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

Objectives This study is conducted with the aim of the relationship between moral courage and the perception of ethical climate in hospital nurses. Results The study was carried out as descriptive-correlation study in 2019. The subjects were 267 nurses working in hospitals who were selected through simple random sampling. Questionnaire was used to collect data. 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. 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.


Introduction
In their daily activities, nurses encounter problems and issues that might be inconsistent with their moral values [1][2][3]. In other words, nurses might face with controversial beliefs and values in doing the right thing and these might affect providing quality nursing care [4][5][6][7]. It is essential therefore, to have moral courage as a strategy to reinforce ethics and doing courageous deeds in nursing care [8,9]. 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 [10] 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 [3].This characteristic allows an individual to act ethically [11].
Sekerka de nes moral courage as the ability of doing ethical work and showing benevolence regardless of external risks [12].In another study, moral courage was de ned as doing the right deed, protecting rightfulness, and performing based on ethical principles in providing health care to patients despite personal risks and threats [13].In fact, moral courage alleviates ethical distress [14,15], leads to personal and professional development [16,17], and motivates gaining skills and preserving knowledge in individuals [12].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 [17].
According to Bandura's social cognitive theory (SCT), there is a mutual relationship among personal factors, behavior, and environment and these factors constantly affect each other [18]. Studies have shown that personal and professional factors [19], organizational culture, and leadership style [20], can affect moral courage in nurses. It appears that ethical climate of organization also affects moral courage [19,21]. Advanced organizations are featured with complicated moral environment that clearly affects the performance of organization. Hannah (2011) showed that people need to have speci c traits to improve their behaviors in the face of controversies [22].
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 [19].Ethical climate helps individuals to assess the problems and also acts as a guide for making decision about acceptable and unacceptable behaviors [23].
Ethical climate is a component of organizational climate and as a part of organization character, represents ethics in the organization [24,25].Ethical standards in organization promote respect and honesty among personnel and increase job satisfaction and organizational success [23].
Moreover, ethical climate enhances motivation in employees, improves organizational commitment, and preserve personnel, [19].It also creates a sense of ownership and attenuates loneliness in employees, which in return adds to the performance of organization [26].On the other hand, improper ethical climate is a factor in understaffed wards, loss of motivation, and job dissatisfaction in nurses [19]. Studies in Iran have shown that nurses' perception of ethical climate in hospital was at moderate level [10]. Limited studies have examined the relationship between moral courage and moral climate and the severity of this relationship, so the present study have been conducted to determine the relationship between moral courage and moral climate in nurses working in hospitals.

Materials And Methods
The present study is a descriptive-correlational study. The study was carried out in all educationaltreatment hospitals located in Rasht City from December 2018 to September 2019. 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 [10], 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 by strati ed random sampling method. Initially, a quota was allocated to hospital nurses based on the number of nurses working in each hospital. Then, the nurses of each hospital were randomly selected. 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. The exclusion criterion was failure to ll out the questionnaires.
To conduct the study after obtaining permission from the Vice Chancellor for Research of Mazandaran University of Medical Sciences and approval of the ethics committee and make the necessary coordination with the managers of the hospitals, the researcher referred to the hospital wards and introduced himself, the purpose of the study and how to answer the questionnaire. Participants were explained and if they wished to participate in the study and obtained written informed consent from them, a questionnaire was given to them and they were assured about maintaining anonymity and it was noted that not participating in the research had no consequences. It will not have a negative effect on their working conditions and they can leave the study whenever they want. . The mid-point is "sometime = 4," and minimum and maximum scores are 15 and 105 respectively. The mean score of statements and total score of the tool represents moral courage of respondent [12]. The Persian version of the professional moral courage was psychometric evaluation by Mohammadi et al. (2014). The content validity index (CVI) structure was 81%. Cronbach's alpha coe cient for the entire questionnaire was 0.85 [27].  [29]. In this research Cronbach alpha values of two instruments was 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%.

Discussion
The predictive factors of moral courage in nurse were identi ed. The results showed that moral courage of nurses can be improved through improvement of moral ethics in hospital wards. Different studies have shown that ethical climate affects main organizational events such as organizational commitment, job satisfaction, and intention to change ward, moral stress, and organizational citizenship behavior [27,30,31]. Kappa found a de nite relationship between ethical climate and individual performance of employees in organization [31]. Suhonen argued about the effects of ethical climate in organization on moral courage [19]. Since the health system is undergoing rapid changes to meet the growing needs of society and these changes have added to the number and complicacy of ethical questions in nurses' 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 [27]. 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 [32].This nding can be explained based on SCT that highlights the reciprocal and continuous relationship between personal factors, behavior, and environment [18].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.

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. Analysis and data interpretation, Drafting the manuscript and revising it critically for important intellectual content. MD and RN: Data acquisition, Drafting the manuscript and revising it critically for important intellectual content. All authors read and approved the nal manuscript.