Courage is an important attribute in life and in your nursing practice. As Helen Keller said,
“Security is mostly a superstition. It does not exist in nature nor do the children of men as a whole experience it. Avoiding danger is no safer in the long run than outright exposure. Life is either a daring adventure, or nothing.”
Nursing is a noble profession that is not for the faint of heart. Opportunities to choose courageous acts present themselves on a regular basis because risk is everywhere. You can attempt to minimize the risks by playing it safe but there are risks to yourself, your colleagues, your profession, and those you serve when you don’t take risks in showing up, speaking up, or practicing according to the highest standards of evidence-based practice. Choosing to practice courageously, consistent with your personal and professional values, will cause some discomfort, bumps, and bruises to you and your career. It will also bring professional and personal fulfillment, strengthen the profession, and improve patient outcomes. You will know that you are making a difference in your daily practice and throughout your nursing career.
One way to cultivate courageous behavior is through personal risk taking (PRT), but first you need to understand the nature of risk and its related concept, positive deviance.
What is risk?
Risk is defined as the possibility of losing something of value, which could be physical, psychological, or economic. Common risks include falling out of favor with others in authority, losing support, or damaging a key relationship. Any of these events could lead to losing status or influence at work, or even losing one’s position or employment.
A related concept called “positive deviance” refers to an intentional act of breaking the rules to serve the greater good. Positive deviance is intentional and honorable behavior that departs or differs from an established norm. It contains elements of innovation, creativity, adaptability, or a combination thereof; and it involves risk for the nurse.
For most nurses, whether a particular action is right or wrong will often be judged by others who are in charge of rules enforcement. The decision to engage in positive deviance, however, lies entirely with the nurse.
Personal risk taking
PRT is behavior that is consciously and freely chosen among available alternatives, some of which are known to incur less risk than the chosen action. It is supported by the strength and belief of personal convictions. Courageous action upholds principles. Calculated inaction due to fear leaves one powerless, with values compromised.
Nurses promote courageous action by sharing courageous behavior, also called hero stories. This can be done formally and informally, verbally and in writing, one on one or in groups, during staff meetings, during change of shift report, or rounds. We create a culture based on what we talk about, what we value, and what we support and reward. Sometimes we stand alone, and sometimes we influence others to follow our lead and take their own personal risks. In one study, risk taking was found to be one of the key elements in attaining expert nursing practice, which supports effective and quality-based healthcare outcomes. Risk taking also was found to enhance clinical and professional development.
Rather than sitting on the sidelines and hurling judgment or advice at others (for example, “Someone needs to do something about this.”), we must dare to show up and let ourselves be seen, which can result in change. (See Success story.)
When residents were not interacting appropriately with pediatric patients, risking psychological harm, I discussed this with the chief and arranged education. I advised our team that in identifying this issue, relationships might become strained, but we had an obligation to our patients to address this problem. I often used the mantra “I am doing the right thing for the right reason” stating it over and over in my head to help me stay the course and follow through with my convictions. As feared, the residents and even an attending physician demonstrated passive aggressive behavior towards us. The care of the children did improve, however, and we knew we had made the right call.
We pay a price when we shut down and disengage, failing to take action. I have heard nurses talk about “staying under the radar.” In doing so they pay a dear price. Their talents, wisdom, knowledge, and values are not being shared to positively influence care and support the development of new nurse graduates and other colleagues through courageous role modeling. Vulnerability occurs in sharing an unpopular opinion, standing up for oneself or others such as a colleague who is being bullied, being accountable, asking for help, trying something new, admitting uncertainty, and asking for forgiveness. When courage and fear meet, it often feels awkward and scary; however, “being all in” is to be alive. To act in alignment with your values is key to personal and professional happiness.
PRT and promoting patient safety
Failing to take risks and practice courageously can lead to threats to patient safety. Focusing on my obligation to “First do no harm,” I made the decision not to deploy a transport team until all the team members demonstrated competency. I was transparent in discussing my concern and contingency plan to send another team with my medical and administrative colleagues. I was told that this was a “career-limiting move.” I simply stated, “I have to be able to sleep at night.”
In another organization, I disagreed with a plan to move critically ill patients multiple times to accommodate unit renovation. I identified an alternative that required only one move. Although my plan was successfully implemented, my action caused me to fall out of favor with the administrator and eventually resulted in my having to move on to another position. In both instances, I had to put my patients first because when I became a member of the nursing profession, I made a promise to protect them.
Why we may not take personal risks
Understanding scarcity is key to understanding why nurses may not take justified risks. The three components of scarcity are shame, comparison, and disengagement.
Shame is the fear of ridicule and belittling often used to control people and to keep them in line. Shame-based cultures are very unhealthy for nurses and patients. The killer of innovation is shame. In these cultures, covert or sometimes overt messages are common, such as to dare not, you’re not good enough, who do you think you are, don’t you dare get too big for your britches”. Shame becomes fear, fear leads to risk aversion, and risk aversion kills innovation and can lead to unsafe patient care. Shame is the intensely painful feeling or experience of believing that we are flawed and therefore unworthy of belonging. Shame makes us feel unworthy of connection. Resilience to shame occurs when recognizing and speaking openly about shame, practicing critical awareness, and reaching out to others.
Healthy competition can be beneficial, but constant overt or covert comparing and ranking suffocates creativity and risk taking. If nurses are held to one narrow standard, they may not question the relevance of a course of action to a specific situation and embrace evidence- based practice.
Disengagement occurs when people are afraid to take risks and try new things. Too often it is easier to stay quiet than to share stories, experiences, and ideas. It is important to do what is right, not what is easy. The best way through a difficult situation is to address the situation directly with honesty and integrity, sharing your story and asking for what you need. An excellent resource for nurses is the book Crucial Conversations. Often what we fear does not happen, but even if it does, we have retained our self-respect and commitment to professional values.
I hope you choose to practice courageously, doing the rights things for the right reasons. As Theodore Roosevelt said,
“Far better it is to dare mighty things, to win glorious triumphs, even though checkered by failure, than to take rank with those poor spirits who neither enjoy much nor suffer much, because they live in the gray twilight that knows not victory nor defeat.”
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Gary JC, Exploring the concept and use of positive deviance in nursing. Am J Nurs. 2013;113(8):26-34.
Haag-Heitman B. The development of expert performance in nursing. J Nurses Staff Dev. 2008;24(5):203-11.
Brown B. Daring Greatly: How the Courage to be Vulnerable Transforms the Way We Live, Love, Parent, and Lead. Gotham Books; 2012.
Patterson K, Grenny J, McMillan R, et al. Crucial Conversations: Tools for Talking When Stakes are High, 2nd ed. New York, NY: McGraw-Hill; 2011.
Carol Dobos lives in Phoenix Arizona and is the past-president of the Arizona Association for Nursing Professional Development, a state affiliate of the Association for Nursing Professional Development.