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Nurs Ethics. 2016 Nov;23(7):743-753. Epub 2015 May 14.

The moral courage of nursing students who complete advance directives with homeless persons.

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The University of Tennessee, USA.



Homeless persons in the United States have disproportionately high rates of illness, injury, and mortality and tend to believe that the quality of their end-of-life care will be poor. No studies were found as to whether nurses or nursing students require moral courage to help homeless persons or members of any other demographic complete advance directives.


We hypothesized that baccalaureate nursing students require moral courage to help homeless persons complete advance directives. Moral courage was defined as a trait of a person or an action that overcomes fears or other challenges to achieve something of great moral worth.


The hypothesis was investigated through a qualitative descriptive study. Aside from the pre-selection of a single variable to study (i.e. moral courage), our investigation was a naturalistic inquiry with narrative hues insofar as it attended to specific words and phrases in the data that were associated with that variable.


A total of 15 baccalaureate nursing students at a public university in the United States responded to questionnaires that sought to elicit fears and other challenges that they both expected to experience and actually experienced while helping homeless persons complete advance directives at a local, non-profit service agency.


The study was approved by the Internal Review Board of the authors' university, and each participant signed an informed consent form, which stated that the study involved no reasonably foreseeable risks and that participation was voluntary.


Before meeting with homeless persons, participants reported that they expected to experience two fears and a challenge: fear of behaving in ways that a homeless person would deem inappropriate, fear of discussing a homeless person's dying and death, and the challenge of adequately conveying the advance directive's meaning and accurately recording a homeless person's end-of-life wishes. In contrast, after their meetings with homeless persons, relatively few participants reported having encountered those obstacles. So, while participants required moral courage to assist homeless persons with advance directives, they required greater moral courage as they anticipated their meetings than during those meetings.


Our study breaks new ground at the intersection of nursing, moral courage, and advance directives. It might also have important implications for how to improve the training that US nursing students receive before they provide this service.


Our results cannot be generalized, but portions of our approach are likely to be transferable to similar social contexts. For example, because homeless persons are misunderstood and marginalized throughout the United States, our design for training nursing students to provide this service is also likely to be useful across the United States. Internationally, however, it is not yet known whether our participants' fears and the challenge they faced are also experienced by those who assist homeless persons or members of other vulnerable populations in documenting healthcare wishes.


Advance directives; end-of-life care; homeless; moral courage; nursing students

[Indexed for MEDLINE]

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