Moral Courage Research Articles

Mobilizing Critical Occupational Therapy Praxis to Promote Structural Justice, Equity, and Rights[Formula: see text

Societal structures and systems compel occupational therapists, at times, to behave in ways that perpetuate injustices. Justice theorists have described how Global North social structures have created the conditions for oppression of some groups while enabling additional groups to have unearned privileges. Mobilizing critical occupational therapy praxis is an essential response. This lecture addresses three questions: why should occupational therapists integrate structural justice, equity, and rights into their everyday practices?; what gives occupational therapy the potential to be a structural justice-, equity-, and rights-oriented profession?; and, how can occupational therapy mobilize critical praxis that will promote structural justice, equity, and rights? Occupational therapy's embeddedness in structures of injustice and therapists' obligations to integrate justice, equity, and rights into their everyday practices are increasingly evident. A focus on occupational participation, growing critical consciousness, socially transformative practices, and capacity for collective action position occupational therapy to be a structural justice-oriented profession. Critical reflexivity and reflection; justice-, equity-, and rights-based lenses; and acts of resistance and disobedience to oppressive systems can help mobilize critical praxis. Occupational therapists have individual and collective opportunities for exercising the moral imagination and moral courage to mobilize critical occupational therapy praxis.

The Impact of a Study Trip to Auschwitz: Place-based Learning for Bioethics Education and Professional Identity Formation.

There are increasing calls for coverage of medicine during the Holocaust in medical school curricula. This article describes outcomes from a Holocaust and medicine educational program featuring a study trip to Poland, which focused on physician complicity during the Holocaust, as well as moral courage in health professionals who demonstrated various forms of resistance in the ghettos and concentration camps. The trip included tours of key sites in Krakow, Oswiecim, and the Auschwitz-Birkenau concentration camps, as well as meeting with survivors, lectures, reflective writings, and discussions. In-depth interviews and reflective writings were qualitatively analyzed. Resulting themes centered on greater understanding of the relationship between bioethics and the Holocaust, recognizing the need for moral courage and social awareness, deeper appreciation for the historical roles played by dehumanization and medical power and their contemporary manifestations, and the power of presence and experiential learning for bioethics education and professional identity formation. These findings evidence the significant impact of the experience and suggest broader adoption of pedagogies that include place-based and experiential learning coupled with critical reflection can amplify the impact of bioethics and humanism education as well as the process of professional identity formation of medical students.

Comparing the effects of movie-based versus case-based methods among bachelor nursing students: A quasi-experimental study

BackgroundIt is challenging for educators to select and apply the most effective educational strategies in teaching ethics to undergraduate nursing students. AimThe study aimed to compare the effect of movies-based and case-based methods, on moral sensitivity and moral courage of nursing students. MethodsThis was a quasi-experimental study conducted on 79 nursing students that divided into case-based and Movie-based groups. Data were collected using the standardized Persian versions of Lützén's moral sensitivity and Sekerka moral courage questionnaires and analysed using SPSS version 16. ResultsThe case-based and movie-based methods were significantly different only in promoting some subscales of moral sensitivity and moral courage (p < .05). However, no statistically significant difference was seen in improving the total score of moral sensitivity and courage (p > .05). ConclusionsThe case-based method may lead to the improvement of the application aspects of moral sensitivity, and the movie-based method, by engagement of emotions and visual, auditory senses, can improve some aspects of moral courage attitude. Therefore, the simultaneous use of these two methods in teaching ethics to nursing students is recommended.

Investigating the relationship between moral courage and caregiving behaviours among nurses working in COVID-19 wards in Iran.

To examine the correlation between moral courage and caregiving behaviour among nurses who are employed in the COVID-19 ward in Iran. This study is a descriptive-correlational and cross-sectional research conducted in 2021 in the city of Tehran, Iran. A total of 270 nurses employed in COVID-19 wards, who had been working in these wards for at least 1 month, were recruited from XXX hospitals and XXX Hospital. Data collection was conducted from September to November 2021. The data collection tools included a demographic information form, the Caring Dimension Inventory (CDI-25), and the Professional Moral Courage Scale (PMC). The designed questionnaire links were provided to the participants virtually through the Persian platform 'Pars Line' and via WhatsApp. Descriptive statistics and inferential statistics were used to examine the relationship between moral courage and care behaviour. There was a significant difference in the mean of caring behaviour between the age groups (<30 and >40 years old), and the work experience groups (<5 years and >15 years) (p < 0.05). Ethical values also varied significantly between certain age and experience groups (p < 0.05), but no significant differences were found in ethical behaviour across most ages (30-40 years) and work experience categories (>10 years) (p > 0.05). The level of moral courage among the nurses was higher than the median score of the instrument (87.31 ± 10.37). Among the dimensions of moral courage, the highest score was related to the dimension of ethical factors (17.64 ± 2.64), and the lowest score was related to the dimension of multiple values (17.26 ± 2.78). The level of caring behaviours among the nurses was lower than the median score of the instrument (46.11 ± 10.84). Among the dimensions of caring behaviours, the highest score was related to physical-technical behaviours (19.22 ± 5.27), and the lowest score was related to professional behaviours (1.35 ± 0.67). Based on the analysis, moral courage had a weak and inverse correlation with caring behaviours among nurses. The higher moral courage does not necessarily result in improved caregiving behaviours, emphasizing the need for further research to explore and address this relationship. No Patient or Public Contribution.

Bearing witness: Medical education and reflecting on the Holocaust then and now.

Despite advocacy from the Association of American Medical Colleges (AAMC) and The Lancet Commission on medicine, Nazism, and the Holocaust, Holocaust education is lacking in medical education. To address this gap, students at Geisinger Commonwealth School of Medicine (GCSOM) viewed an Association of American Medical College (AAMC) webinar about medicine during the Holocaust as part of the required curriculum for first year medical students introduced in 2022. As part of their doctoring course, Physician and Patient Centered Care (PPCC), students viewed the AAMC webinar "The legacy of the role of medicine during the Holocaust and its contemporary relevance" and participated in two structured reflections: a written reflection on how webinar topics inform students' professional development and a verbal reflection on learning from the Holocaust to develop a sense of moral courage, advocacy, and activism in medicine. Researchers conducted qualitative analysis of written reflections and analyzed session surveys to determine key themes and impact of the session. Of the 108 enrolled in PPCC, 59 (54.6%) completed a post session Likert scale survey assessing the impact of the webinar on their personal and professional development. As an average, respondents moderately agreed that the webinar impacted their personal and professional development, with 91% slightly, moderately, or strongly agreeing. Additionally, thematic analysis of required written reflections indicated a majority of students (62.5%) identified the need for additional medical humanities education about the Holocaust and its relevance to medicine. Holocaust education encourages medical students to bear witness to past medical atrocities and critically assess the profession and their personal-professional growth. Continued structured integration of the Holocaust in medical education supports critical self-reflection and the development of morally courageous physicians who endorse and practice social accountability in medicine.

Professional moral courage: A necessary trait that needs attention in modern nursing

Presently, nurses employed in healthcare environments encounter intricate moral and spiritual dilemmas as a result of their professional responsibilities. These challenges encompass issues such as aggressive interventions for terminally ill patients, superfluous medical examinations, and instances of deceit. The findings of the study highlighted deficiencies in the quality of care provided, inequitable power dynamics within the workforce, and a deficiency in organizational backing [1-3]. Conversely, given the numerous ethical dimensions within nursing practice such as upholding human dignity, respecting rights, and adhering to ethical standards, it is evident that ethics plays a crucial role in the framework of nursing [4]. One of the important and influential aspects in the discussion of professional ethics is the courage of professional ethics [5]. Moral courage is defined as standing up for what is right and involves a steadfast commitment to moral principles despite potential risks [6]. Moral courage is a virtue that creates the ability to perform moral behavior in a person and makes him perform morally despite obstacles. Courage is one of the most valuable human personality traits and has a central role in moral life. Moral courage is one of the basic values of the nursing profession. This value was introduced with two other values, love, and respect, by the International Honorary Society of Nurses in 1922 [2].

Nurses' justifications for morally courageous acts in ethical conflicts: A narrative inquiry.

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.

Investigating the Effect of Educational Intervention Using the Case-based Learning Method on the Sensitivity and Moral Courage of Nursing Students

Introduction: The study aimed to assess the impact of Case-based Learning on nursing students' sensitivity and moral courage. Method: The present study is semi-experimental with non-equivalent control group. The research population is nursing students in Medical Sciences who entered the study by census (61 people). The educational program was designed, and the principal learning method was based on case-based learning (CBL). Latzen's ethical sensitivity questionnaire was used to check the level of moral sensitivity, and Sekerka's questionnaire was used to determine the level of moral courage. The students completed the questionnaires before and twice after the educational interventions. The data were analyzed with descriptive and analytical tests (Pearson RM-ANOVA). Results: The number of 61 students participated in the present study. The 29 people were in the intervention group and 32 in the control group. The average age of the participants was 18.41 ± 0.49. The study results showed that the moral sensitivity scores of the students in the intervention and control groups changed significantly over time (one week and three months after the intervention) compared to before the intervention (P = 0.02). Regarding moral courage scores, no significant change was reported between the intervention and control groups before, one week, and three months after the intervention (P = 0.82). Conclusion: The present results showed that the educational intervention using the case-based learning method improved the student's moral sensitivity and maintained it over time. However, improvement in moral courage over time has not been reported significantly.

Moral courage of nursing: Bibliometric analysis.

Moral courage is a recognized virtue. Researchers have focused on various aspects of nursing moral courage, such as its conceptualization and influencing factors. Within these studies, various literature reviews have been conducted, but to our knowledge, bibliometric mapping has not been utilized. This article aims to analyze the production of literature within nursing moral courage research. To investigate publication patterns, we employed VOSviewer and CiteSpace software, focusing on publication dynamics, prolific research entities, and most cited articles. Additionally, we forecasted future research trends. In our study, ethical review was not required. A total of 105 information sources were identified in the WoS database. Overall, there has been a significant increase in research volume after 2020. The most prolific countries are the United States, Finland, and China, while the most prolific source title is "Nursing Ethics." Keywords are also related to moral dilemmas and ethics. However, there are further improvements needed in international cooperation. The results proposed in this paper can serve as a starting point for comprehensive or systematic literature reviews and seek more detailed data, information, and knowledge in the field of nursing moral courage. It can enable outsiders to quickly understand research on nursing moral courage, whether for in-depth exploration or simply to facilitate more effective collaboration with nursing ethics experts.

Connect or detach: A transformative experience for medical students in end-of-life care.

At the beginning of clinical practice, medical students face complex end-of-life (EoL) decisions, such as limiting life-sustaining therapies, which may precipitate emotionally charged moral dilemmas. Previous research shows these dilemmas may cause identity dissonance and impact students' personal and professional development. Despite the prevalence of such dilemmas, medical educators have limited insight into how students navigate these often emotional experiences. This study explores how medical students make sense of and deal with moral dilemmas lived during EoL's care. This cross-sectional qualitative study used thematic analysis (Braun and Clarke) to analyse interviews with 11 Brazilian final-year medical students. The interviews followed the drawing of a rich picture representing moral dilemmas experienced by medical students when engaging with EoL care. The reporting of this study follows the Standards for Reporting Qualitative Research (SRQR). Participants highlighted four main themes when engaging with EoL care: 'experiencing death', 'making decisions at the end-of-life', 'connecting versus detaching: an upsetting dilemma' and 'being transformed'. They described the emotional overwhelm of experiencing death and the uncertainty in navigating EoL decisions. The central moral dilemma faced was whether to connect with or detach from patients. This dilemma was lived in the context of a hidden curriculum that preaches emotional distancing as a coping mechanism. Developing the moral courage to overcome this barrier and choosing to connect became a transformative experience, significantly impacting their personal and professional development and reinforcing their commitment to patient-centred care. Connecting with patients in EoL care involves breaking cultural norms to establish meaningful connections with patients aiming for compassionate care. This process may lead to identity dissonance and also represents an opportunity for transformative learning. Educators can support this transformative process by legitimating students' connections with patients, teaching emotional regulation strategies, and leveraging personal experiences to foster trust.

Putting patients first: when home-based care staff prioritise loyalty to patients above the system and themselves. An ethnographic study

BackgroundThe growing number of older people worldwide poses challenges for health policy, particularly in the Global North, where policymakers increasingly expect seniors to live and receive care at home. However, healthcare professionals, particularly in home-based care, face dilemmas between adhering to care ideals and meeting external demands. Although they strive to uphold ethical care standards, they must deal with patients’ needs, cooperation with colleagues and management guidelines. Home-based care is an essential part of healthcare services in Norway, but staff struggle with high patient numbers and time management. This article focuses on how staff deal with ethical challenges related to contextual and organisational constraints.MethodsAn ethnographic fieldwork in three municipalities in South-East Norway. The first author conducted three to four months of participant observation in each municipality. In addition, she conducted in-depth interviews with key informants in two municipalities and a focus group interview with seven home-based care workers in one municipality. The data was analysed by using a reflexive thematic analysis.ResultsStaff in home-based care are frequently more loyal to the patient than to the system and to their own needs. To provide good care, all informants disregarded the patient’s formal decision, i.e. they provided more care than the formalised decision stipulated. To prioritise beneficence to patients, informants also disregarded some of the rules applicable in home-based care. In addition, staff accepted risks to their own safety and health to provide care in the patient’s home.ConclusionThe loyalty of home-based care staff to their patients can go beyond their loyalty to the rules of the system and even their own safety. This commitment might be attributed to a sense of doing meaningful work, to providing relationship-based and individualised care, and to strong moral courage. However, the staff’s emphasis on flexibility and individualised care also brings challenges related to unclear boundaries related to patient care.

Longitudinal Associations between Adolescents' Character Attributes and Civic Actions.

Research suggests that character attributes may enable youth to envision and perform civic actions that benefit society, but few studies have examined the longitudinal associations between character attributes and civic actions. As a response to this gap, this study investigated how specific character attributes (purpose, future mindedness, humility, and moral courage) may be differently linked to various civic actions (community service, political activities, social activism) cross-sectionally and longitudinally. Survey data were collected from 521 adolescents (Mage = 14.44, SD = 1.92, 58.5% girls, 60.8% White). Structural equation models demonstrated that purpose and future mindedness were positively associated with all three civic actions at Time 1, but not at Time 2. Humility was not associated with any Time 1 civic actions, but was negatively associated with Time 2 political activities. Moral courage was positively associated with Time 1 social activism and Time 2 political activities. Results illuminate the short-term interplay between character attributes and civic actions and point to internal resources that may promote different forms of youth civic action.

EXPLORING ETHICAL CONTINUITY: A COMPARATIVE ANALYSIS OF APOLOGY AND LETTER FROM BIRMINGHAM JAIL

This article examines the enduring relevance of Socrates' "Apology" and Martin Luther King Jr.'s "Letter from Birmingham Jail," highlighting their shared commitment to justice and ethical integrity despite the vast differences in their historical and socio-political contexts. Both texts employ powerful rhetorical strategies to advocate for truth and moral righteousness, challenging deeply ingrained societal injustices. Socrates, through his dialectical method, exposes the inconsistencies in his accusers' arguments, encouraging critical self-examination, while King, through logical reasoning and emotional appeals, compels his audience to confront the moral failings of their society. The thematic connections between the two works, particularly their emphasis on truth, moral integrity, and the courage to challenge unjust laws, underscore their timeless significance in the discourse on moral philosophy and social justice. By situating their arguments within broader ethical and intellectual traditions, both Socrates and King provide timeless models of ethical leadership and moral courage. Their works continue to resonate, offering profound insights into the ongoing struggle for a more just and equitable world, making their messages relevant for contemporary movements against injustice and oppression.

Mediating effect of moral sensitivity and professional identity between moral courage and compassion fatigue among nursing interns: a cross-sectional study

BackgroundCompassion fatigue in nursing interns contributes to career indecision and worsens the nursing shortage. While work environment and psychological factors are well-studied, the ethical dimension remains unexplored. Understanding these mechanisms, particularly the role of moral courage, is essential for designing interventions to combat compassion fatigue and address the workforce crisis. This study investigates the influence of moral courage on compassion fatigue among Chinese nursing interns, focusing on the mediating roles of moral sensitivity and professional identity.MethodsA quantitative, cross-sectional study was conducted in accordance with the STROBE guidelines. We used the convenience sampling method to recruit 467 nursing interns from four public junior colleges in Hunan Province, China in February, 2024. Data were collected using Compassion Fatigue Short Scale, Moral Courage Scale, Revised Moral Sensitivity Questionnaire, and Professional Identity Scale. Data analyses were conducted using SPSS 22.0 and Amos 21.0.ResultsThe modified model exhibited a good fit (χ2/df = 3.437, AGFI = 0.928, IFI = 0.984, TLI = 0.976, CFI = 0.984, NFI = 0.977, RMSEA = 0.072). Moral sensitivity positively influenced both moral courage and professional identity, while professional identity negatively impacted compassion fatigue. Importantly, the effect of moral courage on compassion fatigue was entirely mediated by moral sensitivity and professional identity (β = -0.114, P = 0.001).ConclusionThis study suggests that moral courage in nursing interns mitigates compassion fatigue through the combined mediating effects of moral sensitivity and professional identity. Ethics education programs fostering moral courage, moral sensitivity, and professional values in nursing students could be crucial in alleviating compassion fatigue.

Standing-up against moral violations: The predicting role of attribution, kinship, and severity.

Witnesses of moral violations stand up for their moral principles, despite facing substantial costs for intervening. Notwithstanding its importance, little is known whether responsibility attributions and the relation between the victim and a witness (i.e., kinship) have different effects on the intention to intervene in situations of different severity (e.g., moral courage situations). We predict an interaction between the situation's severity and the victims' responsibility for their plight. In less-severe situations, witnesses would be less willing to help when they perceive the victim to be responsible for their plight. However, those who are not seen as responsible would receive more help. For more-severe situations, responsibility is predicted to have no effect. Opposite effects are predicted for the relationship between the helper and the victim. We further predict that perceived costs for helping mediates witnesses' willingness to intervene. Two studies showed that people are more willing to help individuals who are perceived as being innocent, but only in less-severe situations. In more-severe situations, people's willingness to intervene increases, regardless of responsibility attributions. We did not observe effects for kinship. Moreover, we provide partial evidence that witnesses of more-severe situations indeed accept higher costs for intervention.

Latent profile analysis of nurses' moral courage: a professional values perspective.

Nurses' moral courage (NMC) enhances care quality and patient safety. Nurses' professional values promote ethical adherence, moral obligation fulfillment, and compliance to prevent ethical violations. It is necessary to explore the current status and influencing factors of moral courage from the perspective of professional values. To investigate the current situation of nurses' moral courage, analyze the latent profiles of nurses' moral courage, and explore the influencing factors from the perspective of professional values. A cross-sectional design was employed. Data were collected through convenient sampling at a tertiary hospital during May 2023 in Wuhan, Hubei province, China. A self-designed web-based questionnaire consisting of demographic characteristics, the Chinese Nurses' Professional Values Scale-Revised Version (NPVS-R-CV) and the Nurses' Moral Courage Scale (NMCS) were used for the cross-sectional survey. Latent profile analysis was conducted using the results of 3 explicit indexes of NMCS, and multivariate logistic regression was used to analyze the influencing factors of NMC. Research ethics approval (with the code of TJ- IRB 20220543) was obtained from Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology. This study included 966 nurses, predominantly female and under 30years old, with 91.10% holding a bachelor's degree. Latent profile analysis identified three moral courage profiles: low-level (31.5%), medium-level (47.2%), and high-level (21.3%). Multivariate logistic regression analysis showed significant positive correlations between professional values and moral courage, with head nurses being significantly more likely to exhibit high moral courage (OR = 3.586, p = 0.013). The moral courage of nurses can be classified into 3 subgroups. Nurses' professional values positively correlate with moral courage, with head nurses showing significantly higher levels of moral courage. Strengthening professional values through training can enhance ethical behavior in nursing, potentially improving patient care and safety.

Comparison of psychopathology, purpose in life and moral courage between nursing home and hospital healthcare workers during the COVID-19 pandemic

The COVID-19 pandemic deeply affected healthcare workers, although the impact may have differed according to different workplace contexts. The aim of this current research was to compare the psychopathology presented by hospital versus nursing home healthcare workers during the COVID-19 pandemic and to analyse the predictive role of purpose in life and moral courage in the appearance of psychopathology. This was an observational, cross-sectional study carried out on a sample of 108 healthcare workers, 54 each from a hospital or nursing homes, who were recruited during the 5 and 6th waves of the COVID-19 pandemic in Spain. Various self-reported scales were used to assess anxiety, depression, acute/post-traumatic stress disorder, drug and alcohol abuse, burnout, purpose in life, and moral courage. Compared to the hospital healthcare workers, nursing home healthcare workers had higher scores and a higher prevalence of anxiety (74.1% vs. 42%), depression (40.7% vs. 14.8%), and post-traumatic stress disorder (55.6% vs. 25.9). In the overall sample, purpose in life was a protective factor against psychopathology (OR = 0.54) and burnout (OR = 0.48); moral courage was a protective factor against depression (OR = 0.47) and acute stress (OR = 0.45); and exposure of family/friends to SARS-CoV-2 was a risk factor for acute stress (OR = 2.24), post-traumatic stress disorder (OR = 1.33), and higher burnout depersonalisation subscale scores (OR = 1.84). In conclusion, the increased presence of psychopathology in nursing home healthcare workers may be influenced by workplace and occupational contexts, personal factors such as exposure of family/friends to SARS-CoV-2, or internal dimensions such as purpose in life and moral courage. This knowledge could be useful for understanding how a future epidemic or pandemic might affect the mental health of healthcare workers in different labour contexts.

Moral sensitivity, moral courage, and ethical behaviour among clinical nurses.

Background: Ethical behaviour in nursing practice is integral to establishing a harmonious nurse-patient relationship and improving the quality of care. A multitude of factors shapes such behaviour. Therefore, it is crucial to understand the interplay between these factors. Research objectives: This study aimed to explore the mechanisms underlying the influence of moral sensitivity on nurses' ethical behaviour and clarify the mediating role of moral courage. Research design: This cross-sectional quantitative study was conducted between July and August 2023. Participants and Research Context: The sample comprised 465 clinical nurses from three tertiary hospitals in Zhengzhou City, Henan Province, China. Data were collected using the Chinese version of the Moral Sensitivity Questionnaire-Revised Version, Nurses' Moral Courage Scale, and Ethical Behaviour Scale for Nurses. Data analysis was performed with SPSS 26.0 and AMOS 24.0, using descriptive statistics, Pearson correlation analysis, structural equation modelling, and bootstrapping methods. Ethical considerations: This study was approved by the Ethical Review Committee of Life Sciences of Zhengzhou University, China. Results: The participants were predominantly female (95.1%), with a mean age of 31.9 years. Moral courage and moral sensitivity were positively correlated with ethical behaviour. Moral sensitivity was positively associated with moral courage. Moral courage partially mediates the relationship between moral sensitivity and ethical behaviour. The indirect effect of nurses' moral sensitivity on ethical behaviour was quantified through moral courage (indirect effect = 0.290). Conclusion: Moral courage intermediates nurses' moral sensitivity and ethical behaviour. This conclusion provides nursing administrators with the insight that improving clinical nurses' moral sensitivity and courage can contribute to ensuring appropriate ethical behaviour.

Student nurses experiences of moral distress: A concept analysis.

To understand how pre-registration student nurses experience moral distress and refine the concept in this population. The experience of moral distress has positive and negative effects for health professionals and negatively impacts on patient care. Moral distress is a fluid concept which permits the experience to be varied among different populations. Despite empirical research, a concept analysis has not been performed in the student nurse population. Electronic databases were searched via Ebsco Host Complete and included Cinahl, Medline, APA Psych in March 2024. Search terms included 'Moral Distress' AND 'Student', 'Moral Distress' and 'Baccalaureate.' Search limits included articles between 2014 and 2024, English Language. Twenty-five papers were included in the review and consisted of eight quantitative studies, 11 qualitative studies, three mixed methods studies and three literature/systematic reviews. An integrated mixed research synthesis (Sandelowski, Voils, Barroso 2006) was conducted and organized into Walker, Avant's (2005) framework of antecedents, attributes and consequences. Braun and Clarkes (2006) thematic analysis was then used to generate themes from the literature. Antecedents emerged as students having moral sensitivity, they recognize unethical circumstances. Attributes identified roots of moral distress. These roots include poor patient care, harm to the patient and unsafe care. Students experience of morally reprehensible events is exacerbated by the disempowerment they experience as being 'just a student'. Student nurses who do not exhibit moral courage and do not oppose immoral practices do so due to internal constraints which transpire as fear of conflict, withdrawal of learning opportunities, and fear of disruption to learning. This is influenced by their registered nurse supervisor relationship. Consequences of moral distress identify negative feelings, coping mechanisms and positive effects. The attributes of moral distress in the student nurse population have distinctive features which should be considered by nurse educators and in empirical research. None, as this is a concept analysis that contributes to theory development and is not empirical research.

Moral courage level of nurses: a systematic review and meta-analysis

BackgroundMoral distress occurs in daily nursing work and plagues nurses. Improving the level of moral courage is one of the main strategies to reduce moral distress, and low levels of moral courage may lead to nurse burnout, increased turnover, and reduced quality of care.MethodsNine electronic databases in Chinese and English were searched for the level of moral courage among nurses, including PubMed, Web of Science, EMBASE, CINAHL, CNKI, Wan fang, Wei pu, CBM and Cochrane Library, for the period from the date of database creation to April 5, 2023. The Agency for Healthcare Research and Quality (AHRQ) was used to assess the methodological quality of the included studies, followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and the Meta-analysis and Systematic Reviews of Observational Studies guidelines, and data from the included studies were meta-analyzed in STATA version 15 using a fixed-effects model.ResultsSeventeen cross-sectional studies of moderate or high quality met the eligibility criteria and involved 7718 nurses, and the Nurses’ Moral Courage Scale (NMCS) was used to measure the self-assessed moral courage level of nurses. Eleven of these studies reported total scores for nurses’ moral courage, and the meta-analysis results showed a pooled mean score of 78.94 (95% CI: 72.17, 85.72); Fourteen studies reported mean entry scores for nurses’ moral courage, and the meta-analysis results showed a pooled mean score of 3.93 (95% CI: 3.64, 4.23).ConclusionThe results of the meta-analysis showed that nurses’ moral courage levels were in the medium to high range, among the nurses who seemed to be male, non-nursing managers, high school education, had not experienced ethical issues, and considering resignation had lower levels of moral courage. The results of the meta-analysis may provide some reference for nursing managers and even hospital administrators to develop strategies to optimize nursing quality.