ICNE YALE #28 Moral Courage: Bridging Nursing Ethics and Patient Safety Vicki 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.

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

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

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

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

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.

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

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

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

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

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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.

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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.

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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

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(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.

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