Anesthesia in the News
  • Moral Courage in Healthcare: What Are We Teaching Next Gen CRNAs?

    Healthcare professionals often face complex ethical dilemmas in the workplace.  And CRNAs are not immune to these unethical behaviors.  They encounter ethical dilemmas on a regular basis.  In fact, the pandemic-exacerbated staffing inadequacies, cost containment measures, consolidation of healthcare organizations, and ineffective leadership have escalated the number of ethical dilemmas CRNAs face today.

    Some professionals confront the ethical issues head on.  Still others turn away.  The objective of moral courage development is to empowers individuals to address ethical issues when they arise and take action when doing the right thing is not easy.  However, like many other skills CRNAs possess, their acquisition is not organic.  How well is the next generation of anesthesia providers acquiring these skills and what is their perspective of how mission-critical these character and behaviors attributes are to their role as vigilant stewards of patient safety?

    The April 2022 issue of AANA Journal features a study which explored situations involving moral courage or lack of moral courage in the operating room (OR) specifically from the perspective of a select cohort of 40 SRNAs partaking in their first perioperative practice period at 5 hospitals in Norway.  All SRNAs in Norway have more than 2 years of nursing experience prior to beginning their CRNA education.  During their clinical placement, the SRNAs were asked to write down their narrative impressions of situations in the OR in which they had observed or experienced moral courage—or lack thereof.

    3-step methodology

    Prior to their exposure to these situations, all SRNAs attended lecture sessions on ethical issues and quality assurance during which the concept of moral courage was discussed.  The goal of the lectures was to prepare the SRNAs for ethical issues they might encounter.  Next, participants were asked to observe and describe a situation and the context in which moral courage or lack of moral courage was exhibited.

    Next, the SRNAs were asked to describe the verbal and non-verbal communication which had transpired among the individuals involved.  Finally, they were asked to compose a narrative at home capturing what had happened, including their own thoughts and how they had acted.  These were later discussed in class with each student contributing their views on potential alternative actions which the parties might have elected to take and why they believed the scenarios turned out as they did.

    Scenarios encountered

    The study authors employed the systematic and open-ended “critical incident technique” (CIT) to explore the SRNAs’ responses.  CIT involves analyzing specific situations to determine which communicative actions or behaviors would lead to the best possible outcome of a given situation.

    The SRNA narratives identified 18 situations which involved lack of moral courage, 20 situations in which moral courage was demonstrated, and 2 situations which included both.  All participants acknowledged that they had been made uncomfortable with what they had witnessed using expressions such as “unpleasant,” “shocking,” or “I was put out.”

    In most of these situations, as members of the team, the SRNAs themselves had been involved.  Moreover, most situations focused on the CRNAs’/supervisors’ response to other OR personnel’s actions.  Thirteen of the SRNAs underscored that the student role felt difficult and insecure as they were dependent upon the supervisor and not familiar with the others in the team, or with its dynamics, routines, or procedures.  The majority of SRNAs stated that they had had to discuss the situation with their supervisor afterwards.

    From ‘tacit acceptance’ to ‘ethical competence’

    The authors identified 2 chief themes focusing on “best possible outcome” in line with CIT:

    1) Keeping the patient safe, with the subthemes of speaking up for the patient and tacit acceptance, and

    2) Establishing a constructive work environment, with the subthemes of speaking up for colleagues and lack of collaboration.

    For the SRNAs, the optimal outcome of any situation in the OR was that the patient was safe and comfortable.  When persons involved in the situation were able to take action while showing moral courage, this encouraged patient safety.  In contrast, when moral courage was lacking, patients were potentially exposed to adverse events.  In 14 of the narratives, personnel involved in the situation tacitly accepted unethical or unprofessional behavior instead of speaking up.

    Twenty-six of the SRNAs emphasized a constructive work environment as a positive outcome and something that could be established through mutual respect and ethical behavior.  When they spoke up for colleagues or themselves, the situation turned out positively.  When nobody acted in response to unethical behavior or negative communication, this led to a “strained atmosphere” in the OR and decreased the possibility of constructive teamwork.

    Other situations described included experienced surgeons or anesthesiologists talking rudely to a less experienced colleague.  In these cases, SRNAs used terms such as “constantly yelling,” “being rude,” “being uncomfortable,” or “being self-centered.”  In only 2 such situations did the individuals subjected to this behavior stand up for themselves; otherwise, other colleagues stood up for them.

    Building ethical ‘muscle’

    Only 2 of the SRNAs reported having shown moral courage themselves.  Several studies of undergraduate nursing students have shown that most students choose to remain silent when facing unethical behavior out of a fear of potential consequences and reprisals—including being failed.  This, the study team noted, could lead to moral distress and thereby have a negative impact on students’ professional development.

    However, as in the development of a physical muscle, the authors observe approvingly that that all of the SRNAs in the study expressed having felt challenged by witnessing or feeling compelled to participate in unethical practices.  This exercise, they hypothesize, could make the SRNAs more aware of their own moral standpoint which, in turn, could increase their ethical competence.

    Setting the bar

    Healthcare organizations which acknowledge the importance of following ethical principles can create an expectation that morally courageous behavior will occur when its personnel encounter ethical dilemmas that threaten deeply held values pertinent to the work environment and when silence and inaction may jeopardize patient care.

    The authors cite Lachmann, in stating that nurses must find ways to preserve their professional integrity by demonstrating the moral courage needed to present their point of view.  Nurses who are able to confront people about incompetence, poor teamwork, and disrespect seem to observe better patient outcomes and to be more satisfied with their work.  Moreover, they are more likely to remain working in their unit or hospital.

    “Student courage,” they conclude, “has been linked to attributes like persistence, bravery, overcoming fear, and self-advocacy.  Consequently, these attributes most be cultivated in SRNAs through training to achieve a higher level of ethical competence and moral courage to meet future challenges.”

    Don’t miss the details of the thought-provoking scenarios posed to SRNAs and its examination of this essential element of vigilant patient care, “Moral Courage: Student Registered Nurse Anesthetist Experiences on the Operating Team,” at

    Drug or Alcohol Concerns?

    Call the AANA Peer Assistance Helpline