Courage as a Virtue Necessary to Good Nursing Practice

Courage is a virtue that is necessary to the conscientious practice of all healthcare providers. This is neither a new nor an original idea. Others have written about the importance of virtues in medicine1,2 or have focused on courage in particular as a willingness to adhere to the obligations inherent in professional practice.3 In the current healthcare climate, it is not a simple thing to know and stand up for one’s professional obligations. There are duties that seem always to be in conflict, and the weighing of benefit and harm to all involved is complex and fraught with ambiguity.In this column I will explore the idea of courage as a virtue that supports the goods internal to the practice of nursing, discussing the ways certain features of the hospital environment introduce threats to good practice that demand a courageous response.Aristotle wrote a great deal about virtues and said this about courage: “The man, then, who faces and who fears the right things and from the right motive, in the right way and at the right time, and who feels confidence under the corresponding conditions, is brave.”4(p976) In the Nicomachean Ethics, Aristotle describes how by cultivating the virtues one is able to live an honorable life and avoid shame and disgrace. Bravery or courage is one such virtue that allows the person possessing it to respond appropriately to fear. The brave person is not fearless, but feels appropriate fear when there is a real threat of harm and meets that fear with confidence. As was the case for ancient Greek soldiers in battle, to be courageous meant confronting the threat of bodily harm or death when one is fully aware of the seriousness of the threat and is appropriately fearful but able to stand up to the threat and fight. In keeping with Aristotle’s doctrine of the mean, the courageous person is neither arrogant and fearless nor cowardly and paralyzed by fear; he or she is appropriately fearful according to what the situation demands but is also confident enough to overcome fear and act.Aristotle’s account is less satisfying when applied to some of the typical situations nurses face in acute care. In this context the threat is often much more ambiguous than the bronze spears faced by the Homeric soldiers Aristotle takes as his example. Courage is as important to the practice of healthcare providers as it was to the Trojan heroes Hector and Aeneas, but the qualitative nature of courage and of virtues in general differs in each case.The kind of courage necessary to engage in good nursing practice is derived from the particular kind of practice nursing is. In a discussion of courage and moral distress, Lachman3 draws a distinction between the courage needed to face physical danger and the courage needed to stand up for one’s core values; this author terms the latter “moral courage.” The idea of moral courage seems apt as a description of the courage displayed by a nurse when he or she questions a physician’s order, for example, but adding the qualifier “moral” does not distinguish this kind of courage from that displayed by the Greek and Trojan heroes. In the context of the Trojan War and within the practice of Greek and Trojan soldiers, facing the weapons of their enemies was a display of moral courage, but the values for which these men stood differed from those of 21st century healthcare providers to the point of incommensurability.Although Lachman3 draws the distinction between physical and moral danger, the most important distinction between courage as described by Aristotle and the courage needed by today’s nurse has to do with the purpose and location of virtues. This distinction is best described by MacIntyre5 and is further refined in Benner’s discussion of the purpose of virtues in nursing practice.For Aristotle, the ends or telos of the virtues is that of producing individual happiness. The person who develops the virtues within him- or herself will be happier than one who does not develop these character traits. In this broad formulation, Aristotle takes it for granted that human action is directed toward the good and that achievement of the good results in happiness.4,5 He is less clear about what exactly the good is and how it is that all humans would come to agree on a particular good as their ultimate end.5MacIntyre’s description locates virtues within a practice. In this view, virtues serve to facilitate the realization of the goods internal to that practice.5 MacIntyre corrects Aristotle’s uniform idea of goodness by connecting virtues to practice and practice communities and by defining virtue as directly related to the achievement of the goods internal to a particular practice:A practice is by MacIntyre’s definition a socially established and cooperative activity in which a community of practitioners defines the internal goods and sets standards that identify the achievement of excellence within that practice: “The goods internal to a practice can only be achieved by subordinating ourselves within the practice to our relationship to other practitioners.”5(p191) This relational description of the good does not assume any agreement on a definition outside a particular practice community. For example, as a nurse I share the goods internal to my practice with other nurses, and it is within this community that these goods are defined, enacted, and extended.5Internal goods are those that are realized when one commits to a practice and puts all effort into engaging in that practice in an authentic way. The example MacIntyre uses is the practice of playing chess. When one plays chess, the internal goods of chess playing can be realized only if one commits to the game authentically; that is, if one does not cheat but plays by the rules within the structure of the game with others who are likewise committed. Winning the game is not an internal good; an internal good is the satisfaction of having played well. In nursing practice, internal goods are evident when the nurse knows she or he did the right thing for a particular patient and family.By connecting virtues to practice, MacIntyre provides a basis for the value of particular virtues that may differ depending on the nature of the practice they support. In this way he avoids absolute relativism since committing oneself to a practice means adopting and supporting the goods internal to that practice and cultivating the appropriate virtues. For ancient Greek heroes like Achilles and Agamemnon, such commitment included developing their physical strength and skill with weapons and their courage, understood as the ability to overcome the fear of violent physical harm in order to do what their practice defines as good.Benner extends and refines the definition of virtues by connecting virtue with care ethics.6 By pointing to the essentially relational nature of nursing practice, Benner shifts the telos of virtues from the development of the inner character of the individual actor to a concern with one’s obligation and responsibility to others. According to Aristotle, brave men desire honor and desire to avoid disgrace. Acting bravely demonstrates how one’s character possesses courage, which adds to personal honor. By contrast, nursing practice is always focused outside the self toward vulnerable others and is carried out in relationships with patients (ie, individuals, families, communities) and other healthcare providers. Realizing the goods internal to this practice requires the practitioner to develop virtues such as openness and responsiveness that allow relationships of trust to form and thrive. Similarly, courage does not add to the noble stature of the nurse; instead, it allows the nurse to act in the best interest of the patient.Therefore, in addition to the virtues Benner6 describes, courage—overcoming fear in order to do what the practice defines as good—is also a virtue that is necessary to nursing practice. Sometimes the fear the nurse must overcome has to do with physical harm, such as when he or she provides comfort to a patient by giving a bath and changing linens. In such situations the nurse may need to overcome the fear of being exposed to pathogens contained in body fluids. In addition, the courage of nurses requires overcoming the fear of emotional strain in order to develop empathy and overcoming the fear of loss of status or exposure of one’s own vulnerabilities in order to admit and rectify one’s mistakes.A somewhat more ambiguous threat acute care nurses face comes from the institutions on which their practice depends; nurses often need courage to confront institutional situations that stand in the way of the good they are seeking to realize. Because acute care nursing practice depends on the institution, goods can be in conflict. Determining the priority when goods are in conflict and confronting situations in which the institutional priority is not the same as the nursing priority creates a tension in acute care nursing practice.The hospital is an institution that should offer essential supports for nursing practice.7 At best, the hospital supports and furthers the goods internal to nursing, such as attentiveness to the individual personhood of patients and protection of the vulnerable. But at times the institutional commitment to efficiency and hierarchical organization results in marginalization of caring practices that is in conflict with goods internal to nursing practice. This makes it difficult for nurses to feel supported in their practice; realizing the goods of practice becomes difficult and, without the courage to commit to good nursing practice in the face of institutional impediments, may be impossible.In a discussion of the moral ecology of good nursing practice, Weiss et al7(p107) take issue with the view of nursing practice as simply “the provision and monitoring of various technological fixes.” This view of nursing combined with a drive for efficiency and quantity means nurses are asked to manage more technology (eg, medications, devices, standardized procedures) for more patients with less time. We assume that this can be accomplished by improving efficiency and reducing waste. The primacy of efficiency in this model often accomplishes the goal by instituting a hierarchy that privileges a biomedical model of disease and cure, marginalizes caring practices, and discounts the importance of the nurse’s relationship with the patient and family.To take up hospital-based nursing as a relational practice in this environment requires a nurse to confront several threats to her or his well-being. These threats are associated with understandable fears: If a nurse slows down transportation in order to talk to a patient and family about a procedure, she fears she will be the cause of unnecessary delays in the cardiac cath lab. If a nurse takes time to ask a physician to explain the rationale for changes in a patient’s treatment plan before implementing those changes, he fears he will be the cause of an unnecessary delay or may be mistreated by a physician who believes that a doctor’s position in the hospital hierarchy precludes explaining the plan to a nurse. If a nurse pages a physician to report what she thinks is a significant change in the patient’s condition, she fears she will expose the limits of her own knowledge or skill if the finding is not significant or that she will be wasting the physician’s time if it is something she should be able to handle on her own.It takes courage to face the threats to good nursing practice in each of the situations described above and courage to overcome the associated fears. To act courageously, as Aristotle might point out, is not to act with hubris, aggression, or arrogance, but to articulate the importance of the goods for which nurses and nursing practice stand while acknowledging that there may be other interests in conflict with these goods. Nurses act courageously when they slow down the efficient machinery of acute care in order to attend to the personal and particular needs of one patient and family. Nurses must have courage to insert themselves into the hospital hierarchy to point out conflicts and begin to change the institutional structure of the hospital. As Weiss et al7(p107) astutely observe: