Moral Courage of the Nursing Students of Yazd University of Medical Sciences, Iran

Nursing performance within the framework of professional ethics makes nurses respect their clientschr('39') needs, security, and privacy and enhance the welfare criteria. In contrast, lack of commitment to professional ethics in nurses may influence patient satisfaction and improvement, quality of care, standards of nursing services, and promotion of the nursing profession. Today, nurses are faced with spiritual and ethical issues and conflicts in an unprecedented manner due to their professional status and key role in health care. Some of these ethical issues include the use of invasive treatment protocols for dying patients, unnecessary tests, the manipulation and forging of the test reports, lack of complete and sufficient treatment by other employees, and the unjust distribution of power among healthcare employees. In addition, personal and organizational obstacles may often prompt nurses to avoid fulfilling their ethical obligations toward patients, which in turn prevents value-based nursing performance. Therefore, nurses need ethical courage to properly manage the ethical issues arising in the clinical setting. Biological ethics experts believe that professional ethics must be instructed and strengthened through university courses to enable nurses to battle ethical challenges in clinical settings. Clinical settings are considered a basic component of the nursing curriculum, as well as a permanent source of anxiety for nursing students, especially in the cases where they may be confronted with poor performance. Such examples of poor performance in clinical settings are the physical or emotional abuse of patients, violation of patientchr('39')s privacy, non-standard/outdated care, clinical errors, and the performance of healthcare experts beyond their authority. If nursing students are faced with poor performance in clinical settings, they may internalize their negative feelings and associate them with the nursing profession, questioning whether they must continue their education. Some nursing students question their capability in finding a solution to ethical challenges, which is a major source of diffidence and anxiety in the future. Given the importance of ethical courage in nursing students and its impact on the quality of care in their future profession, the present study aimed to evaluate the ethical courage of the nursing students of Shahid Sadoughi University of Medical Sciences in Yazd, Iran in 2020.

This descriptive, cross-sectional study was conducted in 2019 at the nursing schools of Shahid Sadoughi University of Medical Sciences. A sample of BA and MA nursing students (n=242) were selected via stratified random sampling. In sampling, the level of the students in the class was considered, and the sample size was determined in proportion to the number of the students in each class. The participants were selected randomly from each class. Data were collected using Sekerkachr('39')s ethical courage questionnaire, which was developed by Sekerka et al. in 2009 and consists of 15 items. The questionnaire items measure the adherence of nurses to ethical principles despite their intrinsic needs and external pressures. The five dimensions of the questionnaire include ethical aspects, multiple values, tolerance of threat, sensitivity, and ethical objectives. Each dimension has three items, which are scored based on a five-point Likert scale (Never=1, Rarely=2, Sometimes=3. Often=4, Always=5). The minimum and maximum scores of the questionnaire are 15 (low ethical courage) and seven (high ethical courage), respectively. Data analysis was performed in SPSS version 16 using descriptive statistics (mean, standard deviation, percentile) and inferential statistics (Pearsonchr('39')s correlation-coefficient, independent t-test, one-way ANOVA).

In total, 242 nursing students aged 18-44 years (mean age: 21.90 ± 3.45 years) were enrolled in the study. The mean score of ethical courage was 55.72 ± 7.84. In Meybod and Yazd, the mean score of ethical courage was 56.98 ± 7.06 and 54.46 ± 8.62, respectively, and no significant difference was observed in this regard (P=0.38). The highest score of ethical courage was denoted in the ethical dimension (11.88 ± 2.21), while the lowest score belonged to the dimension of threat tolerance (10.25 ± 1.90). Moreover, data analysis indicated a significant correlation between ethical courage and gender, and the female nursing students reported a higher ethical courage score compared to the males (P=0.04). However, no significant correlations were observed between ethical courage and other demographic variables, such as marital status and place of residence (P>0.05).

According to the results, the mean ethical courage score of the nursing students was average. It seems that nursing students feel responsible when faced with ethical issues. However, optimizing their sense of responsibility requires proper interventions since ethical courage in todaychr('39')s nursing students could result in a favorable ethical atmosphere in the healthcare system, thereby improving the quality of healthcare services and increasing patient satisfaction. Therefore, it is essential for nursing schools to promote ethical responses in the students. Furthermore, instructors should live up to their role and encourage ethical courage in nursing students.