8/6/2019 28_Lachman

1/18

ICNE YALE #28

Moral Courage: Bridging Nursing Ethics and Patient SafetyVicki D. Lachman, PhD, APRN, MBE

You gain strength, courage, and confidence by every experience in

which you really stop to look fear in the face. You are able to say, "I

lived through this horror. I can take the next thing that comes

along." . . . You must do the thing you think you cannot do.

Eleanor Roosevelt

The seriousness of the problem of patient safety has been widely documented since the

Institute of Medicine (IOM) 1999 landmark report, To Err is Human (Blendon, et al.,

2002; Healey, Shackford, Osler, Rogers & Burns, 2002; Starfield, 2000).

Since most errors fall within the sphere of nursing practice, administrators, physicians

and nurses see patient safety predominantly as a nursing responsibility (Cook, Hoas,

Guttmannova, & Joyner, 2004). To bridge the gap that presently exists in patient safety

initiatives, nurses must demonstrate moral courage. We have an ethical obligation to our

patients to do everything we can logically do to make sure they are safe. First, do no

harm. An immense challenge lies before us, but for our patients sake we must meet this

ethical test with moral courage.

This paper with begin with a historical overview of the concept of moral courage from

Aristotle to a present day definition in the book by Kidder (2005). Ethical obligations will

also be extracted from the Code of Ethics for Nurses (2001) to illustrate nursings

responsibility in preventing and disclosing, as well as policy development in patient

safety imperative. Five strategies to comply with this ethical imperative for patient safety

will also be outlined.

1

8/6/2019 28_Lachman

2/18

Historical overview of the concept of moral courage

The early writings of Aristotle were focused on the courage required in war. The

dismantling of the Athenian Empire was occurring due to the Peloponnesian War. In

Nicomachean Ethics (NE), Aristotles (1954) discussion of courage centers on the

battlefield; dying in battle was considered noble, unlike dying from disease. Aristotles

view of courage differed from his teacher Plato. According to Plato, courage is one of

the four cardinal virtues in the lasting tradition of moral character (Stanford Encyclopedia

of Philosophy, 2007). The other three qualities are temperance, justice and wisdom.

However, Aristotles focus was not on cardinal virtues, but on two types of virtues:

virtue of thought and virtue of character (Aristotle, 1954). The former was improved

through education and the latter was amplified through habit. Will is the result of the

education in physical, mental and spiritual realms. Will is an executive function between

impulses (appetites) and rational aspects of human experience. Socrates and Plato both

thought that management of mind over body was the only way in which human actions

could become good. Aristotle thought that action of habit was also necessary.

Aristotle believed that virtue of courage was the balance (mean) between extremes of

cowardice and rashness. Therefore, an individual might charge ahead into danger either

because he is blinded by rage (terrorist) or because he is unaware (intoxication) to the

dangers that lie ahead. According to Aristotle, courage is defined as having rational

control of emotion and passion; the person is expected to have control over fear and other

emotional states. In his view, people acted rationally despite their fears, not because they

2

8/6/2019 28_Lachman

3/18

did not experience fear. He thought that both deficient and excess in a virtue could be

disastrous. 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 (NE III7.1115b15-20).

Aristotle was steadfast in his belief that a virtue, like courage, only be used for honorable

ends. Plato argued that courage for wicked ends was a lack of the cardinal virtue of

wisdom (Stanford Encyclopedia of Philosophy, 2007). Aristotles focal point was on

importance of acting, not just the reasoning. He said that one must not only know what

to do, but he must also be able to act accordingly (NE VII 1152a5-10).

Socrates, Plato and Aristotle, upon who we base our philosophical considerations, did not

live in our time of rampaging medical litigation. Disclosing a medical error, particularly

when the nurse feels personally to blame, requires the virtue of moral courage. For

justice to prevail in any situation, both human beings involved must have their interests

considered, according to societal mores or laws (Mavroudis, Mavoudis, Naunheim, &

Sade, 2005). The nurse must treat the patient in the same manner that s/he would want to

be treated.

Humility is also a virtue and a crucial one in responding to errors. By being humble,

one has the capability for candidness to admit ones own imperfection. Through humility

we know our personal limitations. Humility is defined as the awareness of and being at

ease with ones imperfections (Crigger, 2004). By recognizing our own fallibility, we

have a more sympathetic attitude toward others and more readiness to forgive ourselves

3

8/6/2019 28_Lachman

4/18

and others. Consequently, the ethical response to making a mistake begins with being

humble enough to honestly disclose the error.

This is supported by Kants moral theory of the categorical imperative against lying

(Kant, 1996). This imperative states Act only on the maximum through which you can,

at the same time, will that it become a universal law of values. According to Kant,

anything less than full disclosure of the error would deny the patient his moral dignity.

Trust between the patient and the nurse necessitates this open communication. Nurses are

obligated to steer clear of intentional deception (e.g. stating that the injury occurred

because of other believable causes).

If we fast forward to today, authors tend to see the virtue of moral courage as driven by

principle (Kidder, 2005; Lachman, 2007). When courage supports our values and

maintains core principles, we lean to using the term moral courage. Moral courage is

about facing mental or social challenges that could wreck your reputation and emotional

well-being, your adherence to conscience, and/or your self-esteem. The risks in acts of

moral courage are humiliation, ridicule, unemployment and loss of social standing. The

morally courageous person often goes against the grain, acting contrary to the accepted

norm. Simply put, moral courage is the courage to be moral which means adhering to

the five core moral values of honesty, respect, responsibility, fairness, and compassion

(Kidder, 2005, p.10).

Moral courage, like physical courage, requires the individual to overcome fear and stand

up for his or her core values. It is the willingness to speak out and do what is right in the

face of forces that would lead a person to act some other way (Lachman, 2007). Both

Kidder and Lachman agree with Aristotle, moral courage is measured in action. It

4

8/6/2019 28_Lachman

5/18

requires a conscious reasoning of the risks and a willingness to act regardless of the risks.

We have the ethical responsibility to determine what is needed for patient safety and to

implement the training, mechanisms and strategies necessary (Sharpe, 2003).

Patient safety initiative

The IOM (1999) defines error as a the failure of a planned action to be completed as

intended or the use of a wrong plan to achieve an aim. This could be an act of omission

(e.g. not implementing appropriate antibiotic prophylaxis in pre-operative patient) or an

act of commission (e.g. not decontaminating hands prior to and after direct contact with

patient). The IOM called for an extensive national endeavor to redesign health care

systems to make them safer and to develop a non-punitive attitude to errors.

Instead of blaming and punishing individuals who make errors, the new approach is to

examine and change faulty systems. A systems approach to preventing medical errors

holds that systems set up individuals to make mistakes by faulty design of processes,

problematic work conditions (e.g. disruptive physicians, untenable workloads etc.), lack

of leadership supporting a culture of safety, flawed equipment design and maintenance

and other factors (Reason, 1990). A systems approach increases reporting and actually

empowers healthcare providers to contribute to systems improvement.

Healthcare is a very complex, but other industries that are equally complex have better

safety records. Examples include chemical manufacturing, nuclear power, and aviation.

Leaders in these industries are recognized as high reliability organizations (HRO)

because they manage for safe performance. The results of the research conducted on

5

8/6/2019 28_Lachman

6/18

these organizations will be included in the five strategies to bridge the gap to safety (The

Institute for Safe Medication Practices (ISMP), 2005a). The first and the most critical

underlying attribute of their accomplishments is a strong safety culture.

Creating this culture of safety is the first strategy that will be discussed. The other

strategies that will be described are implement and follow safe practices; create a

reporting system that honors confidentiality; disclose the error and apologize; and deal

with the problem nurses who are unable or unwilling to follow patient safety initiatives.

Creating a culture of safety

Culture is defined as a set of shared basic assumptions about the organizations values

(what is important), beliefs (how things work), and behaviors (the way we do things) that

have been reinforced in the workplace in an explicit or implicit ways (Senge et al., 1999).

These assumptions have worked well enough to be considered valid and therefore, are

taught to new members as the correct way to perceive, think, and feel in relation to

problems. Culture is deeply rooted in an organizations history and collective experience.

This strategic emphasis on safety by HROs is logically based on a healthy respect for the

high-risk nature of the business and an obsession with the possibility for failure (ISMP,

2005a). They know safety does not assure quality, but it is a requirement for high-quality

service. But they are not driven by financial cost of errors; they are driven by the values

that honor their commitment to society. This is the same ethical commitment we need in

order to honor our patients.

6

8/6/2019 28_Lachman

7/18

This commitment begins at the top, but without a consistent message from managers that

safety is a top priority the message will not be believable. These leaders and the

workforce support an uncompromising intolerance for intentional risk-taking that could

lead to error. Misconduct, such as refusal to do correct site verification, is an example of

intentional risk-taking. In a safety culture the workforce trusts the leaders and each other

to report and deal fairly with errors without retribution, concerns about safety are

appreciated and rewarded. Near misses are seen as great catches and errors are

opportunities to learn.

Unfortunately, many healthcare organizations lack these characteristics of HRO culture

of safety. Therefore, nurses need to understand their moral obligations and have the

moral courage to do the right thing, regardless of the culture. A culture of safety supports

nurses in preventing and reporting errors, but the accountability for patient safety never

leaves the nursing professional.

The American Nurses Association (2001) Code explicitly and implicitly states the nurses

duty to patient safety; there are multiple statements that indicate the nurses moral

obligation to prevent, report and disclose errors. Specifically, provision three in the Code

states the nurse promotes, advocates for and strives to protect the health, safety and

rights of the patient (ANA, 2001, p. 12). In provision six of the Code the nurse is

informed of his or her responsibility for creating a moral environment. For example,

acquiescing and accepting unsafe or inappropriate practices is equivalent to

condoning unsafe practice (ANA, 2001, p.21). Silence must be broken if patient safety

7

8/6/2019 28_Lachman

8/18

is truly seen as an ethical imperative. It is in this provision that the specific mention of

courage as a habit of a morally good person is revealed.

Implement and follow safe practice

The second strategy is to utilize what the research tells us will make the most difference

in eliminating errors and avoidable adverse events. If the data is unambiguous, then the

only morally legitimate action is 100% compliance. Therefore, it is imperative is to

implement and follow the safe practices summarized by the National Quality Forum

(2003). However, this list of 30 practices is not carried out in all hospitals; most have

merely put into practice those mandated by Joint Commission on Accreditation of

Healthcare Organizations (JCAHO) (2001).

HROs carefully consider human factors such as sources of distraction, excessive

workloads, unsafe staffing ratios etc (ISMP, 2005b). Nurses report that the

majority of errors are caused by job overload, therefore, nurse staffing plays a

major role in preventing errors (ANA, 2000). But we can not rely on education

only to support these patient safety initiatives; technology such as bar coding

patient identification and Pxyis medication administration can prevent errors.

Nurses need to use other proven principles of error reduction such as

standardization (e.g. time-out before surgical incision) and failsafes (e.g.

medication can not be ordered from pharmacy before specific lab test is

completed).The Code (2001) provision three speaks to the nurses ethical

responsibility

8

8/6/2019 28_Lachman

9/18

to implement and maintain standards of professional nursing practice

Nurses should also be active participants in the development of polices

and review mechanisms designed to promote patient safety, reduce

likelihood of errors, and address both environmental system factors and

human factors that present increased risk to patients. (p. 13-14).

This provision states it is not only the ethical obligation of the nurses to follow existing

safe practices, but also the obligation to identify and address sources of error.

Moral courage could be required in speaking up about any one of these 30 practices. For

example, there is recognized safe practice for verbal orders- write down the order and

read back to the prescriber. If a physician refuses to listen to the read back, then the nurse

has to decide whether it is safe to give the medication. If the nurse does decide to give the

medication, HROs would call this intentional risk-taking. Why would a nurse take this

risk?

In a 2003 survey on workplace intimidation, 40% of the respondents stated they had

questions about the safety of an order in the past year but chose to take for granted the

order was correct rather than talk with a prescriber they perceived as intimidating (ISMP,

2004). A nurse needs to persist despite opposition; a helpful communication strategy such

as SBAR(Situation-Background-Assessment-Recommendation) could help in the

conflict resolution (Safer Healthcare). It is always easier to speak up in conflict when you

have a model to frame the discussion.

Create a reporting system that honors nurses confidentiality

9

8/6/2019 28_Lachman

10/18

The third strategy is establishing an effective reporting system. We have an ethical

obligation to not only our patients, but to future patients. This is only done in a no

blame culture where near misses are mined to prevent hazards to future patients. IOM

(1999) recommends voluntary, confidential reporting systems within all healthcare

institutions.

The Code (2001) requires nurses to report errors to the appropriate supervisory personnel

(p. 14). Under no circumstances should nurses attempt to hide an error; the focus must

clearly be on correcting the error. If a punitive reporting system is in place, the nurse

must still report error, but also work to change the system to one that focuses on

improvement of patient safety. Provision six in the Code suggests nurses should not stay

employed in organizations that habitually violate patient rights or who ask the nurse to

compromise standards of practice (p. 21). Sometimes it takes more moral courage to

leave than to stay in an environment that repeatedly puts patient safety and personal

morality at risk.

Disclose the error and apologize to the patient

Disclosing the error is the fourth strategy to act ethically in patient safety. The injured

patient has a right to know what happened (Leape, 2005). Yet, Cook et al. (2004)

confirmed in one sub-study that only 64% would reveal the error to the patient affected,

notwithstanding there was vast agreement between participants (97%) that an error had

happened. The nurses role as a patient advocate requires disclosing the error, because

10

8/6/2019 28_Lachman

11/18

patients can not make appropriate decisions without the complete information. Such full

disclosure supports patient autonomy (Kelley, 2002).

JACHO standard R.I.1.2.2 requires that patients and when appropriate, their families,

are informed about the outcome of care, including unanticipated outcomes. The standard

is silent on scope and content of error disclosure (Banja, 2003). However, a qualitative

study, which incorporated 45 nurses, determined six elements of disclosure that

complement what patients desire. (Fein et al., 2007, p. 757).

1. Admission: Did the discloser admit to the patient that there was an error?

2. Discuss the event: Was the occurrence of the event containing the error clearly

discussed with the patient?

3. Link to proximate effect: Did the discloser communicate to the patient the link

between the error and its proximate effect in a way the patient could understand?

4. Proximate effect: Was the effect of the error discussed with the patient?

5. Link to harm: If there was harm from the error, was the link between the error and

harm sustained by the patient communicated in comprehensible fashion?

6. Harm: If there was harm from the error, was there communication concerning the

harm?

The following example is a full disclosure using all six elements:

Because of an error on my part, you got your insulin when you should not have.

I apologize for that. It caused you to have very low blood sugar, which caused

you to have a seizure. The seizure caused you to fall out of bed and that is when

you broke your hip.

11

8/6/2019 28_Lachman

12/18

If the hospital also eliminates from the patients bill any costs linked with the error, then

the nurse can also include this to the apology. The patients should not have to bear

expenses caused by mistakes. All of us want to know what went wrong, why and what

will be done to prevent it from happening to someone else.

Presently, the system of liability for medical harms makes meeting this responsibility

for disclosure probable only through courage. Our current system dampens this level of

honesty and openness between health care professionals and patients. Viewed from the

point of view of utility (greatest good for the greatness number), the tort process is

unproductive. However, some early results indicate that patients are less likely to sue if

healthcare providers admit responsibility and apologize (Leape, 2006).

Take responsibility as profession for problem nurses

This fifth strategy requires the reporting of nurses who are commit unethical, unlawful or

incompetent acts to the appropriate person. If we put aside the rare psychopathic nurses

who engage in nurse assisted suicide, the majority of problem nurses impaired

performance is due to drug and alcohol abuse (estimated to afflict 6% to 8%), mental

illness (15% lifetime risk) or physical illness (unknown, but author estimates 5%, but

probably increasing, given average age of aging baby boomers). (ANA, 1984; Kessler et.

al., 2005). Even allowing for an overlap of categories, at any one time 28% of nurses are

at risk of posing a threat to patient safety. This percentage does not include nurses who

are allowed to continue to practice even though they are not competent in knowledge

and/or skill.

12

8/6/2019 28_Lachman

13/18

Most organizations do not have a good quality system to recognize nurses who have

drug/alcohol abuse or mental illness. Nurses with physical illnesses, such as diabetes,

may as well have impaired performance. This breakdown in guaranteeing competent and

safe practice of all nurses is a major weakness of our professions commitment to patient

safety. To accomplish our ethical responsibility to care for the public and help our

colleagues we need improved systems of identification, support and re-entry.

The Code (2001) speaks directly to the nurses responsibility to address impaired

practice. Nurses must be vigilant to protect the patient, the public and the profession

from potential harm when a colleagues practice, in any setting, appears to be impaired

(p. 15). It is equally clear that if impaired practice is not corrected by the organization,

the nurse has an obligation to report to pertinent licensing body of that profession. As

noted in the Code, such reporting may present significant risks to the nurse, but such risks

do not abolish the obligation to address threats to patient safety. The need for moral

courage is obvious in this language.

Conclusion

The concept of moral courage began in the historical writings of Aristotle and Plato.

They continue today because the ability to feel fear and speak and take appropriate action

for values, beliefs and ethical obligations remains relevant in todays healthcare

environment. The ethical obligation to patient safety can be found in the Code (2001) in

numerous provisions. The five strategies to bridge nursing ethics and patient safety are

13

8/6/2019 28_Lachman

14/18

(1) create a safety culture (2) implement and follow safe practices, (3) create a reporting

system that honors confidentiality, (4) disclose the error and apologize, and (5) deal with

the problem nurses, who are unable or unwilling to follow patient safety initiatives.

Moral courage is the bridge between our nursing ethical obligations and the realization of

patient safety.

References

American Nurses Association (ANA). (1984).Addictions and psychological dysfunctions

in nursing: The professions response to the problem. Kansas City, MO: American

Nurses Publishing.

American Nurses Association. (2000). New ANA study provides more proof of link

between RN staffing and quality patient care. Retrieved May 15, 2008, from

http://nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/PatientS

afetyQuality/RNStaffingandQualityPatientCare.aspx

American Nurses Association. (2001). Code for ethics for nurses with

interpretative statements, Silver Spring, MD: American Nurses Publishing.

Aristotle. (1954).Nichomachean Ethics book III. Ross, D (Trans.) London, England:

Oxford University Press.

Banja, J.D. (2003). Disclosing medical error: How much to tell?Journal of Healthcare

Risk Management, 23(1), 11-14.

14

http://nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/PatientSafetyQuality/RNStaffingandQualityPatientCare.aspxhttp://nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/PatientSafetyQuality/RNStaffingandQualityPatientCare.aspxhttp://nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/PatientSafetyQuality/RNStaffingandQualityPatientCare.aspxhttp://nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/PatientSafetyQuality/RNStaffingandQualityPatientCare.aspx

8/6/2019 28_Lachman

15/18

Blendon, J., DesRoches, M., Brodie, M., Benson, J.M., Rosen, A.B., & Schneider E, et

al. (2002). Views of practicing physicians and the public on medical errors.New England

Journal of Medicine, 347(24), 1933-1940.

Cook, A.F., Hoas, H., Guttmannova, K., & Joyner, J.C. (2004). An error by any other

name.American Journal of Nursing, 104(6), 32-44.

Crigger, N.J. (2005). Always having to say youre sorry: An ethical response to making

mistakes in professional practice.Nursing Ethics, 11(6), 568-576.

Quotations Page, Eleanor Roosevelt quotes. Retrieved May 11, 2008, from

http://www.quotationspage.com/quotes/Eleanor_Roosevelt

Fein, S.P, Hilborne, L.H, Spirtus, E.M., Seymann, G.B., Keenan, C.R., & Shojania, K.G.

et al. (2007). The many faces of error disclosure: A common set of elements and a

definition.Journal of General Internal Medicine, 22(6), 755-761.

Healey, M.A., Shackford, S.R., Osler, T.M., Rogers, F.B. & Burns, E. (2002).

Complications in surgical patients.Archives of Surgery, 137(5), 611-618.

The Institute for Safe Medication Practice (ISMP). (2004). Intimidation: Practitioners

speak up about this unresolved problem (part I). Retrieved May 15, 2008, from

http://www.ismp.org/Newsletters/acutecare/articles/20040311_2.asp

The Institute for Safe Medication Practice (ISMP). (2005a). High-reliability

organizations (HROs): What they know that we dont (Part I) July 14. Retrieved May 4,

2008, from http:www.ismp.org/newsletters/acutecare/articles/20050714.asp

15

http://www.quotationspage.com/quotes/Eleanor_Roosevelthttp://www.ismp.org/Newsletters/acutecare/articles/20040311_2.asphttp://www.quotationspage.com/quotes/Eleanor_Roosevelthttp://www.ismp.org/Newsletters/acutecare/articles/20040311_2.asp

8/6/2019 28_Lachman

16/18

The Institute for Safe Medication Practice (ISMP). (2005b). High-reliability

organizations (HROs): What they know that we dont (Part II) July 28. Retrieved May 4,

2008, from http:www.ismp.org/newsletters/acutecare/articles/20050728.asp

Institute of Medicine (IOM), Kohn, K.T., Corrigan, J.M. & Donaldson, M.S. (1999).

(Ed.) To err is human: Building a safer health system, Washington, D.C.: National

Academy Press.

Joint Accreditation Commission Healthcare Organizations (JCAHO).

(2001).Comprehensive Accreditation Manual for Hospitals: The Official Handbook.

Oakbrook Terrace, IL: JCAHO.

Kant, I. (1996).Practical Philosophy. Gregor, M.J. (Trans., ed) Cambridge, NY:

Cambridge University Press.

Kelley, G.A. (2005). Living at the sharp end: Moral obligations of nurses in reporting and

disclosing errors in health care. Critical Care Nursing Clinics of North America, 14(4),

401-405.

Kessler, R.C., Berglund, P., Demler, O., Jin, R., Merikangas, K.R., & Walters, E.E.

(2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the

National Comorbidity Survey Replication.Archives of General Psychiatry, 62(6):593-

602.

Kidder, R.M. (2005). Moral courage. New York: HarperCollins Publishers.

Lachman, V. (2007) Moral courage: A virtue in need of development? MEDSURG

Nursing, 16(2), 131-133.

16

8/6/2019 28_Lachman

17/18

Leape, L.L. (2005). Ethical issues in patient safety. Thoracic Surgery Clinics, 15(4), 493-

502.

Leape, L.L. (2006). Full disclosure and apology-An idea whose time has come. The

Physician Executive, 2, 16-18.

Mavroudis, C., Mavoudis, C.D., Naunheim, K.S. & Sade, R.M. (2005). Should surgical

errors always be disclosed to the patient?Annuals of Thoracic Surgery, 80(2), 399-408.

National Quality Forum. (2003). Safe practices for better health care: A consensus report.

Report No. NQFCR-05-03. Washington, DC: National Quality Forum.

Reason, J. (1990). Human error. Cambridge: Cambridge University Press.

Senge, P.M., Kleiner, A., Roberts, C., Roth, G., Ross, R. & Smith, B. (1999). The dance

of change. New York: Doubleday Business.

Safer Healthcare. SBAR - A Communication technique for today's healthcare

professional. Retrieved May 11, 2008, fromhttp://www.saferhealthcare.com/index.php?

option=com_content&task=view&id=33&Itemid=84

Sharpe, V.A. (2003). Promoting patient safety: An ethical basis for policy deliberation.

Hastings Center Report, 33(5), S3-18.

Stanford Encyclopedia of Philosophy. (2007). Plato's Ethics: An Overview. Retrieved

May 15, 2008, from http://plato.stanford.edu/entries/plato-ethics/

Starfield, B. (2000). Is US health really the best in the world?JAMA, 284, 483-4855.

17

http://www.saferhealthcare.com/index.php?option=com_content&task=view&id=33&Itemid=84http://www.saferhealthcare.com/index.php?option=com_content&task=view&id=33&Itemid=84http://www.saferhealthcare.com/index.php?option=com_content&task=view&id=33&Itemid=84http://plato.stanford.edu/entries/plato-ethics/http://www.saferhealthcare.com/index.php?option=com_content&task=view&id=33&Itemid=84http://www.saferhealthcare.com/index.php?option=com_content&task=view&id=33&Itemid=84http://plato.stanford.edu/entries/plato-ethics/

8/6/2019 28_Lachman

18/18

18