The Relationship Between Moral Courage and the Perception of Ethical Climate in Nurses

Background: Moral courage, as a strategy to reinforce ethics and doing courageous deeds, is essential in providing nursing cares. Proper management of ethical challenges, professional commitment to patients, and ethical performance require moral courage. In addition, this concept is affected by personal and professional traits and organizational cultural. Ethical climate is a part of organization character, represents ethics in the organization. Ethical climate helps individuals to assess the problems and also acts as a guide for making decision about acceptable and unacceptable behaviors. The present study is an attempt to examine some of the predicting variables of moral courage in nurses. Methods: The study was carried out as predictive study in 2019. The subjects were 267 nurses working in hospitals who were selected through simple random sampling. Data gathering tool included a demographics form, Sekerka’s job satisfaction standardized questionnaire, and Elson’s ethical climate standardized questionnaire. Results: The mean scores of moral courage and ethical climate in nurses were 87.07±15.52 and 96.12±17.17 respectively. The ndings showed that 16% of moral courage score in nurses was attributed to ethical climate and overtime work hours per month. Conclusions: Although, ethical climate and overtime work hours were the main factors in moral courage, not a notable percentage of the variance of moral courage was attributed to them. Therefore, there is a need to determine other factors in moral courage.


Background
In their daily activities, nurses encounter problems and issues that might be inconsistent with their moral values (Dehghani et al., 2020;Numminen et al., 2018;Ranjbar et al., 2018). In other words, nurses might face with controversial beliefs and values in doing the right thing and these might affect providing quality nursing care (Belle, 2017;Mahdaviseresht et al., 2015;Mousazadeh et al., 2019). It is essential therefore, to have moral courage as a strategy to reinforce ethics and doing courageous deeds in nursing care (Bickhoff et al., 2017;Hawkins et al., 2014). Studies have shown that as ethical doers, nurses need moral courage to manage ethical challenges, honor professional commitment to patients, and work based on ethical codes (Taraz Z et al., 2019) The concept of moral courage was introduced during Florence Nightingale era and among all personal merits and speci cations, the principle of nursing is benevolence (Numminen et al., 2018).This characteristic allows an individual to act ethically (Yeom et al., 2017).
Sekerka de nes moral courage as the ability of doing ethical work and showing benevolence regardless of external risks (Sekerka et al., 2009).In another study, moral courage was de ned as doing the right deed, protecting righteousness, and performing based on ethical principles in providing health care to patients despite personal risks and threats (Gallagher, 2011).In fact, moral courage alleviates ethical distress (Lachance, 2017;Woods, 2014), leads to personal and professional development (Dinndorf-Hogenson, 2015; Lamiani et al., 2017), and motivates gaining skills and preserving knowledge in individuals (Sekerka et al., 2009).In addition, moral courage is a personal trait and the person who has it insists on their ethical values and commitments. Without moral courage, provision of nursing care is degraded and leads to moral distress or unethical behavior (Lamiani et al., 2017).
According to Bandura's social cognitive theory (SCT), there is a mutual relationship between personal factors, behavior, and environment and these factors constantly affect each other (Bandura, 2014).
Studies have shown that personal and professional factors (Suhonen et al., 2011), organizational culture, and leadership style (Escolar, 2018), can affect moral courage in nurses. It appears that ethical climate of organization also affects moral courage ( In addition, technological advances and changes in therapeutic methods and intervention, limited budgets and decrease in hospitalization capacity, increase of awareness in patients about their rights, reinforcement of supervision systems and health policies and regulations have led to several changes that emphasize on a better ethical climate (Suhonen et al., 2011).Ethical climate helps individuals to assess the problems and also acts as a guide for making decision about acceptable and unacceptable behaviors (Süreci, 2015).
Ethical climate is a sort of organizational climate and as a part of organization character, represents

Methods
The present paper is an attempt to survey the relationship between moral courage and ethical climate in nurses working in hospitals. The study was carried out as a predictive work in all educational-treatment hospitals located in Rasht City. Study population consisted of all nurses working in the hospitals. Minimum sample size was determined in G.Power (3.0.10) with moral courage and ethical climate correlation equal (Taraz Z et al., 2019), α = 0.05, test power equal to 90%, effect size equal to 0.2, and 10% leaves. Therefore, the sample size was obtained equal to 267, who were selected from six hospitals.
Inclusion criteria included at least BSc of nursing, one year of work experience, and working in one of the hospitals at the time of study (o cial, contractual, or other employment plans). The exclusion criterion was failure to ll out the questionnaires.

Data collection
The data were collected by three forms including a demographics form, Professional Moral Courage , mostly correct = 4, sometime correct = 3, rarely correct = 2, and almost correct = 1). The higher the score, the higher the ethical climate (Olson, 1998). Reliability of the questionnaire was supported by Cronbach's alpha equal to 0.91. The designers of the tools gave their permissions for using the tools beforehand.
Data analysis was done using SPSS (v.22). Kolmogorov Smirnov (KS) test was used to examine normal distribution of the quantitative continuous data. Simple linear regression was used to analyze predictive variables of moral courage. The variables that were signi cant in simple linear regression were tested with multiple linear regression at the same time. Multiple consistency and independence test among the remainders was examined using variance in ation factor and Durbin-Watson tests (p < 0.05). The level of missed data was determined using "Multiple Pattern" command. Total response rate of the questionnaires was 97%.

Results
The mean age of men 31.56 (SD = 8.08, CI%95 = 29.33-35.76) was less than that of women 34.45 (SD = 7.65; CI%95 = 33.35-41.50). The key demographics ndings of the nurses are listed   mind, having a decent ethical climate that emphasizes on moralities, the nurses will have more courage to question work process and promote improvement of health services. As our results showed, with a descent ethical climate, moral courage increases (Mohammadi et al., 2014). The importance of ndings lies with the fact that ethical climate can be modi ed like other organizational variables so that it can be used to improve health cares and prepare the ground for making ethical decisions.
Another nding was that an increase in work hours of the nurses increased moral courage signi cantly and trivially at the same time. Although, our search to nd a study on the relationship between work hours and moral courage in nurses was not successful, an analysis by Numminen on the concept of moral courage in nurses showed that experience was a precondition for moral courage (Numminen O et al., 2017).This nding can be explained based on SCT that highlights the reciprocal and continuous relationship between personal factors, behavior, and environment (Bandura, 2014).That is, the longer work hours provide more chance of social and environmental interactions, which prepares the ground for changes in personal factors like moral courage in nurses.
Regression analysis results showed that while ethical climate and work hours were predictors of moral courage in nurses, only 16% of the variance is attributed to these two variables. That is, there are other key predictors that should be found by future works.

Limitation
First, the study samples included nurses from only one type of organization (educational hospital). This means that it would be di cult to generalize the results to other nurses from other elds or private or nonpro t organizations. non-probability samples (Convenience sampling) and low number of male nurses are other limitations of this study that reduce the generalizability of the results.

Conclusion
Overtime work hours and ethical climate were, to some extent, predictors of moral courage in nurses. However, the share of these two factors in predicting moral courage was not notable.

Competing interests
There is no competing interest in the designing or reporting of the study.

Funding
The author(s) disclosed the receipt nancial support for the data collection: This study was nancially