As we enter 2024, perhaps the most important message to emerge for managers and leaders in 2023 was the need for courage in the workplace. It is arguable that a failure in courage led to one of the most shameful episodes for healthcare in 2023, while the exercise of courage led to one of the most inspiring.

Courage is not discussed enough in management and leadership texts and where it is, it is given only a passing mention as if it does not matter or add anything to the role of the manager. This is a gross failure on the part of leadership and management texts because, as we will discuss, courage is often at the heart of good leadership and management practice. 

Here we will look at not only what courage is in the context of health and social care leadership, but also why it is important and what happens when leaders and managers fail to exercise it. Readers are encouraged to examine their own behaviours and ask questions about their own exercise of courage in the health and social care setting. 

What is courage? 

Courage is now frequently mentioned as one of the values for nursing, following on from the publication of the Chief Nurses’ 6Cs, which applied to all nurses and midwives in the UK (Department of Health, 2012). In the 6Cs’ courage is described as enabling ‘us to do the right thing for the people we care for, to speak up when we have concerns and to have the personal strength and vision to innovate and to embrace new ways of working.’

In his book ‘Courage a Philosophical Investigation’, Walton (1986) argues that for courage to be shown, three elements must be present: 

• A careful and considered presence of mind leading to a deliberate action
• Dangerous, difficult and painful circumstances
• A morally worthy intention. 

What Walton is alluding to is that courage is an action people take in the face of something potentially difficult or painful to deal with and that making the choice to act is based on an ethical and moral choice. Courage is therefore not just about thinking the right thing, it is doing it as well, even if doing so is challenging and potentially dangerous. The suggestion here is that being courageous can come at a cost. 

Why is courage important in health and social care? 

At its simplest, courage is required from managers in health and social care settings because their role, as well as leading other staff, includes defending and promoting the welfare and wellbeing of patients, many of whom are unable to do this for themselves. 

The Nursing and Midwifery Council in the Code (2018) requires that nurses challenge poor practice as part of their role in prioritising people, challenging poor practice. Acting with courage, is, in this context, a fundamental element of the role of the nurse in assessing and providing for the needs of people. 

What happens when courage fails?

Throughout the history of health and social care, there are a number of tragedies that are at least in part due to the failure of courage either of individuals or institutions. There are two which stand out, the Bristol Heart Scandal from the 1990’s and more recently the murders committed by Lucy Letby at the Countess of Chester Hospital. In both cases, some individuals showed the courage to speak up when they had concerns and in both cases it is likely that the courage of others, leaders, to act on those concerns failed. 

In the first instance, Dr Stephen Bolsin, an anaesthetist, was reportedly verbally rebuked when he raised concerns about the high death rate among paediatric heart surgery patients at the Bristol Royal Infirmary (Bristol Royal Infirmary Enquiry, 2001). The rebuke centred not around the data he was presenting about the excess deaths within the unit, but the fact that he shared the data outside of the department. Regrettably, the failure to act on the part of hospital managers played a part in some of the subsequent deaths in paediatric heart surgery patients in Bristol (Bristol Royal Infirmary Enquiry, 2001). 

More recently, following three unexpected deaths and one, now known to be, attempted murder on the neonatal unit, at the Countess of Chester Hospital, in June 2015 a consultant, Dr Stephen Brearey, shared his concerns about Letby with the then Director of Nursing and Deputy Chief Executive, Alison Kelly. Similar concerns were raised again later in the year following more deaths and further unexplained near-death episodes on the unit (Halliday et al, 2023). 

As with Bristol, the whistle blowers were castigated as ‘calling the police would be a catastrophe for the hospital and would turn the neonatal unit into a crime scene’ (Moritz et al, 2023). Again, regrettably, the continued failure to address the concerns of the whistle blowers, a failure of courage, allowed Letby to continue to murder and attempt to murder neonates (Halliday et al, 2023). 

The point being made is that the failure to have the courage to act when others have had the courage to raise concerns, can lead to tragic consequences. In both cases cited, the consequences went far beyond those which may have occurred had the people in the positions of leadership acted on what they were told in the first instance — although the inquiry into the Countess of Chester Hospital neonatal unit and Letby has yet to sit. 

When courage works

As well as situations when one party shows courage and the other does not, there is an encouraging example of when both parties show courage to emerge during 2023. In this case, a student nurse blew the whistle on the behaviour of two registered nurses; one of whom, Catherine Hudson, had used unprescribed zopiclone on two patients at the Blackpool Victoria hospital between February 2017 and November 2018 and conspired with another nurse, Charlotte Wilmot, to use it on a third. The reason for the sedations was merely to ensure they had a quiet shift (Gregory, 2023). 

In this case, rather than ignore or try to cover up what was happening, the leaders to whom the whistle was blown took decisive action. In showing courage, they not only ensured the criminal activity was dealt with, but they also avoided compounding the issue and making it worse. 

What does this mean for leaders and managers? 

What these situations, and countless others like them, point to is that managers and leaders need courage in order to do their roles. Courage is significantly more than how it is described in the 6Cs’. It requires not only that people raise concerns, but that they, especially leaders, do something when concerns are raised. 

Edmonson (2013) makes the observation that when leaders stay silent in the face of moral issues, they will eventually become blind to them. Blind leaders, especially ones who are blind to what is right and wrong, will not only fail to set the moral compass for their teams, but will  fail to act, will show a lack of courage, when the occasions requires it of them.

When nurse leaders lack courage and fails to act in ways that are courageous, then they fail to create an environment in which courage is valued and they fail to create a legacy whereby courage is passed down to the next generation (Sweeney, 2017). As we have seen, environments of care that do not value courage are dangerous places to be a patient. 

Conclusion

Here we have identified what courage might be and why it is important in a health and social care setting. We have considered two examples of when managers and leaders might have failed to exercise courage in their roles and the consequences of this. We have also considered a recent example of when both an individual and hospital leaders have put doing the right thing, and acting with courage, before their own short-term benefit and the positive impact this has had.

We have identified, as a result of the examples, that courage is an imperative for health and social care leaders and a little of what this requires of them.

In the next paper in this series, we will consider some more about what courage in leadership is all about and how health and social care managers can go about developing and testing it in their own leadership practice.