Defense Date


Graduation Date

Spring 2015


Immediate Access

Submission Type


Degree Name



Health Care Ethics


McAnulty College and Graduate School of Liberal Arts

Committee Chair

Gerard Magill

Committee Member

Henk ten Have

Committee Member

Joris Gielen

Committee Member

James Swindal


Ethical Leadership, Moral courage, Nursing Home, Nursing Home Administrator


Moral courage will no longer be an option for Nursing Home Administrators (NHA) to lead ethically with the projections for the future needs of healthcare services and the governmental involvement in containing the costs of care in the United States. The estimated increase in the 65 year and older population over the next 40 years and the accompanying impacts necessitate that healthcare will need to make significant changes from the care and services that currently exist. This growth in population of older adults will also be coupled with increased disability and declining resources. Due to these trends, persons in leadership positions in nursing homes are going to be increasingly faced with balancing competing needs and the equitable distribution of resources. For a leader to be able to function effectively within this healthcare environment requires moral courage in making the difficult decisions that are being presented. Healthcare has always been posed with ethical dilemmas at times but the rapid changes and increases in need will not allow for occasional situations to arise that necessitate difficult decisions. These will become the norm for the daily operations for care delivery and the leadership of nursing homes must possess the ability to act courageously as an advocate for the patients and residents within the limited resources.

Like most other healthcare professions, NHAs are not proficiently trained to think in ethical terms, particularly on a day-to-day basis. In addition, there are inadequate ethical guidelines in the professional associations and licensing standards for administrators. Many NHAs do not possess the skills, knowledge, or character to enact moral courage. Without moral courage the residents and patients will not have the ethical representation by the leadership which poses a concern for upholding the best interests of the residents and patients who deserve to be treated with dignity and respect as valued and unique individuals. To think ethically requires education and skill development if not already intrinsic to the person. Ethical actions must follow through the decision making process and moral courage is the conduit for ethical leadership for the Nursing Home Administrator.

To understand these ethical concepts within the healthcare realm of nursing homes and the leadership perspective is to first review the background for this need for moral courage. The heart of holding a leadership position in any healthcare organization is to manage all operational aspects that provide and support the care of the patients and residents. The historical review of healthcare in the U.S. will look at the progression to the current implementation of healthcare reform which is necessitating decisions surrounding competing needs. This evolving healthcare situation is ripening challenges for moral courage in the forms of limited education in ethics, conflicts of interest, and resource allocation. The typical scenario for ethical dilemmas has been deciding between patient and financial benefits however decisions will increasingly involve choices among competing patient needs when each patient could benefit. Past examples are summarized which outline poor ethical choices among healthcare leaders which will further support an increasing need for moral courage in decision making.

In healthcare moral courage is rooted in providing care to patients in a caring manner. The relationship between moral courage and patient care will be assessed by defining morality and courage. Courage will be further explored from a philosophical perspective within its defining qualities of gaining insight, being motivated to act with courage, and to experience a need to help another which connects it very appropriately to care. The provision of care is the core function of nursing homes which can get lost or forgotten within the organizational complexities. The NHAs who possess the attribute of courage can utilize it through acts of caring. This caring nature can be exhibited by going beyond the self for the leadership and recognizing the sanctity and dignity of all human life which can be displayed in morally courageous decisions. For NHAs to act ethically, they must recognize patients as persons first who are in need of care. To come from the point of the patient is the foundation for decisions, ethically, in which the leader must maintain a human connection. The ethics of care brings together several points that are paramount to ethical decision making for the leadership. This theory includes basic principles for moral development and the relationships between the patients and the caregivers. Although the ethics of care is relationship-based, ethical leadership is still bound to upholding the rights of the patients which are supported by traditional ethical theories based in justice. The combination of the relationships with the patients, and being an advocate for their rights, aligns moral courage with caring actions.

Moral courage is the core of ethical leadership in nursing homes and starts with a review of determinates that contribute to the NHA leading morally. While there are contributors to strong ethical leadership such as values, competencies, emotional awareness, and accountability, there are also challenges that can lead to moral compromise. There are a variety of leadership styles which will be discussed along with secondary distinctions formulated on traits, which will offer differing approaches in enacting moral courage. Some styles lend themselves more readily to promoting an ethically grounded nursing home. Several models for ethical decision making will be explained which can be applied to morally courageous resolutions.

The actions and decisions of the leadership of all organizations define the ethical climate and their morally courageous decisions set the expectations for the rest of the organization to follow. The combination of written guidelines and the actions of the leadership flow into a level of trust. The nature of the ethical climate will be apparent through both internal and external means and in the value placed on the decisions surrounding quality of care and safety within nursing homes. Compliance and ethics programs serve as another level of support for providing positive ethical environments. These programs can offer nursing homes a constant mode of checks and balances to insure that an atmosphere is maintained which promotes moral courage throughout the organization.

A barrier for leaders to be effective in making decisions requiring moral courage is the need to comprehend and develop a level of competency to do so. Several strategies will be covered that include ethics education, leadership mentoring, and case study reviews that can be utilized for training and development purposes. Also models for assessing and carrying out decisions based in moral courage will be explained as other resources for leadership development. The author also offers a model of moral courage for consideration.

For the future of nursing homes moral courage will become a requirement in executive leadership for ethical decision making in the best interests of patient care. Given the demographic changes that are evolving along with the anticipated growth and resource allocation, the challenges surrounding ethical dilemmas will become increasingly problematic. Leaders will need to be tethered to a virtuous foundation of courage and care that never loses sight of the patient as person with the sanctity and dignity in all human life. As decisions are navigated through moral courage, which is translated through behaviors and actions of the NHA, they will necessitate that the leadership have the ability to operate beyond self-interests. Where the competencies do not exist there will be a need for leadership development and an even greater need for strength of character among the highest levels of healthcare organizations to establish positive ethical climates. The NHA leaders beginning now and into the future will need to balance the care requirements against resource limitations and financial viability in a more demanding way than ever before in this ever-changing healthcare delivery system.