This study determined the correlation between nurses’ moral courage and psychological empowerment. The findings showed that the participating nurses had a high degree of moral courage. This is consistent with the results of the study by Mahdaviseresht et al. , that reported a high mean score of nurses’ moral courage (90.36±10.56). The studies by Taraz et al. , and Moosavi et al. , also reported a high rate of moral courage among nurses. Nonetheless, the study by Mohammadi et al. , reported nurses’ moral courage at the moderate level. In Day’s study, the rate of this variable was low . The diversity of results in different studies may be attributed to disparities in work environment, ethical atmosphere, organizational culture, organizational and managerial support, fear of social seclusion, collective thought, and lack of acceptance by the organization .
In the present study, the highest score of moral courage belonged to “going beyond compliance” and the lowest score pertained to “multiple values”. Some studies reported the greatest amount of moral courage in “moral agency” [8, 32, 34]. This is not consistent with our results. Yet, consistent with our findings, in the studies by Mahdaviseresht et al. , and Taraz et al. , the lowest score of this variable pertained to “multiple values”. Nonetheless, in the study by Aminizadeh et al. , the lowest score of moral courage belonged to “endurance of threat”.
The high score of “going beyond compliance” indicates that nurses do not merely consider laws and regulations; rather, they progress beyond their internal capacity and consider doing what is correct and ideal [28, 35], suggesting nurses’ responsibility for their profession and patients. The low score of “multiple values” indicates nurses’ inability in ethical decision-making and coping with organizational constraints that may predispose to their moral apprehension, finally affecting their quality of care [28, 32, 35]. This needs to be noted by the responsible authorities. Also organizations must accept moral virtues such as courage and direct organizational culture towards supporting the nurses with moral courage. Some of the consequences are the right decision making, the right action, the patient's safety and comfort, and playing the role of care .
The findings of the present study revealed that the mean score of nurses’ psychological empowerment was at the moderate level. The results of other studies are consistent with this finding [36-40]. Ouyang et al. reported in their study the Chinese nurses’ psychological empowerment at the moderate level . Moreover, another study in Egypt, suggested a moderate level of nurses’ psychological empowerment . Furthermore, the findings of a systematic review demonstrated that Iranian nurses’ psychological empowerment is moderate . Yet, the study by Mirkamli et al. reported Iranian nurses’ psychological empowerment at a high level .
In the present study, the highest score of psychological empowerment pertained to “competence” whereas the lowest score belonged to “confidence”. In the study by Zahednezhad et al., the highest mean score belonged to “competence” while the lowest mean score pertained to “self-determination” , which is consistent with our study in maximal score. In the study by Mirkamli et al., the maximal mean pertained to “meaningfulness” whereas the minimal score belonged to “confidence” , that is consistent with our study in the minimal dimension.
The low score of nurses’ “confidence” in our study indicates that they are not sure that the powerful authorities will behave justly, honestly, and equally towards them; in other words, they do not feel any personal safety and security. Hence, nursing managers ought to pay due attention to this issue.
In our study, there was a direct significant correlation between psychological empowerment and its dimensions so that increased psychological empowerment resulted in nurses’ enhanced moral courage. No study was found to have exactly investigated the association between these two variables though some studies have indirectly implied it. For instance, LaSala et al. emphasize that all nurses in all roles and all work environments ought to commit themselves to creating a structurally powerful environment that supports moral courage . ZahedBabelan et al. also revealed that moral behavior, with its high psychological empowerment path coefficients, can be considered as an influential and powerful factor in empowering or developing nurses . Furthermore, Sadooghiasl et al. refer to ethical and scientific competence, self-construction, and rationalism as antecedents of moral courage. They also refer to protective environment and ethical climate of the organization as a factor contributing to moral courage . Kuokkanen et al. describe courage, tenacity, and self-esteem as qualities of an empowered nurse. An empowered nurse is able to act under pressure, resist criticism, and act in their performance and professional positioning without any fear. Such a nurse accepts responsibility with courage in decision-making .
To clarify this finding, it may be said that since increasing psychological empowerment may lead to reduced mental pressures and work environment stressors, and enhance the power of decision-making and performing moral behavior by the nursing staff [42-44], it can ultimately result in the creation of moral courage in nurses. Having a sense of control, competency, autonomy, positive impact, and increased motivation in relation to work affects the moral courage of nurses. In these circumstances, nurses, as moral agency, can properly manage moral dilemmas. This will improve the quality of care.
The findings showed no significant correlation among demographic variables, moral courage and psychological empowerment except that moral courage was significantly promoted with increasing age and work experience. The study by Mohammadi et al. , and Moosavi et al. , further demonstrated a positive significant correlation between moral courage and work experience that is consistent with our study. With increasing age, individuals’ awareness of a situation is enhanced and their capacity for recognizing behaviors . Aultman believes that moral courage is learned over time by observing the courageous behaviors of others. The occurrence of courageous behaviors is enhanced by increasing work experience and frequent encounters with therapeutic challenges . Murray also states that as the work experience of nurses increases, the impact of barriers in the work environment on nurses' performance decreases and moral courage increases . Generally, moral courage and the decisive behaviors of nurses are enhanced with increasing age and work experience and familiarity with the work environment. Using experienced nurses as role modeling for junior nurses can be an effective factor in promoting nurses' courageous behaviors.
Limitations of the Study
This study used self-reporting instruments for data collection. These instruments suffer from possibility of respondents’ fatigue and impatience in responding or shortage of time. Thus, some nurses may have not provided real answers. Another limitation was lack of control over intervening variables such as factors affecting personnel’s concentration that might have confounded the results.