Care as a matter of courage: vulnerability, suffering and ethical formation in nursing care

Authors

  • Charlotte B. Thorup RN, MSc Nursing,

    Development Nurse
    1. Aalborg Hospital, Aarhus University Hospital, Aarhus, Denmark
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  • Ewa Rundqvist RN, MSc, PhD,

    Retired Lecturer
    1. Ersta Sköndal, Institution for Vårdvetenskap, Ersta Sköndal University College, Department of Health Care Sciences, Stockholm, Sweden
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  • Christel Roberts RN, MA Nursing,

    Lecturer
    1. Arcada, Nylands Svenska Yrkeshögskola, University College, The Arcada University of Applied Sciences, Helsinki, Finland
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  • Charlotte Delmar RN, MSc Nursing, PhD

    Head
    1. The Clinical Nursing Research Unit, Forskningsenhed for Klinisk Sygepleje, Aalborg Hospital, Aarhus University Hospital, Aarhus, Denmark
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Charlotte B. Thorup, Aalborg Hospital, Aarhus University Hospital, Aarhus, Denmark.
E-mail: cbt@rn.dk

Abstract

Scand J Caring Sci; 2012; 26; 427–435

Care as a matter of courage: vulnerability, suffering and ethical formation in nursing care

The aim of the study was to explore nurses’ experience of how their own vulnerability and suffering influence their ethical formation and their capacity to provide professional care when they are confronted with the patient’s vulnerability and suffering. Care is shaped in the meeting between human beings. Professional care is informed by the patient’s appeal for help as it is expressed in the meeting. Ethical formation is understood as a personal ethical and existential process, resulting in the capacity to provide professional care. A nurse must have the sense of being a complete human being with own personal attributes and sensitivity in order to be able to relate to other people. The study is based on qualitative interviews with 23 experienced nurses from Sweden, Finland and Denmark. The analyses and interpretation were carried out in line with Steinar Kvale’s three levels of interpretation. The study clarifies that ethical formation is a union of the nurse’s personal attributes and professional qualifications and that ethical formation is developed over time. Moreover, it also demonstrates that the nurse’s personal and professional life experiences of vulnerability and suffering influence ethical formation. Vulnerability and suffering have proven to be sensitive issues for nurses, like a sore point that either serve as an eye-opener or cause the development of blind spots. Furthermore, vulnerability, suffering and the sore points are seen to shape the nurse’s courage in relation to care. Courage appears to be a significant unifying phenomenon that manifests itself as the courage to help patients face their own vulnerability and suffering, to bear witness to patients’ vulnerability and suffering and to have faith in oneself in arguing for and providing professional care. Courage thus seems to play a significant role in nurses’ ability to engage in care. Nurses’ own vulnerability, suffering and sore points seem to shape their courage.

Introduction

The study reported here is based on a caring science research project carried out by a network of researchers in Sweden, Finland and Denmark. The project was designed in 2005 with the aim to study patients’, nurses’ and nursing students’ experiences when meeting with suffering and vulnerability.

Confronting the vulnerability of patients actualizes the vulnerability of care providers. Nurses experience an existential and ethical challenge when they are confronted by a patient’s suffering and appeal for help, a challenge which has implications for the nurse’s ethical formation (1–7).

This article focuses on nurses’ experience of how their own vulnerability and suffering influence their ethical formation and capacity to provide professional care when they are confronted with the patient’s vulnerability and suffering.

A basic caring science assumption is that nursing, like any other profession, is considered to have an ethical dimension (1–12). Care is understood to be shaped in the meeting between human beings. Professional care is informed by the patients’ appeal for help as it is expressed in the meeting. Professional care is demanded when nurses encounter vulnerable and suffering patients who deliver themselves into the trust of nurses and this influences the nurse’s professional ethics, bringing the nurses in a vulnerable and suffering position (13).

Within this caring science view, vulnerability and suffering are fundamental conditions of life that are experienced by all human beings (4, 5, 9, 13, 14). In nursing, it connects nurses and patients and involves a mutual sensitivity (13–15). The ability to handle own feelings is an important factor for nurses in handling a patient’s feelings related to vulnerability and suffering.

Ethical formation is understood to be a personal ethical and existential process, resulting in the capacity to provide professional care. A nurse must have the sense of being a complete human being with own personal attributes and sensitivity in order to be able to relate to other people. Vulnerability and suffering are thus important resources in nursing (16–21).

Background

In the nursing research literature, vulnerability has been recognized as a human condition, as a resource as well as a burden (9, 10, 14, 15, 18–26). The nurses’ ethical formation may be obstructed by her own vulnerability or by a lack of opportunity to exercise care, resulting from demands for efficiency and other external factors.

Existing literature indicates a number of factors that may support or obstruct nurses’ ethical formation. Some factors relate to patients, while others relate to the institution providing care or to nurses’ themselves (9, 10, 14, 15, 23, 24, 26–28). To gain insight in the ethical formation we focus on factors related to nurses themselves and patient-related factors will be mentioned on the basis of the nurse’s ability to handle the patient’s appeal for help in the meeting.

The concept of ethical sensitivity as an important part of nurses’ ethical formation is fraught with conceptual confusion. It has been described as a caring response, a skill in identifying ethical dimensions of care, intuition and a component of moral care. As a result of a conceptual analysis, Weaver et al. (9) found that ethical sensitivity requires exposure to suffering and vulnerability cues, uncertainty and relationships. Factors related to the nurse’s personal qualities are feelings of uncertainty in the recognition of the fact that a caring situation can never be seen in its entirety; the nurse’s ability to pay attention to the patient, e.g. by diverting attention away from herself and directing it towards the other; the nurse’s ability to act responsibly, a responsiveness grounded in an inner force and not in a sense of duty; and finally courage, understood as the courage to act (9). An absence of these factors may lead to a situation in which the patient’s appeal for help is overlooked (9, 23, 24, 29). Personal attributes such as uncertainty, attentiveness, responsiveness and courage influence nurses’ ethical formation and are important for nurses’ ability to engage in care. Furthermore, the results from this concept analysis will provide a foundation for positioning future inquiry within empirical research in nurses’ ethical formation.

Focusing on empirical research, searches (latest search from 25 May 2011) revealed a scarcity of empirical studies focusing on how nurses themselves experience their own vulnerability and suffering and how they might affect care.

In acute care settings, Sørlie et al. (30) found that when meeting ethical challenges, understood as moral responsibility, the nurses related their troubled conscience to a failure to meet expectations from others as well as from themselves as a reflection of feelings of their own inadequacy.

In elderly care settings, Juthberg & Sundin (31) found that nurses face ethical challenges which may trouble their conscience. Their study was part of a larger study whose main objective was to explore connections between stress stemming from conscience and burnout among Registered Nurses and Nurse Assistants. The Registered Nurses lived experiences were feelings of being trapped in a state of powerlessness, caught in a struggle between responsibility and authority and a sense of inadequacy fuelled by feelings of incompetence, a lack of courage and a fear of revealing themselves and endangering residents’ well-being.

The significance of choosing to see rather than avoid the patient’s vulnerability and suffering is interpreted in palliative care by Arman (32) who engaged in a Socratic dialogue with four nurses and one dialogue leader in an integrative hospital setting. Arman has described that nurses know that presence and actively directed intention was a requisite for seeing the patients’ suffering. The nurse becomes vulnerable and requires courage because a window is opened to the unknown.

Stenbock-Hult & Sarvimäki (13) have recently published a qualitative study aiming to illuminate the meaning of vulnerability to care providers caring for older people. Data were collected by means of qualitative interviews with 16 Registered Nurses and practical nurses working in different settings providing care for older people. Using qualitative content analysis, they found that vulnerability essentially meant being a human being and having feelings. In relation to this, the meaning was ambiguous; vulnerability was seen as a resource as well as a burden. The meaning was illustrated by the six themes: experiencing feelings; experiencing moral indignation; being harmed, having courage, being protective of oneself; and maturing and developing. The authors conclude that it is important to study vulnerability in nurses caring for older people across countries.

Lindh et al. (33) conducted a study on the basis of individual interviews with eight Registered Nurses working in different branches of health care in southern Sweden. The researchers found that moral strength was an important characteristic of nurses necessary for a high quality of patient care. Nurses experienced moral strength in situations where they had the courage to act on their convictions about good care, when they were attentive and recognized vulnerability and when they faced the unpredictable (30). The authors suggested further research to understand the development of moral strength in general and nurses’ moral strength in particular.

Aim and method

Aim

Our background searches indicate that there are good reasons for exploring nurses’ experience of how their own vulnerability and suffering influence their ethical formation and their capacity to provide professional care when confronted with the patient’s vulnerability and suffering.

The study was based on qualitative interviews with nurses from Sweden, Finland and Denmark.

Participants

Twenty-three nurses (eight from Denmark, seven from Finland and eight from Sweden) were selected via strategic and purposeful sampling (34).

Inclusion criteria were the following:

  • At least 5 years of work experience. This was based on Patricia Benner’s understanding that the first years in nursing are formative. Work experience contributes to maturing nurses and makes them feel comfortable about themselves (35)
  • Interest in the subject. This was based on our wish to get as insightful responses as possible.

It was not a formulated criterion that the nurses have experienced vulnerability and suffering, as we consider these phenomena as fundamental human conditions of life.

The participants were recruited from university hospitals, homecare and psychiatry hospitals (Table 1). One hospital, one psychiatry hospital and one homecare from each country were chosen. Head nurses from the selected units were contacted by telephone and sent written information about the project. Nurses who expressed an interest in the project were asked to contact the researchers to obtain further oral and written information. The nurses who wanted to participate were subsequently selected.

Table 1.   Participants
Health contextsNumber of nurses
Psychiatry hospital4
Surgery departments at University Hospitals
 Accident and emergency care2
 Obstetric and birth units2
 Eye unit1
 Transplantation2
 Day surgery1
Medical departments at University Hospitals
 Haematological1
 Dialyze2
 Neurological2
 General medicine1
Home care in the city3
All together23

The nurses had between 8 and 40 years of work experience. No male nurses participated. This was unintended.

Data collection

Data were gathered through qualitative, semi-structured interviews based on a shared interview guide consisting of 10 open-ended questions. The questions were intended to uncover how the nurses consider own vulnerability and suffering confronted by patients’ suffering.

The questions were formulated within the themes vulnerability and suffering, meeting the patient, moral responsibility, feelings and sensitivity.

The interview guide was written in Swedish (for the studies in Sweden and Finland) and translated into Danish. Follow-up questioning technique was used, e.g. by asking questions such as ‘This sounds interesting, please tell me more about it’. The interviews were carried out by the three researchers in each of their country of employment.

All interviews were tape-recorded and transcribed verbatim by each researcher. The interviews lasted from 30 to 90 minutes and were conducted in 2007, either at the hospitals where the participants worked or at the researchers’ institutions.

Ethical approval

All participants were informed about the purpose of the research. They signed a declaration of informed consent and were ensured anonymity in the published work as well as confidentiality as far as their identity was concerned.

The information given to the interviewees and the declarations of consent and confidentiality adhered to the ethical guidelines for nursing research in the Nordic countries (36). This type of qualitative study is not required to be registered with the Danish Research Ethics Committee. In Finland, the study was approved by the Helsinki University Hospital Ethical Committee, on 9 November 2006 (Dnro 417/E9/06). In Sweden, the study was approved by the Regional Board for Research Ethics in Stockholm (2007/134-31).

Analysis and interpretation

The analysis and interpretation followed the principle of coherent interpretation as formulated by Kvale and Brinkmann (37). This consists of three levels: (1) self-understanding is the researchers’ condensed formulation of the interviewees’ statements condensed in meaning units; (2) critical common sense, expressing an initial, thematic framework and (3) abstraction, as a result of theorization on the basis of the findings (37). Interpretations at levels one and two are presented in the findings section, whereas level three is presented in the discussion.

Interpretations at levels one and two were made by each of the researchers in the three participating countries and discussed at all-day research meetings, one each half year, from 2007 to 2009 and frequent email exchanges. Courage appeared as an important factor across the countries and was selected as the main focus for this article. The findings showed broad consensus. Level-three interpretations were mainly made by the first author in correspondence with the co-authors.

Findings

The findings show that ethical formation results from the union of the nurses’ personal attributes and professional qualifications, and that it develops over time. The union is influenced by personal and professional life experiences of vulnerability and suffering. Vulnerability and suffering are seen as sensitive issues that go on to develop into either an eye-opener or a blind spot. Furthermore, vulnerability and suffering shape the nurses’ courage in relation to care. Courage appears to be a significant unifying phenomenon manifesting itself in (Fig. 1):

Figure 1.

 Ethical formation as union of personal attributes and professional qualifications.

  • 1 Courage to help patients face their own vulnerability and suffering
  • 2 Courage to bear witness to patients’ vulnerability and suffering
  • 3 Courage to trust oneself in arguing for and providing professional care

Ethical formation: the nurses’ personal attributes and professional qualifications

The nurses expressed the view that ethical formation is a matter of integrating the ‘professional nurse’ with ‘the person’, thus bringing the nurse’s own painful life experience to bear on their professional work:

The way I perform my professional work today, I’m drawing on my life experience in my professionalism. Today it is a product of who I am, and it is colored by the life I have lived, the people I have met in my life and the experience I have amassed (Dk4).

…one has become more experienced and one has kids and family, so it’s easier to understand the patients’ relatives and how they think and how they worry about the patient… this has given me much more because I have a lot of job experience (Fi3).

It seems that ethical formation is influenced by personal and professional life experiences, and that it develops over time. As in the quote above, the nurses expressed the view that their present approach to their work had been ‘colored by the life [they] have lived’ and that the approach had developed over time. The nurses said that they were challenged ethically and existentially. Their job forced them to respond to ethical and existential questions, and this influenced their ethical formation.

Vulnerability and suffering as a sore point that develops into an eye-opener or a blind spot

The nurses described their own vulnerability and suffering as something hidden and very sensitive, a sore point that made them feel as though they had a knot in their stomach. The nurses meet the patient with their own vulnerability and suffering and this may influence their relationship. The sore point may be the result of painful life experiences such as grief and other kinds of suffering.

[It was] as if I’d become a bit ‘allergic’, you might say, but in a way my suffering was invisible; I just felt that knot in my tummy (Fi3).

Really, you’re at the mercy of your own [vulnerability and suffering]. When we talk about our own vulnerability and suffering, it’s all very physical for me, like some sore points. You really are at their mercy when you meet other people... actually it’s very much about distancing yourself from your own needs (Dk5).

The nurses indicated that a sore point is a constant companion and that everyone has to face it sooner or later. The nurses described various aspects of such sore points and said that they experienced them as a condition to which they were forced to submit. The nurses emphasized that it was their duty to distance themselves from their own needs in spite of their painful experiences.

A sore point can serve as an eye-opener by contributing to a deeper understanding of the patient’s vulnerability:

But if I hadn’t felt that grief inside of me … if I hadn’t had that sense of powerlessness, I would not have [known] those feelings. I don’t know if you have to know the feeling in order to be able to see it in the other... [B]ut I believe you understand it differently when you have experienced it yourself (Dk4).

I myself have experienced suffering which has given me answers to some of the big questions in life (Sw1)

However, there is a risk that sore points may develop into blind spots. Nurses’ life experience involves the risk of developing blind spots that make them blind to the other because they themselves carry a burden of vulnerability and suffering.

If the situation reminds me of my own family... then I don’t know if it’s my grief or the patient’s grief, and then I am of no use (Dk6).

I am aware of my own emotions; if I don’t keep my feet on the ground I won’t succeed (Dk3).

I do not have the lead role in the patient’s suffering (Sw1)

The nurses’ vulnerability and suffering are interpreted as the outcome of painful life experiences, understood as a sore point that can lead to either blindness to the vulnerability and suffering of others or to a process that opens the nurse’s eyes. Although nurses are forced to interact with patients, the nurse, like anyone else, is unable to disengage from her own painful life experience. A sore point seems to affect nurses’ ability to engage in care.

Courage

Courage as a significant unifying phenomenon seems to be fundamental in ethical formation. Courage is shaped by the nurses’ vulnerability, suffering and sore points. Courage is the state of mind that enables one to dare do something, to act:

I have been thinking a lot about courage. I have been a coward, but I have worked on my courage and I think that I have developed courage over the years... I kind of need to get a firm basis before I dare do something, and now I feel that I have found my feet, I’m more daring now – I feel I know what I’m talking about (Sw3).

Courage to help patients face their own vulnerability and suffering

In the nurses’ experience, patients are vulnerable and suffering in their meeting with carers and the hospital system. They saw this vulnerability and suffering as an exposed, fragile and raw sensitivity, which they experience as an insistent appeal for help. The nurses felt that the expression and extent of the patients’ vulnerability and suffering were colored by significant events in the patients’ lives. The illness may cause not only physical suffering such as pain, but also mental suffering. The nurses worried that the patients’ autonomy could be restricted by their lack of ability to take care of themselves and make decisions about their lives, and that this would lead to greater vulnerability and more suffering.

In the nurses’ experience, some patients needed to be confronted with their own vulnerability and suffering to enable a discussion about the issues and take necessary action. The nurses pointed out that they sometimes fear patients’ reactions as they worry that such a confrontation may cause a reaction which they would be unable to handle on their own. The nurses made it clear that it takes courage to confront patients with their own vulnerability and suffering, but that it is occasionally a necessary part of professional care. This is expressed in the quote below:

You’ve got to be tough. You must be able to shoulder it yourself and not be afraid of confronting the patient: ‘Really, is that what you are saying? Is it that you actually don’t want to be here anymore – that you want to die?’ You mustn’t be afraid of using the word ‘die’ (Dk2).

Courage is evident in nurses’ readiness to confront patients with the difficult issues, although they cannot be sure that they can handle the patient’s reaction. As expressed in the quote, nurses must not be afraid to help and they must be able to bear the situation themselves.

Courage to bear witness to the patient’s vulnerability and suffering

The courage to bear witness involves the courage to be present in the patient’s vulnerability and suffering, and to be attentive in spite of the patient’s hardship. This was expressed as daring to enter into the patient–nurse relationship, and it involves the risk of ‘walking into something that I’m not quite sure that I have the guts to face’ (Dk2). The nurses likewise spoke of the necessity of daring to step into the patient’s suffering, if invited:

We as caregivers [must] dare see this and ‘climb onboard’ the suffering if we are invited (Sw1).

The following quote presents the synthesis of the nurses’ experience of bearing witness to a patient’s vulnerability and suffering.

I remember the first really sick lung patient I saw here; she could not get enough air so she was absolutely blue in the face. I really had to force myself to... I literally had to hold on to the guard rail to stay there because it’s almost impossible to endure that terrible craving for air and the desperation, but... well, you learn little by little. For a patient in that kind of situation, it’s really important that the people around them can bear to stay there and be present with the patient (Dk5).

As the quotation above illustrates, the nurses’ pointed out that experience (acquired little by little) builds up the ability to dare. If the nurse cannot muster the courage to face the patient’s vulnerability and suffering, the patient is in danger of experiencing a distancing attitude on the part of the nurse:

[The patient’s] vulnerability has a different effect on each nurse. For instance, a depressive patient can be terribly vulnerable and unsure about everything. As a matter of fact, this is where a person most needs patience from the people around them, but at the same time their vulnerability is so urgent and conveys such an insistent appeal for help that it is automatically met with a distancing attitude. [S]ometimes there is so much unhappiness or suffering that you cannot do anything to ease the pain (Dk5).

It appears that the courage to be attentively present in the patient’s vulnerability and suffering involves the courage to see and stay ‘in there’ with the patient, but the patient’s problems may have such an urgency that it is impossible to alleviate them. As a result, the patient may encounter nurses who have a distant attitude. The findings also indicate that the nurse cannot enter ‘in there’ without permission from the patient.

Courage to trust oneself in arguing for and providing professional care

In the nurses’ own view, professional care is based on genuine compassion, combined with humility, and this enables patients to retain their dignity. Experience and intuition are required for providing professional care in a loving but not overprotective manner. They spoke of professional care as giving the patient a feeling of having ‘landed’ and of being in good hands.

Hopefully, it is not just a question of willing hands; they should also be competent hands. Sometimes nurses happen to do things to patients that make them unhappy, and still they’re in good hands... like you’re not going to get lost …. That’s a sort of very symbolic or a very clear image of having landed (Dk5).

In relation to this point, the nurses characterized care as wholehearted professionalism. The quote below illustrates the view that nurses must have courage to commit themselves fully, and that they are faced with a challenging task:

The courage of the individual nurse also creates the opportunity to provide caritative care. But for you as the nurse to summon this courage, you must also be prepared to put up with quite a lot (Sw1).

It appears that maintaining proper professional care involves some kind of struggle. The nurses described how this places them at risk of expulsion and abandonment by the professional community.

According to the nurses, it takes courage to challenge one’s own professional group on points of ethics. When nurses had experienced a decrease in care standards, they needed the courage to stand up and say: ‘We simply can’t justify that unethical standard’ (Dk7), e.g. when they witnessed disrespectful communication. Without this display of courage, the necessary ethical discussions would not be brought up in the nursing community and in other professional groups. The nurses indicated that with increasing experience, it had become easier to distance themselves from care situations that they considered unethical:

Could I have been more insistent and got her admitted to the emergency ward sooner? Yes, I suppose I could – I suppose I’ll never ever allow ‘the hierarchy’ to bully me again. Now I’ll have the courage to trust my own intuition (Sw1).

The nurses stressed the importance of daring to rely on their intuition in discussions of ethical care issues in a hierarchical health system. They also said that they felt that initiating an ethical discussion and daring to stick their neck out gave them a sense of credibility. The professional discussion of ethics is essential for those working in care as ethical dilemmas are abundant. Continued debate is necessary for nurses to prevent them from succumbing to their own anxiety or dismay:

I do think we should discuss it – an open communication about ethical dilemmas is awfully important because if you have an awful lot of these difficult ethical questions, you might end up with anxiety within the nursing staff... it’s human beings we’re working with and there’re always difficult decisions that must be taken several times a day, so I suppose that this communication is awfully important – that you dare talk about such difficult things as well (Fi1).

It seems clear that it requires courage on the part of the nurses to dare trust and keep a firm hold on their intuition when they are confronted by ethical dilemmas. It takes courage to launch professional ethical discussions involving the other health professional groups, although the nurses had experienced an enhanced credibility after succeeding in putting ethical questions on the agenda.

Furthermore, the nurses described how the courage to trust oneself in arguing for and providing professional care had developed over time.

You know, I think that this belief one has in oneself – that you trust that this is the right thing to do – it matters a great deal that you dare stand up for what you think is right, and that you don’t just hurry along to the next thing. [N]ow I have the guts to step forward and say ‘Listen, this is the way I believe we should handle the situation’. [D]aring to believe in yourself as far as your profession is concerned (Dk3).

I think I have seen and experienced enough in my life to be able to do it my way (Fi3).

This indicates that the courage to argue for and provide professional care involves daring to take a stand instead of just hurrying on. In continuation of this discussion, the nurses said that it is not just a question of having the courage to enter into the care relationship, but also of the will to act in accordance with one’s care.

[It] depends on how we as nurses relate to people, whether we want to help the patient or not. Daring to enter into it, that’s a great challenge for me as a nurse – I sometimes catch myself taking the easy way out when it’s about asking the important questions. It’s not always a question of time. It’s whether we want to do it or not, plain and simple, you know (Dk1).

It seems that arguing for and providing care require both courage and willingness to avoid ‘taking the easy way out’.

Discussion

Ethical formation is a matter of integrating the nurse’ professional qualifications with her personal attributes. The study identifies courage as a significant unifying phenomenon in ethical formation. Even though other studies have already established it as a part of nurses’ ethical formation (9, 11, 13, 19, 23, 25, 28, 29, 31–33), this study expands the understanding of how courage contributes to the ability to engage in professional care.

Our study deepens the understanding of how nurses’ own vulnerability and suffering in their exposed position in confrontation with patients can lead to the development of sore points that may in turn serve to either open the nurse’s eyes or develop a blind spot. Our findings show that blindness to the patients’ situation may occur if the nurse mistakes her own feelings for those of the patient’s, so it is essential that the nurse has the courage to be confronted with herself as well as an ability to distance herself from her own needs. In line with the findings of Weaver et al. (9), we found that this form of ethical sensitivity requires that the nurse is able to pay attention to the patient, e.g. by diverting attention away from herself. This is what Pahuus has described as a ‘self-forgetful preoccupation’ with the other in the endeavour to understand that person (16). But this sensitivity and attentiveness of nurses in certain delicate situations could make them vulnerable and leave them with memories of being exposed with the result that the nurse experiences fear rather than courage and feelings of incompetence and inadequacy (30, 31, 33). This may lead to developing a blind spot.

For vulnerability and suffering, to develop a strength that can open the nurse’s eyes, an awareness of such feelings is required; she must be ready and not afraid to be with the patient and refer back to him (28, 33).

Ethical formation is a development process that takes time. A nurse must be confident of her completeness as a human being equipped with the necessary sensitivity in order to be able to relate to the patient’s suffering in professional care. It is not only about being human and having feelings, but also about confronting and trusting oneself with a feeling of confidence in oneself and the situation at hand (33).

The study demonstrates that it takes courage to help patients face their own vulnerability and suffering. The nurses pointed out that without courage, they would be unable to predict the patient’s reaction in difficult situations. Consequently, the nurse must be willing to endure uncertainty about the patient’s reaction, in other words, have the courage to enter into uncharted territory. Spence’s qualitative study of experienced nurses support this finding as her study showed that it is only the courageous that dare ‘not to know anything for sure’ (38). On the other hand, the same study indicates that certainty and knowledge enhance nurses’ courage and improve their confidence in making their own decisions. Another empirical study, which addressed the importance of conscience in nursing, has also indicated the need for nurses to possess courage, for example in conversations with patients about critical phenomena such as terminal illness (39).

A Danish study has revealed another aspect of courage by showing that entering into a serious relation with the patient requires a willingness on the part of the nurse to run the risk of rejection. In other words, it takes courage to dare accept the possibility of rejection (40). Our interviewees said that they could not enter into patients’ situations unless the patients allowed them in. This might be an indication of the nurses’ fear of being rejected, perhaps a result of painful life experiences. If the nurse is confronted with fear of being rejected, it can develop blind spots. According to Tyler-Bell’s theoretical paper (41) and Arman’s and Lindh et al.’s empirical research (32, 33), courage lies in the nurse’s willingness to walk alongside the patients on their journey to overcome their suffering, no matter where the road leads. This journey is highly unpredictable and seems to require the willingness and ability to bear witness to patients’ vulnerability and suffering. Courage is a prerequisite inner quality and a first step towards the existential caring encounter (32). On this existential level, in facing the unpredictable, courage contributes to the nurturance of personal and professional development.

As already pointed out in the findings, it takes courage to trust oneself in arguing for and providing professional care, both in relation to nurses and other health professionals. Spence has described courage as the energy that commits the nurse to her work (38). In line with Lindh et al. (33), two theoretical papers support our finding in their discussion of moral courage (42, 43) as the person’s individual ability to overcome fear and stand up for own values. They identified courage as the readiness to act on one’s principles (43) and to listen to the patient, even when this means going against doctors’ opinions (33, 38). The articles also identify situations in which moral courage is particularly important, e.g. when technical rationality or efficiency become major factors for care (38, 42, 43).

Trustworthiness and study limitations

The trustworthiness of the study was strengthened by the fact that three researchers from each participating country independently read the interviews. The themes were then constructed by the three researchers and reflected on by the whole research team. Courage is a common personal attribute in professional care across countries. The credibility and confirmability are shown in the consensus as well as the variation of citations.

A limiting factor may have been the absence of male participants, who could have provided other perspectives and alternative perspectives on the topic. Neither can it be ruled out that nurses who agree to participate in a research project concerning care ethics may be atypical in the sense that they are already deeply engaged in ethical questions.

Conclusions

Courage appears to be a significant unifying phenomenon in ethical formation.

It becomes evident in situations where nurses are capable of coping in an indeterminate situation, of standing out ‘in the open’, of engaging with and listening to vulnerable and suffering patients, situations that expose the nurse to the risk of rejection. Courage manifests itself as the ability and willingness to help patients face their own vulnerability and suffering, to bear witness to patients’ vulnerability and suffering and to have faith in oneself in arguing for and providing professional care. Courage seems to generate a strength and energy that enhances nurses’ sense of commitment and hope in their work.

The study has clarified that ethical formation is a result of the nurses’ personal attributes and professional qualifications and that it should be seen as a maturation process. The synthesis of personal attributes and professional qualifications is influenced by personal and professional life experiences of vulnerability and suffering; sore points that either open the nurse’s eyes or make her blind.

The nurses’ sore points shape their professional care and the courage to be and to act.

However, the courage to provide care is not an isolated phenomenon. Aspects of volition are also involved in relation to courage in nursing and would provide a relevant topic for future research.

Acknowledgements

The researchers sincerely thank Head Nurses Margrethe Bisgaard, Susanne Kolding and Hanne Hartmann, Aalborg Hospital, Aarhus University Hospital, for their support for this study. Further more, we would like to thank our co-researchers for advice, valuable discussions and support in the process. We also wish to express our gratitude to the nurses who participated for their willingness to share significant experiences.

Author’s contribution

Charlotte Brun Thorup, Christel Roberts and Ewa Rundqvist are responsible for the interviews and interpretations in Denmark, Finland and Sweden, respectively. Charlotte Brun Thorup wrote the manuscript, Christel Roberts, Ewa Rundqvist and Charlotte Delmar contributed with their comments in the process, and Charlotte Delmar contributed to the finalization of the manuscript. Charlotte Delmar and Ewa Rundqvist were responsible for the project design; Charlotte Delmar was executive project manager for the project as a whole.

Funding

The project received no external funding.

Ancillary