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Teaching courage: An essential for nursing education
Teaching and Learning in Nursing (2012) 7, 121–122
EDUCATE, EXCITE, ENGAGE www.jtln.org
Teaching courage: An essential for nursing education Rojann R. Alpers PhD, RN⁎, Kay Jarrell MS, RN, Roxena Wotring MS, RN Arizona State University College of Nursing and Health Innovation, Phoenix, AZ 85004, USA
Maya Angelou's (n.d.) quote about courage seems most appropriate for nursing, “One isn't necessarily born with courage, but one is born with potential. Without courage, we cannot practice any other virtue with consistency. We can't be kind, true, merciful, generous, or honest.” This quote raises the question: Can we really be nurses and practice nursing without courage? However, having said that, how many nursing programs actually teach nursing courage? Certainly, we can use examples from our rich history— Florence Nightingale stood up against the British military leaders so that the soldiers in the Crimea could have better treatment in the military hospitals. Clara Barton gave care to all soldiers during the Civil War, and the union military leaders tried to have her indicted for treason. Lillian Wald established a nurse-managed clinic in New York City for the poor and immigrant population at the beginning of the 20th century against all medical, social, and political advice. These are but a few examples of extraordinary people making a difference in extraordinary circumstances. However, what about the day-to-day nurse in current clinical practice? How can we assist our students to develop a menu of courage behaviors that will serve them as nursing students and also as professional nurses? Kerfoot (1999) reminds us that as nurses we all encounter situations that require courage, but we do not always respond to the situation with courage. She goes on to point out that courage is a result of a culture of integrity where doing the right thing is required, recognized, and rewarded, and it must start with nursing leaders who plan and build cultures of courage. Courage does not magically emerge upon gradu-
* Corresponding author. E-mail address: [email protected]
ation, so if we are to have cultures of courage within our hospitals and clinics and other practice arenas, then nursing education must now accept its responsibility for developing didactic and clinical content and opportunities to discuss, reflect, and practice courage with our nursing students. A combined didactic and clinical assignment has proven to be valuable for nursing students as we begin to truly inculcate the essentiality of courage to all nursing practice. First, students are assigned three articles to read and discuss in class and clinical conference. These articles are wonderful old favorites, and they cut to the point and continue to resonate with nursing students. The Savage and DeWolfBosek (1998) article uses scenarios that nursing students may face in practice concerning documentation, scope of practice, impaired colleagues, and so forth and then invites reflection (using the American Nurses Association Code of Ethics) on how to respond to such incidents. Kerfoot (1999) overviews the need for nursing courage in practice and offers insight on ways to create such cultures in all organizations. Finally, VitalSmarts (2005), in association with the American Association of Critical-Care treatise—Silence Kills: Seven Crucial Conversations for Healthcare—reports on numerous studies conducted with nurses, physicians, staff, and administration to uncover the seven most crucial concerns for health care providers. This is an eye-opening, heartpounding report that will elicit tremendous discussion with students, colleagues, and other professionals. Following the articles being read, class discussion typically begins with developing a group definition of courage. This is a lively conversation where the “inkblot” approach is used—asking students to react to the word courage and then give one word or one short statement about “what is courage.” Frequently, their responses include “do the right thing,” “ethical,” “fearless,” “caring,” “brave,” and
1557-3087/$ – see front matter © 2012 National Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved. doi:10.1016/j.teln.2012.04.001
122 “dangerous.” With a little work, faculty can tease out a coherent working definition for the group and give everyone a starting point for its clinical application. Second, the assigned articles are discussed, and opportunities for students to share their encounters or observations about difficult clinical situations are solicited. This is when active listening and questioning is important from faculty— questions such as (a) What do you think contributed to this situation? (b) How was it handled and why do you think it was handled in that way? (c) Ideally, how should it have been addressed? (d) After reading the articles, what would you do in a similar situation and would a different outcome have been achieved? This is also a time to inquire as to why courage was or was not displayed. What do the students see as contributing factors to demonstrating or not demonstrating courage in the clinical situation, and then of course discussing the implications and ramifications of being courageous or not. It is important for faculty to keep focused on the purpose of this lesson—to investigate courage in nursing practice and not allow the discussion to become a blame game against colleagues, organizations, and other health care professionals. Now, comes the clinical assignment. Over the next week, students are asked to actively look for instances of nursing courage in their clinical rotations. They are asked to assume the role of ethnographer and to observe not only the courageous actions but also the context of those actions and specific verbal and nonverbal exchanges. The purpose of this active observation is for them to begin collecting a palette of repeatable behaviors and quintessential one-liners that can be shared and then reused in future clinical interactions—they are to start developing a menu of courageous responses. Such an assignment has benefits that overreach the specific assignment. Once students get in the habit of actively observing nurses in practice, the sky's the limit; this often spurs them on to becoming more watchful about acts of caring, leadership, activism, and so forth. Some of the acts of courage reported include the following: (a) being tenacious about getting lab test scheduled based on patient need and less on lab and personnel preference and convenience. (b) A patient had refused a specific blood test but the physician had included the test with his order for several other blood tests. The nurse discovered the order and called the lab indicating the patient had declined that specific test be performed and then notified the physician of her advocacy action. (c) A patient in early labor was admitted to the hospital. The baby's head was not yet engaged in the pelvis, but the physician was insisting that he wanted to rupture the bag of waters because he had a busy schedule and needed things to move along. The nurse pointed out her concerns about a prolapsed cord, etc., and when the physician became insistent, the nurse notified the nursing supervisor and the medical director; the bag of waters was not ruptured. It is
Educate, Excite, Engage important to point out as these stories are shared that very few of them are overly dramatic or in heroic in a super-nurse kind of way, but each tells a tale of patient centeredness, advocacy, and commitment to caring. The final part of this courage assignment is for students to listen for those statements (one-liners) that allows everyone to stop, reflect, rethink, and if appropriate retreat from a difficult situation. I always give the example of using the ANA Code of Ethics (n.d.) as my all-time favorite response “I am not ethically comfortable with….” Other favorite one-liners collected and shared by students include the following: Are we sure this is in the best interest of the patient? Let's take a step back and relook at this situation. Could you please help me understand why this is the best course of action? I think I missed something…why are we doing this? Are we sure the patient (family) understands what we’re doing and why? and Have we looked at all possible options and are we sure this is the best?
When the assignment is complete and all the stories and one-liners have been posted on the course discussion board or presented in class, one of my end-of-semester gifts to the students is a brief paper that has organized their acts of courage by themes (advocacy, interaction, tenacity, etc.) and includes a list of their one-liners—it's the first paper for their “nursing files of courage.” I always end our lesson on courage with the personal observation (from 35 years of practice) that in an ever-changing health care system where business decisions can conflict with moral decisions, personal preferences and conveniences can diverge from best practices and where ethics can clash with power hierarchies; I still believe the most courageous act of any nurse is to start each day by reaffirming her or his commitment to being a nurse and practicing at her or his very best. I believe nurse is synonymous with courage.
References American Nurses Association. (n.d.) Code of ethics. Retrieved from, http://www.nursingworld.org/MainMenuCategories/EthicsStandards/ CodeofEthicsforNurses/Code-of-Ethics.pdf. April 4, 2012. Angelou, M. (n.d.) Retrieved from, http://www.brainyquote.com/quotes/ keywords/courage.html. March 31, 2012. Kerfoot, K. (1999). The culture of courage. Nursing Economics, 17(4), 238−239 July/August. Savage, T. A., & DeWolg-Bosek, M. S. (1998). Moments of courage. Imprint, 34, 31−34 April/May. VitalSmarts. (2005). Silence kills: Seven crucial conversations for healthcare. Retrieved from, http://www.silenttreatmentstudy.com/silencekills/ SilenceKills.pdf. March 29, 2012.
EDUCATE, EXCITE, ENGAGE www.jtln.org
Teaching courage: An essential for nursing education Rojann R. Alpers PhD, RN⁎, Kay Jarrell MS, RN, Roxena Wotring MS, RN Arizona State University College of Nursing and Health Innovation, Phoenix, AZ 85004, USA
Maya Angelou's (n.d.) quote about courage seems most appropriate for nursing, “One isn't necessarily born with courage, but one is born with potential. Without courage, we cannot practice any other virtue with consistency. We can't be kind, true, merciful, generous, or honest.” This quote raises the question: Can we really be nurses and practice nursing without courage? However, having said that, how many nursing programs actually teach nursing courage? Certainly, we can use examples from our rich history— Florence Nightingale stood up against the British military leaders so that the soldiers in the Crimea could have better treatment in the military hospitals. Clara Barton gave care to all soldiers during the Civil War, and the union military leaders tried to have her indicted for treason. Lillian Wald established a nurse-managed clinic in New York City for the poor and immigrant population at the beginning of the 20th century against all medical, social, and political advice. These are but a few examples of extraordinary people making a difference in extraordinary circumstances. However, what about the day-to-day nurse in current clinical practice? How can we assist our students to develop a menu of courage behaviors that will serve them as nursing students and also as professional nurses? Kerfoot (1999) reminds us that as nurses we all encounter situations that require courage, but we do not always respond to the situation with courage. She goes on to point out that courage is a result of a culture of integrity where doing the right thing is required, recognized, and rewarded, and it must start with nursing leaders who plan and build cultures of courage. Courage does not magically emerge upon gradu-
* Corresponding author. E-mail address: [email protected]
ation, so if we are to have cultures of courage within our hospitals and clinics and other practice arenas, then nursing education must now accept its responsibility for developing didactic and clinical content and opportunities to discuss, reflect, and practice courage with our nursing students. A combined didactic and clinical assignment has proven to be valuable for nursing students as we begin to truly inculcate the essentiality of courage to all nursing practice. First, students are assigned three articles to read and discuss in class and clinical conference. These articles are wonderful old favorites, and they cut to the point and continue to resonate with nursing students. The Savage and DeWolfBosek (1998) article uses scenarios that nursing students may face in practice concerning documentation, scope of practice, impaired colleagues, and so forth and then invites reflection (using the American Nurses Association Code of Ethics) on how to respond to such incidents. Kerfoot (1999) overviews the need for nursing courage in practice and offers insight on ways to create such cultures in all organizations. Finally, VitalSmarts (2005), in association with the American Association of Critical-Care treatise—Silence Kills: Seven Crucial Conversations for Healthcare—reports on numerous studies conducted with nurses, physicians, staff, and administration to uncover the seven most crucial concerns for health care providers. This is an eye-opening, heartpounding report that will elicit tremendous discussion with students, colleagues, and other professionals. Following the articles being read, class discussion typically begins with developing a group definition of courage. This is a lively conversation where the “inkblot” approach is used—asking students to react to the word courage and then give one word or one short statement about “what is courage.” Frequently, their responses include “do the right thing,” “ethical,” “fearless,” “caring,” “brave,” and
1557-3087/$ – see front matter © 2012 National Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved. doi:10.1016/j.teln.2012.04.001
122 “dangerous.” With a little work, faculty can tease out a coherent working definition for the group and give everyone a starting point for its clinical application. Second, the assigned articles are discussed, and opportunities for students to share their encounters or observations about difficult clinical situations are solicited. This is when active listening and questioning is important from faculty— questions such as (a) What do you think contributed to this situation? (b) How was it handled and why do you think it was handled in that way? (c) Ideally, how should it have been addressed? (d) After reading the articles, what would you do in a similar situation and would a different outcome have been achieved? This is also a time to inquire as to why courage was or was not displayed. What do the students see as contributing factors to demonstrating or not demonstrating courage in the clinical situation, and then of course discussing the implications and ramifications of being courageous or not. It is important for faculty to keep focused on the purpose of this lesson—to investigate courage in nursing practice and not allow the discussion to become a blame game against colleagues, organizations, and other health care professionals. Now, comes the clinical assignment. Over the next week, students are asked to actively look for instances of nursing courage in their clinical rotations. They are asked to assume the role of ethnographer and to observe not only the courageous actions but also the context of those actions and specific verbal and nonverbal exchanges. The purpose of this active observation is for them to begin collecting a palette of repeatable behaviors and quintessential one-liners that can be shared and then reused in future clinical interactions—they are to start developing a menu of courageous responses. Such an assignment has benefits that overreach the specific assignment. Once students get in the habit of actively observing nurses in practice, the sky's the limit; this often spurs them on to becoming more watchful about acts of caring, leadership, activism, and so forth. Some of the acts of courage reported include the following: (a) being tenacious about getting lab test scheduled based on patient need and less on lab and personnel preference and convenience. (b) A patient had refused a specific blood test but the physician had included the test with his order for several other blood tests. The nurse discovered the order and called the lab indicating the patient had declined that specific test be performed and then notified the physician of her advocacy action. (c) A patient in early labor was admitted to the hospital. The baby's head was not yet engaged in the pelvis, but the physician was insisting that he wanted to rupture the bag of waters because he had a busy schedule and needed things to move along. The nurse pointed out her concerns about a prolapsed cord, etc., and when the physician became insistent, the nurse notified the nursing supervisor and the medical director; the bag of waters was not ruptured. It is
Educate, Excite, Engage important to point out as these stories are shared that very few of them are overly dramatic or in heroic in a super-nurse kind of way, but each tells a tale of patient centeredness, advocacy, and commitment to caring. The final part of this courage assignment is for students to listen for those statements (one-liners) that allows everyone to stop, reflect, rethink, and if appropriate retreat from a difficult situation. I always give the example of using the ANA Code of Ethics (n.d.) as my all-time favorite response “I am not ethically comfortable with….” Other favorite one-liners collected and shared by students include the following: Are we sure this is in the best interest of the patient? Let's take a step back and relook at this situation. Could you please help me understand why this is the best course of action? I think I missed something…why are we doing this? Are we sure the patient (family) understands what we’re doing and why? and Have we looked at all possible options and are we sure this is the best?
When the assignment is complete and all the stories and one-liners have been posted on the course discussion board or presented in class, one of my end-of-semester gifts to the students is a brief paper that has organized their acts of courage by themes (advocacy, interaction, tenacity, etc.) and includes a list of their one-liners—it's the first paper for their “nursing files of courage.” I always end our lesson on courage with the personal observation (from 35 years of practice) that in an ever-changing health care system where business decisions can conflict with moral decisions, personal preferences and conveniences can diverge from best practices and where ethics can clash with power hierarchies; I still believe the most courageous act of any nurse is to start each day by reaffirming her or his commitment to being a nurse and practicing at her or his very best. I believe nurse is synonymous with courage.
References American Nurses Association. (n.d.) Code of ethics. Retrieved from, http://www.nursingworld.org/MainMenuCategories/EthicsStandards/ CodeofEthicsforNurses/Code-of-Ethics.pdf. April 4, 2012. Angelou, M. (n.d.) Retrieved from, http://www.brainyquote.com/quotes/ keywords/courage.html. March 31, 2012. Kerfoot, K. (1999). The culture of courage. Nursing Economics, 17(4), 238−239 July/August. Savage, T. A., & DeWolg-Bosek, M. S. (1998). Moments of courage. Imprint, 34, 31−34 April/May. VitalSmarts. (2005). Silence kills: Seven crucial conversations for healthcare. Retrieved from, http://www.silenttreatmentstudy.com/silencekills/ SilenceKills.pdf. March 29, 2012.