Nurses must summon moral courage to confront unethical behavior

By | 2020-06-02T14:18:24-04:00 October 19th, 2015|12 Comments
Lachman Headshot

Vicki Lachman, PhD

There are times nurses must draw on moral courage, and to draw on it, they need a working definition.

“Moral courage is the ability to overcome your fear and stand up for your core values and your ethical obligations as a nurse,” said Vicki Lachman, PhD, APRN, MBE, FAAN, a member of the American Nurses Association Center for Ethics and Human Rights Advisory Board and an expert on the topic.

“It’s not without fear,” she added. “You might shake and have tightness in your chest, with all the symptoms of anxiety, but you stand up anyway.”

Lt. Col. John S. Murray, PhD

Lt. Col. John S. Murray, PhD, RN, NC, expanded the definition, saying moral courage is when individuals stand up for their ethical beliefs or moral principles when there’s an unethical situation, whether in clinical practice, education, research or administration. Also an expert on moral courage and ethics, Murray is the director of education, training and research, Joint Task Force National Capital Region Medical, Bethesda, Md., and a member of the American Nurses Association Ethics and Human Rights Advisory Board. He is retired from the U.S. Air Force.

Moral courage values

Lachman described five values common to moral courage, as stated by Rushworth Kidder, who she said “wrote the book on moral courage.” Kidder’s research showed that honesty, respect, responsibility, fairness and compassion are universal traits held by morally courageous individuals.

Respect, Lachman pointed out, is not just toward others, but also maintaining respect for oneself, which involves not allowing another person to treat you in a disrespectful way.

Nurses must self assess to understand their own quota of moral courage in preparation for confronting unethical behaviors. Murray recommends they start by developing moral sensitivity.

“Take time to reflect on one’s own personal and professional values and on one’s moral obligations,” Murray said. As nurses, we all have the obligation to those we serve to do the right thing, which means speaking up when an unethical situation occurs that could jeopardize patient safety, he added.

Nurses also must recognize that they might endure adversity for an extended period when they confront and address unethical behavior, according to Murray.

Because exerting moral courage to speak up when an unethical situation arises is risky and creates anxiety, Lachman advises nurses learn self-calming techniques. “Know a relaxation strategy to calm yourself. Tell yourself, ‘I can manage this.’”

Nurses also must assess the risk. She said a nurse must believe that the outcome of speaking up is worth the risk.
“If you [saw] someone break sterile technique and you don’t speak up, the risk is the patient having an infection,” Lachman said. The risk is worth [speaking up].”

Both Lachman and Murray recommend nurses spend time gaining an understanding of the ANA’s Code of Ethics. They agree most nurses don’t know what the code says.

In developing moral courage, Murray encourages open dialogue about ethical principles, the use of case studies and discussion with ethics consultants.

Issues in multiple settings

Areas where moral courage issues arise include clinical practice, research and academia.

Lachman considers the most frequent issues in which nurses must exert moral courage are end-of-life situations, including advanced directives and informed consent. She added other common scenarios are bullying among healthcare staff and social media situations.

In clinical practice, Murray thinks one of the most common situations is reporting an impaired provider. “This is a perfect example [of unethical behavior] because of the potential for interference with patient care and safety,” Murray said.

Murray said a nurse also may need to summon moral courage outside of the clinical setting. If they witness misconduct, which goes against the very strict guidelines governing research, such as funding issues or findings published early for personal reasons. In academia it can occur when faculty members are asked to pass a failing student to uphold the school’s standing, according to Murray.

“We need to frame moral courage in a positive manner so it doesn’t have the negative connotation that is has for so many people,” Murray said. “All healthcare organizations and professionals, not just nurses, have the professional responsibility to uphold a high ethical standard.”

He said some healthcare organizations have an issue with ineffective leadership, which can result in leaders who don’t promote moral courage and won’t address the ethical dilemmas their nurses face.

Organizational cultures can foster moral courage by ensuring nurse leaders at all levels create a workplace where moral courage is not only accepted, but is encouraged and expected, Murray said. To do so, policies and procedures must be in place to uphold ethical behaviors, and nursing leaders must empower staff to speak up.

Lachman said it’s important for nurses to remember that they don’t have to face unethical behavior alone.

“There’s a national movement to a culture of safety,” she said. “If a nurse sees someone who’s violated the culture of safety — whether by not washing their hands, or not disposing of narcotics according to policy — we need to have the courage to speak up.”


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About the Author:

Karen Schmidt, RN, is a freelance writer.


  1. Avatar
    Carolyn Walsh October 19, 2015 at 5:03 pm - Reply

    I stood up with moral courage about 2 patients who died, who shouldn’t have, and was fired eventually for being an advocate of keeping patients alive.
    I understand completely.

    I also graduated from Philadelphia General Hospital, where Dr. Lachman began her career. I’m proud to be a PGH grad, and proud of my further education. Proud of her as well!

    If you’re a nurse, you must have a moral compass. It simply goes with the career at hand.

  2. Avatar
    John Kauchick,RN,BSN October 20, 2015 at 3:52 pm - Reply

    One of the most destructive behaviors that is an ethical dilemma in nursing is defamation and wrongful termination of a nurse. Recently, two nurses have received 2-3 million dollar awards by civil courts. Yet, this topic remains the elephant in the room that nobody will talk about.

    • Avatar
      Kay Gremmels November 26, 2015 at 5:34 pm - Reply

      I agree, I totally agree and there are many of us who do stick up for our moral and ethical practice and advocate for patients and we get fired and no one wants to hear about it. We don’t have money for a lawyer so we go on unemployment with a black mark on our employment record and our proverbial nursing tails between our legs because the profession still doesn’t want to acknowledge this treatment and this means to an end exist. When is the powers that be in the nursing profession going to begin this conversation and begin it big and loud and roar stand behind what its code of ethics says nursing is?

      • Avatar
        Doug June 19, 2019 at 8:00 am - Reply

        there are not “many” of us. There are very few of us. And the ones that that get targeted for doing the right thing get treated that way will the full endorsement of the remainder of the nurses both in the organization and the field that stand by and do absolutely nothing or even worst turn a blind eye.

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    James Russell October 20, 2015 at 4:28 pm - Reply

    It is a fine line we must walk. That is a certainty.

    I am learning to see just how far I can push that line without succumbing to the bias of the majority. To their prejudice or greed.

    I liken this to planting seeds. I try to place them in fertile soil. Perhaps to water them or nurture them if possible. However it is not always my privilege to see them grow to fruition.

    We used to believe as a people that the world was flat! It took quite some time for that to change.

    Fight the good fights that you believe in but do not fall prey to the idea that you alone can change the culture. The war of bias and greed wages on. Fight wisely the particular part of the battle you have. Remember that you must also live to fight another day! Another battle.

    To paraphrase a well known Scripture……..Be wise as serpents….gentle as doves.

    • Avatar
      John Kauchick,RN,BSN October 22, 2015 at 12:26 pm - Reply

      After much persistence over several months of outreach, I finally got a response from a top ethics consultant for the ANA. Basically, the stance is that nurses should work to incorporate the Code of Ethics into evaluations, etc. I told them that institutions will not go any further than posting them until they get a strong signal that there is a no tolerance policy for wrongful termination and defamation. I ask that these topics be included on the agenda at the next national ANA ethics conference. Awaiting a response. If they don’t then we should have our own national conference.

      • Avatar
        Doug June 19, 2019 at 7:58 am - Reply

        and that persistence and delay is because they don’t really want to you say anything. That’s the bottom line right up the chain of command. Telling nurses to come forward is meant in theory only because when you do come forward you will not be supported at all. You will not be supported in the organization, you will not be supported by your local representatives and even when you have actual written proof that the civil rights violations and egregiously bad care you reported was covered up by the hospital in coordination with the Joint Commission. Oh and I have proof of that as well. Yes the Joint Commission who takes money from the organization they are surveying. Don’t worry if you don’t do well or need help. The joint commission has books and programs they will sell you to assist. The most egregious conflict of interests and it continues because there is no real effort to push ethics, values or to protect patients. Only talk..

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    Monika September 23, 2016 at 10:34 am - Reply

    I was terminated for no reason. I took two drug screens with hair, blood and UA. As an ER nurse we have to put in a lot of protocol orders and verbal orders. My results were negative. I have been at the ER for 16 years. This company has always done wrong when terminating employees. One of the doctors stated he did not approve a verbal order and I was turned in to the board of nursing. The big kicker is I already resigned. I also have my masters in FNP and if my license are taken for lies, how am I suppose to fight them???

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    Marie February 10, 2017 at 3:29 am - Reply

    Nurses often stand up to protect ethics and willing to do what licensing for. Unfortunately,when the boss is delegating unethical task. Corporate often support their friends. It is a shame to see how the nurse would be unemployed for standing up to do the right thing as licensed for. This is a dilemma .However, it is better to loose your job for doing the right thing. If you accept to do the wrong ,the same boss can use it and affect your license negatively. There are more abuse in Nursing administration then the bed side . I Thank nurses should be more involved in politic such as running for congress and senator. Nurses must lobby and advocate for no only patient rights but nurses rights.

    • Avatar
      Doug June 19, 2019 at 8:01 am - Reply

      nurses rarely stand up for what’s right and in fact most of the time they turn a blind eye to those that do stand up. Sorry.

  6. Avatar
    Lori Blanchong August 14, 2018 at 4:36 am - Reply

    In some situations the nurse is stuck between a rock and hard place. Reporting the incident privately hasn’t worked so the nurse makes it public. Good for the residents….but career suicide. Gotta be another way. Maybe reporting anonymously to the State Boards of Nursing or Dept of public health.

    • Avatar
      Doug June 19, 2019 at 8:05 am - Reply

      The Department of health will not help as they are usually in bed with protecting the hospital. As is the Joint Commission. I lost everything standing up for serious, borderline criminal neglect. Lost everything and will never be able to recover financially or rebuild my life at 55. Nursing is a disgusting field and nurses are treated like garbage. plain and simple. and we treat each other that way which is the real problem I would strongly discourage anyone from ever coming forward after what was done to me. for any reason and I can tell you If by any chance I end up staying in the field I will never say another word. I am looking the other way like everyone else. What was done to me is disgusting.

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