The moral courage of nursing students who complete advance directives with homeless persons

Introduction and background

In the United States, homeless persons face enormous obstacles to healthcare, ^1,2 and they have disproportionately high rates of illness, injury, and mortality. ^{3 –6} Furthermore, they tend to believe that the quality of their end-of-life (EOL) care will be poor. ⁷ In light of those findings, it is not surprising that some homeless persons show a strong interest in discussing EOL questions and engaging in advance care planning. ⁸ However, their limited access to primary care facilities suggests that they have few opportunities to complete advance directives (ADs). Additionally, efforts to assist them with ADs appear to be rare. Why might that be?

Our study began with the assumption that, for nurses and many others who are not homeless, helping a homeless person complete an AD can be accompanied by identifiable fears or other challenges. For example, it is common knowledge that, in the United States, homeless persons are deeply stigmatized and negatively stereotyped. As a result, many who are not stigmatized risk some degree of disrepute by having extended interactions with them. Because such disrepute—even if minor and temporary—is fearful and otherwise unsettling, it can form a barrier to interacting with homeless persons. Furthermore, many people are frightened by thoughts of death and scared to initiate conversations about it, especially during an initial encounter with another person. But helping a homeless person complete an AD can include precisely these experiences—added barriers to providing such assistance. So, because it can involve overcoming these fears, helping a homeless person complete an AD might require courage, we assumed. But not simply courage; it can demand specifically moral courage, we hypothesized. Before explaining that contention, let us survey how various scholars have spoken of “moral courage.”

In both philosophical literature and recent nursing research, “courage” has been understood in a variety of ways. Philosophers recognize that “courage” is a broad concept that denotes the surmounting of fear, but they often use the term in a specific, moral sense. They speak of “moral courage” as a component of virtuous character, for example, or as a property of certain actions that renders those behaviors morally good or right. ⁹ Taking their cue from these ways of articulating the concept, nursing researchers have studied the roles of moral courage in nurses’ character and practices. Treating moral courage as a virtue, Spence and Smythe, ¹⁰ for example, link it to other character traits, such as nurses’ possession of confidence in their clinical knowledge, a sustained commitment during times of strain, and the hope that things can always be made better. Similarly, Storch et al. ¹¹ regard moral courage as a character trait that nursing leaders require to be self-reflective and to identify their own moral distress, while Arman ¹² finds that moral courage is “a prerequisite inner quality” that nurses must possess before they can enter profound, caring relationships with patients. In contrast, some researchers seem to speak of moral courage as a property of an action that helps to make that act morally good or right. According to Thorup et al., ¹³ part of what makes it admirable for nurses to confront ethical dilemmas, for example, or to bear witness to patients’ suffering is that such acts exhibit moral courage. Such acts contribute to the ethical formation of the nurses who perform them, these researchers found, giving them moral courage to repeat such acts.

Prior to our investigation, there had been no studies as to whether nurses or nursing students require moral courage to help homeless persons or members of any other demographic complete ADs. We investigated whether baccalaureate nursing students required moral courage to help homeless persons complete ADs. This study is important for several reasons. First, for nursing students, helping homeless persons complete ADs is consistent with some of the responsibilities of the profession to which they aspire, such as preventing suffering and mitigating the social conditions that give rise to health-related inequalities. ¹⁴ In this respect, our study was not only concerned with instilling moral courage in students; it was also concerned with showing them the importance of social justice and demonstrating their power to promote it. Second, as some of the studies discussed earlier suggest, moral courage is a trait or behavior that can be learned and that is essential for success in nursing practice. ^{15 –17} Accordingly, by intentionally giving students an opportunity to practice moral courage, our study made a unique contribution to their professional preparation, for, in nursing curricula, such opportunities appear to be rare. ^18,19 Similarly, students also engaged in professional preparation by caring for members of a vulnerable population, as they might be expected to do in their careers. ^20,21 Furthermore, students learned about ADs and acquired skills that are likely to prove useful in their nursing careers when they help patients complete such documents—a task that, in practice, is often performed by nurses. ^{22 –24} Finally, as they learned about ADs and helped homeless persons complete them, students also learned about the value of facilitating another’s autonomy in relationship to EOL care. In connection with his father’s decisions and priorities near the end of life, surgeon Atul Gawande ²⁵ writes, “This is what it means to have autonomy—you may not control life’s circumstances, but getting to be the author of your life means getting to control what you do with them.” An AD is a vehicle for such control when one no longer has the capacity to respond to one’s circumstances directly.

By design, our study avoided taking a side in the aforementioned debate as to whether “moral courage” is best understood as a worthy character trait or a property of certain admirable actions. Instead, adopting a broad, common sense understanding of the concept, we defined “moral courage” as a trait of a person or an action that overcomes fears or other challenges to achieve something of great moral worth. Other researchers have employed very similar definitions. ^{26 –28} We also assumed that, in general, articulating one’s EOL wishes (e.g. by completing an AD) is something of great moral worth, for, among other things, it is exercising one’s autonomy in an important area of life and healthcare, as noted above. Therefore, if a person overcomes fears or other challenges (e.g. fear of discussing death) to help another complete an AD, that person has demonstrated moral courage. More specifically, to explore the ways in which the nursing students’ participation in this project might have involved moral courage, we investigated two questions:

Which fears or other challenges did nursing students anticipate they would face while helping homeless persons complete ADs?

The distinction between these questions is significant. Before a person can engage in a certain action (e.g. skydiving), she might have to overcome fears or other challenges associated with her anticipation of what that action will be like, even if some aspects of that anticipation are misguided (e.g. the mistaken belief that she is very likely to be injured while skydiving). So, seeking a broad picture of the students’ experience, we sought to identify fears or other challenges that they encountered not just as they helped homeless persons complete ADs, but also before they provided that help, even if some of those fears or challenges were misguided or, in hindsight, could have been avoided. That broad picture of the students’ experience reveals much about what should be involved in training them to provide this service, as we will discuss.

Participants and methods

Our study followed a qualitative descriptive design ^29,30 to investigate whether baccalaureate nursing students required moral courage to help homeless persons complete ADs. Aside from the pre-selection of a single variable to study (i.e. moral courage), our investigation was a naturalistic inquiry with narrative hues insofar as it attended to specific words and phrases in the data that were associated with that variable (e.g. “fear,” “challenge”). ²⁹ Nursing students were the research participants, and questionnaires were used to collect data from them. Their responses were analyzed using thematic content analysis, as discussed below.

Results

From the content analysis, three themes emerged, which can be categorized as two fears and a challenge. Prior to the AD Workshop, participants expressed fear that, during the Workshop, they would behave in ways that would be regarded as inappropriate by the homeless persons they would be assisting. Second, participants were afraid to broach the subject of a homeless person’s dying and death—a topic some participants characterized as “morbid” or “taboo.” Third, participants expected to be challenged by the tasks of adequately explaining the AD’s content, answering homeless persons’ questions related to that content, and accurately recording their wishes on the AD. However, each of these themes was found less frequently among participants’ post-Workshop responses (Table 1), indicating that, as a group, participants believed the Workshop would be more frightening and challenging than it turned out to be. In other words, while moral courage was required to participate in this project, participants required greater moral courage as they anticipated the Workshop (i.e. as they remained committed to providing the upcoming service) than during their actual experience of the Workshop. In relationship to each theme, participants suggested several intriguing explanations for the difference between their anticipation and actual experience of the Workshop.

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Table 1.

Participants’ obstacles pre- and post-advance directive workshop (N = 15).

	n	(%)
Fear of behaving inappropriately
Pre-Workshop	9	60.0
Post-Workshop	1	6.7
Fear of discussing dying and death
Pre-Workshop	7	46.7
Post-Workshop	3	20.0
Challenge of discussing advance directive and recording homeless person’s wishes
Pre-Workshop	11	73.3
Post-Workshop	6	40.0

Discussion

As the first study to consider the place of moral courage at the intersection of nursing and ADs, we followed a qualitative descriptive design to investigate whether baccalaureate nursing students required moral courage to help homeless persons complete ADs. Prior to the Workshop during which they provided that assistance, participants reported that they expected to experience two fears and a challenge during the Workshop. However, after the Workshop, relatively few participants reported having encountered those obstacles. So, while moral courage was required to participate in this project, participants required greater moral courage as they anticipated the Workshop than during their actual experience of it. These findings might have important implications for how to improve the training nursing students receive before they provide this service.

Our findings indicate that, for the most part, the fears and challenge that participants experienced prior to the Workshop can be addressed easily. Most participants did not encounter those obstacles during the Workshop, and their post-Workshop responses often revealed why they did not encounter them or why those obstacles proved to be minor and manageable. That information was useful subsequent to this study, enabling the authors to improve the training of a new cohort of nursing students, preparing them to assist homeless persons at another AD Workshop.

First, participants’ responses shed light on the value of some aspects of the training they received—value that the authors did not always anticipate. For example, as discussed earlier, many participants noted that their orientation to the service agency prior to the AD Workshop reduced their fear of behaving in ways that homeless persons might regard as inappropriate. As a result, when the authors planned the training for a new cohort of nursing students, that orientation was retained as an essential step in the students’ preparation for the Workshop.

Similarly, it appears that participants’ opportunity to practice helping one another complete ADs during the training session eased their apprehensions about both behaving inappropriately and discussing a homeless person’s dying and death with him or her. Consequently, training for the new cohort of nursing students allotted much more time for the students to practice completing ADs. This was accomplished without lengthening their training session. The authors leveraged university resources to produce a quality training video. In the video, the two ethicists presented their PowerPoint and performed a role-playing interview. Nursing students in the new cohort received a digital copy of this video, enabling each of them to view the presentation and listen to the accompanying explanation at their leisure before attending the training session as a group. The video was also helpful in that students could use it to refresh their learning, reviewing portions of the presentation or the role-playing interview at any time prior to the AD Workshop.

The creation of another digital file helped members of the new cohort address the greatest challenge that the study’s participants encountered—the challenge of explaining the AD’s content and answering questions related to it. To address this challenge, the researchers proposed a recorded interview with an advanced practice nurse specializing in EOL care. One of the authors (the medical center ethicist) approached a colleague, a palliative care nurse, about being interviewed, and the nurse agreed. During the interview conducted by some of the honors students from the inaugural AD Workshop, the nurse discussed examples of EOL interventions (e.g. ventilator, feeding tube, hospice care, pain medications) and their potential side effects and other possible consequences (e.g. sores, infections, reduced mobility, limited communication). Students in the new cohort listened to the recorded interview prior to the next Workshop. Furthermore, notes from that interview were compiled and hard copies distributed to the students, which they kept accessible during the AD Workshop. All of these steps were designed to teach students more about EOL interventions and to inform and facilitate their discussions of the AD’s content with homeless persons. In the authors’ debriefing session with members of the new cohort, the students reported that these additional aspects of their training had been very helpful. In all of these ways, training for the project was improved to address the fears and challenge that the study participants encountered.

Conclusion

Given our study’s small sample size, its results cannot be generalized; however, portions of our approach might be transferable to similar settings or social contexts. For example, it seems likely that the fears and challenge that our study identified could be found among baccalaureate nursing students in any US state, for, in general, homeless persons are misunderstood and marginalized throughout the nation. Therefore, if nursing students are to be prepared adequately to provide this service, our training design, too, is likely to be useful across the United States.

Beyond these conjectures, additional research is needed at the intersection of nursing, moral courage, and ADs. Are our findings unique to US nursing students who seek to assist homeless persons, or might nursing students in other countries experience similar obstacles with respect to homeless persons or other marginalized groups in their nations (e.g. new immigrants and refugees, disabled persons, prisoners)? Furthermore, is it only nursing students who require moral courage, or do other caregivers—such as nurses, social workers, chaplains, or physicians with years of professional experience—also need moral courage to provide this service? Our study has sought to break new ground in this area of research, but much remains to be explored in the United States and internationally.

Lindh et al. ⁹ highlight the importance of developing pedagogical approaches that will cultivate courage—moral and otherwise—in nursing students “so that graduates will enter the profession with courage.” Because moral courage is necessary in nursing practice, ^{15 –17} our study provides valuable insight as to what the professional preparation of nursing students can include. Unfortunately, in nursing curricula, opportunities designed specifically for students to develop and practice moral courage appear to be rare. ^18,19 Our study is an example of how moral courage might be cultivated in nursing students as part of a project through which they learn other important lessons. However, as our discussion makes clear, we would not advocate attempts to instill moral courage that expose students to avoidable fears or challenges (e.g. a fear of disrepute, the challenge of inadequate knowledge). Pedagogically, such an approach would be irresponsible. Instead, students should be prepared thoroughly and realistically to provide care, and the fears and challenges that could accompany their caregiving should be reduced as much as possible. For example, we minimized the students’ fear of disrepute by having them conduct the Workshop as a group (i.e. with a sense of mutual support)—avoiding the intimidation of meeting one-on-one with homeless persons at separate times—and by praising them for providing this service. So, after minimizing foreseeable fears and challenges in such ways, numerous opportunities for students to exercise moral courage could be offered in a course or curriculum, for some aspects of ordinary nursing practice—the complexity of caring for someone who is vastly different from oneself, for example—seem intractable and daunting enough.