Background:Moral courage is defined as courage to act according to one’s own ethical values and principles even at the risk of negative consequences for the individual. In a complex nursing practice, ethical considerations are integral. Moral courage is needed throughout nurses’ career.Aim:To analyse graduating nursing students’ moral courage and the factors associated with it in six European countries.Research design:A cross-sectional design, using a structured questionnaire, as part of a larger international ProCompNurse study. In the questionnaire, moral courage was assessed with (...) a single question (visual analogue scale 0–100), the questionnaire also covered several background variables.Participants and research context:The sample comprised graduating nursing students (n = 1796) from all participating countries. To get a comprehensive view about graduating nursing students’ moral courage, the views of nurse managers (n = 538) and patients (n = 1327) from the same units in which the graduating nursing students practised were also explored, with parallel questionnaires.Ethical considerations:Ethical approvals and research permissions were obtained according to national standards in every country and all participants gave their informed consent.Results:The mean of graduating nursing students’ self-assessed moral courage was 77.8 (standard deviation 17.0; on a 0–100 scale), with statistically significant differences between countries. Higher moral courage was associated with many factors, especially the level of professional competence. The managers assessed the graduating nursing students’ moral courage lower (66.5; standard deviation 18.4) and the patients slightly higher (80.6; standard deviation 19.4) than the graduating nursing students themselves.Discussion and conclusions:In all countries, the graduating nursing students’ moral courage was assessed as rather high, with differences between countries and populations. These differences and associations between moral courage and ethics education require further research. (shrink)

Background:Moral distress is considered to be the negative feelings that arise when one knows the morally correct response to a situation but cannot act because of institutional or hierarchal constraints.Objectives:To analyze moral distress and its relation with sociodemographic and academic variables in undergraduate students from different universities in Brazil.Method:Quantitative study with a cross-sectional design. Data were collected through the Moral Distress Scale for Nursing Students, with 499 nursing students from three universities in the extreme south of Brazil answering the scale. (...) The data were analyzed in the statistical software SPSS version 22.0, through descriptive statistical analysis, association tests (t-test and analysis of variance), and linear regression models.Ethical considerations:Approval for the study was obtained from the Research Ethics Committee at Universidade Federal do Rio Grande.Findings:The mean intensity of moral distress in the constructs ranged from 1.60 to 2.55. As to the occurrence of situations leading to moral distress in the constructs, the frequencies ranged from 1.21 to 2.43. The intensity level of moral distress showed higher averages in the more advanced grades of the undergraduate nursing course, when compared to the early grades of this course (between 5 and 10 grade, average = 2.60–3.14, p = 0.000).Conclusion:The demographic and academic characteristics of the undergraduate nursing students who referred higher levels of moral distress were being enrolled in the final course semesters, were at a federal university, and had no prior degree as an auxiliary nurse/nursing technician. (shrink)

Background: Moral distress, defined as moral suffering or a psychological imbalance, can affect nursing students. However, many new instruments or adaptations of other scales that are typically used to measure moral distress have not been used for nursing students. Aim: This study aimed to translate, culturally adapt and evaluate the psychometric properties of an Italian version of the Moral Distress Scale for Nursing Students for use with delayed nursing students. Research design: The study used a cross-sectional research design. Participants and (...) research context: Incidental sampling resulted in a sample of 282 delayed nursing students enrolled between May and August 2020 in a University of central Italy. Ethical considerations: The research protocol was approved by the internal review board of the university, and all participants provided their written informed consent. Results: The study confirmed a multidimensional second-order factorial structure for the It-ESMEE with five dimensions: improper institutional conditions to teach user care, authoritarian teaching practices, disrespect for the ethical dimension of vocational training, lack of competence of the teacher and commitment of ethical dimension of user care. The internal consistency was high, and the standard error of measurement and smallest detectable change were adequate. Discussion: The It-ESMEE is able to assess moral distress in delayed nursing students with good validity and reliability. It can be used in research and to determine moral distress levels, helping teachers to monitor the condition in nursing students. Conclusion: This instrument can help in comprehending moral distress, enabling students to develop coping and intervention strategies to maintain their well-being, and to ensure the quality of nurse education. (shrink)

Drawing on the interactionist perspective of innovation and on the sustainable ethical strength framework, the present research examines the moderating role of supervisors’ moral courage to go beyond compliance in the relationships between teamwork quality, team creativity, and team idea implementation. Two field studies, using multi-source and multi-wave data, indicated that teamwork quality was positively related to team idea implementation via team creativity, particularly when team supervisors revealed moral courage to go beyond compliance. When supervisors lacked such courage, teams struggled (...) to develop creative ideas and to implement them. Robustness checks and tests of alternative theoretical explanations indicated that our model and findings are robust. From a theoretical perspective, our findings indicate that, due to its empowering and promotion focused orientation, supervisors’ courage to go beyond compliance has relevance for the teamwork and team innovation domains, playing an important moderating role in defining whether quality teamwork leads to enhanced team creativity and team idea implementation. (shrink)

Background:Nurses exposed to community health nursing commonly encounter situations that can be morally distressing. However, most research on moral distress has focused on acute care settings and very little research has explored moral distress in a community health nursing setting especially among nursing students.Aim:To explore the moral distress experiences encountered by undergraduate baccalaureate nursing students in community health nursing.Research design:A descriptive qualitative design was employed to explore the community health nursing experiences of the nursing students that led them to have (...) moral distress.Participants and research context:The study included 14 senior nursing students who had their course in Community Health Nursing in their sophomore year and stayed in the partner communities in their junior year for 6 and 3 weeks during their senior year.Ethical considerations:Institutional review board approval was sought prior to the conduct of the study. Self-determination was assured and anonymity and confidentiality were guaranteed to all participants.Findings:Nursing students are vulnerable and likely to experience moral distress when faced with ethical dilemmas. They encounter numerous situations which make them question their own values and ideals and those of that around them. Findings of the study surfaced three central themes which included moral distress emanating from the unprofessional behavior of some healthcare workers, the resulting sense of powerlessness, and the differing values and mindsets of the people they serve in the community.Conclusion:This study provides educators a glimpse of the morally distressing situations that often occurs in the community setting. It suggests the importance of raising awareness and understanding of these situations to assist nursing students to prepare themselves to the “real world,” where the ideals they have will be constantly challenged and tested. (shrink)

Background: Nurses encounter complex ethical dilemmas in everyday nursing care. It is important for nurses to have moral courage to act in these situations which threaten patients’ safety or their good care. However, there is lack of research of moral courage. Purpose: This study describes nurses’ experiences of care situations demanding moral courage and their actions in these situations. Method: A qualitative descriptive research design was applied. The data were collected with an open-ended question in the questionnaire used in validation (...) of the Nurses’ Moral Courage Scale. The sample consisted of 286 nurses from four different clinical fields in a major university hospital in Finland, providing a total of 611 answers. Data were analyzed using inductive content analysis. Ethical considerations: The study followed the commonly recognized principles of good scientific practice. The use of data was authorized by the developer of the instrument, the data collector, and the participating hospital. Ethical approval was obtained from the university ethics committee. Findings: Nurses acted morally courageously in most situations but sometimes they failed to do so. Although situations demanding moral courage varied, they could be categorized into seven main domains relating to colleagues, physicians, patients, relatives, nurses themselves, managers, and organizations. Nurses acted in the situations in different ways. The main acts in solving the situations were verbal communication or immediate action, such as interrupting of action. Conclusion: Care situations demanding moral courage focus on good and safe patient care and the patient’s good is at the center of attention. The situations are mostly related to the activities of other healthcare professionals. Findings may be applied in developing ethical nursing care through basic and continuing nursing education. Research is needed on the moral courage of physicians and managers, as well as on patients’ and their relatives’ experiences of care situations demanding moral courage. (shrink)

Background: Empathy and moral courage are important virtues in nursing and nursing ethics. Hence, it is of great importance that nursing students and nurses develop their ability to empathize and their willingness to demonstrate moral courage. Research aim: The aim of this article is to explore third-year undergraduate nursing students’ perceptions and experiences in developing empathy and moral courage. Research design: This study employed a longitudinal qualitative design based on individual interviews. Participants and research context: Seven undergraduate nursing students were (...) interviewed during or immediately following their final clinical placement. Ethical considerations: The Norwegian Social Science Data Services (NSD) approved the study. Participants were informed that their participation was voluntary and were assured confidentiality. They were informed that they could withdraw from the study at any time, without providing reasons. Findings: Affective empathy seemed to be strong among third-year undergraduate nursing students. However, they tried to handle the situations in a ‘professional’ way, and to balance their emotions. At the same time, they expressed how difficult it can be to show moral courage when confronted with poor patient care. In addition, they spoke about a lack of role models during clinical practice and supervision. Conclusions: Undergraduate nursing students are in a vulnerable position throughout their journey to become professional and to develop empathy and moral courage. The professional socialisation and forming of professional empathy and moral courage among nursing students, may be seen as a complex interaction of formal and hidden curriculum, where role models play an important role. We argue that the main theme ‘Vulnerable students – a journey towards professional empathy and moral courage’ may cover the longitudinal project as a whole. This vulnerability is something both teachers and supervisors should be aware of when following up with students in their clinical placements. (shrink)

BackgroundHaving moral courage is a crucial characteristic for nurses to handle ethical quandaries, stay true to their professional obligations towards patients, and uphold ethical principles. This concept can be influenced by various factors including personal, professional, organizational, and leadership considerations. The purpose of this study was to explore the predictors of moral courage among nurses working in hospitals.MethodsIn 2018, an observational cross-sectional study was carried out on 267 nurses employed in six hospitals located in the northern region of Iran. The (...) participants were selected through a simple random sampling technique. To collect data, a demographic information form was used along with two questionnaires. The first questionnaire was a standard survey on moral courage, while the second questionnaire was designed to assess the ethical climate. Linear regression was used to assess the predictors of moral courage.ResultsNurses had an average moral courage score of 87.07 ± 15.52 and an average moral climate score of 96.12 ± 17.17. The study showed that 16% of the variation in moral courage scores among nurses was explained by ethical climate and monthly overtime hours.ConclusionThis study underscores the significance of establishing an ethical work environment and minimizing overtime hours in order to enhance moral courage among nurses. These findings carry weight for both nursing practice and organizational policies focused on fostering ethical conduct within healthcare settings. (shrink)

Background: Food is an important part of nursing care and recognized as a basic need and a human right. Nutritional care for older adults in institutions represents a particularly important area to address in nursing education and practice, as the right to food can be at risk and health personnel experience ethical challenges related to food and nutrition. Objective: The present study investigates the development of coursework on nutritional care with a human rights perspective in a nursing programme for first-year (...) nursing students and draws upon reflections and lessons learned. Research design: The study utilized educational design research. The coursework, developed through two rounds, combined on-campus learning and clinical placement in nursing homes. Nursing studentsʼ perspectives and experiences gathered through focus groups and a written assignment informed the development and evaluation of the coursework. Participants and research context: In the first round, multistage focus group interviews were conducted with 18 nursing students before, during and after placement. In the second round, four focus group interviews with 26 nursing students were conducted shortly after placement. Ethical consideration: The study was approved by the Norwegian Centre for Research Data. Findings: Three main ʽlessons learnedʼ emerged regarding introducing a human rights perspective in nursing education: 1) the contribution of the human rights perspective in changing the narrative of ʽvulnerable and malnourished patientsʼ, 2) the importance of relationships and experiences for learning about human rights and 3) the benefit of combining development of ethical competence with a human rights perspective. Conclusion: A human rights perspective enabled the students to give meaning to nutritional care beyond understanding of food as a basic physical need. Incorporating human rights in nursing education can support nursing students and nurses in recognizing and addressing ethical and structural challenges and being able to fulfil the right to food for patients. (shrink)

Background and aim Ethical sensitivity of nurses often plays an important role in their occupational commitment and moral decision-making. In some working conditions, nurses are affected by ethical distress and fail to pursue correct ethical actions despite having knowledge and a tendency for moral practice. Therefore, the present study aimed to investigate the correlation between sensitivity and ethical distress in the nurses of patients with spinal cord injuries. Materials and methods This descriptive-analytical study was performed on 160 of the nurses (...) of patients with spinal cord injuries. The participants were selected through the purposive sampling method out of the nurses in Khatamolanbia and Sasan hospitals, Tehran, Iran. Data collection tools included the Moral Sensitivity Questionnaire by Han and Corley’s Moral Distress Scale. Data were analyzed by the independent t-test and Pearson correlation coefficient using the SPSS software version 19. Results The mean values of ethical sensitivity was 80.48 ± 14.45 and ethical distress among the subjects was 62.39 ± 3.54. Moreover, a significant negative correlation was observed between moral sensitivityand moral distress. Conclusion According to the results of this study, increased ethical sensitivity is associated with diminished moral distress among the nurses of patients with spinal cord injuries. On the other hand, moral sensitivity is of considerable importance in nurses, especially in taking care of patients with special conditions. Consequently, it is recommended to provide some conditions for maintaining and enhancing ethical sensitivity in nurses taking care of patients with spinal cord injuries. (shrink)

Introduction Good quality of care is dependent on nurses’ strong clinical skills and moral competencies, as well. While most nurses work with high moral standards, the moral performance of some nurses in some organizations shows a deterioration in their moral sensitivity and actions. The study reported in this paper aimed to explore the experiences of nurses regarding negative changes in their moral practice. Materials and methods This was a qualitative study utilizing an inductive thematic analysis approach, which was conducted from (...) February 2017 to September 2019. Twenty-five nurses participated in semi-structured interviews. Results The main theme that emerged from our analysis was one of moral neutralization in the context of an unethical moral climate. We found five sub-themes, including: feeling discouraged; normalization; giving up; becoming a justifier; and moral indifference. Conclusions Unethical moral climates in health organizations can result in deterioration of morality in nurses which can harm both patients and health systems. Some unethical behaviors in nurses can be explained by this process. (shrink)

Background Moral 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. Objective To analyse the moral courage of potential whistle-blowers and its association with their background variables in health care. Research design Was 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 context Nurses 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 considerations Good 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. Findings The 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 conclusion In 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. (shrink)

BackgroundIn order to achieve the goals of the healthcare system, nursing managers are required to comply with ethical principles in decision-making. In complex and challenging healthcare settings, it is shown that the managers’ mere awareness of ethics does not suffice and managers need to be sensitive toward making ethical decisions.AimTo explore nursing managers and their sensitivity toward ethical decision-making by analyzing their related experiences.MethodThe current study has been conducted in Iran in 2017 through a qualitative content analysis approach. Nineteen nurse (...) managers were selected purposefully from different hospitals in Tehran. Data were collected using semi-structured, in-depth, face-to-face interviews, and after transcription, they were analyzed according to the Graneheim and Lundman method.Ethical considerationsThe research was approved by the ethics committee of Tarbiat Modares University, Tehran, Iran. Participants were informed about the purpose of the study and submitted written informed consents regarding their participation. The principle of autonomy, confidentiality, and anonymity was taken into account in data collection.ResultsFifteen subcategories, three categories (assertiveness, commitment, and insight), and one theme of excellent decision-making were the results of data analysis.DiscussionFindings showed that nursing managers’ sensitivity to ethical decision-making allows them to make the best decision by insight, commitment, and assertiveness. Making a morally excellent decision ensures that ethical principles are followed in the healthcare system.ConclusionConsidering that most managers are committed to making ethical decisions, it is required to develop the scope of their insights even further using a professional management and ethical principles training program. Also, by addressing some of the ethical barriers at personal and organizational levels, the assertiveness in managers can be improved, which in turn can facilitate their ethical decision-making. (shrink)

Background: Nursing students experience ethical conflicts and challenges during their clinical education. These may lead to moral distress and disturb the learning process. Objectives: This study aimed to explore and to evaluate the nursing students’ ethical challenges in the clinical settings in Iran. Research design: This was a mixed-methods study with an exploratory sequential design. Participants and research context: A total of 37 and 120 Iranian nursing students participated in the qualitative and quantitative phases, respectively. Ethical considerations: The ethical committee (...) of Kerman University of Medical Sciences, Iran, approved the protocol of the study. Findings: Three main categories were extracted from qualitative data including Low attention of nurses to the patients’ preferences; Lack of authority; and Inadequate support. A total of 97% of the students had more than one ethical challenge in clinical settings and 48% of them stated that their challenges did not resolve. The total score of perceived ethical challenges was 62.03 ± 9.17, which was moderate. The highest mean score related to the “Low attention of nurses to the patients’ preferences” subscale. Discussion: The finding confirmed most of the existing results of other international researches about the frequency and kinds of baccalaureate nursing students’ ethical challenges. Conclusion: Identifying student ethical challenges helps teachers to manage their clinical learning process better. This study may provide a view for the nurses, clinical educators, and managers toward nursing students’ ethical challenges and their impact on nursing students’ clinical experiences. (shrink)

Background: The 21-item Nurses’ Moral Courage Scale was developed and validated in 2018 in Finland with the purpose of measuring moral courage among nurses. Objectives: 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. Research design: 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. Participants: The data were collected from a convenience sample of 559 nurses from two hospitals in Flanders. Ethical considerations: 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. Findings: 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 and all subscales. Nurses’ mean score of the 21-item Nurses’ Moral Courage Scale was 3.77. The total Nurses’ Moral Courage Scale score was associated with age, experience, professional function, level of education and personal interest. Discussion and Conclusion: 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. (shrink)

Ethical awareness enables nurses to recognize the ethical implications of all practice actions, and is an important component of safe and high quality nursing care (Milliken 2016; Milliken and Grac...