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Exploring the foundations and influences of nurses’moral courage: a scoping review

BMC Medical Ethics volume 26, Article number: 43 (2025) Cite this article

Abstract

Introduction

In the realm of healthcare, nurses frequently encounter complex ethical issues that demand moral courage. Nurses'moral courage is defined as the ability to act in alignment with their moral beliefs, even when faced with difficulties and dangers during ethical challenges. This study aims to explore the role of moral courage in nursing practice, highlighting its importance in maintaining patient care standards and fostering ethical decision-making.

Methods

This scoping review on nurses’ moral courage was conducted following Arksey and O’Malley’s five-step approach. Relevant literature was sourced from databases such as Embase, PubMed, ScienceDirect, Web of Science, PsycINFO, Scopus, and CINAHL, spanning the years 2000–2024. A total of 40 studies were selected, focusing specifically on the foundations and influences of nurses’ moral courage, with data extraction and synthesis for reporting.

Results

The study highlights moral courage as crucial in nursing for ethical decision-making and patient care. Global variations in moral courage are influenced by cultural, contextual, and organizational factors. Tools for measurement show score discrepancies. Nursing education shapes moral courage, necessitating tailored programs. Research explores personal and organizational influences on ethical behavior, with factors like age, work experience, and ethics training impacting moral courage. Morning shift nurses and those with official employment exhibit higher moral courage. Gender’s impact remains inconclusive, requiring further study. Training in nursing ethics enhances moral courage, emphasizing its role in care quality.

Conclusion

In conclusion, understanding the diverse factors shaping moral courage in nursing is vital for navigating ethical challenges and improving patient care quality. Tailored educational strategies are essential to foster moral courage among nursing professionals globally, emphasizing the need for ongoing research and interventions to enhance ethical practice and patient outcomes.

Peer Review reports

Introduction

Today, advancements in healthcare have led to increasingly complex decision-making for nurses, who represent the largest group of service providers within healthcare systems [1]. As a critical component of the health system and primary caregivers in society [2], nurses frequently encounter challenging ethical issues that complicate their decision-making processes. To navigate these challenges, they require moral courage [3], which involves acting on moral beliefs even when faced with difficulties and dangers during ethical dilemmas. This kind of courage, grounded in professional integrity, empowers nurses to make decisions and act with conviction and resilience. Moral courage is not only a virtue essential for conscientious practice among all healthcare providers [4], but also a crucial factor in mitigating moral distress. This enables nurses to make courageous decisions that uphold moral frameworks and prevent ethical confusion [5]. Moral distress, a significant challenge in the nursing profession, arises when nurses feel unable to act ethically due to external constraints or internal conflicts, preventing them from doing what they believe is right [6].

Moral courage is essential for managing ethical dilemmas and professional obligations [7]. In the nursing profession, it is crucial to provide humane care and maintain stability in the face of unethical behavior [4]. Since nurses often encounter numerous ethical challenges, they must possess high moral courage to make the best decisions based on ethical principles in clinical situations [8, 9]. Moral courage is also necessary for promoting moral and human care, as well as protecting patient rights in nursing practice [10].

The lack of moral courage in nursing can lead to numerous adverse effects. These include violations of patient rights, compromised patient safety, stagnation in the quality of care, and negative health outcomes [11]. Additionally, nurses may experience depression, guilt, powerlessness, and feelings of worthlessness [12]. A deficiency in moral courage also results in inadequate attention to patient satisfaction, proper treatment, the quality of care provided, and the standards of nursing services [13]. Moreover, it can cause moral distress among staff, lead to unethical behavior, and have irreversible effects on patients [14]. Conversely, nurses who consistently demonstrate moral courage make decisions based on the moral principle of benevolence, guided by personal motivations rooted in virtues, values, and standards, regardless of personal risks [15].

Consequently, despite the complications and challenges, nurses, as moral agents and key members of the health team, are expected to provide quality care with ethical and professional performance. Yet, there is often a noticeable lack of moral courage [16]. Improving moral courage among nurses could reduce their experience of moral distress [17].

Therefore, given the critical importance of moral courage and its necessity in nursing behavior, this study was conducted to investigate the levels of moral courage among nurses and the factors that influence it.

Method

This study was conducted as a scoping review study on nurses'moral courage, utilizing Arksey and O'Malley’s framework. This methodology was selected based on a preliminary literature review, which revealed a significant gap in the scope of studies focused on exploring the foundations and influences of nurses'moral courage. There is a noticeable lack of research aimed at gathering comprehensive knowledge in this scope, which highlights neglected issues and cases. Therefore, a scoping review is essential to effectively compile and analyze experiences and insights from existing studies on this topic.

Given the nature of moral courage among nurses, a study with a scoping review approach aligns better with the research objectives than other review approaches. Scoping review studies aim to clarify the key concepts and the foundation of a research field, which identifies the current state of research conducted in a specific field as well as the existing gaps in that field. The other review methodologies tend to provide limited insights relevant to this investigation.

To date, literature review efforts have not sufficiently focused on examining the breadth of studies concerning nurses’ moral courage. A scoping review is thus imperative to assess the global state of nurses'moral courage, identify influencing components, and evaluate its impact on the quality of nursing services, patient health, and healthcare systems across various countries.

According to Arksey and O'Malley's approach, the five-step process for conducting a scoping review includes: identifying and determining the research question, identifying related studies, selecting studies, charting the data, collecting, summarizing, and reporting the results [18]. In developing this protocol, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist have been taken into consideration [19].

The current study also put the 5 steps of this framework as the basis of the research process on the titles of the studies conducted in the subject scope of Nurses’Moral Courage.

  • ✓ Identifying the research question: In the first step, the research question"What studies have been done in the scope of Nurses'Moral Courage?"was identified.

  • ✓ Identification of relevant studies: In this step, a brief review of existing studies and MeSH and Emtree terms was performed to find the best keywords for the search. Search with keywords “Nurses,” “Moral Courage,” “Ethical Courage,” “Factors influencing,” and “Nurses Moral Courage” in English and Persian-language in the Embase, PubMed, Cochrane, Web of Science, Scopus, and ProQuest was conducted by 2 researchers separately in 2000–2024. The authors chose this time period because their initial search in databases indicated that most articles discussing the moral courage of nurses focused on this period. Also, to complete the review, a manual search was conducted through the Google Scholar search engine and highly relevant references and key journals based on the inclusion criteria.

  • ✓ Selection of related studies: In this step, two researchers examined the titles and abstracts of all studies, as well as the full texts of related articles, separately. To be included in the review, papers needed to focus on the Foundations and Influences of Nurses'Moral Courage. We included peer-reviewed journal articles published between 2000 and 2024 that were written in English or Persian and included a definition of nurses'moral courage. Additionally, the papers had to address differences between countries, discuss influencing factors, and assess moral courage using valid tools. We considered various study types, including quantitative, qualitative, mixed-method, methodological, and review studies, to explore different aspects of Nurses'Moral Courage. Papers were excluded if they were editorials, book chapters, books, theses, opinion pieces, discussion papers, or non-scientific articles. In the research team, a possible disagreement regarding the selection of the articles was investigated.

  • ✓ Data classification: Data extraction was done based on the prepared table by the research team. In this step, a table of data required for the study including authors, year, type of study, and results obtained was prepared and the studies that were related to these items were extracted.

  • ✓ Collection, summary, and report of the results: In the last step, the collected findings of the studies were summarized and reported. The data synthesis was obtained from Table 1.

Table 1 Extracted studies
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Result

The result of the electronic database search and manual search showed that the total number of studies on the Foundations and Influences of Nurses'Moral Courage was 1970 articles. Duplicate articles, unrelated articles, articles without access to full text, and articles that did not match the criteria specified by the research team were excluded. Finally, 40 articles were included in the study. PRISMA Flow Diagram is in Fig. 1 and the data extracted from these papers are in Table 1.

Fig. 1
figure 1

PRISMA Flow Diagram [19]

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In Table 1, we have reviewed and presented important information from the 40 articles we extracted. The information in this table includes the names of the authors, the year of publication, the methodology, and the results of the studies. In the first section, the names of all the authors of each article are listed to provide greater clarity about the scientific sources. Also, the year in which each article was published is included in the table so that we can examine the time course of the research. In addition, in the Methodology section, the research methods and methodologies used in each study are explained. This information helps us to have a better understanding of the different approaches of researchers in this field. Finally, the results of the studies are summarized. This section allows us to quickly identify the strengths and weaknesses of each study and make the necessary comparisons. (Table 1).

Discussion

Moral courage (definition)

Courage as an integral value in the nursing profession, was first presented by International SigmaThetaTau in 1992 to advance the status of nursing as a profession, along with 2 other core moral values, love and respect for the patient [53]. However, the history of courage in the nursing ethical profession goes back centuries, as is evident in Nightingale's letters and other quotes [54]. Courage-based nursing behavior includes logical reflection, commitment to nursing values ​​and principles, action, and risk-taking, which play a significant role in nurses'ability to care [12].

Moral courage is a specific type of courage [20] recognized in recent decades, is essential for nurses facing ethical-moral challenges [6]. The concept of moral courage has been introduced as a valuable human virtue that is rooted in the inner nature of people and is considered one of the most important ethical principles in the whole world [55]. Although moral courage is one of the inherent characteristics of humans, it is also considered a developmental process that can be taught to others or learned from other people [6].

In the fields of philosophy, psychology, and nursing, moral courage is viewed as a fundamental, multidimensional, complex, and abstract value [42]. It involves standing up for what one believes is right, even when faced with adversity such as threats, shame, anxiety, rejection by colleagues, or job loss [24]. Moral courage creates the ability to perform moral behavior in a person, and as a result, a person performs moral action despite the presence of obstacles [21, 25]. Courageous moral behavior can be expressed both in words and actions to protect the rights, safety, and care of the patient [39, 52]. The emergence of this behavior in nurses requires a constant commitment to the principles of professional ethics and ethical codes that preserve the individual's moral identity and belief framework [6].

The concept has been analyzed through various methods. Numminen et al. (2017) utilized Rodgers'evolutionary method to explore its antecedents, such as ethical sensitivity, conscience, and experience, and its core attributes, including true presence, moral integrity, responsibility, honesty, advocacy, commitment, perseverance, and personal risk, along with its consequences like personal and professional development and empowerment [4]. Similarly, Sadooghiasl et al. (2018) applied a hybrid model of concept analysis in their study, revealing features, antecedents, and consequences in three phases of the analysis [20]. Given the vast amount of research on the moral courage of nurses globally, it is suggested that future analyses could benefit from additional methods like the Walker and Avant approach.

Moral courage in different countries

Research indicates that morally courageous behaviors among nurses vary across countries, influenced by several factors. Cultural values, which differ from one country to another, significantly impact the expression of moral courage in nursing [56]. Ethical issues in nursing are notably context-sensitive [12], necessitating that both contextual and individual factors be adequately considered in studies [57].

Organizational factors specific to each country or hospital can also alter the demonstration of moral courage. For instance, professional roles and responsibilities assigned to nurses differ internationally, influencing their ethical behaviors [46]. Additionally, workloads vary significantly across countries; even in regions with similar healthcare structures, such as the Nordic countries, there are notable differences in nursing care organization, workload, and working conditions. These variations can affect factors such as the number of patients a nurse manages, the intensity of patient care required, and the supervision needed for activities of daily living (ADLs). Consequently, such differences impact nurses'job satisfaction, their intentions to remain in the profession, and their ethical behaviors [42].

Lindh (2010) posited that moral courage in nursing is dependent on time and place [56], suggesting that variations in this complex and abstract concept are to be expected and should be assessed based on temporal, spatial, cultural, and social backgrounds [30]. Research further shows that even within a single country, the moral courage displayed by nurses can vary between hospitals and even between different wards within the same hospital [17, 34, 43]. During times of crisis, nurses have experienced varying levels of moral distress, prompting several studies to measure their moral courage [22, 29, 37].

Regarding the measurement of moral courage, various tools have been developed and validated by researchers. Due to differences in the design of these tools—such as item differences, scoring scales, cut-off points, and sensitivity—variations in moral courage scores are expected across different studies [12]. Even when the same tools are employed, differences in findings can still be evident, potentially due to factors like sample size and other study-specific variables.

Another factor that can influence this behavior is the difference in the educational system for nursing students in each country. For example, in Iceland, where nurses have high job satisfaction and a low rate of missed nursing care [58], students work for an extended period before graduating. This allows them to encounter various ethical situations and learn how to behave ethically in the field of nursing [42]. While most countries have educational programs for teaching professional ethics to nursing students, what sets students apart is the practical experience they gain in similar ethical situations, which is essential for them to develop morally courageous behavior [35, 42]. Therefore, it is crucial to modify the educational programs in countries where the moral courage scores of nurses are not at favorable levels. Additionally, valid and reliable tools should be used repeatedly to measure nursing students'moral courage to assess the effectiveness of these changes.

Influencing factors of moral courage

As mentioned, all human beings have the virtue of moral courage in their existence [20], which is manifested according to the internal and external conditions of people [47]. The meaning of internal factors is the individual characteristics that are effective in the tendency of people to show morally courageous behavior or an obstacle to the occurrence of such behavior. According to the review of the literature, the effective internal factors include variables such as age, work experience, marital status, employment status, position, and participation in the professional ethics course [12]. Studies suggest that moral courage tends to increase with age and work experience [16, 45, 48, 59], as nurses become more familiar with organizational conditions and ethical principles [6, 60]. Also, one's experience of ethical situations in the nursing profession increases [4]. In addition, a person's risk-taking, which means a person's ability to face different dimensions of risk (biological, chemical, physical, psycho-social), changes with age, and risk-taking in moral situations may increase with age [12].

Marital status also influences moral courage; married individuals might take more risks due to their experience in managing life's stresses. [17]. Conversely, some studies find greater moral courage among unmarried nurses [43].

Additional studies have explored how changes in moral courage correlate with age, years of service, work environment, and attitudes toward the profession, influenced by varying levels of moral sensitivity among nurses [61]. These studies are guided by the concept of moral sensitivity, which is defined as an individual's awareness of moral dimensions and their emphasis on moral issues. This sensitivity enables nurses to distinguish between right and wrong actions effectively. When combined with moral courage, moral sensitivity helps nurses become attuned to moral phenomena and approach challenges from a deeply ethical perspective [62]. The interplay between moral courage and sensitivity is significantly influenced by factors such as age and work experience. Research indicates that nurses'moral sensitivity generally increases with experience [63]. However, some studies suggest that experienced nurses may struggle to apply ethical principles in important decisions [64]. Other researchers have pointed out that without ongoing education, seasoned nurses may become indifferent to moral issues despite their experience [62].

Work shift is another factor; morning shift nurses reportedly exhibit higher moral courage [12], likely because more experienced nurses tend to work these shifts [6, 60]. Employment conditions also play a crucial role; nurses with stable job statuses, supportive organizational contexts, and less job insecurity show higher levels of moral courage [7, 34, 49].

Regarding gender, the relationship with moral courage is mixed. Some studies report higher moral courage in female nurses [41], while others suggest that male nurses may exhibit greater moral courage [30, 50]. However, many findings indicate no significant gender difference [16, 22, 33, 34], underscoring the need for further research to clarify this relationship.

Various studies have been conducted that show that the moral courage score of nurses has increased after participating in nursing ethics training courses [10, 33, 65]. Since the nursing profession is an ethical profession and nurses face many ethical challenges in their professional performance, they must have high ethical knowledge [4, 45]. Ethical knowledge improves the moral sensitivity of nurses, and as a result, the quality of nursing care is improved and nursing errors are reduced [66]. In addition, studies have shown that moral virtues, including moral courage, can be practiced and strengthened in various ways [24, 26]. In this regard, in addition to paying attention to educational content, different educational methods can be used in studies and the effectiveness of each can be measured [12]. For example, Hosseini et al. (2019) used video-based training along with lectures and group discussions in their study and selected ethical situations that nurses face in their profession from the ethically challenging scenes of the Australian Nurses film. The results indicated an increase in the moral courage of nurses [31]. Also, Joulii et al. (2012) and Ebadi et al. (2016) also used this film to teach professional ethics to nursing students, and the student's perspective on ethical concepts improved significantly [67].

Some studies show that moral courage is a concept that depends on the spirituality of people [12]. Some Islamic studies have paid special attention to prayer as one of the dimensions of worship in divine religions and have listed it as a factor influencing the moral courage of nurses [32].

Regarding the external or organizational factors affecting the moral courage of nurses, we can mention the leadership styles of head nurses, the role of empowerment and the moral atmosphere of hospitals. In the study of Shahbaz et al. (2021), which examined the relationship between head nurses'leadership style and nurses'moral courage, it was found that most nursing leaders use a transformational style, and this style leads to increased innovation in the organization and improved system performance. Finally, it was found that choosing the appropriate leadership style and improving leadership skills by nursing managers leads to an increase in the incidence of morally courageous behavior of nurses [23]. In addition, Hu et al. [28] and Khoshmehr et al. [26], found in their study that hospitals and other organizations can improve the moral courage of their nurses through structural and psychological empowerment. On the other hand, according to the literature review, the moral climate that affects the organizational climate, if appropriate, can reduce the moral distress experienced by nurses, and by increasing their sensitivity, it can increase the moral courage of nurses [36, 38]. Of course, some other studies have violated this relationship and said that there is no significant relationship between the moral climate and moral courage of nurses [27, 50]. The difference in the results of different studies can be due to the differences in the studied hospitals. Because each of the hospitals has different levels of care, policy, and atmosphere that affect this information, and ethics is one of the context-sensitive topics [68]; Therefore, according to the change in the results of each study and even the contradiction in the available information, it seems that a comprehensive study should be designed to accurately measure all these factors related to the moral courage of nurses in different societies including frequency of facing situations that require moral courage at work, factors affecting financial stability [69], death anxiety, resilience [70] and so on.

(Fig. 2). In general, according to the conducted studies, it can be said that the nurse's moral courage has a significant correlation with factors for example there is a strong and direct correlation between moral courage with moral sensitivity (r = 0.91, p < 0.001) with safe nursing care (r = 0.89, p < 0.001) in nurses caring [37], moral distress(P = 0.007, r =—0.2) [29], moral sensitivity, income, ideal behavior, moral reasoning, etc. In the Fig. 2, based on the reports showed a close correlation between moral courage and influenced factors.

Fig. 2
figure 2

influencing factors on moral courage

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Role of education in developing moral courage

Since moral courage in the nursing profession is an expectation, standing up to potential risks and consequences is necessary. These risks can include stress, anxiety, isolation from colleagues, and even leaving the job [11]. Career excellence creates moral courage in nursing and can come from professional care training, creating mental relaxation, making decisions, and correct performance [12].

Research indicates that nursing students often experience self-doubt when confronted with moral dilemmas, primarily due to a lack of confidence. This highlights the importance of education in moral courage [71]. Additionally, students lacking the moral courage to challenge unethical behavior may experience significant moral discomfort [72]. In clinical settings, if nursing students encounter conditions that degrade care quality, they typically remain silent, demonstrating insufficient moral courage to intervene [15].

The absence of moral courage can lead to nurses failing to act ethically in critical situations, such as protecting patient privacy, caring for infectious patients, delivering bad news, or addressing poor care by colleagues. Without proper training and due to the fear of negative reactions, loss of job status, emotional backlash, or violence, nurses may refrain from taking morally correct actions. Consequently, they may experience moral distress, depression, guilt, feelings of worthlessness, and powerlessness [6, 11].

To effectively face ethical challenges, healthcare professionals must receive training to demonstrate moral courage. Educational strategies should be employed in both nursing care and academic settings. Nurses should learn the roles of ethics, moral reasoning, and how to manage moral dilemmas [11].

Teaching moral courage during encounters with moral conflicts is crucial for promoting moral and humane care and upholding patients'rights. Enhancing moral courage through education positively impacts both moral sensitivity and moral courage. Given the ethical challenges inherent in nursing, boosting nurses'moral courage can improve care quality and patient safety [34].

Fear often inhibits the expression of moral behavior; therefore, educating and cultivating moral courage is expected to reduce errors and enhance patient safety [51]. So, moral courage helps nurses to overcome many problems such as fear and as a result, they can support patients well. In the case of training, it will lead to professional ethics among nurses, respect for the client's wishes, security and privacy, and the client's well-being. On the other hand, the absence of professional ethics and the lack of moral courage training of nurses harms the satisfaction and recovery of the client, the quality of care, the standards of nursing services, and the job promotion [13].

However, current nursing training programs are often inadequate in equipping nurses to handle moral dilemmas in high-stress environments [73]. It is necessary to support nurses in navigating morally disturbing situations [74]. Since moral courage is a professional expectation, its enhancement should be a formal objective of nursing education.

Different tools for assessing moral courage

Courage has different aspects including physical, social, psychological and moral. Moral courage means courage in moral matters. Moral courage means individual values and beliefs when facing contradiction and rejection. Most of the questionnaires used in the studies are given in Table 2.

Table 2 moral courage tools
Full size table

Literature reviews reveal that numerous studies have analyzed the concept of moral courage, identifying common features across many definitions [2, 4, 20, 25]. This concept is especially significant within the nursing environment, where it has received considerable attention globally [26, 37].

Research has been conducted across diverse nursing demographics, including clinical nurses, nursing students, and nursing managers. The emergence of moral courage is significantly influenced by cultural values, organizational factors in hospitals, location, and financial issues [1, 6, 24, 42, 79].

Despite extensive research, there is a tendency in studies to concentrate on personal and organizational factors while overlooking how moral courage manifests during critical ethical dilemmas. These dilemmas are especially pertinent to three main groups within the nursing profession: nursing students, clinical nurses who provide care to patients and their families, and nursing leaders responsible for fostering an environment that supports moral courage and implementing supportive policies [36, 80].

Systematic analysis of the factors that influence the development of moral courage is crucial. Such analysis helps protect moral frameworks and prevent ethical disturbances within the nursing profession [5].Additionally, empirical studies have shown that incorporating moral courage education into academic curricula for nursing students and clinical training for practicing nurses can effectively address many ethical challenges [6, 74, 81].

To date, six different tools have been developed to measure the level of moral courage, with the first tool introduced in 2009. These tools can be adapted by researchers according to the specific context and timing of their studies, allowing for a nuanced understanding of moral courage across different settings [17, 49, 82, 83].

Conclusion

In conclusion, the multifaceted nature of moral courage in nursing, influenced by internal and external factors, underscores the importance of analyzing and understanding the complexities that shape ethical decision-making within the profession. Fostering moral courage among nursing professionals through targeted educational strategies and training programs is imperative to navigate ethical challenges and enhance patient care quality. The exploration of moral courage globally reveals a nuanced interplay of individual, cultural, and contextual factors, emphasizing the need for ongoing research and tailored interventions to promote ethical practice and elevate patient outcomes on a global scale. Ultimately, better ethics training can help create a more sustainable and high-quality health system and enable health professionals to respond more effectively to ethical challenges.

Limitation

One of the limitations of this study was the time-consuming nature of the analysis and the large amount of data. This limitation was overcome by creating a strong and well-timed team.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

PMC:

Professional Moral Courage

NMCS:

Nurses’ Moral Courage Scale

MCQN:

The Moral Courage Questionnaire for Nurses

S-CVI:

Scale Content Validity Index

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Acknowledgements

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  1. Student Research Committee, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran

    Mina Mollaei, Fateme Metanat, Amirreza Rafiei Javazm & Mahdieh Motie

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“MM: Methodology, Investigation, and Writing—Original Draft AND FM: Investigation, Writing—Original Draft, and Visualization AND MM: Conceptualization, Methodology, Writing—Review & Editing, and Project administration AND ARJ: Conceptualization, Methodology, Writing—Review & Editing, and Supervision. All authors reviewed the manuscript”.

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Mollaei, M., Metanat, F., Javazm, A.R. et al. Exploring the foundations and influences of nurses’moral courage: a scoping review. BMC Med Ethics 26, 43 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12910-025-01205-5

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