Background: Nursing as an ethical practice requires courage to be moral, taking tough stands for what is right, and living by one’s moral values. Nurses need moral courage in all areas and at all levels of nursing. Along with new interest in virtue ethics in healthcare, interest in moral courage as a virtue and a valued element of human morality has increased. Nevertheless, what the concept of moral courage means in nursing contexts remains ambiguous. Objective: This article is an analysis (...) of the concept of moral courage in nursing. Design: Rodgers’ evolutionary method of concept analysis provided the framework to conduct the analysis. Data sources: The literature search was carried out in September 2015 in six databases: PubMed, CINAHL, Scopus, Web of Science, PsycINFO, and The Philosopher’s Index. The following key words were used: “moral” OR “ethical” AND “courage” OR “strength” AND “nurs*” with no time limit. After applying inclusion and exclusion criteria, 31 studies were included in the final analysis. Ethical considerations: This study was conducted according to good scientific guidelines. Results: Seven core attributes of moral courage were identified: true presence, moral integrity, responsibility, honesty, advocacy, commitment and perseverance, and personal risk. Antecedents were ethical sensitivity, conscience, and experience. Consequences included personal and professional development and empowerment. Discussion and conclusion: This preliminary clarification warrants further exploring through theoretical and philosophical literature, expert opinions, and empirical research to gain validity and reliability for its application in nursing practice. (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: Moral courage is required at all levels of nursing. However, there is a need for development of instruments to measure nurses’ moral courage. Objectives: The objective of this study is to develop a scale to measure nurses’ self-assessed moral courage, to evaluate the scale’s psychometric properties, and to briefly describe the current level of nurses’ self-assessed moral courage and associated socio-demographic factors. Research design: In this methodological study, non-experimental, cross-sectional exploratory design was applied. The data were collected using Nurses’ (...) Moral Courage Scale and analysed statistically. Participants and research context: The data were collected from a convenience sample of 482 nurses from four different clinical fields in a major university hospital in Finland for the final testing of the scale. The pilot comprised a convenience sample of 129 nurses. Ethical considerations: The study followed good scientific inquiry guidelines. Ethical approval was obtained from the university ethics committee and permission to conduct the study from the participating hospital. Findings: Psychometric evaluation showed that the 4-sub-scale, 21-item Nurses’ Moral Courage Scale demonstrates good reliability and validity at its current state of development showing a good level of internal consistency for a new scale, the internal consistency values ranging from 0.73 to 0.82 for sub-scales and 0.93 for the total scale, thus well exceeding the recommended Cronbach’s alpha value of >0.7. Principal component analysis and confirmatory factor analysis supported the theoretical construct of Nurses’ Moral Courage Scale. Face validity and expert panel assessments markedly contributed to the relevance of items in establishing content validity. Discussion and conclusion: Nurses’ Moral Courage Scale provides a new generic instrument intended for measuring nurses’ self-assessed moral courage. Recognizing the importance of moral courage as a part of nurses’ moral competence and its assessment offers possibilities to develop interventions and educational programs for enhancement of moral courage. Research should focus on further validation measures of Nurses’ Moral Courage Scale in international contexts. (shrink)

Background:Moral distress, moral sensitivity, and moral courage among healthcare professionals have been explored considerably in recent years. However, there is a paucity of studies exploring these topics among baccalaureate nursing students.Aim/objective:The purpose of this study was to explore the relationship between and among moral distress, moral sensitivity, and moral courage of undergraduate baccalaureate nursing students.Research design:The research employed a descriptive-correlational design to explore the relationships between and among moral distress, moral sensitivity, and moral courage of undergraduate nursing students.Participants and research (...) context:A total of 293 baccalaureate Filipino nursing students who have been exposed to various clinical areas participated in the study.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:Results indicate that a majority of the nursing students in the clinical areas encounter morally distressing situations that compromise quality patient care. However, despite the fact that they want to do what is in the best interest of their patients, their perception of being the inexperienced among the healthcare team drives the majority of them to ignore morally distressing situations to avoid conflict and confrontation. Another interesting finding is that 79.20% of the respondents hardly consider quitting the nursing profession even if they frequently encounter morally distressing situations. Analysis also shows associations between moral distress intensity and frequency ( r = 0.13, p < 0.05) and moral distress intensity and moral sensitivity ( r = 0.25, p < 0.05). The dimensions of moral courage are also related to both moral distress and moral sensitivity.Conclusion:Results of the study imply that moral distress is a reality among all healthcare professionals including nursing students and requires more consideration by nurse educators. (shrink)

Background: 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. Objective: To describe nurses’ self-assessed level of moral courage and its association with their socio-demographic factors. Research design: Quantitative descriptive cross-sectional study. The data were collected with Nurses’ Moral Courage Scale and analyzed statistically. Participants and research context: 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 considerations: 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. Findings: 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. Discussion: 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. Conclusion: 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. (shrink)

The purpose of this study was to measure professional and personal values among nurses, and to identify the factors affecting these values. The participants were 323 Israeli nurses, who were asked about 36 personal values and 20 professional values. The three fundamental professional nursing values of human dignity, equality among patients, and prevention of suffering, were rated first. The top 10 rated values all concerned nurses' responsibility towards patients. Altruism and confidentiality were not highly rated, and health promotion and nursing (...) research were rated among the last three professional values. For personal (instrumental) values, honesty, responsibility and intelligence were rated first, while ambition and imagination were rated 14th and 16th respectively out of 18. Significant differences (P < 0.05) were found among some personal and professional values rated as functions of culture, education, professional seniority, position and field of expertise. The results may assist in understanding the motives of nurses with different characteristics and help to promote their work according to professional ethical values. (shrink)

Background: Moral courage is one of the most fundamental virtues in the nursing profession, however, little attention has been paid to it. As a result, no exact and clear definition of moral courage has ever been accessible. Objective: This study is carried out for the purposes of defining and clarifying its concept in the nursing profession. Methods: This study used a hybrid model of concept analysis comprising three phases, namely, a theoretical phase, field work phase, and a final analysis phase. (...) To find relevant literature, electronic search of valid databases was utilized using keywords related to the concept of courage. Field work data were collected over an 11 months’ time period from 2013 to 2014. In the field work phase, in-depth interviews were performed with 10 nurses. The conventional content analysis was used in two theoretical and field work phases using Graneheim and Lundman stages, and the results were combined in the final analysis phase. Ethical consideration: Permission for this study was obtained from the ethics committee of Tehran University of Medical Sciences. Oral and written informed consent was received from the participants. Results: From the sum of 750 gained titles in theoretical phase, 26 texts were analyzed. The analysis resulted in 494 codes in text analysis and 226 codes in interview analysis. The literature review in the theoretical phase revealed two features of inherent–transcendental characteristics, two of which possessed a difficult nature. Working in the field phase added moral self-actualization characteristic, rationalism, spiritual beliefs, and scientific–professional qualifications to the feature of the concept. Conclusion: Moral courage is a pure and prominent characteristic of human beings. The antecedents of moral courage include model orientation, model acceptance, rationalism, individual excellence, acquiring academic and professional qualification, spiritual beliefs, organizational support, organizational repression, and internal and external personal barriers. Professional excellence resulting from moral courage can be crystallized in the form of provision of professional care, creating peace of mind, and the nurse’s decision making and proper functioning. (shrink)

Background: In modern healthcare, the role of solidarity, altruism and the natural response to moral challenges in life-threatening situations is still rather unexplored. The COVID-19 pandemic provided an opportunity to obtain a deeper understanding of nurses’ willingness to care for patients during crisis. Objective: To elucidate clinical expressions of ontological situational ethics through nurses’ willingness to work during a pandemic. Research design, participants and context: A qualitative study with an interpretive design was applied. Twenty nurses who worked in intensive care (...) unit at two Swedish hospitals during the first, second, and third waves of the COVID-19 pandemic were interviewed. The analysis was interpretative and applied a theoretical ethics perspective. Ethical considerations: The study was approved by the Swedish Ethical Review Authority and informed consent was obtained from all participants. Findings: From a philosophical perspective, the nurses expressed sovereign life expressions of mercy and compassion, which arose spontaneously in response to seeing vulnerable fellow humans. They referenced ‘‘the nurse inside me’’ and their choice of profession as motives to provide care. Ontological situational ethics in culture and norms were noted in the constructs of competence, responsibility, solidarity with colleagues and organization; and interest and learning were driving forces. Ethical demand was evident when nurses expressed ideas of meaningfulness in helping their fellow humans; but themes of ambiguity, exhaustion and unwillingness were also present. Conclusions: The nurses showed a high willingness to care for patients during a crisis. Responding to the ethical demand and to care for vulnerable human beings while risking their own health and lives could be interpreted as an inter-human vocation. These spontaneous altruistic actions saved the lives of many patients during the pandemic and need to be understood and supported. (shrink)

Background: Currently, graduating nurses face pandemic-related uncertainty including gaps in risk perception, unexpected Covid-19 moral dilemmas, and distress surrounding personal health risk. Research question/aim/objectives/Method: The purpose of this basic qualitative descriptive study is to describe the willingness of graduating nurses to provide care during the Covid-19 pandemic. Participants and research context: One week prior to graduation, students were required to submit a written assignment describing willingness to practice in light of the ongoing pandemic. Ethical considerations: This study was approved by (...) an Institutional Review Board. Findings/results: Eighty-four ( n = 84) assignments were used for analysis. Of these, 82% (n = 69) of the graduating nurses describe a willingness to voluntarily care for Covid-19 patients. After summarizing narrative responses, two themes emerged including self-assessment of personal and familial risk and conflicting obligations. Discussion: The assessment of risk to self and family are key in determining whether graduating nurses will care for Covid-19 patients. Conflicting obligations may contribute to stress and uncertainty potentially leading to early burnout. Conclusion: Findings from this study can inform academicians of the need to adequality prepare graduating nurses for Covid-19-associated risks and ethical decision making. Organizations should alter residencies and orientation to support the needs of new nurses. (shrink)

The aim of this study was to explore and describe how Flemish nurses experience their involvement in the care of hospitalized patients with dementia, particularly in relation to artificial nutrition or hydration (ANH). We interviewed 21 hospital nurses who were carefully selected from nine hospitals in different regions of Flanders. ‘Being touched by the vulnerability of the demented patient’ was the central experience of the nurses, having great impact on them professionally as well as personally. This feeling can be described (...) as encompassing the various stages of the care process: the nurses' initial meeting with the vulnerable patient; the intense decision-making process, during which the nurses experienced several intense emotions influenced by supporting or hindering contextual factors; and the final coping process, a time when nurses came to terms with this challenging experience. From our examination of this care process, it is obvious that nurses' involvement in ANH decision-making processes that concern patients with dementia is a difficult and ethically sensitive experience. On the one hand, the feeling of ‘being touched’ can imply strength, as it demonstrates that nurses are willing to provide good care. On the other hand, the feeling of ‘being touched’ can also imply weakness, as it makes nurses vulnerable to moral distress stemming from contextual influences. Therefore, nurses have to be supported as they carry out this ethically sensitive assignment. Practical implications are given. (shrink)