Moral Courage an Obligation, Says CNO

It's imperative for RNs to do the right thing, even if they are frightened about the consequences they may face. And it's the responsibility of nurse leaders to build work environments that foster courage, says the CNO of Oregon Health & Science University Healthcare.

Last week as I was driving my 4-year-old daughter to the park she asked me, "Mama, when you were little, were you ever afraid?"

I was honest and told that yes, when I was her age, I was indeed afraid of things. I told her that many times I didn't do things, like go on an amusement park ride or introduce myself to new people, because I was too afraid.

"But mommy you should still do things if you're afraid," she counseled. "You take a deep breath and count to three and do it."

Not only was it good advice, but my backseat Yoda had unknowingly summed up a recent conversation that Dana Bjarnason, PhD, RN, NE-BC, vice president and chief nursing officer, Oregon Health & Science University Healthcare in Portland, OR, and I had on the concept of moral courage among nurses and how nurse leaders should commit themselves to building work environments that foster it.

Moral Distress and Its Cousin, Moral Courage
Bjarnason, who presented the session Ethical Challenges: Leading in Complex Organizations at the American Nurses Association's Ethics Symposium in June, defines moral courage as doing the right thing despite fear or potential repercussions. She became interested in the idea as a member of the ANA's board of ethics and human rights.

"One of the things we obviously talked a lot about was the issue of moral distress in nursing which, certainly is a very real problem for us," she says. "It sounded so oppressive and it sounded so helpless."

She's right. Moral distress is not a cheery subject. In its position statement on the topic, The American Association of Critical Care Nurses says moral distress occurs in two scenarios:

1. When a nurse knows the ethical action to take, but is unable to so.
2. When an RN acts in a way that does not align with his or her personal and professional values

Moral distress occurs because of passivity; moral courage occurs because of action. Having moral courage, however, does not mean there is a lack of fear, says Bjarnason. Moral courage often occurs in the presence of fear. Even though they may be afraid, nurses know what the right thing is to do and, as my daughter says, they take a deep breath and do it.

"I think what we need to understand about courage is that courage doesn't mean that you're fearless," she says. "Many times nurses are called upon to do things in the face of fear that they may have from a situation where someone may have more power or more authority [than they do]."

When Bjarnason was a new nurse manager, she was in a position where she needed to report an impaired physician. She did it because she knew it was the right thing to do, but she faced consequences because of her actions.

"I ended up having to leave the organization because it was clear I was never going to be promoted in that organization because of that," she says. "And so the next time I was confronted with an impaired physician, I was really worried about what to do. But I knew what I had to do and that was to talk to the faculty about it."

Find Your Moral 'North Star'
Fortunately, in the second circumstance Bjarnason experienced a very different outcome, likely because she was at an organization where moral courage was valued.

Nurse leaders are key to creating a workplaces where moral courage is not just accepted but encouraged she says. "There's been a lot of work that has taken courage from nurse leaders to stand up for how we do create those environments where nurses can do their best."

She points to the trend that occurred about three decades ago where, in the hopes of containing hospital costs, nursing jobs were eliminated.

"You may remember when we had issues of meeting the bottom line, one of the first things we did was look at nursing because nursing was a huge cost. And we would systematically decimate the bedside nurses [staffing] in order to meet bottom lines," she says.

"You really don't see that happening anymore. I think it is because there were transformational leaders in nursing and nurses continued to achieve higher levels of leadership roles where we could stand up for what it took to maintain a safe, high-quality environment."

When it comes to exercising courage and doing the right thing, Bjarnason uses patient safety to evaluate whether she is on the right track.

"I have always had a very patient-centered approach and so no matter what the question—whether I was a direct care nurse or now as the chief nursing officer—it's about where is the patient in this question. Whenever you put this patient at the center of the question, it's always been my experience that courage flows from that."

She encourages all nurses to find their own "moral North Star," be it patient safety or something else, to help guide them in creating a morally courageous nursing practice and leadership style.

"I signed on the dotted line when I became a registered nurse to do certain things. That is my obligation and responsibility," she says. "As the CNO I have an even larger obligation to the nurses in this organization to help them to create environments that are conducive to high quality patient care. I really consider it an obligation and responsibility and would suggest to everybody that we hold that obligation dear to our heart."