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    Rocking theboat—nursing students' storiesofmoral courage:A qualitativedescriptive study

    examinedhowundergraduatenursing studentsdemonstrate

    Receive

    4September2015 moral couragewhen

    confrontedwith clinical situations thatnegatively impact thequalityofpatient care and/ Received in revised form14March2016 orpatientexperienceand the factors thatencouragedor inhibited theirwillingness tospeakupwhen they iden- Accepted18March2016 tifiedpoorpractice.

    However,placementsarea reportedsourceofstress forstudents,withmanywitnessing,or feelingcompelled toparticipate in,poorpractice. In these instances,nursingstudentsrequire themoralcourage toraiseconcerns inorder toprotectpatientsafety anddignity. Methods: Thiswas aqualitativedescriptive study.Ninenursing students and onenursing graduate from one semi-metropolitanuniversity inAustraliawere interviewedand thedatawere thematicallyanalysed. Findings:Fourkey themesemerged: (1)patientadvocate identity,whichhad two sub-themesofknowingone's ownmoral code andprevious lifeexperiences; (2) consequences to thepatient and to theparticipant; (3) the impactofkey individuals;and (4)pickingyourbattles. Conclusion:Thisstudydemonstratesthe importanceofundergraduatenursingstudents identifyingaspatientad- vocates, themultitudeofconsequencesstudents facewhenquestioningthepracticeofaregisterednurse,andthe influencesupervisingnursesandclinical facilitatorshaveona student'sdecisions to intervene toprotectpatient safety.Furtherresearch isrequiredtoexamine the factors,both intrinsicandextrinsic, that influencenursingstu- dents'moral courage and theirdecisions to intervenewhenpoorpractice iswitnessed. ©2016Elsevier Ltd.All rights reserved.

    1. Introduction

    patient safety can be jeopardised and students can experience on- goingmoraldistress (Callisteretal.,2009). Clinicalplacements are a vital componentofnursingprogrammes providingstudentswith theopportunity to integrate theoreticalknowl-

    2.Background

    edge intopractice (O'Maraet al.,2014).They aredesigned to assist in building students' confidence,knowledge andprofessional identity, as Moral courage is theability to riseabove fearand take actionbased well as consolidatingand/ordeveloping clinical skills (Gunther,2011). on one's ethical beliefs (Lachman, 2007).Moral courage bridges the However, placements have been identified as an ongoing source of gapbetween knowingone'spersonal values andprofessional obliga- stress and anxiety formany students (Bradbury-Jones et al., 2007; tions,andactingon themdespite risks suchas socialostracism,embar-

    Monrouxeetal.,2014),particularly if theyarewitness to,or feel com-

    rassmentor lossofemployment (Aultman,2008; Lachman,2007). For pelled to participate in, poor practice (Bellefontaine, 2009). Rather morally courageous individuals,upholding their corevalues is judged than challengeunsafeorunethicalpractices,many students choose to worthexposing themselves toharmorvulnerability (Lachman,2010). be silentand to conform to theexpectationsof theirnursingcolleagues Moral courage is a crucial virtue fornurses (Kidder,2005;Purtilo, (Levett-Jones and Lathlean,2009;O'Mara et al.,2014).Consequently, 2000) and considered fundamental to professional practice when confrontedwith ethicalmisconduct regardless of thepractice setting (Murray,2010).Nurseswhodemonstratemoral courage areunwaver- ☆ Acknowledgements/Contribution/Funding statements: This review received no ing in their commitment tohonouringand respectingpatients and self specificgrant fromany fundingagency in thepublic,commercial,ornot-for-profitsectors. (Sekera andBagozzi,2007).Whenpressured to conform tounethical ⁎ Corresponding author at:POBox904,Terrigal,NSW2260Australia. E-mailaddresses: laurie@definingnursing.com (L.Bickhoff), or outdatedpractices,nurses require themoral courage to overcome Tracy.Levett-jones@newcastle.edu.au (T.Levett-Jones),Peter.Sinclair@newcastle.edu.au their fears, endure the consequences, and act in amanner consistent (P.M.Sinclair). with theirprofessisacrifice for it”. Transcripts of the interviewswere read and re-read to identify Another subtheme— ‘previous lifeexperiences’ illustratedhowpar-

    themes. Interviewswereanalysedusingan iterativeprocessof reading,

    ticipantsdecision to speakupwhenpoorpracticewaswitnessedwas coding, and interpreting to identify themeswithin the data that de- impacted bypreviouspersonal andwork experiences, andhow they scribed factors that influenced the participants'moral courage. Each “wouldn't have behaved the same way twenty years ago” (Beth). transcriptwas analysed separately, using the four stage process de- Annadescribedhavinghad familymembersor friends inhospital and scribedbyMorse and Field (1996)namely, comprehending, synthesis- how she felt “comfortable in that environmentbecause I've advocated ing, theorising and recontextualisation. Identified themeswere coded for them”, a sentimentwhichwas echoedby otherparticipants.They andcollated.Preliminary themes thatemergedwere testedby identify- alsodescribedpreviously seeingnurses advocate forpatients and this ing examples across interviews to ensure that themes were well- increased their own commitment to be a patient advocate. These grounded and representative of all stories andwere consistentwith experiences also gave them the benefit of seeing the situation from thedata. thepatient'sperspective thereby furtherstrengtheningtheirpatientad- vocate identity. 5.Findings Participants recountedhoweachnewclinicalplacementexperience gave themmoreconfidenceandallowed them to feelmoreconfident to Thedata revealed threekey themes related towhatmotivatedpar- speak upwhere before theymay have remained silent.Mandy de- ticipants todisplaymoral couragewhen theywitnessedpoorpractice: scribedhowherexperiencesshowedher “that superiornursesorsupe- riordoctorsweren't superior.Theywere justequals”andhence she felt

    1. patientadvocate identity,whichhad two

    sub-themesof more comfortable toquestionpractice as sheprogressed throughher a. knowing theirownpersonalmoral codeand degree. b. previous lifeexperiencesonsequences to thepatientand to theparticipant 

    .2.Consequences to thepatientand to theparticipants

    3. the impactofkey individuals.

    A fourth themerelated

    toparticipantsreflectionsontheirdecision to Thedesire topreventnegative consequenceswasevident in the in- intervene in these incidents andhow theywouldact ifpresentedwith terviewdataand included thedesire toavoidadverseoutcomes for the similar situations.This themewas titled ‘pickingyourbattles’. patientand theparticipant.Theparticipantswereveryaware that their When the participantswere asked about their understanding of actions, and thoseofothers,had thepower to causepsychologicaland moral courage theydescribed it as speakingup forwhat theybelieved physicalharm topatients.Participants spokeof knowing thepractice was right, even if thiswasdifficult.They acknowledged that therewas was “going to hurt somebody” (Jenny) or thatwithout intervention a risk involved indisplayingmoral courage and that theymight suffer thepatient “wasgetting sicker” (Melissa).Thisknowledgemotivated negative consequences from their actions.Theparticipants'definitions them to refuse to participate in poor practice or to intervenewhen ofmoral couragealignedwith contemporary literature (Bickhoffetal., poor practicewas conducted by others,with Jenny stating “I could 2015). However, the participants also added that moral courage have injured thatman.

    I couldhave reallyhurthim”. Participantsde- comes from an instinctive reaction, anddenotes intuitively knowing scribed feeling compelled to takeactionwhen thepracticewas seen to the right action to take. As one participant (Beth) stated “it's about compromiseor jeopardisepatient safety.Beth captured this sentiment that feeling inyourgutwhereyouknow something's rightorwrong”. stating “‘It'lldo’will kill people….’It'll do’mightmean that they end up

    with methicillin-resistant Staphylococcus aureus or vancomycin 

    1.Patientadvocate identity resistant enterococcus

    for the rest of their life or theymight lose their leg…..I couldn't livewith that……I just can'taccept that”. Theparticipants strongly identifiedwith their role aspatient advo- Participants spoke ofhaving to livewith the consequences of the cates and thiswas a cited as a compellingmotivation for intervening poor practice if they failed to speak up. Thiswas described both in whenwitnessingpoorpractice.Oneparticipant stated thatpatient ad- regards to avoidingmoraldistress andpotential legal consequences. vocacy was “at the core of what's drivenme to become a nurse” Participantsdescribedhownot interveningwouldhave left themun- (Beth). Patientswere often seen as “elderly and vulnerable” (Jackie) able to “sleep atnight” (Anna)or to “look atyourself in themorning” andunable todefend themselves, thusparticipantsoften felt theneed (Beth).Theneed touphold their legalandethical responsibilitiesas fu- to speakon theirbehalf.Theparticipantsdiscusseddeveloping thera- ture registerednurseswasalsoprevalentwithin this theme,asdemon- peutic relationships, feeling a strong emotional connectionwith their stratedbyCassiewho said “it is the legaldutyof care thatgovernsme” patients and focusing on “what the patient is experiencing andhow and Jennywhodiscussedhow if thepatientwasharmed, “then in the theymaybe feeling” (Sammie). end, I'm responsible too”. Theparticipantsdescribed the idealof treatingpatients theway they Consequencesofspeakingupwhenpoorpracticewere identifiedre- would like their lovedones tobe treated,hencewhen theywitnessed sulted in a range of ramifications. Somewere applauded by the unit poorpractice itwas takenverypersonally.AsMandy stated, “if itwas managerorother registerednurses,butmany studentswereostracised mydaughter, Iwould justbemortified”.Anna summarised this theme and/or experienced horizontal violence. To avoid potential negative by saying “Ibasicallybelieve in treating allmypatients like they are a consequences of speakingup, theparticipantsdescribed ‘playing the familymember andhow I'd like them tobe cared for”. student card’ whereby they portrayed themselves as “confused”

    A sub-themeof ‘patientadvocate identity’was ‘knowingone'sown (Beth)or “dumb”

    (Trish)whenquestioning

    thepracticeof the regis- moral beliefs and values’. Participants described having a strong terednurse.Thiswas adeliberate tactic,as theywereaware thatother “sense of right” (Beth) and the importance of having amoral code nurseswould not like “a student nurse to tell themwhat'swrong” which guided theirbehaviour, especially in regards to “the value and (Melissa). dignityofpeople”(Sammie).Thisknowledgegave them theconfidence Participants spoke of being congratulated by their supervising that their actionswere “right in those situations” (Cassie)and the cor- nurses and feeling theyweregiven ahigher levelof respect following rectcourseofaction.Thiswasseenasessentialwhen therewas riskas- theirdisplayofmoral courage.

    Melissadescribedhowher supervising

    sociatedwith takingactionbuthavingastrongmoralcoderequired the nursewasgrateful “itwaspickedupby someone”,whileMandy stated participants to have taken the time to engage in personal reflection howthe familyhadpersonally thankedher for intervening.Thissupport prior to their placement. Sammie said “you have to be thoughtful increased their confidence and,asBethexpressed, “reinforced…

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