Concept analysis of moral courage in nursing: A hybrid model

Abstract

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.

Keywords

Concept analysis courage hybrid model moral courage nurse

Introduction

Courage is one of the fundamental values in the nursing profession.¹ This value coupled with two other values, namely, love and respect, were introduced by Sigma Theta Tau International in 1992. Since then, love and respect have been regarded as central to nursing care, moral principles in the profession and quality care. However, it has not underscored the value of courage theoretically and in nursing grounds.²

From the humanistic point of view, nurses require virtue of courage not only to be able to have traits of a good human but they also can provide an acceptable care level for their patient, family, and the society.^3
–5 Meanwhile, for professional growth in nursing, professional values such as courage need to be grown up to perform the functions and decisions properly and to avoid the chaos and damage.^1,6

Based on the literature review, there are various types of courage. One is physical courage in which the risk is related to physical harm, the other is moral courage when the threat is of moral or ethical nature, social courage is when there is an element of social disapproval, and physiological courage or the courage displayed when one encounters one’s own irrational fears and anxieties or fear of loss of psychological stability.⁷

Moral courage is a type of courage. Through moral courage, the nurse can sustain doing human care measures and resist against doing immoral things.^4,8 The presence of several roles for the nurses and dominance of ethical guidelines in the profession reveals the dire necessity of attention to the moral courage.⁹ Moral courage helps nurses to overcome many obstacles like fear and as a result can advocate patient in a good manner.^6,10,11 In addition, moral courage is required for compassionate practice.¹²

Although moral courage has been seen as an important element in nursing, little attention has been paid to it, and the number of research done in the area has been remarkably limited. As a result, no clear and precise definition of this phenomenon has been provided.¹³ Using the concept analysis can lead to transparency, identity-giving, and providing meaning to moral courage, creating transparency as well as increasing an understanding that can provide fundamental knowledge for performance¹⁴ and support the role of excellences in making the professional values operational.¹⁵ Also, updating the knowledge and clarifying the concepts would be a key of evidence-based operation and can provide a basis for evidence-based care.¹⁴

Concept such as moral courage is dependent on time and place. It varies based on the values, roles, culture, and social context, and each person has different definition and perception of it in different situations.⁴ This concept analysis tries to answer the following questions:

How is moral courage defined in nursing?

What are its properties, antecedents, and the consequences?

How is moral courage measured in nursing?

This study aimed to analyze the concept of moral courage in nursing using a hybrid model.

Background

According to Dehkhoda dictionary, courage means bravery and fearlessness. It is defined as the ability to do something that frightens one, bravery, and it is strength in dealing with pain or grief.¹⁶

Courage means heart and policy stability and strength in difficult and exhausting conflict; courage is a matter of heart and soul and it is rooted in the depths of the human spirit.¹⁷ Courage is one of the most valuable features of the human personality and moral life is at the focus of attention,⁴ it is also one of the principles of Islamic ethics.¹⁸ Courage, as important virtue, has been mentioned in the holy Quran. Imam Ali (AS) talks of courage as “the most courageous person who has to overcome his desire.”¹⁹

Courage means heart solidity and strength and applying wisdom in difficult conditions and in overwhelming conflicts. Courage is a matter of heart and roots in the human spirit deeply.¹⁷

Courage indeed means the oriflamme that covers a wide range. As its intensity increases, its value and importance would increase. In fact, any degree of it, whether mild or severe, is not undesirable and it is an issue that does not involve extremes.¹⁹

The root of courage is from Old French corage (Modern French courage) “heart, innermost feelings; temper,” from Vulgar Latin *coraticum (source of Italian coraggio, Spanish coraje), from Latin cor “heart,” from Proto-Indo-European (PIE) root *kerd- “heart” which remains a common metaphor for inner strength. In Middle English, used broadly for “what is in one’s mind or thoughts,” hence “bravery,” but also “wrath, pride, confidence, lustiness,” or any sort of inclination. Replaced Old English ellen, which also meant “zeal, strength.”²⁰

Moral courage is the ability to stand on to do the right thing based on moral values when compared with known risks to face.⁸ Kidder believes that without moral courage, brightest virtues rust from lack of use and with it, a more ethical world is built piece by piece.⁸

Methods

In this study, the concept of moral courage in nursing was analyzed using a hybrid model. This model includes three phases: theoretical phase, field work phase, and final analysis phase.²¹

Theoretical phase

A systematic method was conducted in this phase. The procedure was designed and conducted based on York University Guidelines. A protocol including selecting review questions, inclusion criteria, search strategy, study selection, data extraction, quality assessment, data synthesis, and plan for dissemination was set and implemented.²²

The databases of PubMed, PROQUEST, OVID, SCOPUS, WEB OF SCIENCE, CINAHL, Med-lib, SID, MagIran, Iran doc, and Iran-Medex were searched with a combination of keywords (courage/bravery/dare/daring, ethics/moral, nurse/nursing, measure, tool, scale, questionnaire, inventory, instrument, and Moral Courage) both in Persian and English without time limit until the end of 2014. In the initial search, 750 titles were obtained. The inclusion and exclusion criteria were applied and the quality of the texts was assessed.

Inclusion criteria: texts both in English and Persian language were included; an access to the abstracts of studies with qualitative, quantitative, mixed method design was implemented, and instrument development, systematic and integrative review, and peer review of articles were carried out. Definition, properties, antecedent, consequence, and measuring of the concept should be mentioned in the texts. Exclusion criteria: book reviews; texts in other languages.

Figure 1 shows the process of reviewing and selecting the texts in the theoretical phase. As the figure shows, first duplicated records were removed, then abstracts were assessed for concept-relatedness, and after that, full texts were reviewed for eligibility and relatedness in order to conform to the aim of study.

Figure 1.

Flow diagram of search process.

A total of 26 texts in English and Persian were selected and analyzed. Nine original research articles, 15 review articles, a thesis, and 1 chapter of a book were included in the study. The origin of the texts was as follows: 17 texts from America, 3 from England, 2 from Sweden, and 1 from Denmark, New Zealand, Canada, and Iran (in Persian).

Table 1 shows an overview of identified original articles (n = 9) and dissertation (n = 1) on moral courage in nursing.

Table 1.

Overview of identified original articles (n = 9) and dissertation (n = 1) on moral courage in nursing.

Author(s)/country	Sample/sample size	Design/data collection method	Analysis technique
Horton-Deutsch et al. (2014)/USA²⁵	Nurse leader 14	Interpretive phenomenological study Individual interviews and two focus groups	Hermeneutic
Thorup et al.⁵/Denmark	Nurse from Sweden(23), Finland(7), and Denmark(8)	Qualitative semi-structured interview	Coherent interpretation as formulated by Kvale and Brinkmann
Lindh et al.⁴/Sweden	Published research articles CINAHL 12 (9 articles + 3 dissertations)	Theoretical analysis Search	Theoretical analysis
Lindh et al.²³/Sweden	Registered nurse 8	Hermeneutic Individual interview	Hermeneutic
Hawkins and Morse²/Rexburg	Articles 18	Pragmatic meta-analytic concept analysis (Morse) Literature review	Meta-analysis
Mohammadi et al.¹⁰/Iran	Nurse 313	Descriptive correlational study Designing questionnaire Questionnaire	Descriptive and analytical statistics
Spence and Smythe¹/New Zealand	Registered nurse 20	Hermeneutic study Interview	Gadamer’s hermeneutic principles
Black et al.¹¹/UK	Nurse educator 19	Hermeneutic study Individual reflective interview	Gadamer’s hermeneutic principles
Curtis¹²/UK	Student nurse 19	Glazerian grounded theory Individual in-depth interview	Glazerian grounded theory
Dinndorf-Hogenson⁸/Dissertation USA (South Dakota)	Perioperative Registered nurses 154	Descriptive correlational study Designing questionnaire Questionnaire	Descriptive, correlational

The conventional content analysis method was used to analyze texts according to stages proposed by Graneheim and Lundman. The texts were read word by word, line by line, and paragraph by paragraph for several times to obtain the general understanding. Next, some parts of the text were selected; and the meaning of units and initial codes were extracted. Then, similar codes were classified as sub-categories. The sub-category formed categories together. An attempt was made to create homogeneity within the category but the highest heterogeneity between the categories. The categories also formed the themes.²⁴ In this phase, 494 initial codes, 16 sub-categories, 8 categories, and 4 themes were obtained. The search of articles continued into the next phase of the study, that is, field work phase.

Field work phase

Field data were collected from 10 participants beginning from November 2013 and ending to November 2014. The participants were chosen purposefully. Interview and observation of non-verbal behaviors were the main ways to collect the data. Individual, face-to-face, in-depth, and semi-structured interviews with the participants were continued until data saturation, and additional interviews were conducted with the participants, when necessary. Except for one, all of the other interviews were recorded. In the selection of participants, the maximum diversity in terms of gender, age, marital status, education level, clinical experience, sector and type of organization, and employment status were considered. The location and time of the interviews were selected according to the participants’ desired time and location.

The interview guiding questions at this phase included the following:

What do you do in situations where it is contrary to professional ethics?

What is moral courage in nursing?

What factors affect nurses’ moral courage?

What results are followed by moral courage?

How is moral courage measured in nursing?

The interviews’ period time varied between 50 and 110 min (mean, 65.2 min). The place for interviews was selected according to the participants. The interviews were implemented as soon as possible. The data were managed and organized using MAXQDA software, Ver10. To ensure the trustworthiness of qualitative data, the Lincoln and Guba criteria, including credibility, confirmability, dependability, and transferability, were used.²⁶ A total of 11 interviews were conducted with 10 participants. Table 2 shows the profile of the participants.

Table 2.

Profile of participants in field work phase.

Participant	Gender	Age	Marital status	Education level	Clinical experience	Department	Position	Sector and type of organization
1	Female	47	Single	BSc	23	Nursing office	Supervisor	Governmental and educational
2	Female	35	Single	Master’s student	10	CCU	In-charge nurse	Governmental and non-educational
3	Male	29	Single	PhD student	2	ICU	Nurse	Private
4	Male	28	Single	BSc	8	Orthopedic	Nurse	Private (bank)
5	Female	41	Single	BSc	16.5	Pediatric	Nurse	Governmental and educational
6	Female	42	Single	MSc	16.2	Internal (cardiac)	Head nurse	Governmental and educational
7	Male	32	Married	BSc	7	Emergency department	In-charge nurse	Private (military setting)
8	Female	32	Single	MSc	5.3	Internal	In-charge nurse	Private (oil company)
9	Female	44	Married	BSc	15	PICU	In-charge nurse	Governmental and educational
10	Male	37	Married	Master’s student	11	ICU	In-charge nurse	Governmental and educational

CCU: coronary care unit; ICU: intensive care unit; PICU: pediatric intensive care unit.

For data analysis, the conventional content analysis was used according to the proposed process by Graneheim and Lundman.²⁴

Transcribed interviews were read word by word, line by line, and paragraph by paragraph for several times in order to obtain the general understanding and themes. Next, the meaning of units and initial codes were extracted. Then, similar codes were classified as sub-categories. The sub-categories formed categories together. An attempt was made to create homogeneity within the categories but the highest heterogeneity between the categories. The categories also formed the themes.

In the field work phase, 226 initial codes, 44 sub-categories, 12 categories, and 4 themes were obtained.

Ethical considerations

Permission for this study was obtained from the ethics committee of Tehran University of Medical Sciences (Ethics approval number 92/130/1681). Oral and written informed consent was received from the participants. The participants were allowed to leave the study at any time. All participants were assured that recorded interviews would be kept private and results would be reported anonymously.

Model case

Mr R is a 37-year-old nurse and works in an intensive care unit. He observes his colleagues’ inappropriate patient caring. He sees that the patient’s rights and safety is in danger. He decides to interfere and protect the patient’s safety. He knows that his interference makes his colleague upset and is accompanied with retaliation; however, he takes the risk and interferes. At the end, the patient’s life is protected and R feels pleasant.

Contrary case

Mrs M is a young nurse, working in neo-natal care unit and taking care of a 3-day neonate with hydrocephaly. Over her working shift, a physician asks her to withhold the Medicaid and let the infant expire. She should accept or lose the job. She knows the physician’s order is against morality; however, she prefers to perform the physician’s request and save her job.

Results

Theoretical phase

Four main themes at this phase revealed and stated as the term of features (properties), antecedents, and consequences.

Features and the concept definition

Inherent–transcendental

The inherent–transcendental feature has been mentioned in the literature related to moral courage in different disciplines. The moral courage has been named as an admirable professional and humanity virtue,¹⁵ the first and most basic human characteristic and an ethical act,^27,28 an internal and exclusive unique phenomenon.²⁹ Moral courage helps other virtues to stabilize, and its absence causes dwindling of other virtues.³⁰

Facing difficulty

Another characteristic of this concept is in time of facing difficulty that can be summarized in fear and risk management. Its examples are appropriate response to fear and overcoming fear, embracing risk, taking suitable positions on the challenging issues, and standing for the maintenance of the values.

Antecedents of the concept

Model orientation–model acceptance

The presence of courageous leaders in nursing and study of the lives of the brave ones provide the ground for the development of the concept.

Individual excellence

Individual excellence results from moral competencies, scientific competences, self-improvement, and rationalism. The following components fall into this factor: moral sensitivity, moral confidence, moral integrity, moral identity, moral reasoning, moral issue, moral measure, ethical knowledge, ethical practice, reflection, self-confidence, and rationality.

Protective environment

The ethical climate of the organization and the ethical world support the development of the concept through developing the environmental organizational excellence.

Ethical climate refers to the moral atmosphere of the work environment and the level of ethics practiced within a company. It refers to the behaviors that are perceived to be ethically correct and how issues regarding deviations away from those expected behaviors are handled in the organization.³¹

Repressive environment

Ignoring moralities, unethical climate of the organization, and the deterrent organizational culture coupled with the power laddering suppress the formation of moral courage in an environment.

Internal–external personal obstacles

Rejection, shame, job insecurity, and subjective fear are understood by nurses and create some sort of inner barrier for the formation of the concept. Professional expectations of young nurses, time constraints, and fatigue caused by constant fear and anxiety are considered as external obstacles.

Consequences

Professional excellence

The results of manifestation of moral courage include obtaining peace and relaxation, honoring oneself, moral commitment, bearing the side effects of courage, compassion, hopefulness, keeping the individual within faith framework, right decision making and right action, tolerance in the care of the patient, playing the caring role, and patient comfort and safety.

Having courage forms the functional ability of nurses and makes them carry out their professional performance. Nurses overcome the obstacles in their career through courage, and use trust and professional knowledge to understand, interpret, and make judgments in clinical situations, and provide the ground to respect the patient’s rights, security, and justice in taking care of the patient.²³

In the theoretical phase, the operational definition of moral courage in nursing is achieved as follows: moral courage is an inherent and intrinsic worthy characteristic of man, a unique two-dimensional and interactive phenomenon, a kind of human ability and willingness to face dangers and risks. Moral courage is an essential virtue and provides an infrastructure for other virtues. Moral courage is in the midst of a continuum and balances between fear and temerity. The moderate level of courage is admirable; however, its extremes are not considered virtuous.

Field work phase

Features of the concept

Two features of the concept of moral courage which were obtained at this phase are moral self-actualization and risk taking.

Moral self-actualization

Moral self-actualization is one of the concept features that the participants deliberately described it as authority, ability to apologize and acceptance of faults, responsibility and commitment, doing the right thing, an inclination to the right path, modesty and humility, sacrifice and dedication:

If we want to say the patient is right, the nurse is right, the nurse aid is right, the doctor is right, we should exactly respect it; if the patient says so, we need to make it clear for him/her; I entitle to them, every one’s right, I entitle to him/her, and in fact I would like to know who’s right; but not among my colleagues, sometimes you see that what an employee says is right, but your colleague insists on what is wrong. (P4)

Courage means that the one who has the venture and does not say that “I do not know,” and takes the responsibility of her/his job, accepts it and apologizes for it. (P7)

Risk taking

Risk taking was the other property of moral courage in this analysis. These are the examples of risks taking characteristic including paying the costs, breaking the habit, not paying attention to others’ reactions, having venture, and resistance, which were obtained at this phase:

A courageous nurse is a nurse who prefers the patient’s rights to his/her own rights. This is the nurse who is ready to take the necessary action for the patient even when there is a risk for himself/herself. (P3)

At this situation I am not afraid of losing my job, losing my position, I just think of my patient’ beneficence. (P1)

Antecedents of the concept: professional self-actualization

Model orientation/model acceptance

The presence of brave or courageous models among family, colleagues, and officials was introduced as the antecedent of moral courage. Also, moral courage and the courageous behaviors of an individual in different situations can provide a model for his behavior in the future:

When I was a child, I was so brave; I learn to be so because my family trained me to be courageous. (P4)

I learned courage from my childhood in my family. In my family, my father was a brave man.

One of the things helping the nurses’ courage is the presence of courageous leaders in nursing. When I see how my matron acts by courage, I will learn from him/her. The brave managers train their subordinates bravely. (P10)

Rationalism

Having self-confidence, being logical and having rational thinking, having rational discourse, and having an open mind and good vision help moral courage and provide the conditions to the emergence of moral courage:

It means to be logical and think rationally, and also, have enough knowledge in your field of education. (P5)

Academic and professional competences

The competences that a person acquires have an important role in the development of moral courage. These qualifications include awareness of the patient’s rights and receiving the necessary training on the rights of patient and professional ethics, improvement of knowledge and acquiring professional knowledge and skills, having work experience and professional backgrounds, having a supervisory position and awareness of the ward and patients, communication skills, and professionalism:

The higher your academic knowledge, the more courageous you will be. When you see the procedure is done wrongly, you can talk logically and explain that the method is wrong, and provide document and evidence based on which the running procedure is wrong. It depends on your scientific knowledge. (P2)

If you like to say something, you should have enough knowledge about it. Knowledge brings courage. (P9)

Spiritual beliefs

Faith and trust in God and spiritual perfectionism are other qualifiers mentioned by the participants:

Features that help you to be brave … are faith; it means that you believe that even if you’re put aside from your position (having a business advantage), you know that it’s a temporary situation. (P8)

Protective–repressive climate

Supportive organization

The nurses’ organization and work environment play such a major role in their moral performance that can affect their former moral values.²⁹

In this study, the nurses receive support from the nursing officials, peers, supporting laws and organizations, organization’s ethical climate, and a strong nursing management team, which highly influence the moral courage:

When you know that you’re supported, your courage would increase. I, myself, was in a situation that could stand for it; however, I did not know whether the system will support me or not; then I realized that the hospital matron is supporting me. Thus, I found a lot of guts; if such a problem would occur again, I could stand for it easily. (P4 and P8)

Repressive organization

Lack of appreciation for the brave nurse, nurse suppression by the organization and community, disrespect, and lack of professional power among nursing team, and physician paternalism are obstacles to the nurse moral courage:

Lack of support from the system is one of the moral courage obstacles. This means when your courage is in accordance with logic but support coming from the authorities and those who are your direct boss or the higher senior authorities, is not enough. Since, the system does not care and does not support the nurse. (P5 and P10)

There is no value for courageous person where I was working. (P2 and P4)

Personal barriers

Most nurses admitted that the normalcy, triviality, and lack of importance for moralities, high work load, work-related fatigue and lack of time, bitter past experiences, peers’ and the physicians’ bad temperedness, and conflicts of interest are understood by staff nurses as repressors for their moral courage:

If it was possible, I would challenge them more, if I had the time; I really do not have such time and the chance, better to say, I do not have the time; I do not have the nerve, if I had. (P4)

I could not say it is my fault, if I said that, there was a question mark over us. (P6)

Consequences of the concept: professional utility

Professional care

Providing interests, avoiding the injury, and providing safe care to the patient and family are the most important achievements of nurses’ moral courage:

I told her, since, for the patients who is expiring(end of life); why we should not take care of him just based on our thought and consider that he is certainly expiring. (P10)

I just thought of patient safety and tried to keep her/him life. Now I am happy because I got success. (P1)

Nurse’s peace of mind

Peace of conscience and being away from feeling guilty, being satisfied, and intrinsic reward and gratification were expressed by the participants:

When a nurse shows courage, she/he will have a feeling of satisfaction, relaxation and peace of conscience, since she/he is indeed the patient’s advocator; his conscience is in peace; if patient is the priority, and he knows himself the patient’s advocate and the interests of patient would be important to him, he will have satisfaction and is always in peace and knows that he has worked in favor of his patient. (P8)

Right decision and right performance

Proper functioning is shown as right decision making and doing the right thing:

But I say nursing courage means to do properly what you are assigned to. (P10)

Final analytic phase

The results of the field work phase confirmed the theoretical phase findings. Most of the themes and categories obtained from texts were repeated in field work phase.

According to empirical data, moral self-actualization revealed itself as one of the characteristics of moral courage. Moral courage is a great quintessential characteristic of humans and has an inherent–transcendental nature and moral self-actualization, which is difficult to achieve. The difficult nature is due to the ability to manage fear and risk in humans. Right orientation, responsibility, humility, and having authority show the transcendental nature of moral courage. Moral courage manifestation is affected by factors such as model orientation–model acceptance, rationalism, acquiring scientific and professional competency, spiritual beliefs, protective climate, oppressive climate, and internal and external personal barriers. Professional excellence resulting from moral courage can be observed as professional care, creating peace of mind in nurses and proper functioning of nurses.

Discussion

In this study, the concept of moral courage was analyzed using a hybrid model. In this study, the qualitative data were obtained from the Persian and Islamic context, as well as confirming the findings of the literature on nurses’ moral courage in other countries and some other aspects of the concept was explained.

In this analysis, the moral self-actualization characteristic was added to the two previous features, namely, as inherent–transcendental and risk taking.

Self-actualization is among human transcendental features achieved through obtaining a satisfactory level in each individual talent; moral self-actualization is achievement of the culmination of ethics through which a person comes to moral satisfaction.¹⁹

In the Islamic view, human being has a value-based nature, structure, and foundation. This means he has potential and willingness to accept the right and the right orientation and a tendency to do good and appreciate values.³² In fact, the desire for perfection, growth, and self-actualization is embedded in human nature, and there is so much emphasis on self-realization that the characteristics of self-actualized individuals have been mentioned in the Qur’an. Such characteristics can be listed as follows: humility, patience, solitude with God and experiencing the peak moments of spirituality, moderation and observing balance, avoiding unnecessary work, and having responsibility for their actions and sense of responsibility toward others.³³

According to Maslow’s theory, factors such as courage, commitment, creativity, and the ability to take risk provide the background for an individual to achieve self-actualization. In a study by Hawkins and Morse,² self-actualization has been introduced as the results of courage in nursing. This difference can be explained, as self-actualization in Islamic view and Rogers’s view is the goal and extremity of man. Self-actualization has levels that everyone tries to achieve its highest level. Undoubtedly, man requires excellent human features to achieve self-actualization. Also, moral courage needs some arrangements that achieving each of them, such as right orientation and accountability, is a kind of self-actualization. In other words, moral courage, itself, enhances the moral courage. Therefore, self-actualization, in addition to being a feature of moral courage, can be its result as well.

Other prominent finding in this study was model orientation–model acceptance. The models play an important role in education, especially in the field of moral and value concepts. According to Bandura’s social learning theory, people have the ability of model-making, select the behaviors without personal experience and through observing the behaviors of others and their results. Also, people tend to be influenced by the examples with high status and position.³⁴ Nursing managers, in addition to providing the environment for moral courage of other nurses through values-based behaviors, play the role of model for them by showing courage as well.¹³

The presence of courageous models in different stages of personal and professional life of nurses was as noteworthy findings in this study. Family members, co-workers, officials, and even the person himself can play the role of model for the individual. Direct observation of the model behaviors and hearing courageous stories of people each can be somehow effective in the formation, training, and maintaining the moral courage of nurses.^26,35

Imam Ali, one of the models of moral courage, defines the most courageous person as one who overcomes his own ego (self).³⁶

Professional excellence is the result of moral courage of nurses, which includes professional care, correct decision making, performance, and the nurses’ peace of mind. Lind study showed that having courage forms the functional part of the nurse’s ability and makes him or her to fulfill his or her professional performance. Through courage, the nurse overcome the obstacles in his or her career, and uses trust and professional knowledge to understand, interpret, and make judgments in clinical situations, providing the ground for respecting the patient’s rights, security, and justice in taking care of the patient.²³

Limitation

Although this study helped to clarify the concept of moral courage in nurses, it had some limitations as well. Access to all resources via an electronic database was not possible. The use of texts in Farsi and English was another limitation of this study. Using a qualitative approach in the field work phase limited the generalizability of the findings.

Conclusion

The results of this study, through clarifying the concept of moral courage in nursing, emphasize on the need and application of moral courage in nursing.

The results of this study have implications for nursing practice, nursing education, and nursing research. Clarifying the concept of moral courage leads to better understanding and common perception of this concept and helps nurses to exhibit moral courage and support patient safety. They also can report medical errors and prevent more risks from patients. By moral courage, nurses accept their faults and try to improve themselves.

According to these findings, nursing leader can create a supportive environment and omit suppressive factors, so that nurses can act with moral courage in the case of ethical issues. Academic nurses can use these findings as evidence for revising educational curriculum in basic level of nursing and include ethical education.

This study provides a basis for future research with the aim of raising the level of nurse’s moral courage. Future studies will include focus groups of nurses and physicians and action research methods. In addition, designing, implementing, and evaluating a moral courage supporting system for nurses should be considered.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study is a part of PhD thesis of the first author, was supported financially by the research deputy at Tehran University of Medical Sciences (24112-28-03-92).

References

Spence

Smythe

. Courage as integral to advancing nursing practice. Nurs Prax N Z 2007; 23(2): 43–55.

Hawkins

Morse

. The praxis of courage as a foundation for care. J Nurs Scholarsh 2014; 46(4): 263–270.

Fry

Veatch

Taylor

. Case Studies in Nursing Ethics. 4th ed. Burlington, MA: Jones & Bartlett Learning, LLC, 2011.

Lindh

I-B

Silva

ABD

Berg

. Courage and nursing practice: a theoretical analysis. Nurs Ethics 2010; 17(5): 551–565.

Thorup

Rundqvist

Roberts

. Care as a matter of courage: vulnerability, suffering and ethical formation in nursing care. Scand J Caring Sci 2012; 26: 427–435.

Lachman

. Applied ethics in nursing. New York: Springer Publishing Company, 2006.

Woodard

Pury

CLS

. The construct of courage categorization and measurement. Consult Psychol J Pract Res 2007; 59(2): 135–147.

Dinndorf-Hogenson

. Perioperative nurses perceptions moral courage. Brookings, SD: South Dakota State University, 2013.

Negarandeh

Oskoee

Ahmadi

. Mahiate Hemayat az Bimar [Patient advocacy]. majale elmi pazhoheshi daneshgahe olome pezeshkie zanjan [The scientific Journal of Zanjan University of Medical Sciences] 2006; 13(53): 29–38.

10.

Mohammadi

Borhani

Roshanzadeh

. Relationship between moral distress and moral courage in nurses. Iran J Med Ethics History Med 2014; 7(3): 26–35.

11.

Black

Curzio

Terry

. Failing a student nurse: a new horizon of moral courage. Nurs Ethics 2014; 21(2): 224–238.

12.

Curtis

. Learning the requirements for compassionate practice: student vulnerability and courage. Nurs Ethics 2014; 21(2): 210–223.

13.

Hutchinson

Jackson

Daly

. Distilling the antecedents and enabling dynamics of leader moral courage: a framework to guide action. Issues Ment Health Nurs 2015; 36: 326–335.

14.

Baldwin

. Concept analysis as a method of inquiry. Nurse Res 2008; 15(2): 49–58.

15.

Gallagher

. Moral distress and moral courage in everyday nursing practice. Online J Issues Nurs 2010; 16(2): 1–8.

16.

Dehkhoda Dictionary, 2015. Available at: http://www.jasjoo.com/books/wordbook/dehkhoda/%d8%b4%d8%ac%d8%a7%d8%b9%d8%aa/

17.

maani Shojaat va abaad aon. 2015, http://mohadese-borojerd.womenhc.com/?p=41449&more=1&c=1&tb=1&pb=1

18.

Hamedani

. Courage: Meaning and Dimensions, http://www.pajoohe.com/fa/index.php?Page=definition&UID=45847 (accessed 2014).

19.

Mazaheri

. Derasat fi akhlagh va shoon hekmat elmieh [New Exploration on Islamic ethics and dignity practical wisdom] . Tehran, Iran: Mohamad, 2006.

20.

The online Etymology Dictionary, 2015. Online etymology dictionary. Available at: http://www.etymonline.com/index.php?allowed_in_frame=0&search=courage.

21.

Schwartz-Barcott

Kim

. An expansion and elaboration of the hybrid model of concept development. In: Eoyang

(ed.) Concept development in nursing. Philadelphia, PA: WB Saunders Company, 2000, pp. 129–150.

22.

Centre for Reviews and Dissemination and University of York. Systematic reviews: CRD’s guidance for undertaking reviews in health care. York: CRD, University of York, 2009, p. 6.

23.

Lindh

I-B

Severinsson

Berg

. Nurses’ moral strength: a hermeneutic inquiry in nursing practice. J Adv Nurs 2009; 65(9): 1882–1890.

24.

Graneheim

Lundman

. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today 2004; 24: 105–112.

25.

Horton-Deutsch

Pardue

Young

. (2014, 4). Becoming a nurse faculty leader: Taking risks by doing the right thing. Nursing Outlook 62(2): 89–96. https://dx-doi-org.web.bisu.edu.cn/10.1016/j.outlook.2013.12.003.

26.

Polit

Beck

. Nursing research: generating and assessing evidence for nursing practice. 9th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2012.

27.

Lachman

. Moral courage: a virtue in need of development? Medsurg Nurs 2007; 16(2): 131–133.

28.

Larijani

. Health care professional and ethical issue. Tehran, Iran: Baraye Farda, 2004.

29.

Peter

Lunardi

Macfarlane

. Nursing resistance as ethical action: literature review. J Adv Nurs 2004; 46(4): 403–416.

30.

Kalvemarka

Hoglund

Hansson

. Living with conflicts-ethical dilemmas and moral distress in the health care system. Soc Sci Med 2004; 58(6): 1075–1084.

31.

Moore

. The effect of ethical climate on the organizational commitment of faculty members. J Bus Ethics 2014; 9: 1–15.

32.

Faghihi

A-N

Rafiee-moghadam

. Ensan az didghahe Rojers va moghayesey on ba didghahe islami [Rogers human point of view and compare it with an Islamic perspective]. J Studies in Islam and Psychology 2008; 2(3): 143–167.

33.

Bakhshayesh

. baresiy tatbighiynemodhaye khodshokofaee dar quran va ravanshenasi [A comparative study of the Quran and psychological aspects of self-actualization Journal name: Comparative Theology]. elahiyat tatbighi 2013; 3(8): 57–72.

34.

Mokhtari-Nouri

Ebadi

Alhani

. Importance of role-model teaching in nursing students’ education. Iranian Q Educ Strateg 2011; 3(4): 149–154.

35.

Murray

CJS

. Moral courage in healthcare: acting ethically even in the presence of risk. Online J Issue Nurs 2010; 15(3): 2.

36.

Mohammedi-reyshahri

Mizan alhekmat [The wisdom] . Qum, Iran: darol hadith, 2011.