This study aimed to evaluate the current status of moral courage among nurses in central China and explore factors influencing it from an empowerment perspective. The level of the total score of moral courage was above average in this study. There was a positive correlation between structural empowerment, psychological empowerment and moral courage. The level of moral courage experienced by clinical nurses was also influenced by structural empowerment and psychological empowerment.
In our sample, the average NMCS score was 3.90 ± 0.67, between the scores of Konings et al.’s (mean, 3.77 ± 0.537) [6] and Khoshmehr et al.’s (mean, 4.30 ± 0.503) [8] findings. This result may be related to the differences between measurements conducted in different cultural contexts, and also suggests that clinical nurses’ moral courage in this hospital behaves generally well. It is worth noting that the response rate in this study was 20.55%, so that we do not know the level of moral courage of the remaining nurses (about 80%). The response rate of a survey provides an indication of response bias and the consequent representativeness of the results of the study. Therefore, the nonresponse bias may exist in this study, that is systematic variation in a measure of importance to the study, between those who respond to a survey and those who do not [20]. Whilst there is no evidence of an ideal response rate relationship to survey validity, response rates can be enhanced by including monetary incentives, and repeat contact with non-responders in future studies.
The average scores of items on the dimensions of “moral integrity” and “compassion and true presence” were moderately higher than those on the dimensions of “commitment to good care” and “moral responsibility” (Table 2), which was in line with another study in Finland [6]. Moral integrity focuses on adhering to the principles and values of the profession and healthcare in general, particularly in situations where taking the risk of negative consequences from others is a possibility, thus focusing on the very core of moral courage [21]. This finding reflects the fact that the teachings of Confucius, as principles for social interaction, have a great influence on Chinese nurses’ behavior. Confucianism is based on the principles of loyalty and encouraging harmony and altruism, which is related to the fulfillment of duty and the utmost commitment to it, coupled with impartiality in decision-making [22]. Compassion and true presence describe care situations in which encountering the patient’s vulnerability in sickness and suffering demands that the nurse overcome her or his own inner fears, forcing the nurse to encounter her or his own vulnerability to be able to act courageously [21]. Altruism may also be one reason to explain the findings of this study, consistent with Wang et al.’s study in central China [23].
In this study, the total score and the dimensions of the NMCS positively correlated with the CWEQ-II and PES (Table 3, p < 0.001). This finding suggests that empowerment can significantly affect the moral courage of nurses and was consistent with one previous research finding [8]. The mean scores of structural empowerment and psychological empowerment of participants were above average, which is consistent with the results of some earlier studies [24, 25]. Empowerment in the nursing literature was described as something that nurses did for their patients or as an individual process of self-awareness and actualization [26]. In addition, hierarchy in organizations can inhibit moral courage [27]. Highly empowered groups can create a more flexible work atmosphere for the achievement of work targets [28]. Accordingly, empowerment has important contributions to medical care and workers. In addition, empowerment is closely related to the benefits of the practice environment such as increased retention and job satisfaction, improved and safer care [29]. Therefore, when pressured to conform to unethical or outdated practices, empowered nurses will overcome their fears, endure the consequences and act in a manner consistent with their professional values, which is the core ideology of moral courage.
The regression analysis showed that CWEQ-II and PES played significant roles in the NMCS (Table 4, p < 0.05). As the level of structural empowerment and psychological empowerment increased, the moral courage level of nurses improved. This may suggest that there may be an optimum combination of research variables to enforce moral courage. Previous study also found that nurses would experience moral distress when they feel disempowered or impeded in taking the ethically right course of action [30]. This is because that the environment of nurse practice strongly influences ethics norms and social practice, and structural empowerment is an important aspect of the practice environment [31]. In addition, the benefits of structural empowerment with the content of opportunity, support, information, resources, formal power and informal power, can be manifested in improved employees’ attitudes and progress toward meeting organizational goals, in which nurses’ attitudes of their power to resolve ethical problems are essential to the decision of whether to take action and that empowerment strategies can lead to ethical action [13]. Moreover, positive outcomes such as collaborations and trust are the result of providing improved authorization level within the work environment, which can itself be the cornerstone for establishing a positive moral atmosphere. However, interventions to improve delegation were limited in the published literature. Therefore, nursing managers can enhance moral courage by creating a clinical environment that facilitates obtaining the support, information, and resources needed for nurses to perform their duties effectively; recognizing nurses’ achievements; providing opportunities for learning and professional development; and expanding their responsibilities, so that nurses can present greater moral courage for patients’ outcome.
On the other hand, the significant relationship between psychological empowerment and self-assessed moral courage in Table 4 supports the importance of personal feelings in acting morally courageously. In a study in Iran by Khoshmehr et al. [8] also concluded that nurses’ moral courage could be enhanced by reinforcing their psychological empowerment, which led to increased patient satisfaction and quality care. Psychological empowerment refers to one’s perceptions about themselves in relationship to one’s work environment. The four cognitive factors of psychological empowerment with meaning, competence, self-determination and impact reflect an active orientation and feeling of control toward work [32]. Hence, experiencing empowerment and intrinsic motivation can result in positive forms of work performance, including acting courageously on ethical issues. Nurses’ choices, efforts, and determination to cope with and solve ethical dilemmas depend on their own ethical competence [33]. It is noteworthy that ethics education can be effective in improving knowledge, perception, confidence, and ethical behavior [34]. Robinson et al. [35] developed an educational program, the Clinical Ethics Residency for Nurses, to strengthen nurses’ moral agency, that is, an enhanced ability to act to bring about change. This program employed a variety of methods based on adult learning theory, such as the active application of ethics knowledge to patient scenarios in classroom discussion, simulation, lecture-style classes and the clinical practicum. Indeed, being aware of competence or self-determination in a clinical setting can provide a basis for understanding and improving nurses’ moral behaviors. This finding emphasized that further attention needs to cover strategies for psychological empowerment to encourage nurses to demonstrate moral courage when confronted with ethical misconduct.
There were several limitations that need to be acknowledged. First, we only conducted the investigation in one hospital, and convenience sampling was used, so selection bias may have occurred. It is remarkable that we did not identify a significant relationship between moral courage and demographic features, which may be due to the sampling method. Second, since the study sample is small, it is not possible to evaluate a proposed model in which nurses’ psychological empowerment intermediate the association between nurses’ structural empowerment and moral courage. Therefore, further research is required to analyze and explore the direct and indirect effects of variables on moral courage with a more rigorous study design and larger samples from other nursing fields.
