Journal of Nursing Education

Research Brief 

Moral Integrity and Moral Courage: Can You Teach It?

Ruth A. Eby, MSN, RNC; Patricia Lynn Hartley, MSN, RN; Patricia Jeanne Hodges, MSN, RN; Rebecca Hoffpauir, MSN, RN; Shirlene Newbanks, MSN, RN; Jane H. Kelley, PhD, RN

Abstract

Nursing has been spared the ethical scandal of many other professions, but issues of compromised moral integrity are growing in practice and education. This study was structured to investigate faculty perceptions of the challenges encountered regarding moral integrity in academia and strategies to promote nursing students’ moral integrity and moral courage. A content analysis of the responses to questions about challenges and strategies was completed. Themes identified from the data on student and instructor beliefs and behaviors correspond to those found in the literature. The need for instructors to model a high level of integrity and to create high-integrity classrooms and a community of learning were identified as essential. A finding different from other study results is that beliefs drive moral behaviors and must be the focus of strategies for change. A consensus was expressed that mechanisms are urgently needed to further identify and integrate strategies to enhance student moral integrity. [J Nurs Educ. 2013;52(4):229–233.]

Ms. Eby is Chair, Ms. Hartley is Assistant Professor, Ms. Hodges is Assistant Professor, Ms. Hoffpauir is Assistant Professor, Ms. Newbanks is Coordinator, and Dr. Kelley is Adjunct Professor, Post-licensure Division, Indiana Wesleyan University School of Nursing, Marion, Indiana.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

The authors thank Carol Bence, friend and initiator of the conversation.

Address correspondence to Ruth A. Eby, MSN, RNC, Chair, Post-licensure Division, Indiana Wesleyan University School of Nursing, 1900 W. 50th St., Marion, IN 46953; e-mail: ruth.eby@indwes.edu.

Received: July 25, 2012
Accepted: November 14, 2012
Posted Online: March 11, 2013

Abstract

Nursing has been spared the ethical scandal of many other professions, but issues of compromised moral integrity are growing in practice and education. This study was structured to investigate faculty perceptions of the challenges encountered regarding moral integrity in academia and strategies to promote nursing students’ moral integrity and moral courage. A content analysis of the responses to questions about challenges and strategies was completed. Themes identified from the data on student and instructor beliefs and behaviors correspond to those found in the literature. The need for instructors to model a high level of integrity and to create high-integrity classrooms and a community of learning were identified as essential. A finding different from other study results is that beliefs drive moral behaviors and must be the focus of strategies for change. A consensus was expressed that mechanisms are urgently needed to further identify and integrate strategies to enhance student moral integrity. [J Nurs Educ. 2013;52(4):229–233.]

Ms. Eby is Chair, Ms. Hartley is Assistant Professor, Ms. Hodges is Assistant Professor, Ms. Hoffpauir is Assistant Professor, Ms. Newbanks is Coordinator, and Dr. Kelley is Adjunct Professor, Post-licensure Division, Indiana Wesleyan University School of Nursing, Marion, Indiana.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

The authors thank Carol Bence, friend and initiator of the conversation.

Address correspondence to Ruth A. Eby, MSN, RNC, Chair, Post-licensure Division, Indiana Wesleyan University School of Nursing, 1900 W. 50th St., Marion, IN 46953; e-mail: ruth.eby@indwes.edu.

Received: July 25, 2012
Accepted: November 14, 2012
Posted Online: March 11, 2013

Recent reports in the news media suggest that American society is becoming increasingly engulfed in a culture of moral depravity; however, there is still a high expectation for moral integrity in the profession of nursing. Nursing has a firm foundation of values and codes reflecting high moral integrity and obligations to society. The professional, social, and personal responsibility and accountability for nursing practice have been emphasized, from Florence Nightingale (1860) to the International Council of Nurses’ Code of Ethics for Nurses (2006) and the American Nurses Association’s (ANA, 2010) Code of Ethics for Nurses with Interpretive Statement.

Although nursing consistently receives top scores on surveys that rate moral behavior among the professions (Jones, 2011; Wilk & Bowllan, 2011), nurses bring an array of value systems into the profession that do not consistently reflect the high standards of moral integrity on which the profession was founded. Practicing RNs are increasingly demonstrating that the moral foundation of practice is eroding. The meeting minutes of state boards of nursing reveal an alarming number of disciplinary actions reflecting a loss of moral compass (e.g., Indiana State Board of Nursing, 2011; Ohio Board of Nursing, 2011, as two state boards served by the geographical area of this study). The American Association of Critical Care Nurses (2008) acknowledged, “Moral distress is a serious problem in nursing. It results in significant physical and emotional stress, which contributes to nurses’ feelings of loss of integrity and dissatisfaction with their work environment” (p. 1).

A similar pattern has been noted in nursing academic arenas. McCabe (2009) reported a higher rate of cheating and dishonesty among nursing students than among other disciplines studied. The concern raised by faculty in the McCabe study suggested a correlation between those students who are dishonest (e.g., plagiarism, misrepresentation, and falsification [McNabb & Olmstead, 2009]) in academic nursing programs, and those who go on to be dishonest in practice as nursing professionals. Nurse educators need to develop expertise in the concepts of moral literacy and in best practices for teaching moral integrity, and they need to develop a skill set to design classroom experiences that bring students to a deeper level of understanding of moral integrity in nursing practice. This will enhance both their own and students’ moral development and moral courage.

Observing a progressive increase in incidences of plagiarism and cheating among nursing students in their classrooms, a research team of nurse educators recognized the need to study this phenomenon. The research team developed a study to identify the challenges faculty face regarding student moral integrity and the strategies they can use to equip students with a skill set for a higher level of moral integrity and moral courage.

Method

Sample

In August 2011, the team conducted a qualitative study that included approximately 120 faculty members at a midwestern community college, representing multiple disciplines including, but not limited to, nursing. The participants were not differentiated by location or academic area. Participants in the study included both full-time and adjunct faculty, with varying levels of experience in teaching. They were both male and female, with a predominance of female participants. Institutional review board permission was granted.

Data Collection, Teaching Session, and Research Questions

Data Collection. Data collection was conducted through the World Café approach that was modified because of the limited amount of time and space available. (For a full description of the World Café Method, see Burke and Sheldon [2010].) In this modified approach, each faculty member participant sat at a table with faculty from other disciplines of the college. Investigators asked the participants to write down on a provided placemat their thoughts about the research questions presented to them, with the objective of capturing individual perceptions about the questions (Burke & Sheldon, 2010). Participants were then asked to collaborate among members of their table group to refine their thoughts (Burke & Sheldon, 2010).

Study participants consisted of those who returned the placemats. Some table groups collaborated to complete one placemat for the group. Of the 120 attendees, 59 placemats were submitted. Participants granted informed consent by turning in the placemats.

Teaching Session. The presentation, entitled “Moral Integrity and Moral Courage: Can We Teach It?,” consisted of an educational session on the modified World Café format and introduced the issues, relevant concepts, and applicable scenarios.

The introduction described how the need was identified for investigating the questions of moral integrity in the collegiate setting. Moral integrity was defined as knowing what is right and what is wrong, acting on that knowledge even at a personal cost, verbalizing that you are acting on what you know to be the right thing to do, and doing this with a high degree of consistency. Moral courage was defined as “acting ethically even in the presence of risk” (Murray, 2010, p. 15). Moral distress has been defined by Pendry (2007) as “physical or emotional suffering that is experienced when a person does not do what they believe is right” (p. 217). The final concept defined was moral residue. According to UK HealthCare (2012), “Moral residue generally refers to the residual or ‘remnant’ stress resulting from unresolved moral issues” (p. 2).

Three scenarios were presented to demonstrate these three key concepts as related to moral integrity: moral courage, moral distress, and moral residue (Laabs, 2007). The story of a Texas whistle-blower case was used to demonstrate moral courage (Barr, 2011; Blaney, 2011). Moral distress was demonstrated by the true story of a nurse who was unable to convince her brother to sign a “comfort measures only” consent for their mother due to the influence of their traditional culture. The sister’s lack of success resulted in moral distress from the feeling that she had failed to be a patient advocate for her own mother. To demonstrate the feelings associated with moral residue, a lived experience was recounted by an emergency department nurse who found herself in a situation she knew was morally wrong (Hardingham, 2004). Although she knew the right thing to do, she did not have the courage to do it.

Research Questions. Following the presentation, investigators asked participants to participate in the research. They were asked to answer the following questions:

  • What challenges do faculty encounter regarding moral integrity in academia?
  • What strategies can faculty use to equip students with a skill set for a higher level of moral integrity and moral courage?

Content Analysis

One investigator numbered and transcribed verbatim each placemat and separated the data by question. Each of the six research team members received a copy of the raw verbatim data. Team members individually analyzed the data using content analysis by clustering related data into groups, identifying contextual meanings, and applying code names to clusters of related data. Team members submitted individual analyses to an electronic folder. Team members used consensus to agree on subcategories and larger themes and categories into which the codes fit. The limited nature of the questions and the answers made coding beyond initial and consensus categories unnecessary. The team maintained credibility, dependability, and transferability in the content analysis within the limitations of this preliminary study.

The following is an example of the content analysis using information from four placemats related to question 1. Raw data included:

  • “Cheating, lying, plagiarized, false documentation.”
  • “Plagiarism-cheating-lowered class morale, diff[erring] opinions, teaching ethics, copying.”
  • “Plagiarism, cheating, reduced participation, class morale (lowered), lower standards.”
  • “Cheating, different students, some answers, students coming out [and] asking other students to copy their class work.”

From the raw data, investigators clustered lying, cheating, plagiarism, copying from other students, and false documentation. The investigators agreed that the first code for this cluster was dishonesty (with three other codes within the theme). They then clustered the following under the code of dishonesty: lying, cheating, and stealing (including cell phone, computer use, falsifying documents, time logs), and plagiarism (aspects of lying, cheating, stealing), including copying from other students, software, and online information (essays, music, math questions and answers, movies). The theme for this code and the other similar codes (class/learning process; student characteristics; student beliefs reflected in behaviors) became student behaviors reflecting low moral integrity, as opposed to the other themes of class characteristics reflecting low moral integrity and instructor behaviors supporting low moral integrity.

Findings

Themes generated from question 1 included student behaviors, class characteristics, and instructor behaviors (Table). Findings indicated that participants perceived that beliefs drive the moral change in the behavior of current students. These beliefs are based on postmodern relativism, acceptance of moral diversity, rejection of any truth as a norm, and a sense of entitlement and being above the law. The literature reflects these findings, as there are reports of student beliefs changing over time regarding academic moral integrity. Arhin (2009) described students normalizing dishonest behaviors. In her study, students were easily able to identify dishonesty in examination situations, but not during classroom and laboratory assignments. The Center for Research on Learning and Teaching (2012) reported an increase over the past 30 years in student self-report of cheating but not in plagiarism. Birch (2011) noted that the type of plagiarism involved in cutting and pasting from other sources (print, Internet, or other students) is openly self-reported. Balik, Sharon, Kelishek, and Tabak (2010) found that students view academic dishonesty as normal and acceptable. However, this does not mean the student views it as ethical.

Analysis of Responses to Questions 1 and 2

Table: Analysis of Responses to Questions 1 and 2

If beliefs about academic moral integrity are changing among students, then there is an even greater challenge for nurse educators to increase nursing students’ awareness, as well as their practice, of moral integrity. As Balik et al. (2010) reported, “The literature on cheating indicates that the character of both the student and the teaching institution influence the decision to deviate from acceptable practice” (p. 549). Assuming the need for an institutional community context to effect moral integrity belief changes, faculty will have to modify both the classroom characteristics and the content delivered to support such a change.

Findings from question 1 also revealed a broad range of student characteristics that influence student behavior, including knowledge levels, disability, disrespect, pressure to succeed, lowered standards, and lack of work ethic. Beliefs also underpin many of these behaviors. Pressure to succeed may be associated with classroom demographics changing toward older students (McCabe, 2009). Older students often are working, have families, and have financial pressures that create greater demands on their time for schoolwork (McCabe, 2009). Financial pressures may help to drive the pressures to succeed.

Findings from question 1 class characteristics focused on environment and style of delivery. Participants perceived the classroom environment to have low accountability and low class morale, heightened through multiple distractions. Participants perceived online delivery to be a greater source of cheating than onsite delivery. Accountability is related to the beliefs described above. However, the level of distractions and holding the class to higher accountability are within the scope of faculty’s classroom management skills, although they may possibly be influenced by the outside factors affecting this demographic.

The question 1 challenges to moral integrity in instructor behavior, identified by participants, included lack of role modeling high moral integrity, disengagement, exhibiting bias, and inadequate knowledge. An interesting finding in the literature is a Code of Ethics for Nurse Educators (Rosenkoetter & Milstead, 2010), which details the responsibility and accountability of nurse educators for personal competence and moral behavior.

Question 2 yielded fewer data item clusters from which the codes and themes were generated, as the question had a more limited scope. Themes related to strategies to equip students with a skill set to enhance moral integrity included instructor behaviors, teaching methods, and content to be taught (Table). Developing strategies to increase academic moral integrity for the category instructor behaviors went beyond the similar findings for instructor behaviors in question 1, which were oriented toward behaviors that lower moral integrity. The instructor behaviors suggested in question 2’s answers are broader in scope. These behaviors include modeling high integrity and creating a high-integrity classroom environment, developing a community of learning with high academic integrity, and selecting appropriate content to reinforce this context. For teaching methods, the participants emphasized the need to develop a learning community based on academic integrity. The learning community must involve moral behaviors and integrity on the parts of both students and faculty. Content to be taught included definitions and application of behaviors associated with moral integrity and moral courage, confidentiality, emotional intelligence, accountability, and critical thinking, as well as basic information on what plagiarism is, especially for electronics and software.

Discussion and Conclusions

There is a significant gap in the research regarding the concepts of moral integrity and moral courage as they relate to education in general and nursing education in particular. Nurse educators are responding to this need by joining other disciplines to engage in academic discourse and research. The findings regarding student moral integrity and breaches thereof are in line with reports and studies in the literature (Arhin, 2009; Kolanko et al., 2006; McCabe, 2009). The most urgent need identified by educator participants in this survey was to discover strategies to thread concepts related to moral integrity into education programs. In addition, conclusions of the group were that faculty are viewed by students as standard-bearers of professional and ethical behaviors. Faculty have a negative influence on students and reinforce current moral and ethical principles when they demonstrate nonprofessional behaviors, such as late arrival to class, inappropriate dress, being unprepared, lack of responsiveness to students, and breaching the ethical use of print, Internet, or software resources.

Due to the limited research base in the literature related to nursing faculty and students, there is a need for studies with larger groups specific to nursing faculty and students. The findings from this current study are preliminary and did not provide the level of detail included in reports found in the general education literature. The limitations of this study also include its small sample size.

The interest in moral integrity has been shown. The current status of academic moral integrity and the possibility for improving both related beliefs and behaviors have been uncovered. To further this area of study, the investigators recommend that a tool be developed based on findings from this study and the literature. The tool should capture the beliefs underlying academic moral integrity behaviors and determine the change in students’ moral integrity as they progress through the curriculum. Studies are needed to test different methods for improving moral behaviors on the basis of suggested approaches from this study and the literature.

The investigators hope that further study will help nurse educators begin to fill the gap between moral integrity and moral courage in nursing education. Warren Buffett, American businessman and philanthropist, stated, “Chains of habit are too light to be felt until they are too heavy to be broken” (Warren Buffett Quotes, 2010). Breaking long-established habits of cheating and plagiarism is an essential responsibility of nursing faculty.

References

Analysis of Responses to Questions 1 and 2

Question 1: What Challenges Do Faculty Encounter Regarding Moral Integrity in Academia?

Student behaviors reflecting low moral integrityDishonesty

Lying, cheating, stealing (including cell phone and computer use, falsifying documents, time logs)

Plagiarism (aspects of lying, cheating, stealing): copying from other students, software, online information (essays, music, math questions and answers, movies)

Class/learning process

Decreased engagement, absenteeism, glad handling (saying what others want to hear versus truth), decreased participation, not working to potential, external locus of control, lack of respect for diversity

Student characteristics

Lack of knowledge, not knowing how to cite, disability, feeling pressure to compete and succeed, lowered standards (based on student beliefs), lack of work ethic, disrespectful

Student beliefs reflected in behaviors

Postmodern relativism, belief in moral diversity; no truth as norm

Sense of entitlement, sense of being “above the rules/law” (i.e., “I paid a lot of money…you owe me help”)

Class characteristics reflecting low moral integrityEnvironment

Distractions

Low class morale

Low group accountability

Delivery

Online (easier to cheat)

Instructor behaviors supporting low moral integrityPersonal characteristics

Lack of knowledge for role

Online proctoring

Lack of ability to manage classroom

Personal behaviors

Decreased student engagement

Arrive late, releasing students early

Teaching–learning behaviors

Lowered standards

Subjective versus objective assessment compensates for decreased student performance

Modify grades to fit student versus objective grading (lack of fairness in grading)

Less rigorous grading (due to pressure to improve grades)


Question 2: What Strategies Can Faculty Use to Equip Students With the Skillset for a Higher Level of Moral Integrity and Moral Courage?
Instructor BehaviorTeaching Methods and StrategiesContent to Be Taught

Model behaviors: Behaviors reflect honesty, integrity, best practice, confidentiality, respect, accountability for professional behaviorsDevelop a community of learning with academic integrity

Buddy up students, enhance instructor and student responsibility

Define, expect, and reflect respect; be on time, prepared, and vulnerable

Admit what you do not know and when you are wrong

What content?

Confidentiality, moral integrity, moral responsibility, academic integrity, ethics, emotional intelligence

Consequences of behaviors, how to hold self and others accountable

How to identify sources, (written, Internet, software, photo sources)

Critical thinking

Create a high-integrity academic environment: Hold self and students accountable for honesty, respect, confidentiality, professional behaviors, and academic performance, and treat students fairly

10.3928/01484834-20130311-01

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