Courage is a virtue vital for good nursing, and has brought many benefits and advancements to the nursing profession, yet it has received little credit as a nursing skill. Making courage visible to nursing, can help incorporate it as part of the skills training for nurse leaders in nursing schools. This can bring further advancement to the nursing profession. Also, Having a courageous character can benefit patients since it provokes them to be more willing to take treatments and fight illnesses. The literature review identified physical courage, moral courage, psychological courage, and civil courage as different extensions of courage, and it reinforced that moral courage is the one necessary for nursing. It also identified caring, knowledge, and the ability to overcome fears as some of the defining attributes of courage. The willingness to have a courageous character can be provoke by confidence and a sense of duty, and it can lead to self esteem boosts and good learning experiences. Currently, only a few qualitative methods have been identified to study the phenomena of courage in nursing. It is harder to measure courage with quantitative methods because it is subjective in nature, and people experience it differently, depending on their values, believes, and cultures. More studies need to be done to incorporate courage as a nursing concept, and to identify tools and therapies that can entice courage in patients.
Introduction
The identification of nursing concepts has facilitated theory development and the growth of nursing knowledge, which has lead to many nursing advancement. Many concepts have being identified and inquired in nursing, yet there are some that still remain unexplored; one of these concepts is courage. Courage still remains undefined in nursing. Spencer and Smyth (2007) stated that courage is a concept that remains invisible in nursing, Yet it is essential to the advancement of nursing practice (Spencer, and Smythe 2007). While, Day (2010) stated that “ Courage is a virtue that is necessary to the conscientious practice of all health care providers” (Day, 2010). It is the virtue that leads nurses to develop other virtues and skills like leadership, advocacy, commitment, caring, and conflict resolution amongst others. Without courage, nursing would be a robotic job that implies following orders without any regards for the patients health care outcomes. According to Thomas (2007), courage is a requirement to be a leader. “ Leaders must consistently find the courage to hold true to their beliefs and convictions” (Thomas, 2003). Today’s nursing leaders need to be courageous to face the politics of the health care systems and improve nursing for the future.
Courage is a virtue that can also benefit patients in the health care. Being diagnosed with an illness often times creates fears and uncertainties that may cause loss of self esteem and dignity. This can lead to non-compliance to treatments and poor outcomes. Patients need to find the courage from within to fight the physical and physiological disruptions and restore their health. According to Wein (2007), having a fighting spirit can bring real benefits to the patients. Health care providers can use it as a therapeutic tool by appealing to the patient’s sense of courage, through facilitating therapies that ameliorate suffering, restore self esteem, and allow rediscovery of meaning (Wein, 2007).
Courage needs to be recognized as a necessary skill in the health care systems, and it needs to be incorporated as part of the skill training in nursing schools; specifically at the masters and doctoral level. According to Thomas (2003), courage is a skill that can be learned, with the proper training one can learn to control fears and make the right choices (Thomas, 2003). Training nurses to be courageous and stand up for their values is what leads nurses to become great caregivers, great leaders, and great advocates. The purpose of this paper is to recognize courage as a nursing concept and incorporated it as a skill necessary for the growth of the nursing profession, and also to examine it as a potential therapeutic means to improve the patients health.
Literature review
Courage is considered one of the four cardinal virtues, and it has been valued throughout the history of human kind as an important moral virtue. Spence and Smythe stated that the word courage derives from the old French word “ corage” which means “ heart” and “ spirit”. Corage latin origin is “ Cor” meaning “ more at heart”. The word courage is still associated with inner strength (Spence and Smythe 2007) and inner power. According to this etymology, courage seems to derive from feelings that arise from within the heart and can provoke a fighting spirit. The APA Dictionary of Psychology (2007) defined courage as “ The ability to meet a difficult challenge despite the physical, psychological, and moral risks involved in doing so” (The APA Dictionary of Psychology, 2007, p. 239). This definition compensates different types of courage that where found throughout the literature review: Physical courage, psychological courage, moral courage, and civil courage.
Physical courage
Physical courage is defined as an act of confidence done in spite of a potential physical harm or death, in which the means justify the end. According to Thomas (2003), physical courage implies the willingness to risk life to achieve a goal or reach a potential (Thomas, 2003). Also, in Nicomachean Ethics, Aristotle described courage as a brave act done for a noble cause in spite of fears that are real and can bring harm or even death, and he stated that death is the worst of fears (Aristotle, revised trans Version, 2009, III. 6). Although Aristotle was referring mostly to the soldiers during war, his definition of courage can be applied to anybody who is willing to risk their lives to achieve a goal or to save others. It can also be applied to those who are willing to fight against debilitating illnesses. Fighting a debilitating illness like cancer demands physical courage because it requires for the patient to undergoing treatments that can cause severe discomfort, and loss of self image and self esteem. Yet cancer patients find the courage every day to go through with these treatments to have a chance of prolonging their lives.
Moral courage
The literature review differentiates moral courage form physical courage when the dangers or risks do not involve physical injury, but loss of social status, or financial prospects (Encyclopedia of ethics, 2001, p. 352). Moral courage requires to take a stand to protect one’s moral values and duties even at the expense of potential disapproval of society. Lachman (2007) defined moral courage as the ability to speak out and do what is right to put principles into action, even at the risk of “ humiliation, rejection, ridicule, unemployment, and loss of social standing.” She believed that the sacrifices are worthwhile if it makes individuals admit to wrong doing and resolves ethical dilemmas (Lachman, 2007). On the other hand, Thomas (2003) defined moral courage as willingness to do one’s duties in spite of social shame and isolation (Thomas, 2003), and Aultman (2008) described it in terms of the health care providers taking action when there is an ethical problem where the consequences can be handle and positive changes may occur as a result of the action (Aultman, 2008). Moral courage is the type of courage required for nursing, and is used in everyday nursing tasks; from advocating for patients to changing nursing for the future.
Although and act of moral courage does not involve any potential physical harm or death, it can not be considered as less threatening that an act of physical courage. Sometimes it takes more courage to confront and question a doctors order, or to defy a hospital policy, then to jump in the pool to save a drowning child. Thomas (2003) described natural courage as instinctive; an extraordinary act done in a blink of an eye without thinking just reacting (Thomas, 2003). Jumping after the drowning child would be a physical natural courage that happens as a reaction more than elaborated thinking; there is no time to contemplate fears. Whereas, defying a doctor or a hospital policy does not come instinctively, one must think, outweigh the risks and benefits, overcome fears, and then take action. It takes more inner strength to act despite analyzed fears and potential consequences, that to act and think about the consequences later.
Psychological courage
The description of psychological courage was vague in much of the literature review. There was no actual definition for this term, but it was implied that it is the ability of overcoming destructive habits even when it may cause physical or emotional harm to do so. Psychological courage demands the admitting of destructive habits that can cause moral harm since it can lead to rejection and demoralization from family and social connections. Overcoming the destructive habit itself-whether it is an addiction or a phobia-can result in physical harm because it can disrupt physical and emotional health. The term, psychological courage seemed to blend in with physical courage and moral courage because even though the brave action was psychological in nature, the risks or threats still leads to potential physical or moral harm.
Civil courage
The literature review also refers to civil courage as social courage, and it is described as civilians standing up against injustice and crime even if it may lead to their death, physical injury, or any other harm. It implies for civilians to take action to help a complete stranger that is a victim of a crime. According to wikipedia (2010), may countries reinforce civil courage as the law, which refers to civilians being obligated to interfere or call the authorities if they witness a conflict or crime (wikipedia, 2010). Greitemeyer, Fischer, Kastenmuller, and Frey (2006) attempted to differentiate between civil courage and helping behavior. They defined helping behaviors as “ behaviors intended to do someone a favor” and it refers to civilians helping victims after the event. Their examples were, helping the victims of hurricane Katrina, Sept 11, and the Tsunami. In contrast, they defined civil courage as “ a brave behavior, which is shown to express displeasure towards authorities or superiors in a certain situation without weighing possible disadvantages” and it refers to helping the victim during the event; even if it implies risking their own lives. Their example was that in 2001 five Turks, witnessed and intervened to save the life of a young Greek boy who was being brutally beaten by twenty Nazi skin heads. The Turks risked their lives by doing so. (Greitemeyer, T, Fischer, P, Kastenmuller, A, and Frey, D, 2006). Civil courage also has attributes of both moral courage and physical courage. To have moral courage one must first have the morals and distinguish between right and wrong, then have the courage to act against injustice. In physical courage one must be willing to risk one’s own life to stop the injustice. In the case of civil courage, the civilian must be able to perceive the act as morally wrong and then take action risking potential physical harm to stop the conflict.
Defining attribute
A defining attribute of courage is caring. Peterson, S and Bredow, T (2009) defined caring as a “ nurturing way of relating to a valued other toward whom one feels a personal sense of commitment and responsibility” (Peteson, S. Bredow, T, 2009. p. 193). The feeling of caring and feeling connected to someone or something leads to willingness to make sacrifices to protect what is loved and cared for. Caring is a crucial component of courage. Without caring, there is no need for courage, and without courage, caring does not last; the sense of duty and responsibility is lost because the person lacks the courage to do what it takes to provide the caring. Caring is a concept widely recognized in nursing, yet the concept of courage is often overlooked. Caring about the patients and the profession can bring positive changes, but only when there is the courage to provoke the changes. The sense of responsibility that nurses have towards their patients and the profession is what has driven generations of nursing leaders to be courageous and work on research, theories, and hospital policies to re-shape the nursing profession.
Another defining attribute of courage is knowledge. Having knowledge builds confidence, and confidence provokes acts of courage in the face of injustice. “ Knowing” how to react when necessary exemplifies courage. Aristotle believed that knowledge and experience is what differentiates courage from recklessness. He stated that acts base on knowledge are courageous, whereas acts without knowledge are a compulsion and not brave. He exemplified it with courageous soldiers that prepared for battle by learning the art of war and fighting techniques, and also by preparing themselves physically and mentally (Aristotle revised trans 2009, III. 8). Though the art of nursing is different from the art of war, nurses also need to be knowledgeable to be prepared to confront the everyday challenges that the nursing profession brings. Acts of moral courage are based on knowledge. The nurse needs an understanding of morals and values to differentiate between right and wrong and to assess the need to intervene and protect what is valued. Without the proper knowledge, the nurse may be reckless and not know how to act to reach the valued objective. Also, having partial knowledge can lead to embarrassments and self-ridicule; a nurse boycotting against abortions in front of a hospital that does not perform elective abortions can be discrediting and will not bring any benefits to the abortion cause.
Overcoming fears is also a defining attribute of courage. Per the literature review, to commit a courageous act, one must first overcome fears. Fears are a physiological response to threats causing a chemical reaction in the body that leads to the fight or flight response. This chemical reaction gets the body ready to act, however, the action that follows depends on the person’s core values and ability to cope. If the fears are not overcome, then the action may be labeled as cowardice instead of courage. According to the Encyclopedia of Ethics (2001), Cowardice is the opposite of courage and is consider a vice in most cultures. Cowardice is failing to act properly because of fears, whereas, courage requires to control the emotion of fear and act appropriately in an given situation; and it rejects the idea that courage is the absence of fears (Encyclopedia of Ethics, 2001, p. 353-354). Aristotle mentioned that acts done without fear are not courageous acts, and the person that has no fears is not courageous, but does not care and has lost love for life itself (Aristotle revised trans 2009. III. 7).
Model case
A 59 year old Male is admitted to the telemetry unit on a Thursday night with complaints of chest pain, elevated cardiac enzymes, EKG changes, critical BUN and creatine levels, and electrolyte imbalances. The Cardiologist wants to do a cardiac angiogram, but the procedure is placed on hold due to the kidney function because the dye will further damage his kidneys. The nephrologist on consult sees the patient on Friday afternoon, diagnoses him with acute renal failure, and orders Intervention Radiology to place a Quinten catheter to start patient on hemodialysis as soon as possible. Intervention Radiology only take cases until five PM from Monday to Friday and close on the weekends. Because the order was placed on such late notice, the procedure will not be done until Monday. The nurse calls the Interventional Radiology manager to see if there is anyway that it can be done on Friday, but the manager is not able help. The attending physician is informed, he orders Cardiovascular surgery to be on consult for placement of the Quinten catheter. The cardiovascular surgeon states that the consult will be done in the late evening because the operating room cases take priority. The cardiologist then schedules the angiogram for Monday.
At three pm the patient get diaphoretic and starts complaining of sever chest pain. Upon assessment, there are changes in the vital signs. The nurse orders a stat EKG and gives the patient morphine and nitroglycerin 0. 5mg sublingual time three doses. The patient confirms alleviation of symptoms with the interventions. The cardiologist is informed, but states that the angiogram can not be done until the dialysis catheter gets placed. At five PM the patient has another episode of chest pain in which the above interventions are repeated and the patients pain level improves again. The cardiologist is informed again, but now he is infuriated over the phone call, and the answer remains the same. At six thirty PM the patient has a third episode of chest pain, but this time, the nurse senses panic in the patient’s eyes as the patient holds her hand and says “ Help me”. The nurse then calls a rapid response to get the arrhythmia nurse and the MICCU nurse in the room. Then she goes over the cardiologist head and pages the cardiac fellow to come and evaluate the patient. Upon assessment, the cardiac fellow states “ If we do not do an angiogram now there will be no need for the kidneys”. The patient is rushed to the angiogram and then transferred to the intensive care unit. While the patient is getting an angiogram, the nurse goes over the cardiovascular surgeon’s head and calls the head of surgery. The head surgeon sends the cardiovascular surgeon on call to place the dialysis catheter at the same time as the angiogram is being done. The nurse then proceeds to inform the nephrologist so that dialysis can be scheduled after the procedure. Two of the doctors were furious with the nurse, but the patient’s life was saved.
This case represent the moral courage that nurses express on a daily bases to protect their patients, and their licenses. It also includes the defining attributes of courage. The nurse displays caring through her sense of responsibility and commitment to meet the patient’s health care needs. She does everything in her power to prevent the delay of care, from calling the Intervention Radiology manager in an attempt to accelerate the process, to going over two of the consulting physicians heads to increase the patients survival chance. The nurse caring attributes drive her to display courage and stand up for the patient’s right to live; even at the expense of potential failure. Knowledge is also displayed in the above case. The nurse uses her knowledge to examine the situation, then, base on this knowledge she decides to act. Her intuition and experience is telling her that the patient is having a myocardial infarct, and that something needs to be done promptly. The doctors on consult are not listening to her so she calls a rapid response to get nurses with more experience and knowledge in the room to assist. Then, base on her knowledge of the chain of command, she decides to call the cardiac fellow and the head surgeon to get help for the patient. Her knowledge of the situation reinforced her ability to overcome her fears. Overcoming fears is another defining attribute that is displayed in the case. The nurse has the knowledge to act, but still has to overcome the fears of angry co-workers and retaliation. She knows that bypassing the doctors will infuriate them and can have potential consequences for her career, but base on her professional knowledge, if she does not act, the patient will not make it through the night. The nurse then chooses her sense of duty to protect her patient over fear of angry co-workers.
Contrary Case
Continuing with the above case, when the patient holds the nurse’s hand and says “ help me”, the nurse picks up on the patients panic, but does not know what to do. She already called the cardiologist twice and got yelled at for doing so. The nurse proceeds to tell the patient that she is doing everything in her power to help him, and that he has to wait for the cardiovascular surgeon to place the catheter. She then proceeds to give the patient more morphine and nitroglycerin. two hours later, the nurse received a phone call from central telemetry informing her that the patient is sustaining ventricular tachycardia. The nurse rushes to the room and finds the patient unconscious, she calls the code blue and starts resuscitation attempts. By the time the code blue team gets to the room the patient is in ventricular fibrillation. Further attempts to resuscitate the patient continues for twenty minutes, and then the patient gets pronounced death. The nurse may have the defining attribute of caring, but lacks the courage to do extraordinary measurement to save the patients life. The cardiologist had yelled at her for the continuous calling, and so, she is afraid to call again. Also the defining attribute of knowledge is lacking in this case. The nurse might know-base on her experiences-that the patient is in trouble, but she does not know how to help him. She might not know that there is a cardiac fellow on call or an arrhythmia nurse available to help, and so she does not intervene due to the lack of knowledge. The nurse is also not able to overcome her fears. She is to afraid to advocate for the patient, and call others for help. Even if she does not know about available resources, she can always resort to her manager or team leader for further assistance, but she does not do so for fear of demoralization and being labeled incompetent.
Variables
The antecedent variable that allows the concept of courage to occur is, the willingness to take risks to achieve the goal. Aristotle’s believed that courage is only a virtue when it is a deliberated choice, and any involuntary acts can not be considered courageous (Aristotle revised trans 2009. III. I). Pury and Hensel (2010) characterized courage as willingness, intentional, and deliberation acts (Pury and Hensel, 2010). Committing acts that are force upon can not be consider a virtue since there is no free will. The choice to act is motivated by confidence, which is another antecedent variable of courage. Through out the literature review, confidence seem to be interrelated with courage, and it is defined as a feeling of certainty; knowing that the action is the best choice. Having confidence facilitates the willingness to be courageous since a person is more likely to act if he/she is confident that the action will cause the best results. Aristotle believed that lacking confidence leads to cowardice, overconfidence leads to reckless acts, and having enough confidence base on knowledge leads to courageous acts (Aristotle, revised trans Version. 2009. III. 7).
A sense of duty is also an antecedent variable of courage. Courage is an action committed despite of fears. In order for the action to happen, there is got to be feelings of commitment and responsibility that inspires the action and makes taking a risk worthwhile. Lachman (2009) did a review of the nursing code of ethics provisions five to ten. In provision five, she talks about the moral duties that nurses owe to themselves and there patients. She states that commitment to moral ideas and living up to personal principals can facilitate moral courage (Lachman, 2009). A sense of duty is built in a subject’s character, and the same goes for courage and any other virtue. Courage can be learned and built into the character through training and practice. Day (2010) described how courage is demonstrated through brave actions that evolve from the development of inner character (Day, 2010). To develop courage as part of the character one must refer to one’s own moral values to revaluate what is important and make positive changes. Then, one must practice these positive changes until it becomes a reflex and part of one’s character. Nurses can develop a courageous character with some training. According to Aultman (2007), health care providers can learn to have moral courage through modeling and mentoring by having ethics committees, continuing of ethics education, and policy development updates (Aultman, 2007).
Courageous actions can have positive effects on self esteem, It gives a feeling of adequacy, and self-respect. Wein (2007) explained how heroism gives meaning to a person’s life and restores the morale. It provides with the feeling of making a contribution to the world, and feelings of self worth (Wein, 2007). Self-respect promotes independence and happiness, and gives nurses the moral courage to protect their patients (Lachman, 2009). Courage can also have a negative impact on self-esteem, depending on the outcome of the action. If it causes a negative outcome, it may provoke feelings of inadequacy and worthlessness. A nurse that advocates for a patient and gets negative results may feel incompetent and distressed, even when the action was the correct choice. Through out the literature review, there seems to be the misconceptions that courageous acts are only does that produce positive outcomes. Pury and Aultman did a qualitative study in 2010 to disprove this misconception, they provided one hundred and fifty two subjects a case scenario with four different endings. Some where successful endings, others where failure endings. They concluded that actions with unsuccessful outcome where still viewed as courageous, but where not praised as much as successful actions (Pury, and Aultman 2010). Courageous actions can lead to successful and unsuccessful outcomes, but that does not imply that the unsuccessful actions are less courageous. Having the courage to act regardless of the success of the outcome can provide with exposure to different situations and good learning experience. The nurse with a courageous character is more prone to get involved in a courageous action and learn from the experience.
Empirical referents
Currently tools to measure courage are qualitative in nature. Garon (2006) used a Narrative Analysis method to measure nurses’ resistance to abuse and ethical dilemmas. She analyzed the structure/content, patterns, and unique threads of the participants narratives to explore the phenomena of courage (Garon, 2006). Spence and Smythe (2007) used a similar method which involved collecting nursing narratives and analyzing them with the hermeneutic method. This methology examines the phenomena with the purpose of understanding in a thought provoking manner the relation of the phenomena “ within a social and historical context.” (Spence, and Smythe 2007). Both methods facilitate the exploration of courage as a nursing skill through real nursing stories and experiences, but they do not provide statistics that can measure courage in nursing. Other methods where use to measure how the consensus perceives courage. Greitemeyer et al. (2006) used vignettes of different scenarios to measure the perception of civil courage versus helping behavior. In their second study they asked the subjects to write a story of a time when they had to act courageous, then they gave them a questioner about feelings and thoughts that they experienced before and during the act (Greitmeyer et al, 2006). This method seems more effective in measuring antecedents that lead to courageous acts, and could be transfer to nursing research to measure the reasoning behind nursing courage.
Courage is a human character that can be measured through exploring the actual experience of the act itself. It is difficult to measure in numbers because it is subjective in nature. Every person experiences courage differently. Some are more willing to act due to their knowledge and experiences, where as others may not be as ready to act because of the lack of exposure to certain situations. Also, courageous acts can be perceived differently amongst individuals, depending on their culture and personal believes, a specific action may be perceived as courageous to some, but insignificant to others.
Implications of Nursing Practice
Without courage nurses would have no voice in society and as a profession. Thomas (2003) stated that courage is a necessary skill to be a successful nurse leader (Thomas, 2003). While Day (2010) stated that courage is necessary for every day nursing, from overcoming the fear of exposure to pathogens and emotional strains, to overcoming the fears of guilt for delaying a procedure when the patient is requiring additional information. (Day, 2010). More research needs to be done and more tools need to be identified to measure the phenomena of courage in nursing, and also to incorporate it as a nursing concept. Nurses need guidance to become more courageous and let their voices be heard. According to Thomas (2003), nurses can be trained the same way soldier are train for battle, by being exposed to simulated situations that reduces uncertainties, and increases the ability to control fears (Thomas, 2003). Simulated situations can be use in nursing schools to help students develop courage and prepare for leadership roles. A pilot study could be done to study the effect of courage training in nursing. Perhaps a nursing school can incorporate courage training as part of their leadership class and follow up with these students after they graduate to see if they are more assertive and successful than a control group.
Also, more research studies need to be done on the effects of courage in patients. Wein (2007) stated that appealing to patients courage could be use as a therapeutic tool to improve the success of their recovery (Wein, 2007), but actual research studies-qualitative or quantitative-need to be done to support this theory. It can open many possibilities for researchers to develop tools to entice the patients courage, and create new therapies and resources that will assist with patients recovery. In conclusion, Many benefits can arise from resorting to courage for both patients and health care providers a like.
