, values, and beliefs as the source of truth. The moral compass work modernizes the way in which participants can more easily think about and make decisions in today’s complex environment.

The intervention was divided into three phases. The intervention context was that of a ‘just’ culture in an organization with a mature, shared governance model, designed specifically for raising nurse managers’ voices. In phase one, participants self-evaluated their current level of professional moral courage. In phase two, the group was taught about ethics and moral courage. In phase three, participants completed a two-week, post-education re-evaluation of their level of professional moral courage. The sequence and references are outlined as follows:

  1. Pre-Situational self-assessment utilizing the Professional Moral Courage Scale (PMCS) (Corley, 2002; Rittenmeyer, & Huffman, 2009; Sekerka et al., 2009)
  2. CODE Moral Courage Model implementation in professional nurse leaders (American Nurses Association, 2001, 2009; Fry, Harvey, Hurley, & Foley, 2002; Lachman, 2007; Rushton, 2008). Ethics Education Program for building nurse leader competencies (Grady et al., 2008; Kelly, 1998; Lang, 2008; Ketefian, 1980, 1981, 2001Sekerka, 2007).
  3. Post-Situational self-assessment utilizing the Professional Moral Courage Scale and Courageous Acts Debriefings (Corley, 2002; Rittenmeyer, & Huffman, 2009; Sekerka et al., 2009)

Implementation of the Intervention

Implementation occurred at a large, tertiary, community hospital in North Texas among a targeted group of nurse managers. This implementation project was approved by the Institutional Review Boards of both the participating facility and the author’s university. The nurse managers voluntarily participated in the pre and post survey; attending a class both addressing virtue ethics within a framework of balanced experiential inquiry; and a discussion about the CODE moral courage model (Lachman, 2007).

Nurse managers were first made aware of the opportunity to participate during a routine leadership meeting that I led, and during which I offered a brief explanation of the project and opportunity for voluntary participation. Following the meeting, nurse managers received an email invitation and a calendar appointment option regarding the time and place for education sessions.

Upon arrival at the education sessions, the participants signed in on a numbered attendance roster and received the Pre-PMCS survey. I briefly described the nature of the project, reconfirmed voluntary participation, and provided directions on completing the Pre-PMCS. This was followed by a two-hour class describing the CODE model (Lachman, 2007) and discussing virtue ethics.

At the conclusion of the class, the participants completed two evaluations, (a) an evaluation for the CODE model content (Lachman, 2007) and (b) an evaluation for the virtue ethics content of the classes. Participants were then instructed on next steps, including courageous acts debriefings with the researcher and completion of the post-PMCS two weeks after the class. A follow up time was established for completion of the post-PMCS survey two weeks after classes were completed. Sixteen participants completed the post survey.

Findings

In this section, I will describe the sample size and demographics. Additionally, I will compare the pre-and post-assessment findings.

Sample Size Description

In phase one of the intervention, the PMCS was targeted to an original number of 23 nurse managers in the practice intervention environment of a large, not-for-profit hospital in the southwestern part of the United States. However, calendar appointments were sent using the list-serve for nurse managers within the organization. This list-serve included all 23 managers, as well as interim managers and directors that were former managers in the organization, for a total of 27 nurse leaders who received the invitation via Outlook calendars. Of the participants invited (both those invited intentionally and the four invited unintentionally), 20 total attended the class (16 nurse managers, one supervisor, and three directors). The four unintended participants (supervisor and directors) were allowed to stay for the class but were excluded from the PMCS assessment as they did not meet the study definition of a manager, leaving a sample of 16 nurse managers according to the project description and protocol.

Demographics

Sixteen nurse managers from various acute care and post acute care services participated in the project. Their mean age was 43.1 (SD = 8.2) years; the mean years of nursing management experience was 6.4 (SD = 7.5); and the mean years of nursing experience was 18.3 (SD =8.4). Most of the participants were women (94%).

Comparison of Pre and Post Assessment Findings

Differences between the pre- and post-class results were analyzed using a paired-t test for the final sample (N = 16 group). Relationships between individual characteristics and differences between pre- and post-class scores were analyzed using simple linear regressions.

Overall, nurses’ responses were positive both before the class (scores ranged from 4.7 to 7.0) and after the class (scores ranged from 5.0 to 7.0). Table 1 presents the five themes that were assessed using the PMCS and compares the pre-and post-class results of PMCS scores. The ‘Going Beyond Compliance’ theme showed statistically significant improvement from 6.0 before the class to 6.4 after the class (p < 0.05) with a t = 2.26. There were positive trends in responses to other themes (ranging from 0.1 to 0.3). Overall PMCS showed marginal improvement from 6.1 in the pre class to 6.2 in the post class (p = 0.050) with a t = 2.13.

Table 1. Professional Moral Courage Scale (PMCS) Assessment (paired t-test); N = 16

PMCS

Pre

Post

Difference (post-pre)

t

p-value

Theme

Mean

SD

Mean

SD

Mean

SD

Moral Agency

6.2

0.5

6.3

0.5

0.1

0.4

1.19

0.252

Multiple Values

6.1

0.5

6.2

0.5

0.1

0.5

0.97

0.347

Endurance of Threats

5.7

0.7

6.0

0.7

0.3

0.7

1.70

0.110

Going Beyond

Compliance

6.0

0.5

6.4

0.4

0.4

0.6

2.26

0.039

Moral Goals

6.4

0.4

6.5

0.5

0.0

0.4

0.40

0.697

Overall PMCS

6.1

0.4

6.2

0.4

0.1

0.2

2.13

0.050

PMCS: Professional Moral Courage Scale, SD: Standard Deviation; p-value based on the paired-t test.

Simple linear regression analyses revealed that years of nursing management experience was an important predictor of the Multiple Values theme differences between pre- and post-class PMCS scores (b = - 0.004713, p < 0.01); the Moral Goals theme (b = -0.02972, p < 0.05); and the overall PMCS (b = -0.01342, p < 0.05). The negative impact of the educational intervention on experienced manager scores for the two themes and for the overall PMCS score represented an unanticipated finding, as scores for these two themes and for overall PMCS scores decreased for managers with 20 plus years of managerial experience.

This finding regarding years of experience was surprising. When the data were explored graphically for the Multiple Values and Moral Goal themes, participants 16 and 18 had an ‘odd’ response. The class had a negative effect on the two participants who had more than 20 years of nurse manager experience. The statistician and I agreed to explore the data set using the same statistical tests (paired t-test and simple linear regression) excluding these two outliers with more than 20 years of nurse manager experience and to compare the results to better understand the impact on the group with less than 20 years of experience, which represented the majority of the sample. Table 2 represents the paired t-test of the group (N = 14) excluding the two subjects with greater than 20 years of nurse manager experience.

Sub-Group Analysis N=14 (Excluding Participants 16 and 18)

Overall, nurses’ responses were again positive both before (scores ranged from 4.7 to 7.0) and after the class (scores ranged 5.0 to 7.0). Table 2 compares both the pre-and post-class results of PMCS score. The Multiple Values theme showed the statistically significant improvement from 6.1 in the pre-class to 6.4 in the post class (p < 0.05) with a t = 3.71. The Going Beyond Compliance theme showed statistically significant improvement from the 6.0 in the pre-class to 6.4 in the post class (p < 0.05) with a t = 2.53. There were also positive trends in the other themes, (ranging from 0.1 to 0.3). Overall PMCS showed significant improvement from 6.1 in the pre class to 6.2 in the post class (p < 0.05) with a t = 3.37. A simple linear regression analysis showed that the years of nursing management experience was a marginally important predictor of the Multiple Values Theme differences between the pre- and post- class PMCS scores (p = 0.0505).

Table 2. Professional Moral Courage Scale Assessment (paired t-test): Sub-Group Analysis without Participants 16 and 18, N = 14

PMCS

Pre

Post

Difference (post-pre)

t

p-value

Theme

Mean

SD

Mean

SD

Mean

SD

Moral Agency

6.2

0.5

6.4

0.5

0.1

0.4

1.25

0.234

Multiple values

6.1

0.5

6.4

0.4

0.3

0.3

3.71

0.003

Endurance of Threats

5.6

0.7

6.0

0.7

0.3

0.7

1.83

0.090

Going Beyond Compliance

6.0

0.6

6.4

0.4

0.4

0.6

2.53

0.025

Moral Goals

6.4

0.4

6.5

0.4

0.1

0.3

1.33

0.208

Overall PMCS

6.1

0.4

6.2

0.4

0.1

0.1

3.37

0.005

PMCS: Professional Moral Courage Scale, SD: Standard Deviation; p-value based on the paired-t test.

Evaluation of the Effectiveness of the Intervention

Evaluation of process (how) and outcomes (what) is crucial to understanding the effectiveness of the intervention. Understanding the differences between the planned and the actual intervention, as well as expected and actual outcomes will add to the existing knowledge and practice of moral courage and ethics among nurse leaders. Both the process evaluations (including the moral courage class and the ethics class evaluations) and the outcome evaluations (including the first courageous act and second courageous act) are presented below.

Process Evaluation

Both classes used incorporated andragogical principles for adult learning, including didactic content, a concrete experience, reflection, scenarios, discussion, and expressing action, into the teaching process. The process evaluation section of this article is based on completed evaluations for the moral courage and the ethics class. The CODE Model (Lachman, 2007) was the foundation for the moral courage class, which included a review of moral courage (Edmonson, 2010), along with two case scenarios in which participants were asked to apply the model and discuss results. The ethics class, which used the BEI model with a virtue ethics foundation, incorporated two YouTube videos on normative ethics and leadership, and concluded with a real clinical scenario. The scenario was presented by a nurse and manager involved in a morally distressing situation regarding patient care in the project’s organization. Both classes used incorporated andragogical principles for adult learning, including didactic content, a concrete experience, reflection, scenarios, discussion, and expressing action, into the teaching process.

Moral courage class evaluations. The 20 class/course teaching evaluations were not able to be separated in terms of manager, supervisor, and/or director, resulting in the full sample size of 20 participants. Twenty completed and usable evaluations from the moral courage class were returned. The evaluations were positive for both the content and the resonance sections of the evaluations. The content section asked for participants’ view of the covered material in terms of practicality and applicability to their work. Participants agreed 100% with the questions in the content section regarding usefulness, practicality, presentation level, insight gained, applicability and usability of CODE model. The resonance evaluations that addressed participants’ ability to connect the intervention to their work demonstrated 100% agreement with questions regarding class content resonating with ‘me as a leader,’ with 'me as a nurse,’ and with a ‘belief that I have a strong foundation enabling me to be courageous.’

Ethics class evaluations. Twenty complete and usable evaluations were returned after the ethics class. The participants again offered positive evaluations of both the content section and the resonance section of the teaching. The content section measured participants’ view of the covered material being practical and applicable to their work. All of the participants agreed 100% with five of the questions in the content section, regarding usefulness, presentation level, insight gained, applicability, and usability of the ethics model. Ninety-five percent of the participants agreed that the ethics content was practical. The resonance section demonstrated 100% agreement with questions addressing content resonating with me as leader, a nurse, and believing I have a strong foundation to be courageous.

Outcome Evaluation (Courageous Act Debriefings)

The project plan incorporated the use of self-reported, courageous-act debriefings with the project director. These served as a second mechanism to evaluate the effectiveness of recommendation outcomes. Two participants reported courageous acts in the two weeks following the classes, thus demonstrating clinical significance for the practice recommendation.

First courageous act. Nurse manager A discussed an experience of supporting a nurse who felt the need to confront a physician colleague about negative comments the physician had made regarding nursing care for a patient on her unit. Nurse manager A clarified the situation using the CODE model framework with the direct care nurse, practiced the interaction with the nurse, and coached the nurse on ‘doing the right thing.’ The staff nurse approached the physician on the next rounding cycle, asked the physician to step into a private area, and confronted the physician regarding his comments. According to the nurse, the physician appeared somewhat surprised and embarrassed by the situation. He apologized to the nurse and corrected the comments to the patient.

Second courageous act. Nurse manager B discussed a situation with a physician that she felt pre-judged a patient in the unit regarding the patient’s reasons for seeking pain medication. The nurse manager confronted the physician regarding the situation. The physician denied pre-judging of the patient’s reasons. Although the physician did not change the pain medication treatment plan, he also ordered non-pharmacologic measures to address the pain. The nurse manager shared with the project director that although this was not the outcome she had hoped for, it was a positive and empowering experience to confront the situation and feel as though she had done the right thing.

Discussion

This educational intervention showed marginal to significant improvements for participants; it demonstrated some statistical significance regarding the practice recommendation. Specific themes of Going Beyond Compliance and Multiple Values demonstrated the most change and sensitivity to the practice recommendation. The Going Beyond Compliance theme relates to the participant’s view of self and co-workers regarding the utilization of more than rules, laws, or regulations to make decisions, thus implying moral review of their decisions. Essentially, Going Beyond Compliance refers to the ability to use an internal moral compass as opposed to using laws and rules as a basis for making decisions. The Multiple Values theme relates to considering both one’s own values and organizational values when making decisions. Lessons learned and future directions will be considered below.

A positive correlation was noted between improvements in the professional moral courage scale and the number of years as a nurse manager up to 20 years of experience. After 20 years of nurse manager experience, the class had a negative impact on the overall PMCS score. This represents an unusual finding and should be explored further in future research.

The courageous act debriefings demonstrated clinical significance as to a change in behavior that occurred as a result of the interaction. Both nurses demonstrated new behaviors that had not been demonstrated prior to the practice recommendation classes.

Lessons Learned

...inadequate dwell time... for the content and lack of ongoing or subsequent classes or forums for ethics discussions may prevent improvements in scores. The post survey of class participants was conducted two weeks after classes were completed. Sekerka, the author of the PMCS tool suggested that either very little (or significant) improvement may be seen following an intervention to increase moral courage, based on her experience and work in the area of bolstering moral courage in managers outside of nursing (L. Sekerka, personal communication). Sekerka suggested that inadequate dwell time (the time between education and re-measuring) for the content and lack of ongoing or subsequent classes or forums for ethics discussions may prevent improvements in scores. Future applications should be designed to allow for more content dwell time and for frequent follow-up forums to discuss the content. These forums could include both discussing concrete experiences of the group in applying the concepts and exploring ongoing ethical situations requiring moral courage.

Ethnicity data for participants was not collected for the group for comparison or correlation with the PMCS tool. Due to the observed diversity of participants in the class, assessing this diversity may have proved interesting in determining possible relationships between diversity and improvement in PMCS results.

Previous ethics education data was not collected for the group for comparison or correlation with the PMCS tool. The literature review revealed that nurses with previous ethics education were more likely to act in a morally distressing situation than their counterparts who had not had previous ethics education (Grady et al., 2008). Previous studies findings may have been further supported had this study collected date related to previous ethics education.

Additionally, I considered the potential for bias in the results as I served as both the chief nursing officer (CNO) of the target organization and as the researcher. Even though participant responses were blinded, a bias, if present, may have resulted from a desire to please the CNO and/or not appear to have low moral courage. The possibility exists that the CNO, being the project director and the executive nurse leader in the organization, may have influenced the PMCS scores. 

Future Directions

Moral distress specific to nurse leaders is seldom addressed in the literature. Further work is needed including replication of this study, development of a nurse leader moral distress tool, and partnering with professional nursing organizations for program development and distribution.

The project was conducted at a single site with a small sample size. Replication is recommended with larger groups at multiple sites with sufficient time periods for debriefings and morally courageous acts to occur.

A longitudinal study of the PMCS measures to demonstrate effect may also provide additional information. The two-week time frame and the single class in ethics and moral courage may not have provided enough time, content, reinforcement, or practice opportunities to generate statistically more significant changes in PMCS scores. According to the BEI model (Sekerka & Bagozzi, 2009), small group work with more time to discuss concrete experiences, reflect on the experience, discuss possible actions with peers, and then demonstrate moral courage is advisable.

Current measurement tools are focused on measuring professional moral courage among leaders in all disciplines or else on bedside nurses. A tool specific to nurse leaders’ self-assessment of moral courage and experience of moral distress could further define the problem of moral distress and evaluate moral courage in this population.

Simply put, the higher one is on the hierarchy, the higher the expected use of courage and advocacy to do the right thing in the organization. Moving the work to a broader population of nurse leaders may best be accomplished by partnering with a professional nursing organization, such as American Organization of Nurse Executives or its affiliates. Without a defined plan and partners for moving this work forward, the work may have limited exposure among nurse leaders who are most likely to benefit from it.

Like their clinical counterparts, nurse leaders work in hierarchical structures that presume and encourage the use of a chain of command and have increasingly higher expectations of moral courage with increases in authority and responsibility. Simply put, the higher one is on the hierarchy, the higher the expected use of courage and advocacy to do the right thing in the organization. Directing this intervention to upper management and chief nursing officer levels of the organization may prove beneficial.

Conclusion

Organizations and healthcare systems today are in great need of moral leadership. Organizations and healthcare systems today are in great need of moral leadership. The influence of morally courageous nurses, regardless of position, is critically needed to transform healthcare and care systems so as to safeguard patients. Given that nurses are the largest group of healthcare providers in the United States, that more Americans than ever are asking nurses to be influential in healthcare reform, and that the Institute of Medicine (IOM, 2010) Future of Nursing report has called for more nurses to advance their education, the potential for nurse leaders to demonstrate increased moral courage is exciting. As nurse leaders in the healthcare system and in specific facilities, we need to demonstrate moral courage and create environments that promote morally courageous acts so as to keep us centered on the very thing that drew us into healthcare, namely the patient, the families, and the communities we serve.

Author

Cole Edmonson, DNP, RN, FACHE, NEA-BC
Email: coleedmonson@yahoo.com

Dr. Edmonson is currently practicing nursing at Texas Health Presbyterian Hospital, Dallas, as the Chief Nursing Officer. He has facilitated the development of numerous programs throughout his career designed to develop front-line managers, increase job satisfaction, improve quality metrics, and evaluate outcomes related to performance. Dr. Edmonson, a Robert Wood Johnson Foundation (RWJF) Executive Nurse Fellow, serves as the President of the Texas Organization of Nurse Executives and as the co-leader for the RWJF Texas Team, State Action Coalition for the Future of Nursing. He serves as adjunct faculty at the University of Texas, Arlington, College of Nursing and at the Texas Woman’s University. His clinical background is varied and includes critical care, intermediate care, and cardiac cathether lab care. He has also worked in pediatrics and post coronary care units at both the community and tertiary hospital levels. Dr. Edmonson received his Bachelor and Master of Science degrees in Nursing from the University of Oklahoma and his Doctor of Nursing Practice degree at Texas Christian University (Fort Worth). He is a Fellow in the American College of Healthcare Executives, a member of the American Nurses Association, and Board Certified as Nurse Executive Advanced through the American Nurses Credentialing Center.

References

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© 2015 OJIN: The Online Journal of Issues in Nursing
Article published , February 17, 2015


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