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

BACKGROUND: The 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. METHODS: An 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. RESULTS: Staff 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. CONCLUSION: The 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.

Student nurses experiences of moral distress: A concept analysis.

AIM: To understand how pre-registration student nurses experience moral distress and refine the concept in this population. BACKGROUND: 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. DATA SOURCES: 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. METHODS: 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. RESULTS: 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. CONCLUSION: The attributes of moral distress in the student nurse population have distinctive features which should be considered by nurse educators and in empirical research. PATIENT OR PUBLIC CONTRIBUTION: None, as this is a concept analysis that contributes to theory development and is not empirical research.

Nurses' moral courage and related factors: A systematic review.

BACKGROUND: Nurses face various ethical conflicts when taking care of patients, and such conflicts require moral courage. This systematic review was conducted with the aim of investigating moral courage and its related factors among nurses. METHODS: To find related studies, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. The PubMed, Web of Science, Google Scholar, Scopus, Embase and Science Direct databases were searched using keywords such as Courage, Moral Courage, and Nurses, and no lower time limit was imposed when conducting the searches. The identified studies were published between January 2000 and March 2023. Quality of articles was assessed using the STROBE checklist. RESULTS: The pooled sample size for the 19 included studies was 7863. All studies were observational and cross-sectional. The results showed that three categories of factors most related to moral courage are individual, moral, and factors related to the organization. Underlying factors of each category are also provided within this paper. CONCLUSION: Moral courage is an integral part of nursing, which as a profession, is becoming even more challenging with the advancement of science and technology. Therefore, there is a need for nurses and especially nursing managers to be considerate of factors affecting moral courage of nurses, with a view to strengthening the positive factors and reducing the negative impacts.

The relationship between moral courage, team work, and safe nursing care in clinical nurses: a multicenter cross-sectional study in Iran.

BACKGROUND: Moral courage and team work are the most important aspects of professional competence in clinical nurses; nurses with moral courage and team work are thought to be able to deliver safe nursing care to patients. The present study aimed to investigate whether moral courage and teamwork correlate with safe nursing care among clinical nurses. METHODS: This descriptive cross-sectional multicenter study was carried out from December 2023 to February 2024. A total of 375 nurses who were practicing in four hospitals in the south of Iran were enrolled in this study using convenience sampling. The data collection tools used consisted of a demographics survey, Moral Courage Questionnaire (MCQ), Team STEPPS Team Perception Questionnaire (T-TPQ), and the Assessment of Safe Nursing Care Questionnaire (ASNCQ). The data were analyzed using descriptive statistics, t-test, chi-square, multiple regression analysis, and Pearson's correlation coefficient. SPSS version 22 was used to analyze the data. RESULTS: The participants' mean age was 32.66 ± 6.63 years, and their work experience was 8.56 ± 6.22 years. The total mean scores for moral courage, teamwork, and safe care were 422.37 ± 52.92, 144.09 ± 18.43, 315.84 ± 41.95, respectively. A statistically significant positive correlation was found between teamwork and safe care (r = 0.57, p < 0.001), teamwork and moral courage (r = 0.49, p = 0.002), and moral courage and safe nursing care (r = 0.59 p < 0.001). According to the results, work experience, moral courage, and teamwork explained 44.4% of the variance in safe nursing care (R2 = 0.44, p < 0.001). CONCLUSION: The results indicated that the moral courage and teamwork of nurses were positively and significantly correlated with the participants' safe nursing care. Accordingly, since moral courage and teamwork are the qualities that can contribute to improving the quality of care and ensuring safe nursing care, it is recommended that nursing managers pay special attention to these factors.

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

BACKGROUND: Moral 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. METHODS: Nine 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. RESULTS: Seventeen 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). CONCLUSION: The 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.

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

BACKGROUND: Compassion 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. METHODS: A 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. RESULTS: The 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 (ß = -0.114, P = 0.001). CONCLUSION: This 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.

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.

The relationship between nurses' moral courage and whistleblowing approaches.

BACKGROUND: Whistleblowing is an action that particularly requires moral courage. Understanding the relationship between nurses' levels of moral courage and their whistleblowing approaches is important for reducing adverse situations in healthcare services. OBJECTIVES: This study aims to understand and analyze the relationship between nurses' levels of moral courage and their whistleblowing approaches. RESEARCH DESIGN: This is a descriptive and correlational study. METHODS: The study sample consists of 582 nurses actively working in a province in northwest Türkiye. Research data were collected using an Information Form, the Nurses' Moral Courage Scale, and the Whistleblowing Scale. ETHICAL CONSIDERATIONS: Ethical approval from the ethics committee, institutional permission, and informed consent from the participants were obtained for data collection. FINDINGS: Nurses were found to perceive their moral courage as high, and their whistleblowing levels were at a moderate level. There was a significant and moderate relationship between participants' levels of moral courage and whistleblowing levels (p < .05). CONCLUSIONS: The findings emphasize the importance of promoting moral courage and creating an appropriate environment for exposing ethical violations. This study can contribute to the development of strategies to enhance nurses' moral courage and foster a more ethical working environment in healthcare services.

Moral courage of nursing: Bibliometric analysis.

BACKGROUND: 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. AIM: This article aims to analyze the production of literature within nursing moral courage research. RESEARCH DESIGN: 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. ETHICAL CONSIDERATIONS: In our study, ethical review was not required. RESULTS: 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. CONCLUSIONS: 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.

Enhancing the moral courage of nurses: A modified Delphi study.

BACKGROUND: The urgency of ensuring adequate moral courage in clinical nursing practice is evident. However, currently, there are few formal intervention plans targeted at enhancing the moral courage of nurses. AIM: To develop a training program for improving the moral courage of nurses using the modified Delphi method. RESEARCH DESIGN: A modified Delphi study. PARTICIPANTS AND RESEARCH CONTEXT: From November to December 2022, a literature review and expert group discussion were conducted to develop a preliminary training plan framework. From January to March 2023, a two-round Delphi survey was performed, and a consensus was reached regarding the plan through online questionnaires. Descriptive statistics were used to analyze the data. ETHICAL CONSIDERATIONS: This study was approved by the institutional ethics committee (No. 138, 30 August 2021). All participants provided written informed consent. RESULTS: Consensus was reached on eight themes and 33 items to strengthen the moral courage training program for nurses. CONCLUSIONS: Guided by a unified goal of moral education, a multi-level and acceptable intervention plan was designed to enhance the moral courage of nurses.

Moral courage of emergency nurses in care-limited environments: A mixed-methods study.

BACKGROUND: Professional ethics in nursing exist to guide care and allow for decision-making to be patient-centered. In the current medicolegal landscape post-Roe and in light of bans on gender-affirming care, the decision-making processes of emergency nurses in the clinical environment of care as informed by both professional and personal ethics are an important area of inquiry. AIM: The aim of this study was to examine the contribution of moral courage to decision-making by emergency nurses. RESEARCH DESIGN: A mixed-methods exploratory sequential approach was used, using a standard demographics form and the Nurses Moral Courage Scale to collect quantitative data. These data were used to inform an interview guide for qualitative data collection. Situational analysis was used to analyze the interview data. ETHICAL CONSIDERATIONS: Prior to recruitment, this study was reviewed and approved by the University of Massachusetts IRB (#00003909). Participants were provided with an informed consent document at the time of registration and at the time of interview; participants provided both signed consent and verbal assent. Participants were assigned study codes to maintain anonymity and data were maintained in a secure University cloud. PARTICIPANTS AND RESEARCH CONTEXT: US-based emergency nurses working in environments with care limitations. RESULTS: 70% of respondents reported that they would speak up if they were aware of a situation that was ethically challenging. Respondents reported that it was fairly easy or very easy to defend their values when addressing ancillary staff, coworkers, authorities outside the organization, patients, and patient families. Respondents reported challenges in defending their professional values to charge nurses, physicians, or administrators. In response to a serious ethical problem, 65.8% of respondents answered that they would bring up the problem for discussion, 21.1% would file an internal report, and 13.2% would report externally. Interview participants reported significant social and professional barriers to acting in response to an ethical violation. Willingness to act centered on personal values and not professional codes of ethics. CONCLUSIONS: While emergency nurses in this study reported high perceived levels of moral courage, they also reported low willingness to act directly, citing burnout and significant social and professional barriers. Adherence to professional codes of ethics is not the primary driver of moral courage.

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.

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

INTRODUCTION: 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. AIM: 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. RESEARCH DESIGN: A cross-sectional design was employed. PARTICIPANTS AND RESEARCH CONTEXT: 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. ETHICAL CONSIDERATIONS: Research ethics approval (with the code of TJ- IRB 20220543) was obtained from Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology. FINDINGS: This study included 966 nurses, predominantly female and under 30 years 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). CONCLUSIONS: 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.

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.

The relationship between moral courage and lovingkindness-compassion levels in critical care nurses: A cross-sectional study.

BACKGROUND: Ethical dilemmas and ethical problems are very common in intensive care units. Nurses need moral courage to deal with these problems. Nurses' high empathy, humility, lovingkindness, and compassion support them to act with moral courage. OBJECTIVES: The aim of this study was to determine the moral courage, lovingkindness, and compassion levels of critical care nurses and to reveal whether there is a relationship between them. METHODS: One hundred sixty-eight nurses working in the intensive care unit of a university hospital in Turkey were included in this correlational descriptive cross-sectional study. The data were collected with the Nurses' Moral Courage Scale (NMCS) and the Loving-kindness Compassion Scale (LCS). RESULTS: There was a positive and significant relationship between the NMCS and the LCS lovingkindness (r = .377, p < .05) and compassion (r = .405, p < .05) subdimensions; on the other hand, a negative and significant relationship was observed with the LCS self-centredness subdimension (r = -.215, p = .025). In addition, the mean scores of the LCS subdimensions of compassion, self-centredness, and lovingkindness were predictors of the NMCS total score (R = .475, R2 = .286, p < .05). CONCLUSIONS: In this study, it was determined that critical care nurses with high moral courage levels had high levels of compassion and lovingkindness and low levels of self-centredness. A high level of moral courage and compassion in nurses may contribute to quality and safe patient care. In-service trainings may be planned to increase nurses' awareness of moral courage, loving-kindness, and compassion.

Personality processes of everyday moral courage.

INTRODUCTION: Moral courage manifests in acts intended to intervene to stop or redress witnessed moral norm violations, despite the risk of negative consequences for the intervener. We investigate moral courage in everyday life and ask what personality processes are involved. Based on an extended process model of moral courage, we derived hypotheses on cognitive and emotional processes that should facilitate or hinder intervention. Further, we identified candidate personality dispositions that should shape these processes and thereby predict who tends to intervene against others' norm violations and who does not. METHODS: Using a quota-based sample of the German population (N = 1108), we conducted a personality assessment, followed by a 7-day experience sampling during which participants reported norm violations witnessed in their daily life as well as their cognitive, emotional, and behavioral reactions. RESULTS: In total, 678 participants reported 1965 norm violations and intervened against 32% of them. Dispositional self-efficacy facilitated intervention by increasing a sense of efficacy when confronted with others' norm violations. Conversely, dispositional moral disengagement hindered intervention by reducing perceived own responsibility. DISCUSSION: Our findings provide novel insights into the situations affording moral courage in everyday life, and the personality processes that uniquely guide this behavior.

A study on different types of moral courage and coping styles of clinical nurses: based on potential profile analysis.

BACKGROUND: In professional ethics-related events, there are various unpleasant and complex ethical issues that require strong moral courage. Our aim is to identify and describe the potential categories of moral courage among nurses and to clarify the coping styles of nurses under different categories. METHOD: A cross-sectional study was conducted using three data collection tools: a self-designed general information questionnaire, a Chinese version of the Moral Courage Scale, and a Trait Coping Style Questionnaire. Three hundred fourteen nurses from a tertiary hospital in Heilongjiang Province, China, were analysed using potential profile analysis, descriptive analysis, and Mann-Whitney U test data. RESULT: The latent profile analysis (LPA) results indicate that the two-profile model is the most suitable and supports the existence of two different moral courage profiles: the low moral courage group (60.51%) and the high moral courage group (39.49%), with a high relative entropy value (0.922). The results point to a good profile solution, and there are significant differences between the two profiles. The Mann-Whitney U-test results showed that the positive coping scores of the high moral courage group were significantly higher than those of the low moral courage group, and the negative coping scores of the high moral courage group were significantly lower than those of the low moral courage group. CONCLUSION: Our results reveal the heterogeneity of moral courage in the nurse sample and indicate that nurses in the high moral courage group tend to choose positive coping styles, while nurses in the low moral courage group are more likely to develop negative coping emotions. This provides important significance and reference value for nursing managers, who can propose customised management plans based on the types of moral courage of the nursing community and the coping styles under different categories.

Is there any relationship between nurses' perceived organizational justice, moral sensitivity, moral courage, moral distress and burnout?

AIM: The present study is an attempt to investigate the relationship between Corley's model variables in mental health nurses. BACKGROUND: Based on Corley's model, burnout and moral distress in nurses are, in retrospect, the consequences of the interplay of organizational and individual factors such as perceived organizational justice, moral sensitivity, and moral courage. The relationship between two variables or three variables of Corley's moral distress model has been investigated, but the test of Corley's moral distress model with more variables has not been done. Therefore, this research was proposed with the aim of investigating the relationship between the variables of moral courage and moral sensitivity (as characteristics of nurses), perceived organizational justice (as an antecedent), moral distress, and job burnout (as consequences of moral distress). METHODS: The study was conducted as a descriptive correlational study involving 500 nurses working in the mental health wards of hospitals. Data collection was conducted using perceived organizational justice scale, moral sensitivity scale, moral courage scale, moral distress scale, and burnout inventory. RESULTS: The results showed a significant relationship between perceived organizational justice, moral sensitivity, moral courage, and moral distress (< 0.05). Moreover, perceived organizational justice and moral distress had an inverse relationship. Moral sensitivity and moral courage had a direct relationship with moral distress (< 0.05). Furthermore, the results showed inadequate model fitness. CONCLUSIONS: This study adds to the existing knowledge about the experiences of mental health nurses and their interactions with both organizational and individual factors. It highlights that the connections between perceived organizational justice, moral sensitivity, moral courage, moral distress, and burnout are intricate and multifaceted. As we deepen our understanding of these relationships, it opens the door for the development of interventions and strategies to enhance nurses' well-being and the quality of care they deliver in mental health settings. Moreover, future research and ongoing refinement and expansion of Corley's model will be crucial in addressing the complex challenges within the healthcare sector.

Moral courage, burnout, professional competence, and compassion fatigue among nurses.

BACKGROUND: Moral courage is the ability to defend and practice ethical and moral action when faced with a challenge, even if it means rejecting pressure to act otherwise. However, moral courage remains an unexplored concept among middle eastern nurses. AIM: This study investigated the mediating role of moral courage in the relationship between burnout, professional competence, and compassion fatigue among Saudi Arabian nurses. RESEARCH DESIGN: Correlational, cross-sectional design following the STROBE guidelines. PARTICIPANTS AND RESEARCH CONTEXT: Convenience sampling was used to recruit nurses (n = 684) for four government hospitals in Saudi Arabia. Four validated self-report questionnaires (Nurses' Moral Courage Scale, Nurse Professional Competence Scale-Short Form, Maslach Burnout Inventory, and Nurses Compassion Fatigue Inventory) were used to collect data between May to September 2022. Spearman rho and structural equation modeling analyses were employed to analyze the data. ETHICAL CONSIDERATIONS: The ethics review committee of a government university in Ha'il region, Saudi Arabia, approval this study (Protocol no.: H-2021-012; Approved: 08/022,021). Participants were fully explained the study aims, and consent was voluntarily secured. RESULTS: The emerging model showed that burnout had a direct and positive influence on compassion fatigue, while professional competence had a direct, negative effect on compassion fatigue. Moral courage had a small and direct but negative influence on compassion fatigue. Mediation analyses also indicated that moral courage significantly mediated the indirect effects of burnout and professional competence on compassion fatigue. CONCLUSION: Moral courage can be a crucial aspect in preserving the psychological and mental health of nurses, particularly under stressful conditions. Therefore, it is advantageous from an organizational and leadership standpoint to implement measures such as programs and interventions to foster moral courage among nurses.

Moral distress, moral courage, and career identity among nurses: A cross-sectional study.

BACKGROUND: The concept of career identity is integral to nursing practices and forms the basis of the nursing professions. Positive career identity is essential for providing high-quality care, optimizing patient outcomes, and enhancing the retention of health professionals. Therefore, there is a need to explore potential influencing variables, thereby developing effective interventions to improve career identity. OBJECTIVES: To investigate the relationship between moral distress, moral courage, and career identity, and explore the mediating role of moral courage between moral distress and career identity among nurses. DESIGN: A quantitative, cross-sectional study. METHODS: A convenient sample of 800 nurses was recruited from two tertiary care hospitals between February and March 2022. Participants were assessed using the Moral Distress Scale-revised, Nurses' Moral Courage Scale, and Nursing Career Identity Scale. This study was described in accordance with the STROBE statement. ETHICAL CONSIDERATION: Research ethics approval was obtained from the researcher's university and hospital where this study was conducted prior to data collection. FINDINGS: Moral distress is negatively associated while moral courage is positively associated with career identity among nurses. Moral courage partially mediates the relationship between moral distress and career identity (ß = -0.230 to -0.163, p < 0.01). DISCUSSION: The findings reveal a relationship between moral distress, moral courage, and career identity among nurses. CONCLUSION: By paying attention to nurses' moral distress and courage, healthcare providers can contribute to the development of effective interventions to improve career identity, and subsequently performance, among nurses.