Moral courage is a virtue that makes a person show moral performance in dangerous situations, while recognizing the existing challenges and barriers. Moral courage is an important part of nurses' professional competences (1, 2) and means performance based on the values and principles of nursing ethics. Moral courage in nursing requires having professional knowledge, skills, and awareness of values, laws and principles of nursing ethics and sensitivity to moral issues at the patient's bedside (3).
Nurses face many ethical issues daily in the workplace, including colleagues who are careless and negligent in patient care or have unprofessional behaviors, as well as unethical actions and behaviors of the doctor treating the patient, such as medical malpractice, ignoring the rights of the patient or inappropriate treatment of the patient, or discrimination between patients. In addition, nurses may be placed in situations where patient-based care is not supported due to organizational pressure, insufficient resources, and the organization's economic approach and moneymaking, and the nurse is at risk of defending the organization's interests instead of the patient's interests (4, 5).These ethical issues can lead to moral stress in nurses and as a result create a situation where nurses feel that they are unable to act based on the principles and values of their professional ethics and this moral stress can have a negative impact on the health of nurses and the quality of patient care. Moral stress manifests itself in the form of emotional, behavioral or physical symptoms, such as frustration, guilt, inadequacy, sleep disorders and many physical symptoms. In addition, moral stress is related to reducing job satisfaction and leaving the profession (2, 4–6). Nurses need moral courage to deal with moral issues in the workplace and reduce moral stress. Moral courage relieves moral stress and as a result increases the physical and mental health and commitment of the nurse to work and the quality of patient care increases (1, 7).
In fact, Low moral courage of nurses in the face of moral issues in the workplace threatens the safety or proper care of patients. While having moral courage increases the professional self-confidence and moral sensitivity of nurses and helps nurses to take care of patients well. In short, moral courage helps nurses to deal with ethical issues and challenges in the workplace better and experience less moral stress (2, 4, 7, 8). In order to guarantee the quality of nursing care and the safety of patients and the proper interaction of nurses with other colleagues and patients, it is necessary to promote their professionalism and moral empowerment (9, 10) .
Despite the importance of courageous actions in moral situations, studies have shown that often nurses do not act bravely when faced with moral situations and issues. The study results of Khatiban et al(11) showed that nurses did not have appropriate moral courage. In a study by Aminzadeh et al (8) the score of moral courage of nurses in special care departments in educational hospitals in Kerman was average. The study results of Black (12) mentioned that 34% of the nurses did not report it even though they were aware of the injury to the patient, and the main reason was the fear of confrontation and administrative reprimand. This problem shows the lack of moral courage in nurses. The study results of Bickhoff et al.(7) showed that most nursing students lack moral courage despite feeling moral obligation. When faced with a moral event, most remain passive spectators and the fear of consequences hinders moral action, and when they do not have the courage to face moral issues, they experience moral stress. In a review study, Arablarim et al.(13) investigated moral courage of nurses during 2000–2021, and the results showed average moral courage of nurses.
Given that courageous action when facing moral situations and issues cannot be appropriate and effective without awareness and knowledge of the principles and values of professional ethics, it is necessary to pay attention to the development of moral sensitivity, moral decision-making and moral courage in the training program of nurses and nursing students(14, 15). Studies have shown that nurses' awareness and knowledge of the principles and values of professional ethics helps them to make ethical decisions and it has a significant effect on their ability to manage ethical issues in the workplace and develop have their moral courage(10, 14, 16). The study results of Khatiban et al. (11) showed that the knowledge of professional ethics predicted moral courage of nurses. In order to improve the moral performance of nurses, the concepts and principles of professional ethics in nursing should be properly considered in the design of the nursing education program, and considering the importance of the issue of courage in nursing ethics and its effects on the quality of nursing care, and the inadequacy of existing training programs in promoting moral courage of nurses, this study was conducted to investigate the effect of a professional ethics empowerment program on the courageous behavior of nurses.