MU Moral Courage Ethical and Law in Nursing Paper

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Article Moral courage in nursing: A concept analysis Nursing Ethics 2017, Vol. 24(8) 878–891 ª The Author(s) 2016 Reprints and permission: sagepub.co.uk/journalsPermissions.nav 10.1177/0969733016634155 journals.sagepub.com/home/nej Olivia Numminen and Hanna Repo University of Turku, Finland Helena Leino-Kilpi University of Turku, Finland; Turku University Hospital, Finland Abstract Background: Nursing as an ethical practice requires courage to be moral, taking tough stands for what is right, and living by one’s moral values. Nurses need moral courage in all areas and at all levels of nursing. Along with new interest in virtue ethics in healthcare, interest in moral courage as a virtue and a valued element of human morality has increased. Nevertheless, what the concept of moral courage means in nursing contexts remains ambiguous. Objective: This article is an analysis of the concept of moral courage in nursing. Design: Rodgers’ evolutionary method of concept analysis provided the framework to conduct the analysis. Data sources: The literature search was carried out in September 2015 in six databases: PubMed, CINAHL, Scopus, Web of Science, PsycINFO, and The Philosopher’s Index. The following key words were used: ‘‘moral’’ OR ‘‘ethical’’ AND ‘‘courage’’ OR ‘‘strength’’ AND ‘‘nurs*’’ with no time limit. After applying inclusion and exclusion criteria, 31 studies were included in the final analysis. Ethical considerations: This study was conducted according to good scientific guidelines. Results: Seven core attributes of moral courage were identified: true presence, moral integrity, responsibility, honesty, advocacy, commitment and perseverance, and personal risk. Antecedents were ethical sensitivity, conscience, and experience. Consequences included personal and professional development and empowerment. Discussion and conclusion: This preliminary clarification warrants further exploring through theoretical and philosophical literature, expert opinions, and empirical research to gain validity and reliability for its application in nursing practice. Keywords Concept analysis, moral courage, nursing, qualitative research, virtue ethics Introduction Moral courage is a highly valued element of human morality and today an acknowledged virtue in nursing care.1,2 Serious and focused approach on the concept of moral courage has started to emerge as a result of new interest in virtue ethics in nursing, medicine, and society at large.2,3 Traditional deontological and Corresponding author: Olivia Numminen, Department of Nursing Science, University of Turku, Turku 20014, Finland. Email: [email protected] Numminen et al. 879 teleological ethical theories, principlism, or ethics of care individually and exclusively have not been able to provide comprehensive tools to discuss and solve ethical problems in complex healthcare environments.4,5 Nurses’ earlier, a somewhat adverse attitude toward virtue ethics has its roots in the historical development of nursing. Florence Nightingale’s virtue-based view of nurses and nursing care was seen as a major reason to nursing’s subservience to medicine preventing nursing’s development to an autonomous profession, and for that matter, to an autonomous moral agency.6 Nursing is considered as an ethical endeavor. Nurses encounter ethical problems in their daily practice, which should be solved for the ultimate good of the patient pointing to nursing’s moral end.7 Additionally, occasionally either personal or organizational hindrances have prevented nurses from fulfilling their moral duties toward their patients and from acting according to their values causing nurses moral distress.8 Nurses’ experiences and suffering of moral distress have prompted the profession to seek effective ways to relieve it.9,10 Moral courage has been introduced as one empowering way to tackle the issue,1,2,11–14 but also because there is a recognized need for moral courage in all areas and at all levels of nursing.15 Despite the new interest in moral courage and virtue ethics, there is a surprisingly small number of substantive writing of moral courage in nursing, particularly in scientific literature. However, implicit or indirect references to nurses’ moral courage can be found in literature, often referring to various other terms, such as moral integrity, moral sensitivity, or vulnerability, or references are made to ‘‘a good nurse’’ or nurses’ heroic deeds. This implicit and indirect use of the term refers to lack of adequate conceptual clarity of moral courage as a virtue in context of nursing care. Background In nursing literature, moral courage has been discussed since Florence Nightingale’s era. According to Nightingale, among the many personal traits and competencies, moral disposition was an essential characteristic of a good nurse.6 Since then, moral courage has been addressed in the nursing literature, increasingly during the last two decades,14 but thus far it has not gained such attention as, for example, discussion of moral distress.9 In theoretical nursing literature, moral courage has been discussed in various contexts. Most articles provide a general definition of moral courage and continue discussing the need and strategies to enhance the virtue and courageous action to provide good nursing care.12,14,16–19 Discussion has also focused on nursing leadership and practice environment’s role in supporting moral courage.15,20–22 Moral courage has also been linked to moral distress as a way to support nurses against adverse consequences of moral distress.2,11,23,24 Empirical research, in which the main focus is on moral courage, is extremely scarce.14,25 However, there are studies in which moral courage is brought up in context of other moral concepts.26–29 Nevertheless, both theoretical and empirical literature have discussed moral courage mainly based on its general definition and as a trait the nurse should have and to use in context of the issue in question rather than having tried to explicitly clarify what are the attributes, antecedents, and consequences of the concept in nursing. This study set out to clarify the concept of moral courage in nursing. Origin and dictionary definitions of moral courage The concept of courage has its origin in the vulgar Latin word ‘‘coraticum,’’ formed on ‘‘cor’’ meaning heart, furthermore in Old French ‘‘curage,’’ and in Middle English ‘‘corage,’’ referring to having spirit or heart as the seat of feelings.30,31 Courage is defined as an attitude and a quality of mind that enables one to face anything recognized as dangerous, difficult, or painful with firmness and without fear, instead of withdrawing from it.31,32 Courage is divided into different types, representing different circumstances and motives for acting courageously. Physical courage refers to facing physical harm,1 psychological courage to staying committed in situations where fear results in psychic instability,33 and moral courage in acting according to one’s convictions and doing what one thinks is right despite criticism in moral contexts.30,32 880 Nursing Ethics 24(8) Moral is an adjective having its origin in late Middle English from Latin ‘‘moralis,’’ that is, morality referring to ‘‘mor, mores’’ translating to customs and human behavior. Moral is concerned with right conduct or the distinction between right and wrong, good and bad, and moral attitudes. The antonym of courage is cowardice indicating lack of courage. The antonym to moral is immoral.30,32,34 Not until the 19th century did the term moral courage emerge to the English language to separate moral courage from other types of courage, such as physical courage.35–37 Moral courage was defined as ‘‘facing the pains and dangers of social disapproval in the performance of what one believed to be duty,’’38 including the same elements as in contemporary definitions.37 Method The ‘‘evolutionary’’ concept analysis method introduced by Rodgers was chosen for this study. It is seen suitable for the clarification of the concept in its early stage and to provide a foundation for its further development.39 Furthermore, for the purpose of future instrument development, literature was restricted here to empirical studies. Literature search In the first phase of the literature search, synonyms and related concepts for ‘‘moral’’ and ‘‘courage’’ were traced in dictionaries.30,34 Colloquial words as synonyms for courage were rejected as their use in scientific literature was unlikely. Preliminary searches in relevant databases using ‘‘backbone,’’ ‘‘bravery,’’ ‘‘dare,’’ ‘‘daring,’’ ‘‘fortitude,’’ ‘‘heart,’’ ‘‘mettle,’’ ‘‘spine,’’ ‘‘spirit,’’ and ‘‘tenacity’’ as synonyms for courage did not yield meaningful results. The search was carried out in September 2015 in six databases: Scopus, PubMed, Web of Science, CINAHL, PsycINFO, and The Philosopher’s Index using Boolean Phrase search technique. The following key words were used: ‘‘moral’’ OR ‘‘ethical’’ AND ‘‘courage’’ OR ‘‘strength’’ AND ‘‘nurs*.’’ No time limit was set for the publications. Searches from databases were merged to remove duplicates. The following inclusion criteria applied: The article (1) dealt with moral courage in nursing context, (2) was an empirical study, (3) was published in a scientific journal, and (4) was written in the English language. Exclusion criteria were as follows: The article (1) was theoretical, (2) was published in a non-scientific journal, and (3) was an editorial, letter to the editor, commentary, doctoral dissertation, or a book chapter. All retrieved titles were screened according to inclusion and exclusion criteria and abstracts of selected studies retrieved. Thereafter, the abstracts were screened for their relevance, and full texts of selected studies were retrieved. The relevance of the full text articles was confirmed by their careful reading and quality appraisal. The relevance of the included studies was appraised by two researchers. One researcher carried out the systematic literature search. Two researchers independently selected the relevant studies, and in case of differing opinions, problematic issues were discussed to reach a consensus. Finally, a manual search was carried out from the reference lists of the included studies. The literature search yielded 31 studies. All these studies had used qualitative research design. The literature search procedure is illustrated in Figure 1. Data analysis The initial question of this concept analysis was as follows: What is nurses’ moral courage as conceptualized in nursing studies? Data analysis started with reading each selected study to capture the general impression of its content. Thereafter, using inductive content analysis, the verbatim expressions referring to moral courage were recorded on a matrix sheet initially classifying them into main categories of attributes, antecedents, and consequences, surrogate and related terms according to Rodgers’ concept Numminen et al. 881 PubMed CINHAL Scopus Web of science PsychINFO n = 341 n = 195 n = 229 n = 120 n = 143 The Philosopher’s Index n = 15 Titles from 6 database searches n = 1043 Non-English titles n = 44 Duplicate titles n = 640 Titles in non-scientific journals n = 26 Titles for screening n = 359 Editorials, book-reviews etc. n = 24 Dissertations n =1 3, Books n = 28 Titles for abstract review n = 268 Articles irrelevant to concept analysis n = 162 Theoretical articles n = 66 Studies for full text review n = 40 Studies irrelevant to concept analysis n = 23 Studies from database search n = 17 Studies from manual search from reference lists n = 14 Total number of studies included n = 31 Figure 1. Literature search procedure. analysis framework.39 Within each main category, the expressions were further classified into subcategories based on their common features of being or acting as a courageous nurse (Table 1). Finally, an exemplar case based on real-life situation to describe the concept was presented.39 882 Nursing Ethics 24(8) Table 1. Manifestation of moral courage in nursing. Moral courage in nursing Attributes Being a courageous nurse Acting as a courageous nurse Reference True presence Seeing the patient as a fellow human being by realizing the universal aspect of human existence Responding to the patient’s needs Creating an interpersonal relationship with the patient Daring to be touched by the patient’s vulnerability Daring to admit one’s own vulnerability Enduring ethical uncertainty Daring to face unpredictable care situations Knowing one’s own values Being true to herself or himself Living as me Mastering one’s own life Not compromising Not conforming with mainstream Feeling empowered Standing criticism Staying by the patient’s side Listening Being open Being true Being responsive Expressing one’s own feelings Showing love, compassion and empathy Providing hope, optimism and human spirit Breaking rules and conventions Arman26 Bryon et al.43 Jensen and Lidell45 Lindh et al.25 Lindwall et al.28 Nåden and Eriksson44 Sefer40 Stenbock-Hult and Sarvimäki27 Thorup et al.42 Committing to acting if needed Intervening in unethical behavior Acting under pressure/ uncertainty Being open Being trustworthy Being patient Being persevering Resisting Staying firm Speaking out one’s values and views Not compromising Being available to patient Not losing control Enduring uncertainty Feeling empowered Managing consequences Being flexible Being trustworthy Being honest Black et al.29 Garon49 Gray47 Johansson et al.46 Kuokkanen and Leino-Kilpi53 Laabs52 Lindh et al.25 Murphy48 Sauerland et al.54 Spence and Smythe50 Stenbock-Hult and Sarvimäki27 Thorup et al.42 Torjuul et al.51 Moral integrity Responsibility Honesty Aiming at excellence at work Committing to the patient’s wellbeing Preserving the patient’s dignity Admitting own mistakes and limitations Committing to authentic leadership Managing one’s own anxiety and ambivalence Having emotional intelligence Questioning one’s own behavior/ Speaking up Reporting unsafe practices actions Questioning colleagues’ behavior/ Being trustworthy Being open actions Admitting one’s shortcomings and Having clear conscience mistakes Arman26 Arndt57 Black et al.29 Björkström et al.55 Carroll58 Heijkenskjöld et al.56 Johansson et al.46 Kuokkanen and Leino-Kilpi53 Arndt57 Gustafsson et al.41 Jensen and Lidell45 Laabs52 (continued) Numminen et al. 883 Table 1. (continued) Moral courage in nursing Attributes Being a courageous nurse Acting as a courageous nurse Reference Advocacy Staying on the patient’s side Focusing on the patient Preserving the patient’s dignity Responding to the patient’s needs and rights Intervening for and with the patient Encouraging the patient Baughman et al.59 Promoting/facilitating patients’ courage Björkström et al.55 Providing hope and optimism Garon49 Speaking for the patient Heijkenskjöld et al.56 against others’ humiliation Johansson et al.46 and insults of human Lindh et al.25 dignity Lindwall et al.28 Exceeding professional Weiskopf61 obligations Wilkes and Wallis60 Speaking up Arman26 Having professional confidence Björkström et al.55 Avoiding superficiality in care Black et al.29 Risk-taking to provide safe Bryon et al.43 patient care Hawkins and Morse14 Lindh et al.25 Sefer40 Spence and Smythe50 Thorup et al.42 Risking one’s own reputation Arman26 Reflecting one’s own Gustafsson et al.41 behavior Lindh et al.25 Expressing personal feelings Nåden and Eriksson44 Seeing one’s own Stenbock-Hult and vulnerability Sarvimäki27 Commitment Identifying with self and the and perseverance profession Committing to good care Recognizing professional boundaries Enduring strain Using resistance Personal sacrifice Standing alone Committing to care with one’s whole being Results Attributes The primary focus was on finding the key attributes to define the concept as presented in nursing studies.39 The following attributes were identified to define what it is to be and to act as a courageous nurse: true presence, moral integrity, responsibility, honesty, advocacy, commitment and perseverance, and personal sacrifice (Table 1). True presence. Being a courageous nurse was being truly present to the patient in care situations. At the existential level, it meant being human and encountering the patient as a fellow human being referring to the universal aspect of human existence. Courage was understanding the human otherness in another person, an ability to see things through others’ eyes, and encountering the care situation with others.26–28,40–42 Nurses’ experience of patients as a fellow human being was expressed as ‘‘we see them naked.’’43 Courage as a human encounter was responding to the patient’s needs. Referring to Emanuel Lévinas’ philosophy, Arman26 described that ‘‘seeing the otherness is uniting with another. Courage is a bridge to an existential encounter and alleviation of suffering through nurse’s perceiving and responding to the patient’s needs.’’ Courage was willingness and daring to enter into a humanely intimate, interpersonal relationship with the 884 Nursing Ethics 24(8) patient.42–44 For the nurse, it meant daring to be touched by the patient’s dependent situation and attentiveness to and recognition of the patient’s vulnerability in sickness, suffering, and death.25–28,42,43 Courage was also needed for the nurse to recognize her own human vulnerability.27 At the existential level, courage was transcending the earlier limits without prejudice, opening up to unknown aspects in caring encounters, willingness to endure uncertainty in entering unpredictable situations, and running the risk of rejection allowing a possible new understanding of life to the nurse and the patient.26,42 Acting as a courageous nurse in relation to presence meant being open, true, and responsive to patient’s needs as opposite of being manipulative, indifferent, and superficial in patient encounters. Courage was engagement manifested as love and compassion.26,28,42 It was confronting and expressing one’s own feelings and empathizing with the patient.27,43 It meant acting against conventions and breaking the rules in being sensitive to patients’ vulnerability and suffering.44 Acting courageously meant remaining with the patient, daring to sit and listen, and to talk openly in ethically difficult care situations.45 Courageous action was providing hope, optimism, and human spirit in patients.40 Moral integrity. Being a courageous nurse meant knowledge of one’s own values and acting on them.25,29,42,46–51 Upholding the commitment to values required courage because it left oneself open to criticism from others and open to consequences personally and professionally.25,42,52,53 In nursing leadership, courage meant not to compromise in cases of uncertainty. Authentic nurse leader had moral courage to do the right thing, to espouse to live out his or her values. Courageous nurse leader had willingness to take risks and to engage in difficult debates.48 Courage as moral integrity was associated with empowerment and resistance. In an empowered nurse, moral integrity appeared as equilibrium and mastery over one’s own life manifesting as courage, tenacity, and self-esteem. An empowered nurse had courage to intervene when observing unethical behavior toward patients; she was fearless in taking stand and in taking action, and had courage to submit her own action to collective judgment and to consult a colleague. Empowered nurse had courage to make autonomous decisions and assume responsibility.53 Resistance needed courage. It meant standing up for what one believes in, to speak out or to act on an ethical matter, and not conforming to the mainstream. Nurses found that speaking up about concerning issues meant gathering courage to challenge what was unspoken by others and bringing the issue into public. Resistance meant importance for living as me thus referring to moral integrity.49 Acting as a courageous nurse in relation to moral integrity meant behavior that was coherent with the nurse’s beliefs and principles. Courage was being honest, trustworthy, patient, and persevering, and consistently doing what was right and good25,51,52 and acting against harassment and threats.48 It was responsible behavior by voicing one’s views and staying firm in commitments.25,29,54 Courageous behavior was ability to speak up by bringing up one’s inner thoughts and sharing experiences with others having focus on patient’s perspective.27,46,50 Responsibility. Being a courageous nurse meant professional responsibility and accountability43,46,53,55 instigated by moral integrity.29 Courage was an attribute of a good, responsible, and professional nurse aiming at excellence in work.55 Courage meant taking responsibility of other person’s vulnerability and well-being in a true relationship26 and preserving his or her human dignity.56 Courage was admitting and taking responsibility of one’s mistakes and discussing and learning about them.57 Acting as a responsible nurse was availability and presence in a situation of the patient’s suffering46 and preserving the patient’s human dignity. In the leadership role, courage was taking personal responsibility, not losing control or resorting to impulsive acts. Courage was an ability to work through one’s own anxiety and ambivalence, to be good in self-observation and self-analysis, to be motivated to reflect, to deal with disappointments in life, and to live a balanced life. Courageous leaders had emotional intelligence, ‘‘gut Numminen et al. 885 instinct.’’ They knew their strengths and limits, had self-worth, and displayed honesty, integrity, and trustworthiness. In changing situations, they were flexible, overcoming obstacles, and strived for inner standards of excellence.58 Honesty. Courage is daring to reflect honestly your thoughts and activities, for example, in acknowledging one’s own shortcomings and admitting mistakes, discussing, learning, and correcting them. It is also to question one’s own and colleagues’ behavior, seeing things through others’ eyes, and being flexible to interpret.41,45,52,57 Acting honestly meant trustworthiness, open-mindedness, and clear conscience.52 Advocacy. A courageous nurse meant standing on the patient’s side and speaking up for the patient despite the risks involved.25,55,59 Courage was advocating for the patient’s needs and rights of treatment, intervening for and with the person.60 Courage was the bridge between personal and professional values, and it helped nurses to stand up for different values and focus on patients’ perspectives.46 To preserve the patient’s dignity needed courage from the nurse.28 According to Weiskopf,61 caring for prisoners intervening with custody matters was a risk needing courage. However, to care for inmates was experienced as a moral imperative, a commitment to feel respect and maintain inmates’ human dignity. A courageous nurse stood on her patient’s side against other persons’ humiliation and violation of human dignity.56 Courage takes the form of resistance for the part of the nurse in advocating her patient.49 Commitment and perseverance. Courage was a characteristic of a good nurse. It was a personal wish and pride to dare to be a nurse with moral integrity and professional responsibility.29 Courage was commitment to good care,43 enduring difficulties, and avoiding an easy way out.42,48 Courage was an inner quality, an attitude of engagement and commitment, and caring and acting out from love and compassion.26 Courageous nurses know their professional boundaries and have strength to reject demands from others.55 Acting courageously was commitment to risk-taking actions to ensure safe patient care.14 Personal risk. Moral courage of the nurse was a personal sacrifice. Courage was an inner quality of the nurse, a commitment and participation with one’s whole being in a care situation.26,44 Courage was acting in accordance with one’s convictions, meaning readiness to risk your own reputation by becoming personally involved. Courage meant being prepared to stand alone for the right thing to do and not compromising in front of injustice and threats.25,48,52 It was daring to reflect your own behavior and actions needing experience in life and in the profession.41 Courage meant confronting and expressing one’s own feelings and seeing one’s own vulnerability and limitations.27 Failing a student needed moral courage. A supervisor failing a student suffered moral distress, thus paying a personal sacrifice in defending patients’ right to safe and quality care.29 Exemplar case. The exemplar case can be derived through a qualitative research or it can represent a specific practice situation from the real world of nursing.62 The latter is applied here. Explorative laparotomy was planned to a female patient in her late 40s diagnosed with an advanced pancreatic cancer. The operation was planned to be the first in the hectic schedule of the day. The anesthesia nurse was the first person to meet the patient in the operating theater and to prepare her for anesthesia. Nurse’s discussion with the patient revealed that despite the heavy premedication, the patient was extremely anxious wanting to discuss with the surgeon about her situation before the operation. Because the patient was aware of the gravity of her illness, the nurse could sense the existential anxiety and suffering of the patient. The nurse discussed the situation with the nurse manager who said that waiting for the surgeon was not possible because it took too much time delaying the planned schedule. The nurse insisted that the patient 886 Nursing Ethics 24(8) should be allowed to discuss with the surgeon because the patient’s anxiety was genuine and real. After negotiations with the manager with negative results, the nurse called the surgeon and the anesthetist, explained the situation, and subsequently the operation was postponed for 30 min and the patient was allowed to meet the surgeon which seemingly relieved her anxiety. The case illustrates how the nurse was able to be present and compassionate in the care situation. She advocated her patient by speaking on behalf of the patient and by resisting the manager’s decision. The nurse showed moral integrity by not compromising her professional values as a professional nurse to take the responsibility of the situation and to provide good care to her patient in confronting resistance from others. The nurse had also honestly reflected the situation, what is the right thing to do having anticipated the possible negative consequences for herself and other workers by delaying the hectic operating schedule. Nevertheless, she was ready to take this personal risk for her patient’s good care, risking to be reprimanded by other staff. Antecedents Antecedents of moral courage were ethical sensitivity, conscience, overcoming fear, and experience. Sensitivity developed in context of uncertainty, patient suffering, and vulnerability, and in relationships characterized by receptivity and responsiveness. These were prerequisites to courage.63,64 Sensitivity meant seeing the morally salient aspects of the situation (e.g. risk or need for protection) instigating courage to challenge fixed conceptions of conventions, placing values in tension with one another, and taking action to prevent suffering and assuming the responsibility of consequences.44 Ethical sensitivity consisted of sense of moral burden, moral strength, and moral responsibility. Moral burden meant an ability to sense the patient’s needs, difficulties to deal with feelings caused by the patient’s suffering, and awareness whether doing good or harming the patient, but resulting in lack of strength to respond. Moral strength helped nurses to talk about difficult matters with the patients. Moral strength was courage to act and to argue to justify the actions on behalf of the patient. Moral responsibility meant providing good care even in case of inadequate resources and to know what is good or bad for the patient. These factors were found conceptually interrelated and indicated that moral sensitivity may involve more dimensions than cognitive capacity.63 Conscience was the driving force behind courageous acts giving courage to discuss difficult subjects. Conscience strengthened nurses’ ability to stick to their values and set boundaries to their actions. It helped to question prevailing practices and opinions.45 Overcoming fear was yet another antecedent of courage. An empowered nurse acted courageously being fearless in taking stand and acting and facing criticism by submitting her own actions to collective judgment.53 Nurses mustered courage in perceiving a threat to patient safety, for example, management neglecting necessary safety measures.57 Being truly present meant overcoming the fear to face the unpredictable consequences in ethical situations.25,26,42 Feelings of moral distress and moral uncertainty reinforced the held values and commitment resulting in moral strength to act according to the held values.29 Need to manage value conflicts mobilized moral courage.65 Nåden and Eriksson44 quoted a nurse saying, ‘‘I’m not afraid to use myself, to enter into interpersonal relationships and to go into situations that may be difficult.’’ Both life and professional experience were needed to be courageous. To become courageous required a commitment to a lifelong, progressive, and disciplined training. This training is for some the often unconscious habit of reflection on underlying values and morals behind decisions and assessments made. Consequently, to be a nurse with courage requires both life and professional experience.41 Experience gave nurses the courage to voice their own needs and feelings to be able to endure morally difficult situations. Voicing their opinions and having courage to display their vulnerability and need of support were acquired by experience. ‘‘Something you learn by experience is that you need not to carry moral burden alone.’’ ‘‘Collegial discussions are important giving me courage to stay in difficult situations.’’ Nurses felt respected as they became more experienced which added to their confidence and courage to voice their opinions.51 Numminen et al. 887 Consequences Consequences of moral courage were nurses’ personal and professional development and the feeling of empowerment. Having courage to recognize human vulnerability and being truly present to the patient brought a shared meaning and a new understanding of life between the nurse and the patient. It provided enrichment to one’s inner life in general and in the face of death and suffering.26 Courage meant development as a person, as a human being, and as a professional.28 Listening, discussing, and sharing experiences gave students courage to stand up and act for their patients’ rights enhancing their professional growth.46 Honesty and responsibility were crucial to the nurse’s personal development.57 Acting courageously gave feeling of empowerment, strength, and growth, also increasing self-knowledge.41,47 Surrogate and related terms Rodgers and Knafl39 emphasizes surrogate and related terms as an important element of her concept analysis method. Moral strength was the sole concept that could be considered as a surrogate to the term moral courage, indicating a closely identical set of attributes.25,26 As to related terms in this analysis, concepts such as moral integrity, responsibility, or advocacy could be defined as related terms, but at the same time they were also found as attributes of moral courage.27,51 Discussion This study set out to clarify the concept of moral courage in nursing, employing Rodgers’39 evolutionary concept analysis method on empirical studies retrieved from nursing literature. Despite extensive literature searches, research directly focusing on moral courage was scarce. In the included studies, moral courage was discussed in a rather tangential way and courage was mainly referred to as a required trait, while the main focus of the study was in some other concept. Consequently, the analysis captured something what it is to be a courageous nurse rather than how nurses actually understand, consciously think, experience, and act out moral courage and what kind of processes are involved in their decision-making and acting courageously. Psychological research has indicated that moral courage is affected by cognitive information processing in the form of self-efficacy, outcome expectations, and interpersonal and group norms. Moreover, social forces shape decisions to act morally courageously as functions of subjective and group norms and social identity.66 This indicates that the concept’s definition and meaning in nursing have not been corroborated with empirical evidence, and therefore, more comprehensive and even cross-disciplinary empirical research is needed about the concept. This concept analysis indicated that definitions of moral courage referred in nursing literature are rather general and therefore unfocused to explicate what moral courage is in nursing. However, the found attributes have been considered as central and important moral concepts in nursing, whereas referring to them as attributes of moral courage has not been paid specific attention. Given that this connection holds true, it suggests that moral courage has a central and important role as an element of ethical nursing care. Kidder67 describes moral courage through five universally accepted values: honesty, fairness, respect, responsibility, and compassion. Given that his definition is true, these values are recognized also as central nursing values. The most dominantly presented attribute was true presence.25–27,42 In the majority of these studies, the approach was in caritative nursing theory referring to love, responsibility, and compassion and to respect and reverence to human holiness and dignity. The central theme is in suffering, which means lack of caritative care.68 Studying moral courage from the viewpoint of different theoretical approaches might further expand understanding the concept in nursing. 888 Nursing Ethics 24(8) Nurses’ moral distress has been recognized as a significant issue with mainly negative consequences indicating a problem area needing ways to alleviate it. Moral courage has been suggested to be a positive and an empowering way to address this issue.2 Moral courage is a virtue requiring ethical deliberation and action, being an important element in nurses’ general moral competence.69 This preliminary clarification of the concept analysis will help nurses to see how closely moral courage is related to professional nursing values and needed in acting according to them in daily practice. Moral courage is not only heroic deeds carried out by exceptional nurses in exceptional circumstances. However, moral courage is a complex concept, and due to its importance in ethical nursing care, its defining needs further explication. Conclusion Nursing as a moral practice needs nurses who have courage to think and act morally in their professional practice. Although a valued element of human morality, the concept of moral courage in nursing has remained ambiguous. This preliminary clarification affords nurses a better understanding of moral courage and its inherence in nurses’ daily practice. The attributes of moral courage—true presence, moral integrity, responsibility, honesty, advocacy, commitment and perseverance, and personal risk—reflect the basic nursing values and principles. Antecedents were ethical sensitivity, conscience, overcoming fear, and experience. Consequences were personal and professional growth and feeling of empowerment. As a surrogate term, moral strength came the closest, and some attributes of moral courage might also be interpreted as related concepts suggesting their further analysis in relation to moral courage more profoundly than in current literature. Moral courage in nursing is an elusive, multidimensional, and multilevel concept. Therefore, the concept’s further development warrants inclusion of theoretical and philosophical literature as well as experts’ critical assessment to better understand the depth and breadth of the concept. The concept would be even further strengthened by focusing empirical research on nurses’ courageous thinking and acting. The impact of personality, environmental factors, and education needs studying. Only a sufficiently comprehensive definition of the concept allows a valid and reliable foundation for recognizing moral courage and for educational programs and interventions targeted to develop nurses’ moral courage. Limitations Certain limitations of this concept analysis warrant comment. Dictionaries provide a large array of synonyms and related terms to the word courage. Here, the search terms were limited to the most used words related to moral facet of courage using Boolean Phase searching method which may have somewhat narrowed the findings. Searches were also limited to empirical studies. The aim of the study was to provide a preliminary analysis of the concept of moral courage in nursing for further development. In the further development of the concept, also theoretical literature should be included for a better understanding of the concept. Implications Researchers can use the findings as a basis of operationalizing the concept into an instrument to be used in the empirical nursing world. The analysis presents a foundation for its further development and a basis for identifying new focus areas on moral courage. Nursing management can use the concept in assessing nurses’ moral courage to detect areas in which nurses experience themselves strong and to detect areas in which they need development for creating Numminen et al. 889 continuing education programs and environments targeted to meet these needs and which enhance moral courage. Nursing education can use the findings in developing the content of nursing curricula and in assessing nurses’ development in moral courage through measurement. Teaching and learning moral courage is an integral part of nurses’ ethical competence and a personal trait that can be learned and developed. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by a grant from Finnish Nurses Association and Finnish Foundation of Nursing Education. References 1. Crigger N and Godfray N. Of courage and leaving safe harbors. Adv Nurs Sci 2011; 34(4): E13–E22. 2. Gallagher A. Moral distress and moral courage in everyday nursing practice. Online J Issues Nurs 2011; 16(2): 8. 3. Sekerka L, Bagozzi R and Charnigo R. 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Iseminger K. Overview and summary: moral courage amid moral distress: strategies for action. Online J Issues Nurs 2010; 15(3). 12. Lachman V. Strategies necessary for moral courage. Online J Issues Nurs 2010; 15(3): Manuscript 3. 13. LaSala C and Bjarnason D. Creating workplace environments that support moral courage. Online J Issues Nurs 2010; 15(3): Manuscript 4. 14. Hawkins S and Morse J. The praxis of courage as a foundation for care. J Nurs Scholarsh 2014; 46(4): 263–270. 15. Bjarnason D and LaSala C. Moral leadership in nursing. J Radiol Nurs 2011; 30: 18–24. 16. Day L. Courage as a virtue necessary to good nursing practice. Am J Crit Care 2007; 16: 613–616. 17. Lachman V. Moral courage: a virtue in need of development? Medsurg Nurs 2007; 16(2): 131–133. 18. Murray J. Moral courage in healthcare: acting ethically even in the presence of risk. Online J Issues Nurs 2010; 15(3): Manuscript 2. 19. Lachman V, Murray J, Iseminger K, et al. Doing the right thing: pathways to moral courage. Am Nurs Today 2012; 7(5): 24. 20. Clancy T. Courage and today’s nurse leader. Nurs Adm Q 2003; 27(2): 128–132. 890 Nursing Ethics 24(8) 21. Hader R. Leadership anxiety? Choose courage over complacency. Nurs Manage 2007; 38(5): 6. 22. Edmonton C. Moral courage and the nurse leader. Online J Issues Nurs 2010; 15(3): Manuscript 1. 23. Corley M. Nurse moral distress: a proposed theory and research agenda. Nurs Ethics 2002; 9(6): 646–650. 24. Epstein EG and Delgado S. Understanding and addressing moral distress. Online J Issues Nurs 2010; 15(3): Manuscript 1. 25. Lindh I, Severinsson E and Berg A. Nurses’ moral strength: a hermeneutic inquiry in nursing practice. J Adv Nurs 2009; 65(9): 1882–1890. 26. Arman M. Bearing witness: an existential position in caring. Contemp Nurse 2007; 27(1): 84–93. 27. Stenbock-Hult B and Sarvimäki A. The meaning of vulnerability to nurses caring for older people. Nurs Ethics 2011; 18(1): 31–41. 28. Lindwall L, Bouissad L, Kulzer S, et al. Patient dignity in psychiatric nursing practice. J Psychiatr Ment Health Nurs 2012; 19: 569–576. 29. Black S, Curzio J and Terry L. Failing a student nurse: a new horizon of moral courage. Nurs Ethics 2014; 21(2): 224–238. 30. Stevenson A (ed.). Oxford dictionary of English. 3rd ed. Oxford: Oxford University Press, 2010. 31. The Oxford dictionary of English etymology. London: Oxford University Press, 1976. 32. Webster’s encyclopedic unabridged dictionary of the English language. New York: Random House, 1996. 33. Putman D. Psychological courage. Philos Psychiatr Psychol 1997; 4(1): 1–11. 34. New Oxford thesaurus of English. New York: Oxford University Press, 2000. 35. Broadie S and Rowe C. Aristotle Nicomachean ethics: translation, introduction, and commentary. Oxford: Oxford University Press, 2002. 36. Aristotle: The Nicomachean ethics (trans. JAK Thompson). London: Penguin Books, 2004. 37. Miller W. The mystery of courage. Cambridge, MA: Harvard University Press, 2002. 38. Sidgwick H. The methods of ethics. 7th ed. London: Macmillan, 1913. 39. Rodgers B and Knafl K. Concept development in nursing: foundations, techniques, and application. 2nd ed. Philadelphia, PA: W.B. Saunders Company, 2001. 40. Sefer E. The courage to care: nurses facing the moral extreme. Aust J Adv Nurs 2004; 21(4): 28–34. 41. Gustafsson C, Asp M and Fagerberg I. Reflection in night nursing: a phenomenographic study of municipal night duty registered nurses’ conceptions of reflection. J Clin Nurs 2008; 18(10): 1460–1469. 42. Thorup C, Rundqvist E, Roberts C, et al. Care as a matter of courage: vulnerability, suffering and ethical formation in nursing. Scand J Caring Sci 2012; 26(3): 427–435. 43. Bryon E, Dierckx de Casterle B and Gastmans C. ‘‘Because we see them naked’’—nurses’ experiences in caring for hospitalized patients with dementia: considering artificial nutrition or hydration (ANH). Bioethics 2012; 26(6): 285–295. 44. Nåden D and Eriksson K. Understanding the importance of values and moral attitudes in nursing care in preserving human dignity. Nurs Sci Q 2004; 17(1): 86–91. 45. Jensen A and Lidell E. The influence of conscience in nursing. Nurs Ethics 2009; 16(1): 31–42. 46. Johansson I, Holm A-K, Lindqvist I, et al. The value of caring in nursing supervision. J Nurs Manag 2006; 14: 644–651. 47. Gray M. Nursing leaders’ experiences with the ethical dimensions of nursing education. Nurs Ethics 2008; 15(3): 332–345. 48. Murphy L. Authentic leadership: becoming and remaining an authentic nurse leader. J Nurs Adm 2012; 42(11): 507–512. 49. Garon M. The positive face of resistance. J Nurs Adm 2006; 36(455): 249–258. 50. Spence D and Smythe L. Courage as integral to advancing nursing practice. Nurs Prax N Z 2007; 23(2): 43–55. 51. Torjuul K, Elstad I and Sorlie V. Compassion and responsibility in surgical care. Nurs Ethics 2007; 4(4): 522–534. 52. Laabs C. Perceptions of moral integrity: contradictions in need of explanation. Nurs Ethics 2011; 18(3): 41–440. Numminen et al. 891 53. Kuokkanen L and Leino-Kilpi H. The qualities of an empowered nurse and the factors involved. J Nurs Manag 2001; 9: 273–280. 54. Sauerland J, Marotta K, Peinemann M, et al. Assessing and addressing moral distress and ethical climate, part 1. Dimens Crit Care Nurs 2014; 33(4): 234–245. 55. Björkström M, Johansson I and Athlin E. Is the humanistic view of the nurse role still alive—in spite of an academic education. J Adv Nurs 2006; 54(4): 502–510. 56. Heijkenskjöld K, Ekstedt M and Lindwall L. The patient’s dignity from the nurse’s perspective. Nurs Ethics 2010; 17(3): 313–324. 57. Arndt M. Nurses’ medication errors. J Adv Nurs 1994; 19: 519–526. 58. Carroll TL. Leadership skills and attributes of women and nurse executives—challenges for the 21st century. Nurs Adm Q 2005; 29(2): 146–153. 59. Baughman K, Aultman J, Ludwick R, et al. Narrative analysis of the ethics in providing advance care planning. Nurs Ethics 2014; 21(1): 53–63. 60. Wilkes L and Wallis M. A model of professional nurse caring: nursing students’ experience. J Adv Nurs 1998; 27: 582–589. 61. Weiskopf C. Nurses’ experience of caring for inmate patients. J Adv Nurs 2005; 49(4): 336–343. 62. Rogers B. Concepts, analysis, and the development of nursing knowledge: the evolutionary cycle. J Adv Nurs 1989; 14(4): 330–335. 63. Lützén K, Dahlqvist V, Eriksson S, et al. Developing the concept of moral sensitivity in health care practice. Nurs Ethics 2006; 13(2): 187–196. 64. Weaver K, Morse J and Mitcham C. Ethical sensitivity in professional Practice: concept analysis. J Adv Nurs 2008; 62(5): 607–618. 65. Dahl B, Clancy A and Andrews T. The meaning of ethically charged encounters and their possible influence on professional identity in Norwegian public health nursing: a phenomenological hermeneutic study. Scand J Caring Sci 2014; 8: 600–608. 66. Sekerka L and Bagozzi R. Moral courage in the workplace: moving to and from the desire and decision to act. Bus Ethics Eur Rev 2007; 16(2): 32–149. 67. Kidder R. Moral courage. New York: HarperCollins Publishers, 2006. 68. Mosby medical dictionary. 8th ed. St. Louis, MO: Elsevier, 2009. 69. Kulju K, Stolt M, Leino-Kilpi H, et al. Ethical competence: a concept analysis. Nurs Ethics. Epub ahead of print 9 February 2015. DOI: 10.1177/0969733014567025. Moral Courage | Ethics | Law – Case Study: Change is ever prevalent in healthcare. The way we do our work seems to be in a constant state of reform, especially with the rapid pace of technological advancements. Your nurse manager is very pleased, though, that you have a proposed quality improvement idea. The manager recommends that you seek feedback from your peers. When you discuss the proposed quality improvement project to staff during shift huddle, you overhear some grumblings and negative comments. One specific colleague confronted you after the huddle, stating, “Why do you have to suggest this change during such a chaotic time, especially when we are so short-staffed and exhausted?” You offer some evidence-based reasons on why the change is essential, but the colleague walks away. Throughout the remainder of the shift, you ponder the conversation that you had with your colleague. You feel that morale is very low, not just with one colleague. Still, several healthcare team members verbalize stress related to high patient acuity, increasing census, and inadequate staffing. The next day, the nurse manager asks you, “How did it go when you introduced your quality improvement idea during shift huddle?” You reply, “I am not sure,” then you discuss some of your concerns about staff morale, their seeming unwillingness to change, and even the frustration they express. The nurse manager then replies, “What would you like to do about all that?” You leave the meeting wondering, “What can I do?” A week later, you stay an extra hour after your shift to collect baseline data for your proposed quality improvement project. The data collection requires reviewing the EHR and auditing relevant information in the patient’s chart, specifically nursing assessment, re-assessments, and annotated nursing note documentation during the previous month. You notice as you do the chart audits that several assessments are incomplete. After reviewing only 20 charts, you realize fall risk assessment was missing in eight (8) of the twenty (20) charts, or in other words, 40% of the fall risk assessments were incomplete. Your goal is to review fifty (50) charts, but you begin to wonder how many charts are missing information about fall risk. As you review the following chart, you realize the nurse responsible for the patient’s care on day 3 of the hospital stay copied and pasted the assessment information in the EHR from the previous day documented by another nurse. Copying and pasting assessment information alarms you because you recently heard about an event that happened at another healthcare facility where a patient had mental status changes and a sentinel event occurred. The patient sustained a fall that resulted in severe head trauma and, unfortunately, a fatal outcome. Leadership at the facility conducted a root cause analysis that revealed deficiencies in nursing assessment and documentation. Specifically, a nursing assessment from the previous day was copied and pasted by a nurse who administration re-assigned to the unit due to staff call-in. The patient had mental status changes and fall risk, yet the nurse did not adequately document assessment. Furthermore, there were no nursing notes that communicated the difference in patient status | condition. Copying and pasting nursing documentation – especially that of another nurse – puts patients, the nursing unit, and the healthcare organization at risk. Acknowledging the risk, you look closer at the current chart you are reviewing to identify the nurse who copied and pasted the information. You feel like you should talk to the nurse and share what happened at the other healthcare facility. When you see the nurse’s name who copied and pasted the information, you get a sick feeling in your stomach – the nurse is the same nurse who confronted you after you presented your quality improvement idea in the shift huddle. Your nurse manager’s question rings in your mind – “What do you want to do about all that?” How do you respond? Consider the following to guide your response: • • • • • • • • • • Identify the competing issues and priorities Explain the ethical dilemma(s) that you feel are inherent in the situation. What are legal issues at stake, and why? Differentiate the pros and cons of “speaking up” and “taking the lead” – especially among your peers. Defend your responsibility as a nurse leader to promote a culture of safety Clarify the ethical principles nurse leaders must uphold As a morally courageous nurse leader, describe actionable steps that you would take to intervene in the situation. (Be specific) Realizing resistance to change is a possibility, even peer to peer, explain how you will address the barrier of resistance Recommend communication skills to help address problematic behaviors How can you, as a nurse leader, create and optimize a motivating climate for change? A complimentary publication of The Joint Commission Issue 57, March 1, 2017 Published for Joint Commission-accredited organizations and interested health care professionals, Sentinel Event Alert identifies specific types of sentinel and adverse events and high risk conditions, describes their common underlying causes, and recommends steps to reduce risk and prevent future occurrences. Accredited organizations should consider information in a Sentinel Event Alert when designing or redesigning processes and consider implementing relevant suggestions contained in the alert or reasonable alternatives. Please route this issue to appropriate staff within your organization. Sentinel Event Alert may be reproduced if credited to The Joint Commission. To receive by email, or to view past issues, visit www.jointcommission.org. ________________________ The essential role of leadership in developing a safety culture In any health care organization, leadership’s first priority is to be accountable for effective care while protecting the safety of patients, employees, and visitors. Competent and thoughtful leaders* contribute to improvements in safety and organizational culture.1,2 They understand that systemic flaws exist and each step in a care process has the potential for failure simply because humans make mistakes.3-5 James Reason compared these flaws – latent hazards and weaknesses – to holes in Swiss cheese. These latent hazards and weaknesses must be identified and solutions found to prevent errors from reaching the patient and causing harm.6 Examples of latent hazards and weaknesses include poor design, lack of supervision, and manufacturing or maintenance defects. The Joint Commission’s Sentinel Event Database reveals that leadership’s failure to create an effective safety culture is a contributing factor to many types of adverse events – from wrong site surgery to delays in treatment.7 In addition, through the results of its safety initiatives, The Joint Commission Center for Transforming Healthcare has found inadequate safety culture to be a significant contributing factor to adverse outcomes. Inadequate leadership can contribute to adverse events in various ways, including but not limited to these examples:  Insufficient support of patient safety event reporting8  Lack of feedback or response to staff and others who report safety vulnerabilities8  Allowing intimidation of staff who report events9  Refusing to consistently prioritize and implement safety recommendations  Not addressing staff burnout10,11 In essence, a leader who is committed to prioritizing and making patient safety visible through every day actions is a critical part of creating a true culture of safety.12 Leaders must commit to creating and maintaining a culture of safety; this commitment is just as critical as the time and resources devoted to revenue and financial stability, system integration, and productivity. Maintaining a safety culture requires leaders to consistently and visibly support and promote everyday safety measures.13 Culture is a product of what is done on a consistent daily basis. Hospital team members measure an organization’s commitment to culture by what leaders do, rather than what they say should be done. * The Joint Commission accreditation manual glossary defines a leader as: “an individual who sets expectations, develops plans, and implements procedures to assess and improve the quality of the organization’s governance, management, and clinical and support functions and processes. At a minimum, leaders include members of the governing body and medical staff, the chief executive officer and other senior managers, the nurse executive, clinical leaders, and staff members in leadership positions within the organization.” www.jointcommission.org © The Joint Commission Published by the Department of Corporate Communications Sentinel Event Alert, Issue 57 Page 2 The Joint Commission introduced safety culture concepts in 2008 with the publication of a Sentinel Event Alert on behaviors that undermine a culture of safety.14 Further emphasis was made the following year with a Sentinel Event Alert on leadership committed to safety (this Alert replaces and updates that one), and the establishment of a leadership standard requiring leaders to create and maintain a culture of safety. The Patient Safety Systems (PS) chapter of The Joint Commission’s Comprehensive Accreditation Manual for Hospitals emphasizes the importance of safety culture. As of Jan. 1, 2017, the chapter expanded to critical access hospitals, and to ambulatory care and office-based surgery settings. Safety culture foundation Safety culture is the sum of what an organization is and does in the pursuit of safety.15 The PS chapter defines safety culture as the product of individual and group beliefs, values, attitudes, perceptions, competencies, and patterns of behavior that determine the organization’s commitment to quality and patient safety. Organizations that have a robust safety culture are characterized by communications founded on mutual trust, by shared perceptions of the importance of safety, and by confidence in the efficacy of preventive measures.16 The safety culture concept originated in the nuclear energy and aviation industries, which are known for their use of strategies and methodologies designed to consistently and systematically mitigate risk, thereby avoiding accidents.17,18 The Institute of Nuclear Power Operations defined safety culture characteristics19 that are adaptable to the health care environment: 1. Leaders demonstrate commitment to safety in their decisions and behaviors. 2. Decisions that support or affect safety are systematic, rigorous and thorough. 3. Trust and respect permeate the organization. 4. Opportunities to learn about ways to ensure safety are sought out and implemented. 5. Issues potentially impacting safety are promptly identified, fully evaluated, and promptly addressed and corrected commensurate with their significance. 6. A safety-conscious work environment is maintained where personnel feel free to raise safety concerns without intimidation, www.jointcommission.org harassment, discrimination, or fear of retaliation. 7. The process of planning and controlling work activities is implemented so that safety is maintained. Leaders can build safety cultures by readily and willingly participating with care team members in initiatives designed to develop and emulate safety culture characteristics.13 Effective leaders who deliberately engage in strategies and tactics to strengthen their organization’s safety culture see safety issues as problems with organizational systems, not their employees, and see adverse events and close calls (“near misses”) as providing “information-rich” data for learning and systems improvement.3-5 Individuals within the organization respect and are wary of operational hazards, have a collective mindfulness that people and equipment will sometimes fail, defer to expertise rather than hierarchy in decision making, and develop defenses and contingency plans to cope with failures. These concepts stem from the extensive research of James Reason on the psychology of human error. Among Reason’s description of the main elements of a safety culture20 are:    Just culture – people are encouraged, even rewarded, for providing essential safety-related information, but clear lines are drawn between human error and atrisk or reckless behaviors. Reporting culture – people report their errors and near-misses. Learning culture – the willingness and the competence to draw the right conclusions from safety information systems, and the will to implement major reforms when their need is indicated. In an organization with a strong safety culture, individuals within the organization treat each other and their patients with dignity and respect. The organization is characterized by staff who are productive, engaged, learning, and collaborative.19 Having care team members who gain joy and meaning through their work has been found to have an important role in establishing and maintaining a safe culture. The Lucien Leape Institute’s Joy & Meaning in Workforce Safety initiative addresses clinician burnout, which is at record highs.11,21 Clinician burnout is associated with lower perceptions of patient safety culture and may directly or indirectly affect patient outcomes.22 © The Joint Commission Sentinel Event Alert, Issue 57 Page 3 Joy and meaning will be created when the workforce feels valued, safe from harm, and part of the solutions for change. When team members know that their well-being is a priority, they are able to be meaningfully engaged in their work, to be more satisfied, less likely to experience burnout, and to deliver more effective and safer care.11,21 Leaders who encourage transparency in response to reports of adverse events, close calls and unsafe conditions, and who have established processes that ensure follow-up to ensure reports are not lost or ignored (or perceived to be lost or ignored), help mitigate intimidating behaviors because transparency of action itself discourages such behavior. On the opposite end of the spectrum, intimidating and unsettling behaviors causing emotional harm, including the use of inappropriate words and actions or inactions, has a detrimental impact on patient safety10 and should not occur in a safety culture. This includes terminating, punishing or failing to support a health care team member who makes an error (the “second victim”). Unfortunately, as attention to the need for a culture of safety in hospitals has increased, “so have concomitant reports of retaliation and intimidation targeting care team members who voice concern about safety and quality deficiencies,” according to a National Association for Healthcare Quality report.9 Intimidation has included overtly hostile actions, as well as subtle or passive-aggressive behaviors, such as failing to return phone calls or excluding individuals from team activities. Survey results released by the Institute for Safe Medication Practices (ISMP) show that disrespectful behavior remains a problem in the health care workplace. Most respondents reported experiences with negative comments about colleagues, reluctance or refusal to answer questions or return calls, condescending language or demeaning comments, impatience with questions or hanging up the phone, and a reluctance to follow safety practices or work collaboratively.23 Actions suggested by The Joint Commission The Joint Commission recommends that leaders take actions to establish and continuously improve the five components of a safety culture defined by Chassin and Loeb: trust, accountability, identifying unsafe conditions, strengthening systems, and assessment.18 These actions are not intended to be implemented in a sequential manner. Leaders will need to address and apply various components to the workforce www.jointcommission.org simultaneously, using tactics such as board engagement, leadership education, goalsetting, staff support, and dashboards and reports that routinely review safety data.12 1. Absolutely crucial is a transparent, nonpunitive approach to reporting and learning from adverse events, close calls and unsafe conditions,16,24 states the Patient Safety Systems (PS) chapter of The Joint Commission’s Comprehensive Accreditation Manual for Hospitals. Develop trust and accountability through an organizational-wide and easy-to-use reporting system. This reporting system should be accessible to everyone within the organization. Having this system is essential for developing a culture in which unsafe conditions are identified and reported without fear of punishment or reprisal for unintentional mistakes, leading to proactive prevention of patient harm.14,18,25,26 Leaders can augment voluntary reporting by using other methods, such as trigger tools and observational techniques, to proactively address risk and identify potential errors.27 2. Establish clear, just, and transparent riskbased processes for recognizing and separating human error and error arising from poorly designed systems from unsafe or reckless actions that are blameworthy.18 Mistakes, lapses, omissions and other human errors are opportunities for improvement and lessons learned from them should be shared. Punishing, terminating or failing to support an employee who makes a mistake during the course of an adverse event can erode leadership’s credibility and undermine organizational safety culture.28 The Incident Decision Tree, from the United Kingdom’s National Patient Safety Agency, is one example that supports the aim of creating an open, fair and accountable culture, where employees feel able to report patient safety incidents without undue fear of the consequences, and health care organizations know where to draw the accountability line. 3. To advance trust within the organization, CEOs and all leaders must adopt and model appropriate behaviors and champion efforts to eradicate intimidating behaviors.18,25,26 These behaviors include demonstrating respect in all interactions, personally participating in activities and programs aimed at improving safety culture, and by making sure safety-related feedback from staff is acknowledged and, if appropriate, © The Joint Commission Sentinel Event Alert, Issue 57 Page 4 implemented. Leadership must maintain a fair and equitable measure of accountability to all. 4. Establish, enforce and communicate to all team members the policies that support safety culture and the reporting of adverse events, close calls and unsafe conditions.19 5. Recognize care team members who report adverse events and close calls, who identify unsafe conditions, or who have good suggestions for safety improvements. Leaders can recognize “good catches” – in which adverse events are avoided – and share these “free lessons” with all team members (i.e., feedback loop).29 The Joint Commission Center for Transforming Healthcare’s Safety Culture project found that two effective ways of reporting back to team members who raised safety issues were through 1) shift and unit huddles, and 2) visual management boards. They found that care team members stopped making suggestions when they received no feedback from team or hospital leaders. and implement unit-based quality and safety improvement initiatives designed to improve the culture of safety.33,39-40,42-46 Examples from Joint Commission-accredited organizations include:  An obstetrics service line created a multidisciplinary code of professionalism as a mechanism to address unprofessional behavior. Physicians, nurses, and support staff underwent education that addressed why and how to report unprofessional behavior. Leadership followed up on all reports concerning unprofessional behavior with coaching. As a result of the education, reporting and coaching, statistically significant improvement was shown on the following AHRQ Hospital Survey on Patient Safety Culture dimensions: teamwork within units, management support, organizational learning, and frequency of events reported.47  The Rhode Island Intensive Care Unit (ICU) Collaborative conducted a study to examine the impact of a Safety Attitudes Questionnaire Action Plan (SAQAP) on ICU central-line associated blood stream infections (CLABSIs) and ventilatorassociated pneumonia (VAP) rates. Teams that developed SAQAPs improved their unit culture and clinical outcomes. Units that developed SAQAPs demonstrated higher improvement rates in all domains of the SAQ, except working conditions. Improvements were close to statistical significance for teamwork climate (+18.4 percent in SAQAP units versus -6.4 percent in other units, p = .07) and job satisfaction (+25.9 percent increase in SAQAP units versus +7.3 percent, p = .07). Units with SAQAPs decreased the CLABSI rates by 10.2 percent in 2008 compared with 2007, while those without SAQAP had a 2.2 percent decrease in rates (p = .59). Similarly, VAP rates decreased by 15.2 percent in SAQAP units, while VAP rates increased by 4.8 percent in units without SAQAP (p = .39).48  An academic medical center developed a comprehensive unit-based safety program that included steps to identify hazards, partnered units with a senior executive to fix hazards, learned from defects, and implemented communication and teamwork tools. In 2006, 55 percent of units achieved the SAQ-measured safety climate goal of meeting or exceeding a 60 percent positive Also useful toward recognizing safety initiatives and promoting safety culture are activities involving leaders, such as team safety briefings and planning sessions,17,30 huddles31,32 about safety threats or issues, debriefs to learn from identified errors or safety defects,30,33 and safety rounds or walkarounds.34-36 6. Establish an organizational baseline measure on safety culture performance using the Agency for Healthcare Research and Quality (AHRQ) Hospital Survey on Patient Safety Culture (HSOPS) or another tool, such as the Safety Attitudes Questionnaire (SAQ).3739 A summary of these tools can be found in the Resources section of this alert. 7. Analyze safety culture survey results from across the organization to find opportunities for quality and safety improvement.33,39-40 Analyzing data in this manner enables an organization to find improvement opportunities and solutions in line with organizational priorities and needs. This analysis must drill down to local unit levels so that unit-specific solutions can be developed and implemented.41 Share the results with frontline staff throughout the organization and with governing bodies, including the board. 8. In response to information gained from safety assessments and/or surveys, develop www.jointcommission.org © The Joint Commission Sentinel Event Alert, Issue 57 Page 5 score or improving the score by 10 or more percentage points. In 2008, 82 percent of units achieved the goal. For teamwork climate, the two-year improvement was 61 to 83 percent. Scores improved in every SAQ domain except stress recognition.39 10. Proactively assess system (such as medication management and electronic health records) strengths and vulnerabilities and prioritize them for enhancement or improvement.18,58 Many other examples of successful and measurable safety culture initiatives can be found in health care literature. Some of these initiatives39,49 successfully used tactics such as walkarounds,34-36 huddles,31,32 employee engagement,50,51 team safety briefings and planning sessions,17,30 debriefs to learn from identified errors or safety defects,30,33 and safety ambassadors52 to improve various aspects of safety culture. Improvement on safety culture measures is associated with positive outcomes, such as reduced infection rates,38,53 fewer readmissions,38,53 decreased care team member turnover,39 better surgical outcomes,54 reduced adverse events,55,56 and decreased mortality.55 Health care organizations in which care team members have positive perceptions of safety culture tend to have positive assessments of care from patients as well.57 11. Repeat organizational assessment of safety culture every 18 to 24 months to review progress and sustain improvement.38 Ensure that the assessment drills down to unit levels,41 and make these assessments part of strategic measures reported to the board.18 9. Embed safety culture team training into quality improvement projects33,39-40,49 and organizational processes to strengthen safety systems.17,18,30 Team training derived from evidence-based frameworks can be used to enhance the performance of teams in high-stress, high-risk areas of the organization – such as operating rooms, ICUs and emergency departments – and has been implemented at many health care facilities across the country.17,30 Safety Culture Key to High Reliability The Joint Commission established a theoretical framework that emphasizes safety culture, leadership and robust process improvement as three domains that are critical to high reliability within a health care organization.18 By promoting the core attributes of trust, report and improve,15 highreliability organizations create safety cultures in which team members trust peers and leadership; report vulnerabilities and hazards that require riskbased consideration; and communicate the benefits of these improvements back to involved staff. Leaders can self-assess performance and improvements relating to high reliability by using the Oro™ 2.0 High Reliability Organizational Assessment and Resources Tool. See this alert’s Resources section for more information. www.jointcommission.org Related Joint Commission requirements Many Joint Commission standards address issues related to the design and management of patient safety systems. These requirements and elements of performance, which include the following, can be found in the Patient Safety Systems (PS) chapter of The Joint Commission’s accreditation manuals for hospitals and critical access hospitals, and for ambulatory care and officebased surgery settings: LD.03.01.01: Leaders create and maintain a culture of safety and quality throughout the organization. EP 1. Leaders regularly evaluate the culture of safety and quality using valid and reliable tools. EP 4. Leaders develop a code of conduct that defines acceptable behavior and behaviors that undermine a culture of safety. EP 5. Leaders create and implement a process for managing behaviors that undermine a culture of safety. Resources Hospital Survey on Patient Safety Culture (HSOPS) – Identifies 12 dimensions of safety culture (10 climate dimensions and two outcomes variables):53  Communication openness  Feedback and communication about error  Frequency of events reported  Handoffs and transitions  Management support for patient safety  Non-punitive response to error  Organizational learning (continuous improvement)  Overall perceptions of safety  Staffing  Supervisor/manager expectations and actions promoting safety © The Joint Commission Sentinel Event Alert, Issue 57 Page 6   Teamwork across units Teamwork within units United Kingdom’s National Patient Safety Agency’s Incident Decision Tree – Supports the aim of creating an open culture, where employees feel able to report patient safety incidents without undue fear of the consequences. The approach does not seek to diminish health care professionals’ individual accountability, but encourages key decision makers to consider systems and organizational issues in the management of error.28 Institute for Healthcare Improvement’s Joy in Work initiative – Addresses clinician burnout. The Joint Commission Center for Transforming Healthcare’s Oro™ 2.0 High Reliability Organizational Assessment and Resources application – High reliability organizations routinely self-assess. This self-assessment tool is intended for hospital leadership teams. It can be used in combination with tools (such as HSOPS and SAQ) that measure the perceptions of staff at all levels of the organization. The tool evaluates:  Leadership commitment  Safety culture  Performance improvement Patient Safety Systems (PS) chapter of The Joint Commission’s Comprehensive Accreditation Manual for Hospitals (as of Jan. 1, 2017, also applicable to critical access hospitals, and to ambulatory care and office-based surgery settings) Safety Attitudes Questionnaire (SAQ) – Measures six culture domains:  Teamwork climate  Safety climate  Perceptions of management  Job satisfaction  Working conditions  Stress recognition Safety Culture Project, The Joint Commission Center for Transforming Healthcare – Seven participating organizations focused on identifying unsafe conditions before they reached the patient and finding reliable, sustainable solutions. The organizations found that reporting back to team members about how their suggestions improved care increased team member satisfaction, particularly if the feedback included praise, either public or private as appropriate, for those who www.jointcommission.org spoke up.29 The project utilized The Joint Commission’s Robust Process Improvement® (RPI®), a blended approach to improve business and clinical processes and outcomes using Lean, Six Sigma and change management methodologies. RPI is intended for all staff, including leaders. Strategies for Creating, Sustaining, and Improving a Culture of Safety in Health Care – Published by Joint Commission Resources, this second edition book expands the idea of “building” a culture of safety by spotlighting the best articles related to this topic from The Joint Commission Journal on Quality and Patient Safety. These articles provide unique perspectives of challenges inherent when establishing and maintaining a culture of safety. References 1. Schein EH. Organizational Culture and Leadership, 4th ed. 2010. 2. Institute of Medicine (U.S.) Committee on the Work Environment for Nurses and Patient Safety. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: National Academies Press (U.S.). 2004. 4, Transformational Leadership and Evidence-Based Management. Available from: https://www.ncbi.nlm.nih.gov/books/NBK216194/ (accessed Oct. 12, 2016). 3. Clarke JR, et al. The role for leaders of health care organizations in patient safety. American Journal of Medical Quality. Sept./Oct. 2007:22(5):311-318. 4. Parand A, et al. The role of chief executive officers in a quality improvement initiative: a qualitative study. BMJ Open. 2013;3:e001731. 5. Causal Factors Analysis: An Approach for Organizational Learning. B&W/Pantex. 2008. 6. Agency for Healthcare Research and Quality. Patient Safety Network (PSNet) Systems Approach webpage. Last updated March 2015 (accessed Dec. 8, 2016). 7. Smetzer J, et al. Shaping systems for better behavioral choices: lessons learned from a fatal medication error. Joint Commission Journal on Quality and Patient Safety. 2010;36:152-163. 8. Sorra J, et al. Hospital Survey on Patient Safety Culture 2014 User Comparative Database Report. (Prepared by Westat, Rockville, MD, under Contract No. HHSA 290201300003C). Rockville, MD: Agency for Healthcare Research and Quality. AHRQ Publication No. 14-0019-EF. March 2014. 9. National Association for Healthcare Quality. Call to action: Safeguarding the integrity of healthcare quality and safety systems. October 2012. 10. Stewart K, et al. Unprofessional behavior and patient safety. The International Journal of Clinical Leadership. 2011;17:93-101. 11. Institute for Healthcare Improvement. Joy in Work (accessed June 2, 2016). 12. National Patient Safety Foundation. Free From Harm: Accelerating patient safety improvement 15 years after To Err Is Human. 2015 (accessed Dec. 8, 2016). © The Joint Commission Sentinel Event Alert, Issue 57 Page 7 13. Leonard M and Frankel A. How can leaders influence a safety culture? The Health Foundation Thought Paper. May 2012. 14. The Joint Commission. Sentinel Event Alert, Issue 40: Behaviors that undermine a culture of safety. July 9, 2008 (accessed Oct. 28, 2016). 15. Reason J and Hobbs A. Managing Maintenance Error: A Practical Guide. Ashgate. 2003. 16. The Joint Commission. Comprehensive Accreditation Manual for Hospitals: The Patient Safety Systems Chapter, Update 2. January 2015. 17. Health Research and Educational Trust. Improving Patient Safety Culture through Teamwork and Communication: TeamSTEPPS®. Chicago, Illinois. Health Research and Educational Trust. 2015, June (accessed Sept. 23, 2016). 18. Chassin MR and Loeb JM. High-reliability health care: getting there from here. The Milbank Quarterly. 2013;91(3):459–490. 19. Institute of Nuclear Power Operators. Traits of a Healthy Nuclear Safety Culture. Revision 1, 2013. 20. Adapted from Reason J. Managing the Risks of Organizational Accidents. Ashgate.1997. 21. Lucian Leape Institute. Through the Eyes of the Workforce: Creating Joy, Meaning, and Safer Health Care. Boston, Massachusetts: National Patient Safety Foundation. 2013. 22. Profit J, et al. Burnout in the NICU setting and its relation to safety culture. BMJ Quality & Safety. 2014;23:806–813. 23. Institute for Safe Medication Practices. Intimidation still a problem in hospital workplace, survey shows. News release dated Oct. 3, 2013 (accessed Sept. 23, 2016). 24. National Patient Safety Foundation’s Lucien Leape Institute. Shining a light: Safer health care through transparency. Boston, MA: National Patient Safety Foundation; 2015. 25. Blouin AS and McDonagh KJ. Framework for patient safety, Part 1: Culture as an imperative. The Journal of Nursing Administration. Oct. 2011;41(10). 26. Blouin AS and McDonagh KJ. Framework for patient safety, Part 2: Resilience, the next frontier. The Journal of Nursing Administration. Oct. 2011;41(10). 27. Institute for Healthcare Improvement. Introduction to trigger tools for identifying adverse events. (Accessed Dec. 8, 2016). 28. Meadows S, et al. The incident decision tree: guidelines for action following patient safety incidents. Advances in Patient Safety. 4:387-399 29. Reason JT. The Human Contribution: Unsafe Acts, Accidents and Heroic Recoveries. Ashgate Publishing Limited. Surrey, England. 2008; page 35. 30. Thomas L and Galla C. Building a culture of safety through team training and engagement. BMJ Quality and Safety. 2013;22:425-434. 31. Criscitelli T. Fostering a culture of safety: the OR huddle. AORN Journal. Dec. 2015;102(6):656-659. 32. Sikka R, et al. How every hospital should start the day. Harvard Business Review. Dec. 5, 2014. 33. Muething SE, et al. Quality improvement initiative to reduce serious safety events and improve patient safety culture. Pediatrics. August 2012;130(2):e423e431. www.jointcommission.org 34. Singer SJ and Tucker AL. The evolving literature on safety WalkRounds: emerging themes and practical messages. BMJ Quality and Safety. 2014;23:789– 800. 35. Rotteau L, et al. ‘I think we should just listen and get out’: a qualitative exploration of views and experiences of patient safety walkrounds. BMJ Quality and Safety. 2014;23:823–829. 36. Sexton JB, et al. Exposure to Leadership WalkRounds in neonatal intensive care units is associated with a better patient safety culture and less caregiver burnout. BMJ Quality & Safety. 2014;23:814–822. 37. Safety culture proven to improve quality, must be monitored and measured. Hospital Peer Review, May 2016;41(5):49-60. 38. Hospital culture must be measured, not just improved. Case Management Advisor, April 2016; p. 46. 39. Paine LA, et al. Assessing and improving safety culture throughout an academic medical centre: a prospective cohort study. Quality and Safety in Health Care. 2010;19:547-554. 40. Burström L, et al. The patient safety culture as perceived by staff at two different emergency departments before and after introducing a floworiented working model with team triage and lean principles: a repeated cross-sectional study. BMC Health Services Research. 2014;14:296. 41. Campbell EG, et al. Patient safety climate in hospitals: Act locally on variation across units. The Joint Commission Journal on Quality and Patient Safety. July 2010:36(7):319-326. 42. Leape L, et al. A culture of respect, part 2: Creating a culture of respect. Academic Medicine. 2012 July;87(7):853-858. 43. Wu A, ed. The Value of Close Calls in Improving Patient Safety: Learning How to Avoid and Mitigate Patient Harm. Oak Brook, IL. Joint Commission Resources. 2011. 44. Agency for Healthcare Research and Quality. Becoming a High Reliability Organization: Operational Advice for Hospital Leaders. Rockville, MD: AHRQ. 2008. 45. Fei K and Vlasses FR. Creating a safety culture through the application of reliability science. Journal of Healthcare Quality. 2008 Nov.-Dec.;30(6):37-43. 46. Massachusetts Coalition of the Prevention of Medical Errors: When Things Go Wrong: Responding to Adverse Events. March 2006 (accessed May 31, 2016). 47. DuPree E, et al. Professionalism: a necessary ingredient in a culture of safety. The Joint Commission Journal on Quality and Patient Safety. Oct. 2011;37(10):447-455. 48. Vigorito MC, et al. Improving safety culture results in Rhode Island ICUs: lessons learned from the development of action-oriented plans. Joint Commission Journal of Quality and Patient Safety. Nov. 2011;37(11):509-14 (accessed Oct. 27, 2016). 49. Jones KJ, et al. A theory-driven, longitudinal evaluation of the impact of team training on safety culture in 24 hospitals. Quality and Safety in Health Care. 2013;22:394–404. 50. Collier SL, et al. Employee engagement and a culture of safety in the intensive care unit. Journal of Nursing Administration. Jan. 2016;46(1):49-54. © The Joint Commission Sentinel Event Alert, Issue 57 Page 8 51. Daugherty Biddison EL, et al. Associations between safety culture and employee engagement over time: a retrospective analysis. BMJ Quality & Safety. 015;0:1– 7. 52. Pressman BD and Roy LT. Developing a culture of safety in an imaging department. Case Studies in Clinical Practice Management. 2015. American College of Radiology. http://dx.doi.org/10.1016/j.jacr.2014.07.010 53. Fan CJ, et al. Association of safety culture with surgical site infection outcomes. Journal of the American College of Surgeons. 2016;222:122-128. 54. Sacks GD, et al. Teamwork, communication and safety climate: a systematic review of interventions to improve surgical culture. BMJ Quality & Safety. 2015;0:1-10. 55. Berry JC, et al. Improved safety culture and teamwork climate are associated with decreases in patient harm and hospital mortality across a hospital system. Journal of Patient Safety. 2016. www.jointcommission.org 56. Birk S. Accelerating the adoption of a safety culture. Healthcare Executive. March/April 2015:19-26. 57. Sorra J, et al. Exploring relationships between patient safety culture and patients’ assessments of hospital care. Journal of Patient Safety. 2012;8:131-139. 58. Braithwaite J, et al. Resilient health care: turning patient safety on its head. International Journal for Quality in Health Care. Oct. 2015;27(5):418-20. ________________________________________________ Patient Safety Advisory Group The Patient Safety Advisory Group informs The Joint Commission on patient safety issues and, with other sources, advises on topics and content for Sentinel Event Alert. © The Joint Commission

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Title: MU Moral Courage Ethical and Law in Nursing Paper

Grading Rubric

Performance Category	100% or highest level of performance 100% 16 points	Very good or high level of performance 88% 14 points	Acceptable level of performance 81% 13 points	Inadequate demonstration of expectations 68% 11 points	Deficient level of performance 56% 9 points	Failing level of performance 55% or less 0 points
Total Points Possible= 50	16 Points	14 Points	13 Points	11 Points	9 Points	0 Points
Scholarliness Demonstrates achievement of scholarly inquiry for professional and academic topics.	Presentation of information was exceptional and included all of the following elements: Provides evidence of scholarly inquiry relevant to required TD topic(s). Presents specific information from scholarly sources to develop a comprehensive presentation of facts. Uses at least one outside scholarly reference that is relevant, less than 5 years old (use of older references requires instructor permission) and reliable for the required topic.* Uses in-text citation and full reference at end of posting when presenting another person’s thoughts as quotes or paraphrase of information.	Presentation of information was good, but was superficial in places and included all of the following elements: Provides evidence of scholarly inquiry relevant to required TD topic(s). Presents specific information from scholarly sources to develop a comprehensive presentation of facts. Uses at least one outside scholarly reference that is relevant, less than 5 years old (use of older references requires instructor permission) and reliable for the required topic.* Uses in-text citation and full reference at end of posting when presenting another person’s thoughts as quotes or paraphrase of information.	Presentation of information was minimally demonstrated in all of the following elements: Provides evidence of scholarly inquiry relevant to required TD topic(s). Presents specific information from scholarly sources to develop a comprehensive presentation of facts. Uses at least one outside scholarly reference that is relevant, less than 5 years old (use of older references requires instructor permission) and reliable for the required topic.* Uses in-text citation and full reference at end of posting when presenting another person’s thoughts as quotes or paraphrase of information.	Presentation of information is unsatisfactory in one of the following elements: Provides evidence of scholarly inquiry relevant to required TD topic(s). Presents specific information from scholarly sources to develop a comprehensive presentation of facts. Uses at least one outside scholarly reference that is relevant, less than 5 years old (use of older references requires instructor permission) and reliable for the required topic.* Uses in-text citation and full reference at end of posting when presenting another person’s thoughts as quotes or paraphrase of information.	Presentation of information is unsatisfactory in two of the following elements: Provides evidence of scholarly inquiry relevant to required TD topic(s). Presents specific information from scholarly sources to develop a comprehensive presentation of facts. Uses at least one outside scholarly reference that is relevant, less than 5 years old (use of older references requires instructor permission) and reliable for the required topic.* Uses in-text citation and full reference at end of posting when presenting another person’s thoughts as quotes or paraphrase of information.	Presentation of information is unsatisfactory in three or more of the following elements Provides evidence of scholarly inquiry relevant to required TD topic(s). Presents specific information from scholarly sources to develop a comprehensive presentation of facts. Uses at least one outside scholarly reference that is relevant, less than 5 years old (use of older references requires instructor permission) and reliable for the required topic.* Uses in-text citation and full reference at end of posting when presenting another person’s thoughts as quotes or paraphrase of information
	16 Points	14 Points	13 Points	11 Points	9 Points	0 Points
Application of Course Knowledge Demonstrate the ability to analyze and apply principles, knowledge and information learned in the outside readings and relate them to real-life professional situations	Presentation of information was exceptional and included all of the following elements: Applies principles, knowledge and information from scholarly resources to the required topic. Applies facts, principles or concepts learned from scholarly resources to a professional experience. Application of information is comprehensive and specific to the required topic.	Presentation of information was good, but was superficial in places and included all of the following elements: Applies principles, knowledge and information from scholarly resources to the required topic. Applies facts, principles or concepts learned from scholarly resources to a professional experience. Application of information is comprehensive and specific to the required topic.	Presentation of information was minimally demonstrated in the all of the following elements: Applies principles, knowledge and information from scholarly resources to the required topic. Applies facts, principles or concepts learned from scholarly resources to a professional experience. Application of information is comprehensive and specific to the required topic.	Presentation of information is unsatisfactory in one of the following elements: Applies principles, knowledge and information from scholarly resources to the required topic. Applies facts, principles or concepts learned from and scholarly resources to a professional experience. Application of information is comprehensive and specific to the required topic.	Presentation of information is unsatisfactory in two of the following elements: Applies principles, knowledge and information from scholarly resources to the required topic. Applies facts, principles or concepts learned from scholarly resources to a professional experience. Application of information is comprehensive and specific to the required topic.	Presentation of information is unsatisfactory in three of the following elements Applies principles, knowledge and information and scholarly resources to the required topic. Applies facts, principles or concepts learned scholarly resources to a professional experience. Application of information is comprehensive and specific to the required topic.
	10 Points	9 Points			6 Points	0 Points
Interactive Dialogue Initial post should be a minimum of 300 words (references do not count toward word count) The peer and instructor responses must be a minimum of 150 words each (references do not count toward word count) Responses are substantive and relate to the topic.	Demonstrated all of the following: Initial post must be a minimum of 300 words. The peer and instructor responses must be a minimum of 150 words each. Responses are substantive Responses are related to the topic of discussion.	Demonstrated 3 of the following: Initial post must be a minimum of 300 words. The peer and instructor responses must be a minimum of 150 words each. Responses are substantive Responses are related to the topic of discussion.			Demonstrated 2 of the following: Initial post must be a minimum of 300 words. The peer and instructor responses must be a minimum of 150 words each. Responses are substantive Responses are related to the topic of discussion.	Demonstrated 1 or less of the following: Initial post must be a minimum of 300 words. The peer and instructor responses must be a minimum of 150 words each. Responses are substantive Responses are related to the topic of discussion.
	8 Points	7 Points	6 Points	5 Points	4 Points	0 Points
Grammar, Syntax, APA Points deducted for improper grammar, syntax and APA style of writing. The source of information is the APA Manual 6th Edition Error is defined to be a unique APA error. Same type of error is only counted as one error.	The following was present: 0-3 errors in APA format AND Responses have 0-3 grammatical, spelling or punctuation errors AND Writing style is generally clear, focused on topic,and facilitates communication.	The following was present: 4-6 errors in APA format. AND/OR Responses have 4-5 grammatical, spelling or punctuation errors AND/OR Writing style is somewhat focused on topic.	The following was present: 7-9 errors in APA format. AND/OR Responses have 6-7 grammatical, spelling or punctuation errors AND/OR Writing style is slightly focused on topic making discussion difficult to understand.	The following was present: 10- 12 errors in APA format AND/OR Responses have 8-9 grammatical, spelling and punctuation errors AND/OR Writing style is not focused on topic, making discussion difficult to understand.	The following was present: 13 – 15 errors in APA format AND/OR Responses have 8-10 grammatical, spelling or punctuation errors AND/OR Writing style is not focused on topic, making discussion difficult to understand. AND/OR The student continues to make repeated mistakes in any of the above areas after written correction by the instructor.	The following was present: 16 to greater errors in APA format. AND/OR Responses have more than 10 grammatical, spelling or punctuation errors. AND/OR Writing style does not facilitate communication
	0 Points Deducted					5 Points Lost
Participation Requirements	Demonstrated the following: Initial, peer, and faculty postings were made on 3 separate days					Failed to demonstrate the following: Initial, peer, and faculty postings were made on 3 separate days
	0 Points Lost					5 Points Lost
Due Date Requirements	Demonstrated all of the following: The initial posting to the graded threaded discussion topic is posted within the course no later than Wednesday, 11:59 pm MT. A minimum of one peer and one instructor responses are to be posted within the course no later than Sunday, 11:59 pm MT.					Demonstrates one or less of the following. The initial posting to the graded threaded discussion topic is posted within the course no later than Wednesday, 11:59 pm MT. A minimum of one peer and one instructor responses are to be posted within the course no later than Sunday, 11:59 pm MT.