Exploring self-reported helping, punishment, and moral courage within and across group boundaries: Implications for the Inclusion of Others in Self scale

Nurses need moral courage to ensure ethically good care. Moral courage is an individual characteristic and therefore it is relevant to examine its association with nurses' socio-demographic factors. To describe nurses' self-assessed level of moral courage and its association with their socio-demographic factors. Quantitative descriptive cross-sectional study. The data were collected with Nurses' Moral Courage Scale and analyzed statistically. A total of 482 registered nurses from a major university hospital in Southern Finland completed the Finnish language version of Nurses' Moral Courage Scale in autumn 2017. Ethical approval was obtained from the university ethics committee and permission for the data collection from the participating hospital. Ethical principles and scientific guidelines were followed throughout the research process. Nurses' self-assessed level of moral courage was rather high. On Visual Analogy Scale (0-10), the mean value was 8.20 and the mean score of the four dimensional, 21-item Nurses' Moral Courage Scale was 4.09 on a 5-point Likert-type scale. Respondents' gender, present work role, ethical knowledge base, additional ethics education, self-study as a means to acquire ethical knowledge, and frequency of work situations needing moral courage were statistically significantly associated with nurses' moral courage. Strongest association was found between nurses' higher moral courage level and formal and informal ethics education. Honesty and patient's humane and dignified encounter received the highest scores indicating respondents' internalization of the core values of nursing. Although nurses were fairly morally courageous, moral courage should be a part of nurses' basic and continuing education thus covering its theoretical and practical learning. Since moral courage is a virtue that can be taught, learnt, and practiced, education is a relevant way to maintain and further strengthen nurses' moral courage.

AimThe purpose of this study was to assess the level of moral courage among nurses in China, and to explore related influential factors, to help nursing managers take measures to improve nurses' moral courage.DesignA cross‐sectional study.MethodsThe data adopted a convenient sampling method. From September to December 2021, 583 nurses from five hospitals in Fujian Province completed the Chinese version of the Nurses' Moral Courage Scale (NMCS). Data were analysed using descriptive statistics, chi‐square test, T‐test, Pearson correlation analysis and multiple regression analysis.ResultsThe Chinese nurses perceived themselves, on average, as morally courageous. The mean NMCS score was 3.64 ± 0.692. The six factors showed statistically significant correlations (p < 0.05) with moral courage. Regression analysis showed that the main factors influencing nurses' moral courage were active learning of ethics knowledge and nursing was a career goal.ConclusionThis study provides the self‐evaluation level and related influencing factors of Chinese nurses' moral courage. There is no doubt that nurses still need strong moral courage to face unknown ethical problems and challenges in the future. Nursing managers should pay attention to the cultivation of nurses' moral courage, using various forms of educational activities to help nurses alleviate moral problems and improve their moral courage, to maintain patients' access to high‐quality nursing.

Moral courage and understanding of its meaning are essential when nurses face ethical conflicts in their practice. This integrative review aimed to explore moral courage in nursing and possible associated individual and organizational factors. A database search in January 2020 identified 1308 scientific articles of which 25 were selected for the review. Inductive analysis with clear steps for defining and synthesizing themes in research reviews revealed three categories concerning moral courage in nursing: definition and descriptions of moral courage, characteristics of the morally courageous nurse, and skills and acts of the morally courageous nurse. Individual and organizational factors, such as positive personal experiences, commitment to ethical principles, supportive work environment and teamwork, were associated with moral courage in nursing, contributing to a more comprehensive description of nurses' moral courage. Findings indicate that in nursing practice, there is a need for promoting multi-professional collaboration and discussion of ethical dilemmas to provide opportunities to enhance moral courage. Developing care environments in which hierarchy does not inhibit nurses' moral courage seems justified. Further research on moral courage with varying methodologies and multi-disciplinary and international approaches is needed.

BackgroundMoral courage means courage to act according to individual’s own ethical values and principles despite the risk of negative consequences for them. Research about the moral courage of whistle-blowers in health care is scarce, although whistleblowing involves a significant risk for the whistle-blower.ObjectiveTo analyse the moral courage of potential whistle-blowers and its association with their background variables in health care.Research designWas a descriptive-correlational study using a questionnaire, containing Nurses Moral Courage Scale©, a video vignette of the wrongdoing situation with an open question about the vignette, and several background variables. Data were analysed statistically and inductive content analysis was used for the narratives.Participants and research contextNurses as healthcare professionals (including registered nurses, public health nurses, midwives, and nurse paramedics) were recruited from the membership register of the Nurses’ Association via email in 2019. A total of 454 nurses responded. The research context was simulated using a vignette.Ethical considerationsGood scientific inquiry guidelines were followed. Permission to use the Nurses’ Moral Courage Scale© was obtained from the copyright holder. The ethical approval and permission to conduct the study were obtained from the participating university and the Nurses’ Association.FindingsThe mean value of potential whistle-blowers’ moral courage on a Visual Analogue Scale (0–10) was 8.55 and the mean score was 4.34 on a 5-point Likert scale. Potential whistle-blowers’ moral courage was associated with their socio-demographics, education, work, personality and social responsibility related background variables.Discussion and conclusionIn health care, potential whistle-blowers seem to be quite morally courageous actors. The results offer opportunities for developing interventions, practices and education to support and encourage healthcare professionals in their whistleblowing. Research is needed for developing a theoretical construction to eventually increase whistleblowing and decrease and prevent wrongdoing.

Social responsibility can motivate disaster relief nurses to devote themselves to safeguarding rights and interests of people when facing challenges that threaten public health. However, few studies focused on the relationship of moral courage, job-esteem, and social responsibility among disaster relief nurses. To explore the influence of moral courage and job-esteem on the social responsibility in disaster relief nurses and clarify the relationship model between them. A cross-sectional study was conducted among 716 disaster relief nurses from 14 hospitals in central China through an online survey, including moral courage scale, job-esteem scale, and social responsibility questionnaire. The data were analyzed by Pearson's correlation, and the mechanism of the effect of moral courage and job-esteem on social responsibility was completed. This study was approved by the Medical Ethics Committee of the Second Xiangya Hospital of Central South University (Approval Number: 2019016). Disaster relief nurses' moral courage positively impacted social responsibility (r = 0.677, p < 0.01), and moral courage could affect social responsibility through the mediating role of job-esteem. Job-esteem mediated between moral courage and social responsibility among disaster relief nurses. Nursing managers regular assessment of nurses' moral courage and interventions such as meetings and workshops can reduce moral distress, foster morally courageous behavior, enhance job-esteem, and improve social responsibility performance among disaster relief nurses.

Background: Moral courage is defined as the courage to act in ethical conflicts based on individual or professional values despite the personal risks involved. Nurses justify their decisions to act morally courageously as part of their ethical decision-making.Objective: To describe registered nurses’ justifications for acting morally courageously, or not, in ethical conflicts where they needed moral courage.Research design: A narrative inquiry with a holistic content approach was used. Individual, in-depth interviews were conducted in January–February 2023. The data were analysed using holistic content analysis.Participants and research context: Fourteen registered nurses with experience in situations where they needed moral courage participated. The nurses came from the somatic, palliative, mental health, and substance abuse care fields in Finland.Ethical considerations: Good scientific practice was followed. Ethical approval was obtained before data collection from the university’s ethics committee.Findings: The nurses needed moral courage in ethical conflicts with patients present and between professionals. Individual responsibility, professional ethics, and emotions were identified as bases of nurses’ justifications for morally courageous acts. The justifications for acting morally courageously, or not, had individual, contextual, and organisational perspectives. Morally courageous acts included starting a discussion about the conflict with other professionals and reporting the situation in writing within one’s organisation.Discussion and conclusions: The identified bases and perspectives of justifications illustrate the complexity of nurses’ decision-making in ethical conflicts, either leading to morally courageous acts or not. These results can inform nursing practice and research in developing processes to strengthen nurses’ moral courage and examining relationships between moral courage and other concepts, such as moral resilience.

At the end of their article in the September 2014 issue of the Journal of Business Ethics, Douglas R. May, Matthew T. Luth, and Catherine E. Schwoerer state that they are “hopeful in outlook” about the “evidence that business ethics instructors are….able to encourage students…to develop the courage to come forward even when pressures in organizations dictate otherwise” (p. 78). We agree with May et al. (2014) that it is essential to augment students’ moral courage. However, it seems overly optimistic to believe that this improvement will result from any course in business ethics. Indeed, we question the appropriateness of their measure of moral courage and assert that business ethics educators must purposely design their courses to develop students’ moral courage. In particular, we advocate introducing business ethics students to works of literature featuring protagonists who exercise moral courage in organizations. Fiction provides rich accessible narratives that show students worlds beyond their experience, awaken their imaginations, and evoke their emotions. Further, we highlight morally courageous exemplars because they inspire the cultivation of character. Joining those who underscore the role of virtue in business ethics education, we argue that exposure to moral exemplars in fiction will help students to build the moral courage they need to carry out ethical decisions in the workplace. Results from 46 students at the end of an MBA ethics course featuring moral courage provide preliminary evidence of the effectiveness of our approach.

Nurses need to be resilient to be able to endure their working conditions, and their moral courage can affect their resilience. This work aimed at studying the relationship between resilience and professional moral courage among nurses working in hospitals. This descriptive cross-sectional study was conducted on 375 nurses working in teaching hospitals in the city of Ardabil in Iran in 2019. Data was collected using the following questionnaires: a demographic questionnaire, Sekerka et al. Moral Courage Scale and Davidson-Connor Resilience Scale. The reliability of the Davidson-Connor Resilience Scale, and Moral Courage Scale were found to be 89% and 85% using the test-retest method. The data were analyzed by Pearson correlation coefficient, t-test, variance analysis, and linear regression using the SPSS software version 24.In participating nurses, mean scores were 6.35±0.5 for total moral courage (favorable) and 79.35±0.35 (moderate) for resilience, respectively. A positive and significant relationship was observed between resilience and professional moral courage (P<0.05, r=0.1). Given the positive and significant relationship between resilience and professional moral courage, nurses require to have the high moral courage to enhance their resilience. Determining factors affecting moral courage and resilience, as well as finding strategies and creating an appropriate moral climate can increase nurses' morally courageous behaviors and resilience.

Nursing students required to be prepared to face ethical problems in their future workplace. Solving moral dilemmas requires the implementation of moral decisions, which necessitates significant moral courage. Moral sensitivity and moral reasoning can play a key role in the emergence of morally courageous behavior. The aim of this study was to investigate the relationship between moral sensitivity and moral reasoning with moral courage in nursing students. This was a cross-sectional study. The participants consisted of 296 nursing students of Isfahan University of Medical Sciences, Iran, in 2021, which selected through the census method. Data were collected using the Persian versions of the Moral Sensitivity and Sekerka's Moral Courage questionnaires and Nursing Dilemma Test. Data were analyzed by SPSS software (v. 25.0) using descriptive and analytical statistical methods (t-test, ANOVA, Pearson correlation, and regression analysis). A total of 296 nursing students participated in this study. The results showed no significant correlation between moral sensitivity and moral courage (r = 0.04, p = 0.41); however, a significant positive correlation was observed between moral reasoning and moral courage (r = 0.19, p < 0.05). The results of multiple regression analysis showed that moral reasoning was the only predictor of moral courage in nursing students (p < 0.05). oral reasoning ability played a more significant role in developing moral courage than moral sensitivity. Tracking the sensitivity, reasoning, and moral courage status during education can reveal valuable information on the process of moral practice formation in nurses.

Nurses need moral courage in their ethical decision-making. As a personal characteristic, moral courage varies between individuals. The aim of this study was to analyse nurses’ self-assessed moral courage, morally courageous acts and associated individual factors in older people care in one large city in Finland. The data of this cross-sectional study were collected with the ‘Nurses’ Moral Courage Scale’ (NMCS) and the main analyses were conducted with multi-way ANOVA. A total of 205 nurses responded. Respondents’ self-assessed moral courage was 4.16 on a Likert scale of 1 to 5. Higher moral courage was associated with a higher knowledge base in ethics, more frequent encountering of ethical conflicts and having several sources for knowledge of ethics, suggesting that providing ethics education for nurses in the care of older people is important. The STROBE checklist was used as the reporting guideline for the manuscript.

The relationship between occupational burnout and moral courage in operating room personnel: A cross-sectional study

Moral distress among practicing nurses is frequently discussed in the nursing literature, along with well-developed recommendations for increasing moral courage in practicing nurses. Implementing these recommendations depends on nurse leaders being morally fit to lead and to create an environment in which moral courage actions can emerge. The literature is lacking pertaining to nurse leaders’ preparation to lead in a morally courageous and transformational manner in our current corporate environments and hierarchies of healthcare. In this article, the author reviews the literature addressing moral distress and moral courage among direct care nurses; describes the development of an intervention to strengthen the moral courage of nurse leaders; reports a study that involved implementing this intervention; presents the findings of this study; evaluates the effectiveness of the intervention; and discusses the findings in terms of lessons learned and future directions. He concludes with a call for healthcare leaders to demonstrate moral courage and create environments that promote morally courageous acts that enable nurses to remain centered on the patients, families, and communities we serve.

Moral Courage – An Essential Component for Teachers’ Continuous Professional Development

The 21-item Nurses' Moral Courage Scale was developed and validated in 2018 in Finland with the purpose of measuring moral courage among nurses. The objective of this study was to make a Dutch translation of the Nurses' Moral Courage Scale to describe the level of nurses' self-assessed moral courage and associated socio-demographic factors in Flanders, Belgium. A forward-backward translation method was applied to translate the English Nurses' Moral Courage Scale to Dutch, and a pilot study was conducted to improve readability and understandability. A non-experimental, descriptive cross-sectional exploratory design was used to conduct a survey. Descriptive analysis was used. The data were collected from a convenience sample of 559 nurses from two hospitals in Flanders. Ethical approval was obtained from the university ethics committee, permission to conduct the study was obtained from the participating hospitals. Participants received a guide letter and gave their informed consent. The readability and understandability of the Dutch Nurses' Moral Courage Scale were positively evaluated, and the scale revealed a good level of internal consistency for the total scale (α = .914) and all subscales. Nurses' mean score of the 21-item Nurses' Moral Courage Scale was 3.77 (standard deviation = 0.537). The total Nurses' Moral Courage Scale score was associated with age (p < .001), experience (p < .001), professional function (p = .002), level of education (p = .002) and personal interest (p < .001). The Nurses' Moral Courage Scale was successfully translated to Dutch. The Flemish nurses perceived themselves as morally courageous, especially when they were in a direct interpersonal relationship with their patients. Acting courageously in ethical dilemmas that involved other actors or organizations appeared to be more challenging. The results strongly suggest the important role of education and ethical leadership in developing and supporting this essential virtue in nursing practice.

To holistically illustrate the consequences of nurses' morally courageous acts for patients, nurses, and work communities. Narrative inquiry was used to explore the topic in the context of encountering ethical conflicts in nursing care. Consequences of nurses' morally courageous acts were illustrated to understand the significance of the acts for the good of patients, nurses, and work communities. Ethical approval was received from the University's ethical committee. The participants were registered nurses who gave their informed consent to participate voluntarily. Individual in-depth interviews with fourteen registered nurses of varying working experience were conducted in January-February 2023. Data were analysed inductively with holistic content analysis. This report follows the Consolidated criteria for reporting qualitative research (COREQ). Nurses demonstrated moral courage in ethical conflicts such as disrespectful behaviour, collaboration issues, missed care, and privacy violations. In doing so, they initiated discussions, completed written reports, admitted mistakes, and provided attentive patient care. Morally courageous acts helped mitigate the ethical conflicts, although some remained unresolved. The direct and indirect consequences were positive and negative for nurses who acted, and positive for patients and the work community. The nurses considered the consequences of morally courageous acts for themselves and others, expressing their experiences, which excluded other people's perspectives. The complexity of the topic posed challenges in reporting the findings coherently, with only a few concepts. Nurses act morally courageously in varying ethical conflicts, indicating that they can defend morally responsible conduct. The consequences identified in this study highlight the potential for nurses who act morally courageously to promote well-being among patients and professionals. However, complex ethical conflicts cannot always be resolved with one courageous act. Thus, healthcare organisations can aim to develop processes that facilitate nurses acting morally courageously and that enhance multi-professional collaboration in ethical conflicts.