courage in nursing essay

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Perspectives: Courage in nursing leadership and innovation

This Perspectives piece is about courage in nursing leadership and innovation. I reflect on how hard it is to self-identify as a courageous nurse leader and how as a nurse pushing for innovation, you must expect to be resisted. What you do with negative responses, and how you survive, helps you to be a courageous nurse leader. In conclusion I present five pieces of personal learning from experience and reflect on how being a female in a largely female profession influences all of this. I am writing from a personal point of view, as a psychiatric and general registered nurse who has worked in the United Kingdom (UK) National Health Service (NHS), mainly in clinical care of older people. More recently I have worked in a trade union, the civil service and in a university, but currently I am a writer and broadcaster and the adviser to the Dementia Services Development Trust.

Courage can be defined as the ability to do something that frightens you. Does this mean a courageous nurse leader is someone who feels fear? Possibly. But courage is also the capacity to show strength in the face of pain or grief. I like this definition more because my experience as a nurse leader includes pain and grief. In idiomatic English ‘giving someone grief’ means to hassle or abuse them. I have had plenty of hassle and abuse in my leadership role over recent years. It has been so extraordinary I have even been asked to speak about it at a (temporarily postponed) international conference in Australia on the consequences of taking part in public discourse called ‘Care in the Age of Outrage’. Being unpopular because you are ahead of the crowd can draw the anger of people from all over the globe who may be outraged and will question your right to have a view and express it.

First question, though, am I a nurse leader? ‘Leader’ is not a title you give yourself. That would be presumptuous. The mantle of leadership only fits if given to you by followers, who may be only in a particular niche. If I am called a leader does that imply ‘as a nurse’ or ‘as a human’ or is it about my role as a citizen or political activist? The term also has emotive power. Can I claim it in my defence when confronted? We talk about people ‘setting themselves up’ as a leader. That sounds like what happens before you are knocked over, having foolishly set yourself up only for a fall. It is like when people say, ‘you’re brave’ in a tone of voice that actually means ‘you’re ill advised’.

So, it feels brave, bold or courageous to call myself a nurse leader. To give me courage, I might point to some evidence. I have definitely been described by others as a nurse leader. I have won awards for leadership from nursing journals and a national paper in my own country. But a new award ceremony follows very quickly; if you add up all the winners of all the awards there would be thousands of us, and I am ancient history on that timeline.

Other evidence might be the lists of senior jobs I have done that make people say ‘ Of course you’re a leader.’ Or maybe they mean ‘manager’, which is not the same thing. Or they might just be referring to the seniority. I was a government nurse, but did that only make me a senior manager rather than a nurse leader? And as they no longer employ me, am I now a ‘former leader’?

All this came to mind recently when I presented some difficult new ideas to a post-legislative scrutiny committee in my national parliament. I was invited as an ‘independent consultant’. Being introduced as a consultant avoids the sort of problems that would crop up if I self-identified as a nurse leader. It cannot be ‘nurse consultant’ because that is a job title I do not have. ‘Independent’ means I am not paid by anyone or employed by them to disseminate their view. I have not been given a mandate by people who voted for me, telling me what view they wanted me to represent for them. So that felt fine. I had no power from an organisational role and was completely dependent on my own capacity to get an idea across, accountable only to myself.

My message was that the politicians around the table were disingenuous in asking what should be done about failings of leadership in the NHS. I said that the jobs of those NHS leaders, including nurse directors, are now impossible. They are expected to do more but cope with fewer resources every year. They are scrutinised endlessly in a system that is relentlessly interfered with by politicians. NHS leaders are working with one hand tied behind their backs because significant numbers of acute hospital beds are filled by medically fit old people who are stuck there because the system was designed by politicians and does not reflect the demographics of real life. It is no wonder staff turnover is so high, because the culture does not encourage anyone to speak out and so they leave.

Politicians blame and shame NHS leaders, limiting their careers and crushing them with hyper-accountability. In the meeting, I used all my powers of argument, including facts and figures, telling stories and rhetorical techniques such as irony and non-verbal flourishes by waving my hands about and catching their eyes. I conveyed what many nurses and families told me they would say if they were allowed to or had the courage.

Unexpectedly, though, I made myself a hostage to fortune because it was all caught on a recording and the part where I sarcastically suggested politicians would find the current coronavirus pandemic useful for taking away their problem as a cure for delayed discharge made the front page of the national papers the next day. They implied I was advocating the use of the virus to kill people. In context, I do not regret saying it. It was not a recommendation, it was an ironic remark highlighting that politicians were failing, not the NHS staff. The clear demographic evidence of the ageing population has been available to them for decades. They needed to wake up.

Any criticism causes considerable pushback from politicians and advisers around them. I know this because I have been one – a civil servant, that is. But no politician spoke out against me at the meeting and none after. However, a charity released their mock-outrage to the worst sort of newspapers and delivered emotional tirades on radio and television describing me as odious for frightening old people. Understanding the system and why a charity would do that is important. Always ask yourself who funds and controls them.

Thus, they released an onslaught of outrage against me. I will not repeat the worst of the social media and press comments. Insulting names such as ‘scumbag’ cannot hurt you. They asked if people should check my patients for an increased rate of mortality that would reflect my criminal attitude to older people. Some insults are funny, such as the pompous retired doctor who said I am a disgrace to the nursing profession. Misogynistic terms were used and comments were made on my appearance (‘doesn’t look too healthy so she’s heading for care herself’) and other comments that were vaguely threatening, ‘May God have mercy on your soul’ – a classic phrase from pronouncement of a death sentence. One nursing organisation that should have known better ‘no platformed’ me, and cancelled a public lecture in a condescending phone call, indicating it was for my own good because the event would end up being about me rather than the topic. Theirs was a strange mix of courage/lack of courage. Brave enough to insult me, but not brave enough let me face my detractors.

However, this was balanced by so many positive responses that, after a few days of intense communication with others, I could imagine that I am indeed a national treasure. But it was a tough few days and I needed courage to get through. So, from my own experience I propose five learned behaviours that could help any nurse leader under stress.

• High-impact communication. You will be misquoted. It was painful to hear them say I thought we should ‘cull’ the older population. Counterintuitively, it actually helped me reach a far wider audience through broadcasts and interviews. I outlined on television the failure to reduce the number of delayed discharges and failure of politicians to engage with a solution. There is no point just calling out in the echo chamber of your own friends and colleagues, whether you are highlighting a wrong or proposing an innovation. You need the attention of decision makers. So, take every chance to fight back immediately in public. Do not just lick your wounds.
• Be known. When people heard the twisted misrepresentation of me, they asked who on earth this was. The smart people checked, if they did not already know, that I have a good track history of writing for publications, public pronouncements and action to improve the lives of older people. So, they listened and were supportive. Hostile people with an axe to grind joined the trolls and thoughtless correspondents, but that is a small price to pay. If you have a good reputation, defend it vigorously when it is attacked. You are worth it. But make sure you take every chance to build it in advance on a solid rock of communications about ordinary issues. You need a foundation.
• Know your stuff. Being able to say how many older people were stuck in hospital and for how long meant I was highlighting a problem that is invisible to most of the public. In spite of what is being said about ‘experts’, your expertise will be recognised if you communicate it in the right way. Use facts always. Of course, you can clothe them in emotion, but the facts are fundamental to your expertise.
• Understand the system. Your courage would drain away if you thought that a negative headline was going to finish your career. However, if you cannot afford public utterance, your professional organisation can speak for you. Use journalists who will protect a source. If your reputation is attacked, defend it as hard as you can. Do this without being defensive. One person said, ‘They picked the wrong woman’. When I asked why, they said they already knew I had the courage to push back at those attacking. In fact, knowing the social media system, I simply blocked those who were using it to try to undermine me. Using broadcast media, I defended my corner. The personal email insults I have kept in a file, making it known in public that harassment is a crime and I am storing the evidence. Know your rights, including the right to free speech.
• The fifth and final point applies to me as a woman, nurse and leader. I am a graduate of a small project called the BBC Expert Women Academy. It is a training programme for improving the gender balance of experts in the news. Journalists and producers say women are generally more inclined to let someone else take the lead and front stories. Perhaps women have been socialised into this attitude. Though there has been significant change in my lifetime, more is needed. As a high proportion of nurses are women and in leadership positions, it is clear that our profession is disproportionately affected by this self-effacement. Projects such as the academy taught me to always say yes to media opportunities and take any training available to learn how to get a message across.

In conclusion, as an older nurse with a record of leadership, my recognition is that we all need to train for it, with training based on hard experience. Make sure you know what you are talking about and push yourself forward, if that is who you are. If you do not have that power, for any reason, do what hundreds of people have done and express your support, privately or publicly, when another nurse leader such as me is in the line of fire for speaking the truth to power.

Professor June Andrews , FRCN, worked in the NHS, government, university and private sectors and is now a writer, broadcaster and international expert on health and social care of older people.

How Courageous Should Nurses Have to Be?

According to three scholars, it’s asking a lot for health care professionals to be completely selfless.

Since the start of the pandemic, we’ve heard a lot about the courage of nurses and other health care workers. But as medical ethics scholars Ann B. Hamric, John D. Arras, and Margaret E. Mohrmann argue in a 2015 paper, talking about courage in nursing can be a double-edged sword .

Hamric, Arras, and Mohrmann describe courage in terms of Aristotelian virtue ethics. Basically, a courageous person takes deliberate action in pursuit of a worthy goal despite difficulty, pain, or danger. Medical professionals helping people with contagious, deadly diseases exhibit obvious courage, they write. So do nurses who speak up about unsafe medical practices in their institutions at the risk of being fired.

Another kind of courage medical professionals need is “fortitude to risk error and failure,” the authors write. “Clinicians need courage to competently discharge their inescapable obligations to decide and to act despite irreducible uncertainty.”

In Aristotle’s view, courage is a mean between the extremes of cowardice and thoughtless, foolhardy action. One medical professional may fail to act courageously by backing away in the face of a difficult choice, but another may fail equally by blundering forward with inappropriate confidence.

Seen this way, courage seems to be a praiseworthy individual virtue. But that doesn’t tell us how an institution like a hospital or a professional group like a nurses association should think about it. For example, the authors argue, a nurse or doctor may make the heroically courageous choice to join the front lines of the fight against Ebola, but doing so shouldn’t be seen as a universal professional obligation.

“These people not only have obligations to their patients, but in many cases they also have obligations to their spouses, partners, and children, and any health care worker might also morally put her own life before that of a patient,” they write.

A different professional moral dilemma arises in the case of nurses’ responses to ethical violations within their institutions. The authors note that nursing literature often calls on nurses to courageously confront these issues. Yet this can create a no-win situation for nurses. Those who refuse to speak up might feel a sense of moral distress, viewing themselves as cowardly. But speaking up can result in real harms, like ostracization from colleagues and disunity within teams. Some people may also interpret calls to be courageous as encouragement to solve problems through confrontation, which can tip into foolhardy bravery. In some situations, the virtue required might not be courage but wisdom or compassion.

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Rather than focusing on encouraging courageous behavior in these situations, the authors argue, institutions and professional groups should focus on addressing the dysfunctional systems and power imbalances that make ethical violations more likely.

“To be sure, courage should be celebrated,” the authors write. “But demanding individual courage is no substitute for institutional justice.”

In our own moment of botched responses to the pandemic at many institutional levels, that may resonate with some nurses in new ways.

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Moral courage in nursing: A concept analysis

Affiliations.

• 1 University of Turku, Finland.
• 2 University of Turku, Finland; Turku University Hospital, Finland.
• PMID: 27005953
• DOI: 10.1177/0969733016634155

Background: Nursing as an ethical practice requires courage to be moral, taking tough stands for what is right, and living by one's moral values. Nurses need moral courage in all areas and at all levels of nursing. Along with new interest in virtue ethics in healthcare, interest in moral courage as a virtue and a valued element of human morality has increased. Nevertheless, what the concept of moral courage means in nursing contexts remains ambiguous.

Objective: This article is an analysis of the concept of moral courage in nursing.

Design: Rodgers' evolutionary method of concept analysis provided the framework to conduct the analysis.

Data sources: The literature search was carried out in September 2015 in six databases: PubMed, CINAHL, Scopus, Web of Science, PsycINFO, and The Philosopher's Index. The following key words were used: "moral" OR "ethical" AND "courage" OR "strength" AND "nurs*" with no time limit. After applying inclusion and exclusion criteria, 31 studies were included in the final analysis. Ethical considerations: This study was conducted according to good scientific guidelines.

Results: Seven core attributes of moral courage were identified: true presence, moral integrity, responsibility, honesty, advocacy, commitment and perseverance, and personal risk. Antecedents were ethical sensitivity, conscience, and experience. Consequences included personal and professional development and empowerment.

Discussion and conclusion: This preliminary clarification warrants further exploring through theoretical and philosophical literature, expert opinions, and empirical research to gain validity and reliability for its application in nursing practice.

Keywords: Concept analysis; moral courage; nursing; qualitative research; virtue ethics.

Publication types

• Concept Formation*
• Ethics, Nursing*
• Qualitative Research

Moral Courage

Nursing continues to be the most trusted of professions (Norman, 2016, cited in DeSimone 2019).  As a profession, nursing cannot separate itself from moral/ethical intent and behavior.  Nursing educators therefore have a huge responsibility for building a strong moral and ethical foundation upon which future nurses will build their practice.  

Moral courage is the ability to stand up for and practice that which one considers ethical, moral behavior when faced with a dilemma, even if it means going against countervailing pressure to do otherwise.  Those with moral courage resolve to “do the right thing” even if it puts them at personal risk of losing employment, isolation from peers and other negative consequences. One should stand up for what is right even if it means standing alone (Murray, 2010). According to former Senator from Maine Margaret Chase Smith: The right way is not always the popular and easy way. Standing for right when it is unpopular is a true test of moral character.

One should not confuse moral courage with moral arrogance or moral certitude. Individual, social, and cultural values may differ, so it is important to have open, respectful communication (Murray, 2010) While the values of honesty, integrity, fairness, compassion and respect seem to be universal, different cultures might prioritize them differently.

Nurses need moral courage to assure quality care and safety of patients, to interact with other healthcare professionals and to advocate for consistent universal care with healthcare and community organizations (Pajakoski, 2021).  Moral courage is needed to deal with unethical, unsafe or discriminatory practices (Murray, 2010).

To clarify the elements of moral courage, Numminen et al. (2016) analyzed literature and arrived at these attributes:  true presence, moral integrity, responsibility, honesty, advocacy, commitment and perseverance, and personal risk. Antecedents were ethical sensitivity, conscience, and experience. Consequences included personal and professional development and empowerment (Numminen et al., 2016)

(Adapted from  Kidder, 2005 )

He further makes us aware of impediments to exercising moral courage:

Lachman (2010) has written extensively about the virtue of moral courage.  To bolster the teaching and ability to act with moral courage, she suggests the following using the acronym CODE:

• C ourage to be moral requires:
• O bligations to honor (What is the right thing to do?)
• D anger management (What do I need to handle my fear?)
• E xpression and action (What action do I need to take to maintain my integrity?)

She discusses strategies for overcoming risk-aversion and fear in order to speak out and “do what’s right.”

Reflections:

Questions and exercises to consider with classmates and/or colleagues:

• Courage means overcoming fear - fear of failure, fear of ostracism, fear of being wrong.  Identify which aspects of clinical care cause you most fear.  What do you do to overcome that fear?
• What do you fear most in interpersonal interaction?  How do you overcome that fear in order to manage difficult discussions?
• Could we say the staff who opposed the openness and kind of care being given on 5B were exhibiting moral courage? 

Helpful Resources

Learn How to Cultivate Moral Courage Blog post by Senior Policy Advisor Liz Stokes for Healthy Nurse Healthy Nation

Recommended Readings & Viewings

DeSimone, B.  (2019). Curriculum redesign to build the moral courage values of accelerated bachelor’s degree nursing students . Sage Open Nursing , Vol 5, 1-10.

Edmonson. C. (February 17, 2015). Strengthening moral courage among nurse leaders .  OJIN: The Online Journal of Issues in Nursing ,  Vol. 20 No. 2.

Fowler, M.D. (April 7, 2021). The Nightingale still sings: ten ethical themes in early nursing in the United Kingdom, 1888-1989 .  OJIN: The Online Journal of Issues in Nursing,  Vol. 26, No. 2.

Kidder, R. M. (1996). How good people make tough choices: Resolving the dilemmas of ethical living (1st Fireside ed.). New York: Simon & Schuster.

Lachman, V.D. (September 30, 2010). Strategies necessary for moral courage . OJIN: The Online Journal of Issues in Nursing , Vol. 15, No. 3, Manuscript 3.

Murray, J. S. (September 30, 2010). Moral courage in healthcare: acting ethically even in the presence of risk . OJIN: The Online Journal of Issues in Nursing, Vol. 15, No 3.

Numminen, O., Repo, H. & Leino-Kilpi, H. (2016). Moral courage in nursing: A concept analysis. Nursing Ethics , 24(8), 878-891.

Olson, L.L., (January 31, 2021). Envisioning an ethical climate in nursing education programs .  OJIN: The Online Journal of Issues in Nursing ,  Vol. 26, No. 1, Manuscript 7.

Pajakoski, E., Rannikko, S., Leino-Kilpi, H. & Numminen, O. (2021). Moral courage in nursing: an integrative literature review.  Nursing & Health Sciences , 23(3), 570-585.

www.moraldistressproject.med.uky.edu

https://youtube.com/watch?v=eFxQfHOnVVc

Courage in everyday nursing practice

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 .)

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 Conversation s. Often what we fear does not happen, but even if it does, we have retained our self-respect and commitment to professional values.

Courageous practice

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.”

Selected references

Dobos C. Defining risk from the perspective of nurses in clinical roles. J Adv Nur . 1992;17:1303-9.

Dobos C. Understanding personal risk taking among staff nurses: critical information for nurse executives. J Nurs Adm . 1997;27(1):1-2.

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 , 2 nd 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.

1 Comment .

Very interesting information. I have been a nurse for almost 20 yrs. and have seem many changes and one very common one is the fear of taking risk because of the repercussion it might bring.

Comments are closed.

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Emerging Nurse Leader

A leadership development blog

Courage in Nursing Leadership

December 15, 2011 by rose

By Rose O. Sherman, EdD, RN, FAAN

What is Courage in Leadership

Courage in leadership is doing what is right, despite being afraid or risking negative repercussions.  Fear is the most common common reason that people give when they avoid being courageous.  Think about how you feel when you watch a leader who demonstrates personal courage.  Most likely, you will trust that leader more.  Courage comes from feeling very deeply about important values and working to achieve goals that are consistent with those values.  Although sticking to the status quo may be tempting, this is not how change occurs.  Every leader ultimately has the choice to either lead with courage or lead without it.  Taking a risk in situations where you feel passionately or a deep sense of purpose does not guarantee a successful outcome.  But many leaders over the course of their careers have situations where they did not speak up and later deeply regret it.

Examples of Courageous Leadership Behaviors

• Providing honest feedback in conversations and discussions.
• Sharing alternative viewpoints to the rest of the team.
• Speaking up rather than being compliant in silence.
• Not settling for “we have always done it this way”.
• Making decisions when you are in uncharted territory and the safe path is to do nothing.

Developing Courage

The first step to becoming a more courageous leader is to be very clear about your own vision and values.  When you choose to be courageous, it is important to know what your goals are in the situation and what you hope to achieve.   Scripting in advance what you are about to say can be helpful and anticipate the  people who will disagree with your message most.  To be courageous, you must also have the honesty to admit when you have made a mistake or took a wrong path.  Telling staff that you were wrong in a situation is a powerful act of leadership courage as is the willingness to entertain new ideas and change your assumptions.  Courage is a learned skill and all of us have the capacity to be courageous.  To be courageous means stepping our of your comfort zone and taking the risk.  As we move into the future, we will need innovation in nursing and health care that is both ground-breaking and tradition defying. Keep in mind, most great ideas begin in situations where there are naysayers who believe that it cannot be done until it happens.

Read to Lead

American Hospital Association, (November 2011).  Wrong-Site Surgery.  Hospitals and Health Networks. p. 34.

Kantor, R.M. (2011).  Courage in the C-Suite.  Harvard Business Review. 89(12), 28.

© emergingrnleader.com 2011

• Research article
• Open access
• Published: 24 May 2020

Moral courage and psychological empowerment among nurses

• Zahra Khoshmehr 1 ,
• Maasoumeh Barkhordari-Sharifabad   ORCID: orcid.org/0000-0002-9832-2280 1 ,
• Khadijeh Nasiriani   ORCID: orcid.org/0000-0003-3600-9456 2 &
• Hossein Fallahzadeh   ORCID: orcid.org/0000-0001-6518-366X 3  

BMC Nursing volume  19 , Article number:  43 ( 2020 ) Cite this article

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Moral courage is one of the fundamental values of nursing profession and a powerful method of coping with ethical problems. Psychological empowerment is a suitable method of enabling individuals to coping mental pressures of the work environment. This study determined the correlation between moral courage and psychological empowerment of nurses.

This was a descriptive cross-sectional study. A total of 180 nurses employed in different wards were selected randomly. Data were collected by Demographics Questionnaire, Sekerka’s Moral Courage Scale, and Spreitzer’s psychological empowerment Scale and analyzed with SPSS16 using descriptive and inferential statistics.

The results indicated that the mean score of moral courage was 21.11 ± 69.90 and the greatest amount of moral courage was in the dimension of “going beyond compliance”. The mean score of “psychological empowerment” was 30.9 ± 73.58 and the greatest mean belonged to “competence”. There was a positive significant correlation between “psychological empowerment” and “moral courage and its dimensions” ( P  < 0.05).

The findings suggested a correlation between moral courage and psychological empowerment. Thus, nurses’ moral courage could be enhanced by reinforcing their psychological empowerment leading to increased patient satisfaction and quality care.

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Morality is an indispensable part of human life and a subset of practical philosophy looking for the right and wrong and determining good and bad in a collection of behaviors under certain conditions [ 1 ]. The nursing profession is one of the sciences with abundant illustrative ethical aspects in the past, present, and future [ 2 , 3 ]. Since distinguishing the good and bad is in the body of ethics, the moral competency of the nursing profession may be rendered as equal to professional competency [ 3 ].

Indeed, nurses face some moral problems in their daily work that need to be resolved [ 4 , 5 ]. Identification of ethical problems requires moral sensitivity [ 6 ], and also an awareness of ethical principles [ 7 ]. Nonetheless, mere moral sensitivity and knowledge will not suffice. Nurses ought to possess moral courage to perform on the basis of what is considered ethically right provided personal values and criteria correspond to the accepted healthcare values [ 4 ].

When a person is not able to act according to the correct ethical performance, moral courage helps them to try their best to achieve their ultimate goal regardless of its consequences. To do so, they consider moral principles and perform a correct act that is not easy to do [ 8 ]. Some studies have demonstrated that moral courage is related to concepts concerning assessment of ethics under certain conditions like sensitivity to justice [ 9 ], perception of control on one’s emotions and performance such as emotional self-regulation [ 10 ], and self-efficacy [ 11 ]. Moral courage predisposes to performing ethical norms regardless of social costs [ 12 ], helping patients reduce symptoms of pain and agony, communicating effectively with patients and their families, and cooperating with physicians [ 13 ], inclination for recognizing others’ sufferings and sensitivity to them, expression of sympathy and kindness, helping the needy, doing something to decrease others’ pains and sufferings, and challenging the current situation [ 14 ].

Stress, anxiety, fear of being scolded, and rejection by colleagues and seclusion are some of the negative consequences that may be created by moral courage [ 15 ]. Moral courage helps nurses overcome many barriers like fear, thence enabling them to defend the patient effectively [ 16 ]. In their study, Day reported the rate of moral courage as low in healthcare settings and mentioned many factors such as lack of occupational certainty as barriers to nurses’ inclination for brave behaviors [ 17 ].

On the other hand, courage is the token of a powerful nurse’s good performance and quality care. Empowerment is a process completed by personal values and struggles and also by environmental factors [ 18 ]. Psychological empowerment is an appropriate solution for enabling individuals to cope with mental pressures and work stressors [ 19 ]. Studies have shown that psychological empowerment is correlated with professional satisfaction [ 20 ], exerting a predictive effect on emotional commitment [ 21 ]. The results of many studies have suggested that empowerment of personnel influences responsibility, productivity, and quality of care [ 22 ], diminishes costs, enhances organizational loyalty and confidence, and organizational entrepreneurship [ 23 ]. The findings of other studies also demonstrate that increased development and empowerment leads to reduced staff displacement, fatigue and work leave [ 24 ], promoted quality of nursing care [ 25 ], increased patient satisfaction [ 20 ], increased occupational satisfaction, and decreased turnover of nurses [ 26 ].

Observing professional ethics is an effective and powerful factor in nurses’ development [ 27 ]. Ethic of care, that is one component of nursing performance, creates and promotes moral courage [ 7 ]. Although moral courage is rendered as an important element of nursing, little attention has been paid to it so that there are very few studies focusing on this topic. Hence, this study investigated the correlation between nurses’ moral courage and psychological empowerment.

Design of the Study

This descriptive cross-sectional study was conducted in 2019. The study population consisted of all nurses employed in Khatam-al-Anbia Hospital and Shahid Beheshti Hospital affiliated to Shahid Sadoughi University of Medical Sciences, Yazd, Iran. A total of 180 participants were selected randomly using sample volume formula with confidence interval of 95%, test power of 80% and the correlation coefficient of 0.18 according to the pilot study. The inclusion criteria were: holding at least a Bachelor of Science (BS) in nursing, at least 1 year of clinical nursing experience, and inclination for participation. The research instruments were distributed by the researcher in various work shifts and collected after completion.

Data collection instruments

Data were collected by Demographics Questionnaire, Sekerka’s Moral Courage Scale, and Spreitzer’s Psychological Empowerment Scale.

The Demographics Questionnaire included information on age, gender, employment status, literacy level, marital status, official position, and work experience.

The Moral Courage Scale was developed by Sekerka et al. [ 28 ]. This 15-item scale covers five aspects: moral agency, multiple values, endurance of threat, going beyond compliance, and moral goals. Each aspect includes 3 separate items. This instrument uses a 7-point Likert scale wherein each item receives 1–7 points (from never correct = 1 to always correct = 7). Thus, the score of each item may range from 3 to 21. The minimum and maximum total scores were 15 and 105, respectively. The mean score of items in each aspect and in the whole item was considered as the moral courage score [ 28 ]. The validity of Moral Courage Scale was reported as 81% in the study by Mohammadi et al. and its reliability was estimated to be 0.85 (Cronbach’s α) using a sample volume of 30 nurses under study [ 29 ].

Spreitzer’s Psychological Empowerment Scale was used to measure nurses’ psychological empowerment [ 30 ]. This 15-item inventory uses a 5-point Likert scale (form completely disagree = 1 to completely agree = 5) to measure 5 aspects: meaningfulness, competence, self-determination, impact, and confidence so that 3 items are devoted to each aspect. The scores of this tool ranged from 15 to 75 and a higher score indicated higher perceived psychological empowerment [ 30 ]. Content and face validities were confirmed using a qualitative method by asking the opinions of 10 expert professors. The reliability of the instrument was reported as Cronbach’s α = 0.84 [ 31 ].

Data analysis

The gleaned data were imported to SPSS16 and analyzed with descriptive statistics (frequency distribution, mean and standard deviation) and inferential statistics (independent t-test, ANOVA, and Pearson correlation coefficient). Normality of data distribution was examined by Kolmogorov-Smirnov (KS) test ( P  > 0.05).

All 180 questionnaires were returned and analyzed. The mean age of the participants was 33.55 ± 6.07 years with a mean work experience of 2.40 ± 1.51 years. Most participants were female (79.4%), were married (81.1%), held a BS in nursing (93.9%), formally employed (61.7%), and held the post of a nurse (96.7%) (Table 1 ).

The results revealed that nurses enjoy a high level of moral courage so that the greatest mean belonged to “going beyond compliance” and the least mean pertained to “multiple values”. Moreover, the findings demonstrated that the rate of nurses’ psychological empowerment was moderate so that the greatest mean belonged to “competence” and the smallest mean pertained to “confidence” (Table 2 ).

The findings indicated a positive significant correlation between “psychological empowerment” and “moral courage and its dimensions” ( P  < 0.05). Besides, there was a significant correlation between moral courage and all dimensions of psychological empowerment except for “confidence” ( P  < 0.05) (Table 3 ).

The results of Pearson Correlation Coefficient Test showed a significant correlation between age and moral courage ( r  = 0.230, P  = 0.002) and between work experience and moral courage ( r  = 0.181, P  = 0.015) so that moral courage increased with increasing age and work experience (Table 4 ).

The rate of moral courage and psychological empowerment was higher among the married, those with MSc degree, head nurses/supervisors, and formally employed personnel. Moral courage score was greater in males whereas psychological empowerment score was higher in females, albeit, the difference was not statistically significant ( P  > 0.05) (Table 4 ).

This study determined the correlation between nurses’ moral courage and psychological empowerment. The findings showed that the participating nurses had a high degree of moral courage. This is consistent with the results of the study by Mahdaviseresht et al. [ 8 ], that reported a high mean score of nurses’ moral courage (90.36 ± 10.56). The studies by Taraz et al. [ 32 ], and Moosavi et al. [ 33 ], also reported a high rate of moral courage among nurses. Nonetheless, the study by Mohammadi et al. [ 29 ], reported nurses’ moral courage at the moderate level. In Day’s study, the rate of this variable was low [ 17 ]. The diversity of results in different studies may be attributed to disparities in work environment, ethical atmosphere, organizational culture, organizational and managerial support, fear of social seclusion, collective thought, and lack of acceptance by the organization [ 34 ].

In the present study, the highest score of moral courage belonged to “going beyond compliance” and the lowest score pertained to “multiple values”. Some studies reported the greatest amount of moral courage in “moral agency” [ 8 , 32 , 34 ]. This is not consistent with our results. Yet, consistent with our findings, in the studies by Mahdaviseresht et al. [ 8 ], and Taraz et al. [ 32 ], the lowest score of this variable pertained to “multiple values”. Nonetheless, in the study by Aminizadeh et al. [ 34 ], the lowest score of moral courage belonged to “endurance of threat”.

The high score of “going beyond compliance” indicates that nurses do not merely consider laws and regulations; rather, they progress beyond their internal capacity and consider doing what is correct and ideal [ 28 , 35 ], suggesting nurses’ responsibility for their profession and patients. The low score of “multiple values” indicates nurses’ inability in ethical decision-making and coping with organizational constraints that may predispose to their moral apprehension, finally affecting their quality of care [ 28 , 32 , 35 ]. This needs to be noted by the responsible authorities. Also organizations must accept moral virtues such as courage and direct organizational culture towards supporting the nurses with moral courage. Some of the consequences are the right decision making, the right action, the patient’s safety and comfort, and playing the role of care [ 16 ].

The findings of the present study revealed that the mean score of nurses’ psychological empowerment was at the moderate level. The results of other studies are consistent with this finding [ 36 , 37 , 38 , 39 , 40 ]. Ouyang et al. reported in their study the Chinese nurses’ psychological empowerment at the moderate level [ 38 ]. Moreover, another study in Egypt, suggested a moderate level of nurses’ psychological empowerment [ 37 ]. Furthermore, the findings of a systematic review demonstrated that Iranian nurses’ psychological empowerment is moderate [ 39 ]. Yet, the study by Mirkamli et al. reported Iranian nurses’ psychological empowerment at a high level [ 41 ].

In the present study, the highest score of psychological empowerment pertained to “competence” whereas the lowest score belonged to “confidence”. In the study by Zahednezhad et al., the highest mean score belonged to “competence” while the lowest mean score pertained to “self-determination” [ 31 ], which is consistent with our study in maximal score. In the study by Mirkamli et al., the maximal mean pertained to “meaningfulness” whereas the minimal score belonged to “confidence” [ 41 ], that is consistent with our study in the minimal dimension.

The low score of nurses’ “confidence” in our study indicates that they are not sure that the powerful authorities will behave justly, honestly, and equally towards them; in other words, they do not feel any personal safety and security. Hence, nursing managers ought to pay due attention to this issue.

In our study, there was a direct significant correlation between psychological empowerment and its dimensions so that increased psychological empowerment resulted in nurses’ enhanced moral courage. No study was found to have exactly investigated the association between these two variables though some studies have indirectly implied it. For instance, LaSala et al. emphasize that all nurses in all roles and all work environments ought to commit themselves to creating a structurally powerful environment that supports moral courage [ 7 ]. ZahedBabelan et al. also revealed that moral behavior, with its high psychological empowerment path coefficients, can be considered as an influential and powerful factor in empowering or developing nurses [ 27 ]. Furthermore, Sadooghiasl et al. refer to ethical and scientific competence, self-construction, and rationalism as antecedents of moral courage. They also refer to protective environment and ethical climate of the organization as a factor contributing to moral courage [ 16 ]. Kuokkanen et al. describe courage, tenacity, and self-esteem as qualities of an empowered nurse. An empowered nurse is able to act under pressure, resist criticism, and act in their performance and professional positioning without any fear. Such a nurse accepts responsibility with courage in decision-making [ 18 ].

To clarify this finding, it may be said that since increasing psychological empowerment may lead to reduced mental pressures and work environment stressors, and enhance the power of decision-making and performing moral behavior by the nursing staff [ 42 , 43 , 44 ], it can ultimately result in the creation of moral courage in nurses. Having a sense of control, competency, autonomy, positive impact, and increased motivation in relation to work affects the moral courage of nurses. In these circumstances, nurses, as moral agency, can properly manage moral dilemmas. This will improve the quality of care.

The findings showed no significant correlation among demographic variables, moral courage and psychological empowerment except that moral courage was significantly promoted with increasing age and work experience. The study by Mohammadi et al. [ 29 ], and Moosavi et al. [ 33 ], further demonstrated a positive significant correlation between moral courage and work experience that is consistent with our study. With increasing age, individuals’ awareness of a situation is enhanced and their capacity for recognizing behaviors [ 45 ]. Aultman believes that moral courage is learned over time by observing the courageous behaviors of others. The occurrence of courageous behaviors is enhanced by increasing work experience and frequent encounters with therapeutic challenges [ 46 ]. Murray also states that as the work experience of nurses increases, the impact of barriers in the work environment on nurses’ performance decreases and moral courage increases [ 5 ]. Generally, moral courage and the decisive behaviors of nurses are enhanced with increasing age and work experience and familiarity with the work environment. Using experienced nurses as role modeling for junior nurses can be an effective factor in promoting nurses’ courageous behaviors.

Limitations of the study

This study used self-reporting instruments for data collection. These instruments suffer from possibility of respondents’ fatigue and impatience in responding or shortage of time. Thus, some nurses may have not provided real answers. Another limitation was lack of control over intervening variables such as factors affecting personnel’s concentration that might have confounded the results.

Given the correlation found between psychological empowerment and moral courage, it may be concluded that promotion of nurses’ psychological empowerment can increase their moral courage. Consequently, organizations and nursing managers are obliged to provide some strategies like changing managerial style in clinical wards, nurses’ contribution to decision-makings, and expanding a suitable organizational culture to move towards promoting nurses’ mental power and its various aspects as far as possible. Providing the necessary prerequisites for promoting nurses’ psychological empowerment can lead to increased morally courageous behaviors, ultimately ending in improved nursing quality care.

Availability of data and materials

The datasets generated and analyzed during the current study are not publicly available due to an agreement with the participants on the confidentiality of the data but are available from the corresponding author on reasonable request.

Abbreviations

Master of science

Bachelor of science

Standard deviation

Analysis of variance

Kolmogorov-Smirnov

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Acknowledgments

The authors give their special thanks to all authorities and nurses that supported them in all stages of the study.

The authors received no financial support for the research, authorship, and/or publication of this article.

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Zahra Khoshmehr & Maasoumeh Barkhordari-Sharifabad

Department of Nursing, Nursing and Midwifery Research Center, Research Center for Neonate & Mother, Shahid Sadoughi University of Medical Sciences and Health Services, Yazd, Iran

Khadijeh Nasiriani

Department of Biostatistics and Epidemiology, Faculty of Health, Shahid Sadoughi University of Medical Sciences and Health Services, Yazd, Iran

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All authors (ZKH, MB-SH, KHN, and HF) have participated in the conception and design of the study. ZKH and MB-SH contributed the data collection and prepared the first draft of the manuscript. MB-SH and KHN critically revised and checked closely the proposal, the analysis and interpretation of the data and design the article. MB-SH and HF carried out the analysis, interpretation of the data and drafting the manuscript. MB-SH and KHN has been involved in revising the manuscript critically. All authors read and approved the final manuscript.

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Khoshmehr, Z., Barkhordari-Sharifabad, M., Nasiriani, K. et al. Moral courage and psychological empowerment among nurses. BMC Nurs 19 , 43 (2020). https://doi.org/10.1186/s12912-020-00435-9

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Legacy and Impact: the Life and Death of Rosa Parks

This essay about Rosa Parks highlights her significant role in the civil rights movement, particularly her refusal to give up her seat on a Montgomery bus in 1955. It emphasizes how her act of defiance sparked the Montgomery Bus Boycott, led by Martin Luther King Jr., and discusses her lifelong advocacy for justice and equality. The narrative portrays Parks as a symbol of courage and resilience, whose legacy continues to inspire the fight for civil rights, underscoring the impact one individual can have on history.

How it works

In the tapestry of history, the thread of Rosa Parks weaves a tale of defiance and determination, etching her name in the fabric of time as a luminary of courage and resilience. Her life’s journey, from the shadowed corners of segregation to the forefront of the civil rights movement, resonates as a testament to the enduring power of human spirit against the backdrop of oppression.

Rosa Louise McCauley Parks entered the world on February 4, 1913, amidst the segregated landscape of Tuskegee, Alabama.

Raised in a milieu of racial prejudice and inequality, she bore witness to the injustices inflicted upon African Americans in the Jim Crow South, igniting a spark of defiance within her soul. Yet, it was on a seemingly ordinary day—December 1, 1955—that Parks would etch her name into the annals of history.

As the evening sun dipped below the horizon, Parks boarded a Montgomery bus, her weary frame a testament to a day’s toil as a seamstress. Little did she know that her simple act of refusing to relinquish her seat to a white passenger would ignite a blaze of resistance that would reverberate across the nation. “No,” she whispered, her voice echoing through the corridors of history, as she stood her ground against the tide of injustice.

Parks’ defiance sparked the flames of the Montgomery bus boycott—a grassroots movement led by a young preacher named Martin Luther King Jr. For 381 days, African Americans in Montgomery walked in solidarity, their footsteps echoing the rhythm of change, as they boycotted the segregated bus system. In the face of adversity, Parks remained resolute, her unwavering commitment to justice inspiring millions to rise against the shackles of oppression.

Yet, Parks’ legacy transcends the confines of a single act of defiance. Throughout her life, she remained a steadfast advocate for civil rights and social justice, tirelessly working to dismantle the barriers of discrimination and inequality. In the wake of the boycott, she co-founded the Rosa and Raymond Parks Institute for Self Development, nurturing the seeds of empowerment in future generations.

Parks’ impact on the civil rights movement was profound, her courage serving as a beacon of hope in a sea of despair. Her name became synonymous with resistance, her image immortalized in the annals of history as a symbol of defiance against the tyranny of segregation. But perhaps her greatest legacy lies in the example she set for future generations—a reminder that ordinary individuals, armed with nothing but courage and conviction, can shape the course of history.

On October 24, 2005, Rosa Parks breathed her last, her legacy enduring as a beacon of light in a world shrouded in darkness. Yet, her spirit lives on in the hearts of those who continue to fight for justice and equality, her name whispered in hushed reverence as a testament to the power of one individual to ignite the flames of change. As the pages of history turn, Rosa Parks stands as a testament to the indomitable human spirit—a reminder that even in the darkest of times, hope prevails.

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"Legacy and Impact: The Life and Death of Rosa Parks." PapersOwl.com, May 12, 2024. Accessed May 15, 2024. https://papersowl.com/examples/legacy-and-impact-the-life-and-death-of-rosa-parks/

"Legacy and Impact: The Life and Death of Rosa Parks," PapersOwl.com , 12-May-2024. [Online]. Available: https://papersowl.com/examples/legacy-and-impact-the-life-and-death-of-rosa-parks/. [Accessed: 15-May-2024]

PapersOwl.com. (2024). Legacy and Impact: The Life and Death of Rosa Parks . [Online]. Available at: https://papersowl.com/examples/legacy-and-impact-the-life-and-death-of-rosa-parks/ [Accessed: 15-May-2024]

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Nursing student receives johnson & johnson scholarship.

by  Kelsey Lee ’25

I heard about this scholarship through the student’s announcements and decided to apply. There was nothing to lose, and I just wanted to help offset the burden of tuition on my mom, who is a nurse and pays for my tuition. The least I can do is try to help in any way possible.

I've learned it's always better to try and fail than not try at all.”

In the scholarship essay, I shared, “The nursing program here at USF strongly values diversity, equity, and inclusion, and those values are embedded into our learning. Not only have I learned to care for a patient, but I have also learned how to look at their situation from a holistic perspective, considering every patient’s cultural background and personal beliefs. I’ve had the pleasure of participating in culturally competent care in my clinicals by meeting and interacting with patients from all walks of life. I also had the privilege to participate in a poverty simulation. I learned how poverty can have major impacts on health when you don’t have the financial resources or access to healthy foods.”

One of the values I hold very personally is diversity and equity. This is one of the reasons why I chose USF. I'm interested in labor and delivery, and black women have the highest mortality rates in childbirth. I want to learn more about the causes and implement changes to decrease this inequity.

“Kelsey is very determined to complete her nursing program and possesses the qualities of a caring and compassionate nurse. She is a very smart, independent learner and is resilient to changes and challenges,” shared a faculty member who submitted a letter of recommendation for Kelsey.

I’ve learned a lot in my clinicals. It's definitely a big learning curve, and finally, I'm at that point where everything's starting to come together. It's really exciting to start working with a psychosocial perspective. My clinical instructor has helped me reflect and develop my thought process as a nurse. I have learned to ask, and by asking, you're empowering the client to tell you what is OK to do within their culture. It's important not to assume.

My mom and older sister, who are both nurses, have always inspired me. I have always wanted to make a positive difference in the world and help people meaningfully, and pursuing nursing is my way.

At USF, you have extra opportunities related to social justice. The community is from different parts of the world, and you learn to empathize with people from various countries. It is a very open and safe space.

I feel honored and privileged to have been selected for the Johnson & Johnson Scholarship. It is a reminder that I am heading in the right direction.

To future nursing students, I would say not to let fear of failing ever stop you from applying to the program, the scholarship, or the internship. There will be challenges, but embrace them with courage and confidence. Nursing school can be hard, and you can doubt yourself. I think we've all doubted ourselves at one point in nursing school. But just remember, you're here for a reason.

SONHP Dean Receives Distinguished Alumnus Award from The University of Rochester

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An Appraisal

Alice Munro, a Literary Alchemist Who Made Great Fiction From Humble Lives

The Nobel Prize-winning author specialized in exacting short stories that were novelistic in scope, spanning decades with intimacy and precision.

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By Gregory Cowles

Gregory Cowles is a senior editor at the Book Review.

The first story in her first book evoked her father’s life. The last story in her last book evoked her mother’s death. In between, across 14 collections and more than 40 years, Alice Munro showed us in one dazzling short story after another that the humble facts of a single person’s experience, subjected to the alchemy of language and imagination and psychological insight, could provide the raw material for great literature.

And not just any person, but a girl from the sticks. It mattered that Munro, who died on Monday night at the age of 92, hailed from rural southwestern Ontario, since so many of her stories, set in small towns on or around Lake Huron, were marked by the ambitions of a bright girl eager to leave, upon whom nothing is lost. There was the narrator of “Boys and Girls,” who tells herself bedtime stories about a world “that presented opportunities for courage, boldness and self-sacrifice, as mine never did.” There was Rose, from “The Beggar Maid,” who wins a college scholarship and leaves her working-class family behind. And there was Del Jordan, from “Lives of Girls and Women” — Munro’s second book, and the closest thing she ever wrote to a novel — who casts a jaundiced eye on her town’s provincial customs as she takes the first fateful steps toward becoming a writer.

Does it seem reductive or limiting to derive a kind of artist’s statement from the title of that early book? It shouldn’t. Munro was hardly a doctrinaire feminist, but with implacable authority and command she demonstrated throughout her career that the lives of girls and women were as rich, as tumultuous, as dramatic and as important as the lives of men and boys. Her plots were rife with incident: the threatened suicide in the barn, the actual murder at the lake, the ambivalent sexual encounter, the power dynamics of desire. For a writer whose book titles gestured repeatedly at love (“The Progress of Love,” “The Love of a Good Woman,” “Hateship, Friendship, Courtship, Loveship, Marriage”), her narratives recoiled from sentimentality. Tucked into the stately columns of The New Yorker, where she was a steady presence for decades, they were far likelier to depict the disruptions and snowballing consequences of petty grudges, careless cruelties and base impulses: the gossip that mattered.

Munro’s stories traveled not as the crow flies but as the mind does. You got the feeling that, if the GPS ever offered her a shorter route, she would decline. Capable of dizzying swerves in a line or a line break, her stories often spanned decades with intimacy and sweep; that’s partly what critics meant when they wrote of the novelistic scope she brought to short fiction.

Her sentences rarely strutted or flaunted or declared themselves; but they also never clanked or stumbled — she was an exacting and precise stylist rather than a showy one, who wrote with steely control and applied her ambitions not to language but to theme and structure. (This was a conscious choice on her part: “In my earlier days I was prone to a lot of flowery prose,” she told an interviewer when she won the Nobel Prize in 2013. “I gradually learned to take a lot of that out.”) In the middle of her career her stories started to grow roomier and more contemplative, even essayistic; they could feel aimless until you approached the final pages and recognized with a jolt that they had in fact been constructed all along as intricately and deviously as a Sudoku puzzle, every piece falling neatly into place.

There was a signature Munro tone: skeptical, ruminative, given to a crucial and artful ambiguity that could feel particularly Midwestern. Consider “The Bear Came Over the Mountain,” which — thanks in part to Sarah Polley’s Oscar-nominated film adaptation, “ Away From Her ” (2006) — may be Munro’s most famous story; it details a woman’s descent into senility and her philandering husband’s attempt to come to terms with her attachment to a male resident at her nursing home. Here the husband is on a visit, confronting the limits of his knowledge and the need to make peace with uncertainty, in a characteristically Munrovian passage:

She treated him with a distracted, social sort of kindness that was successful in holding him back from the most obvious, the most necessary question. He could not demand of her whether she did or did not remember him as her husband of nearly 50 years. He got the impression that she would be embarrassed by such a question — embarrassed not for herself but for him. She would have laughed in a fluttery way and mortified him with her politeness and bewilderment, and somehow she would have ended up not saying either yes or no. Or she would have said either one in a way that gave not the least satisfaction.

Like her contemporary Philip Roth — another realist who was comfortable blurring lines — Munro devised multilayered plots that were explicitly autobiographical and at the same time determined to deflect or undermine that impulse. This tension dovetailed happily with her frequent themes of the unreliability of memory and the gap between art and life. Her stories tracked the details of her lived experience both faithfully and cannily, cagily, so that any attempt at a dispassionate biography (notably, Robert Thacker’s scholarly and substantial “Alice Munro: Writing Her Lives,” from 2005) felt at once invasive and redundant. She had been in front of us all along.

Until, suddenly, she wasn’t. That she went silent after her book “Dear Life” was published in 2012, a year before she won the Nobel, makes her passing now seem all the more startling — a second death, in a way that calls to mind her habit of circling back to recognizable moments and images in her work. At least three times she revisited the death of her mother in fiction, first in “The Peace of Utrecht,” then in “Friend of My Youth” and again in the title story that concludes “Dear Life”: “The person I would really have liked to talk to then was my mother,” the narrator says near the end of that story, in an understated gut punch of an epitaph that now applies equally well to Munro herself, but she “was no longer available.”

Gregory Cowles is the poetry editor of the Book Review and senior editor of the Books desk. More about Gregory Cowles