Relationship between Moral Sensitivity and Moral Reasoning with Moral Courage in Nursing Students

Abstract

Background:

Nursing students required to be prepared to face ethical problems in their future workplace. Solving moral dilemmas requires the implementation of moral decisions, which necessitates significant moral courage. Moral sensitivity and moral reasoning can play a key role in the emergence of morally courageous behavior. The aim of this study was to investigate the relationship between moral sensitivity and moral reasoning with moral courage in nursing students.

Materials and Methods:

This was a cross-sectional study. The participants consisted of 296 nursing students of Isfahan University of Medical Sciences, Iran, in 2021, which selected through the census method. Data were collected using the Persian versions of the Moral Sensitivity and Sekerka’s Moral Courage questionnaires and Nursing Dilemma Test. Data were analyzed by SPSS software (v. 25.0) using descriptive and analytical statistical methods (t-test, ANOVA, Pearson correlation, and regression analysis).

Results:

A total of 296 nursing students participated in this study. The results showed no significant correlation between moral sensitivity and moral courage (r = 0.04, p = 0.41); however, a significant positive correlation was observed between moral reasoning and moral courage (r = 0.19, p < 0.05). The results of multiple regression analysis showed that moral reasoning was the only predictor of moral courage in nursing students (p < 0.05).

Conclusions:

oral reasoning ability played a more significant role in developing moral courage than moral sensitivity. Tracking the sensitivity, reasoning, and moral courage status during education can reveal valuable information on the process of moral practice formation in nurses.

Introduction

During clinical practice and providing services, nursing students experience various ethical dilemmas, such as incorrect patient guidance, unethical treatment of patients by healthcare professionals, discrimination between patients according to their socioeconomic status,[1] violation of patient rights regarding confidentiality, respect for the patient and their privacy,[2] and the staff’s request to ignore the patient care measures.[3] Nursing students encounter specific ethical conflicts, such as problems in providing end-of-life care and dealing with patient death, particularly during crises and emergencies such as the COVID-19 pandemic.[4] Although nursing students feel deeply responsible for their patients[5] and tend to consider patients’ benefit in their practice, their perception of being inexperienced compared to the healthcare team compels them to remain silent and not take action in dealing with ethical dilemmas, instead of struggling to solve ethical problems and challenge unethical and unsafe practices, and they act based on other nurses’ expectations to avoid the conflict,[6,7] which may lead to moral distress, frustration, and disappointment with this field and ultimately the loss of qualified nurses.[6,8,9]

Since care is the essence of nursing,[10] it is essential for future nurses to enjoy professional and ethical competence to provide optimal and safe patient care.[11,12] Nursing not only includes theoretical and practical knowledge but also requires the ability to make moral decisions in challenging situations,[9] necessitating moral sensitivity,[13] moral reasoning[11,14] and moral courage.[12,15] Moral sensitivity has been proposed as the foundation of ethical behavior and ethical competence[16] and implies the ability to recognize ethical issues in the clinical setting.[13] Lack of ethical sensitivity can lead nurses to ignore ethical issues, resulting in irrational clinical decisions and conflicts between nurses and patients.[17] Spekkink[16] introduces the promotion of moral reasoning ability as one of the dimensions of moral sensitivity. Moral reasoning is the ability to analyze moral issues using rules and a logical justification for the choice made and a decision following that.[9,14]

After recognizing the ethical dilemma and opting for the most appropriate solution, moral courage is required to act based on moral reasoning and under moral principles and values.[12,18] Moral courage is the courage one manifests when facing ethical dilemmas to logically defend their moral principles and values despite the likelihood of negative consequences.[19]

The years of studying at the university are the appropriate time to learn moral characteristics and skills, including moral sensitivity,[6] courage,[20] and reasoning.[21] Considering that nursing students are more likely to witness and get involved in ethical dilemmas than other students of health professions[22,23] and since moral sensitivity and reasoning abilities will remain as an internal response and will not lead to moral care until they change to behavior; therefore, the creation and development of moral courage in nursing education is a significant issue.[19] Uncu[8] reported that 52.5% of students considered materials on ethics in the curriculum insufficient, and 73.5% of nursing students stated that they needed more education on ethics before graduation.

Several studies have investigated this concepts[20,24,25,26] and the level of moral sensitivity and courage in students[19,27,28] and nurses.[13,29,30] Moreover, numerous studies have investigated the relationship between moral sensitivity and courage and report a significant positive correlation between these two components in nurses.[10,31] However, limited studies have been conducted to measure the correlation between moral sensitivity, reasoning, and courage in nursing students. This study was conducted to investigate the relationship between moral sensitivity and moral reasoning with moral courage in nursing students.

Materials and Methods

This was a cross-sectional study conducted in the School of Nursing and Midwifery of Isfahan University of Medical Sciences in Iran. The research population included all undergraduate nursing students in the third and fourth years in the first semester of 2021–2022. Sampling was performed through the census method. Based on the inclusion criteria, 333 individuals were invited to the study. The inclusion criteria included the willingness to participate in the study, passing the nursing ethics credit, and having no severe mental disorders or family problems (based on self-report). The informed consent form was sent to the participants through a link, and after completing the informed consent form and confirming it, the questionnaire was given to the participant. Data were collected from October to December 2021. Owing to the COVID-19 pandemic, questionnaires were created online using Porsline website. To design the questionnaires, after signing up on the Porsline.ir website, study tool’s information were designed, typed, and uploaded to the panel, and finally, the questionnaire link was sent to the students on the social networks. To remind the participants, researchers made phone calls. Before the online response started, the study objectives and inclusion criteria had been loaded at the beginning of the questionnaire to inform the participants.

The data were collected using the following four tools: The questionnaire of students’ demographic characteristics, including age, gender, marital status, semester, place of residence, clinical work experience, obtaining information about the nursing field before choosing it, and interest in this field at present.

Persian version of Moral Sensitivity Questionnaire (MSQ) contains 25 items in 6 dimensions: “respect to autonomy,” “interpersonal orientation,” “trust in medical knowledge and principles of care,” “experiencing moral conflict,” “structuring moral meaning,” and “benevolence.” The items are scored based on a 5-point Likert scale from completely agree (4) to completely disagree (0). The total score between 0 and 50 indicated low, 50 and 75 indicated moderate, and 75 and 100 indicated high moral sensitivity.[32] MSQ was prepared by Lutzen et al. (1994) in Sweden. MSQ was translated into Persian by Abbaszadeh et al. (2010).[33] The tool’s validity was confirmed with a score of 97%, and its reliability was confirmed by measuring Cronbach’s alpha coefficient of 0.81.

Persian version of Nursing Dilemma Test (NDT) was used to investigate moral reasoning. NDT includes six scenarios: (1) newborn with anomalies, (2) forcing medication, (3) adult’s request to die, (4) new nurse orientation, (5) medication error, and (6) uninformed terminally ill adult. Each scenario can be a problem for the nurse. Six questions are presented concerning each scenario based on the second to sixth stages of Kohlberg’s theory. Respondents should prioritize these six questions the in order of importance. For the first priority, a score of six is given, and for the following priorities, scores are given from five to one. Two questions out of the six express one’s logical reasoning. If the respondent chooses these two questions as their priorities, they will score six in one item and five in the other. Therefore, the minimum and maximum scores of moral reasoning in total are 18 and 66, respectively. Higher scores indicate a higher level of moral reasoning. NDT was prepared by Crisham et al. (1981).[34] NDT was translated into Persian by Borhani et al. (2010),[35] and its content and face validity were confirmed based on the opinion of ten medical ethics experts. The reliability of the instrument was established using the test–retest method and a reliability coefficient of 0.82.

Professional Moral Courage Questionnaire (PMCQ) contains 15 items in 5 dimensions: moral agency, multiple values, endurance of threats, going beyond compliance, and moral goals. The items are scored on a 7-point Likert scale from Always True (7) to Never True (1). The total score between 15 and 50 indicated low, 51 and 75 indicated moderate, and 76 and 105 indicated high moral courage. This questionnaire was prepared by Sekerka et al. (2009).[36] PMCQ was translated into Persian by Mohammadi et al. (2014).[37] The tool’s validity was 81%, and its reliability has been confirmed by measuring Cronbach’s alpha coefficient of 0.85. In the study by Hanifi et al.,[3] the reliability was calculated using Cronbach’s alpha coefficient of 0.85.

Data were analyzed using SPSS software (v. 25.0). Descriptive statistics were used to show the frequency, mean, and standard deviation (SD) of the variables. To investigate the relationship between moral sensitivity, moral reasoning, and demographic characteristics with moral courage, Pearson correlation, an independent t-test, and One-Way Analysis of Variance (ANOVA) were used, and the variables that were correlated with the moral courage (p < 0.05) entered the multiple regression model. The level of statistical significance was p value < 0.05.

Ethical considerations

This study was conducted by obtaining the ethics code: IR.MUI.RESEARCH.REC.1399.674 from Isfahan University of Medical Sciences. Upon entering the website to respond to the questionnaires, the researcher was introduced to the participants, and information was provided about the study objectives. They were also assured that participation in the study was voluntary, they could withdraw at any time, and all their information would remain confidential. Online informed consent was obtained from each participant to participate in the study. The questionnaires were anonymous.

Results

In total, 296 of participants from 333 individuals were invited to the study, completed the questionnaire, and the effective response rate was 89%. The mean (SD) age of the participants was 23.51 (4.59) years.

According to the results of “Table 1,” the highest score of moral sensitivity 79.7% was obtained in the “trust in medical knowledge and principles of care” dimension Mean (SD) = 15.94 (3.09), with the lowest score of 55.8% obtained in the “respect to autonomy” dimension Mean (SD) = 11.16 (2.95). The demographic characteristic of the participants is shown in “Table 2.”

Table 1.

Mean (SD) of nursing students’ scores in sensitivity, reasoning, and moral courage (n=296)

Variable	Dimensions	Mean (SD)
Moral sensitivity	Respect to autonomy (0 –20)	11.16 (2.95)
	Interpersonal orientation (0 –12)	8.28 (2.16)
	Trust in medical knowledge and principles of care (0 –20)	15.94 (3.09)
	Experiencing moral conflict (0–20)	12.06 (2.94)
	Structuring moral meaning (0–20)	11.31 (3.28)
	Benevolence (0 –8)	4.96 (1.64)
	Total (0 –100)	63.74 (10.72)
Moral reasoning	–	48.39 (7.73)
Moral courage	Moral agency (3 –21)	18.53 (2.57)
	Multiple values (3 –21)	7.80 (3.28)
	Endurance of threats (3 –21)	17.39 (2.80)
	Going beyond compliance (3 –21)	12.88 (2.04)
	Moral goals (3 –21)	11.92 (2.15)
	Total (15 –105)	68.55 (5.44)

Table 2.

Comparison of mean scores of moral sensitivity, moral reasoning, and moral courage regarding nursing students’ demographic characteristics

Characteristics		n (%)	Moral sensitivity		Moral reasoning		Moral courage
			Mean (SD)	p	Mean (SD)	p	Mean (SD)	p
Gender	Male	144 (48.7)	63.70 (11.02)	0.94	48.06 (8.06)	0.50	68.54 (6.06)	0.97*
	Female	152 (51.3)	63.78 (10.46)		48.69 (7.44)		68.56 (4.81)
Marital status	Single	249 (84.1)	63.52 (10.98)	0.41	48.41 (7.62)	0.92	68.49 (5.32)	0.68*
	Married	47 (15.9)	64.91 (9.20)		48.29 (8.42)		68.85 (6.10)
Semester	5	72 (24.3)	63.37 (10.76)	0.92	49.07 (8.42)	0.22	69.48 (5.88)	0.41**
	6	69 (23.3)	64.28 (8.51)		47.27 (7.52)		68.31 (5.25)
	7	61 (20.6)	63.19 (14.02)		47.24 (7.50)		68.11 (5.35)
	8	94 (31.8)	63.98 (9.78)		49.33 (7.43)		68.29 (5.29)
Place of residence	Dormitory	99 (33.5)	63.45 (10.42)	0.94	47.17 (7.58)	0.12	68.06 (5.46)	0.51**
	With family	185 (62.5)	63.89 (10.98)		49.09 (7.78)		68.83 (5.42)
	Private home	12 (4)	63.91 (9.88)		46.45 (7.10)		68.25 (5.80)
Clinical work experience (years)	0	274 (92.6)	63.62 (10.90)	0.79	48.30 (7.56)	0.77	68.33 (5.46)	0.04**
	<1	6 (2)	65.66 (11.29)		49.00 (9.67)		71.16 (3.65)
	≥1	16 (5.4)	65.06 (7.18)		49.73 (10.05)		71.37 (4.80)
Obtaining information about the nursing field before choosing it	Yes	202 (68.2)	63.17 (10.45)	0.17	47.91 (7.85)	0.13	69.19 (5.10)	0.003*
	No	94 (31.8)	64.97 (11.23)		49.43 (7.40)		67.17 (5.91)
Interest in the nursing field at present	Yes	214 (72.3)	64.14 (10.17)	0.30	48.54 (7.78)	0.60	69.07 (5.50)	0.008*
	No	82 (27.7)	62.70 (12.04)		48.00 (7.63)		67.20 (5.08)

**ANOVA, *Independent t-test

There was a statistically significant difference in the total score of moral courage based on the factors of clinical work experience (F_2,293 = 3.11, p = 0.04), obtaining information before choosing the nursing field (t₂₉₄ = 3.02, p = 0.003), and interest in the field of nursing (t₂₉₄ = 2.66, p = 0.008). There was no statistically significant difference in the score of moral courage between gender, marital status, academic semester, and place of residence variables. In addition, no significant difference was observed in the score of moral sensitivity and moral reasoning based on demographic characteristic “Table 2.”

There was a significant positive correlation between the mean score of moral reasoning and moral courage (r = 0.19, p < 0.05). There was no correlation between the total mean scores of moral sensitivity and moral courage. Nevertheless, there was a positive correlation between the “trust in medical knowledge and the principles of care” dimension of moral sensitivity with the mean score of moral courage (r = 0.12, p < 0.05) “Table 3.”

Table 3.

The relationship between moral sensitivity and moral reasoning scores with the total score of moral courage

Variable	Statistical	Respect to autonomy	Inter personal orientation	Trust in medical knowledge and principles of care	Experiencing moral conflict	Structuring moral meaning	Benevolence	Total moral sensitivity score	Moral reasoning
Moral courage	r	0.01	0.02	0.12	-0.01	0.04	-0.06	0.04	0.19
	p*	0.74	0.66	0.02	0.81	0.42	0.23	0.41	0.002

*Pearson’s correlation coefficient

Multiple regression analysis showed that by entering the moral sensitivity, moral reasoning, clinical experience, obtaining information before selecting the nursing field, and interest in the nursing field in the analysis, moral reasoning was the only significant predictor of moral courage (p < 0.05) “Table 4.”

Table 4.

Results of Multiple Regression Analysis to predict moral courage

Variables	Unstandardized coefficients		Standardized coefficients Beta	t	p
	B	Std. Error
Respect to autonomy	0.09	0.12	0.04	0.70	0.481
Interpersonal orientation	-0.05	0.16	-0.02	-0.32	0.742
Trust in medical knowledge and principles of care	0.17	0.12	0.09	1.45	0.146
Experiencing moral conflict	-0.17	0.12	-0.09	-1.38	0.167
Structuring moral meaning	0.13	0.11	0.08	1.21	0.227
Benevolence	-0.39	0.207	-0.12	-1.90	0.058
Moral reasoning	0.13	0.04	0.19	3.25	0.001*
Clinical work experience	1.17	0.67	0.10	1.75	0.080
Obtaining information about the nursing field before choosing it	-1.29	0.69	-0.11	-1.87	0.062
Interest in the nursing field at present	-1.21	0.72	-0.10	-1.68	0.093

*Significance of statistical test

Discussion

This study was conducted to determine the relationship between moral sensitivity and moral reasoning with moral courage in undergraduate nursing students. The results of this study showed that the sensitivity and moral courage of nursing students were at a moderate level, and their moral reasoning was above a moderate level. The results showed that moral reasoning had a significant positive relationship with moral courage. Furthermore, moral reasoning was the only predictor of moral courage.

Similarly, in Khatiban et al.’s study,[14] moral reasoning was reported to be a factor affecting nurses’ moral courage. Recent research has stated that accurate thinking, thinking rationally, and being logical are among the factors affecting moral courage,[12,24] which, in fact, refers to moral reasoning that includes reasoning abilities and logical thinking.[11]

Although it seems that sensitivity to moral issues and the ability to recognize moral complexities is a requirement to achieve morally courageous behavior, this study showed no statistically significant relationship between the total scores of moral sensitivity and moral courage. Goktas et al.[38] reported a weak and inverse relationship between nurses’ sensitivity and moral courage during the COVID-19 pandemic. However, other studies have reported a significant positive correlation between moral sensitivity and moral courage.[6,10,31] In addition, other studies have reported moral sensitivity to be a prerequisite for moral courage.[19,25,35] Therefore, it seems that awareness and sensitivity to moral issues often lead to the development of morally courageous behaviors. However, it is possible that one manifests moral courage due to being influenced by others or at their company, and moral courage occurs without moral sensitivity. In fact, moral courage may not necessarily be expressed by recognizing the moral problem, or several factors may hinder the ability of one’s moral sensitivity. Borhani et al.[39] reported obstacles to moral sensitivity from the point of view of nursing students: unawareness (lack of moral awareness, lack of specialized knowledge, and lack of awareness of laws), unwillingness (destructive consequences, normalization of moral violations), and inability (lack of facilities, nonsupportive communication, moral conflict with Law).

In this study, among the dimensions of moral sensitivity, only the “trust in medical knowledge and principles of care” dimension significantly correlated with moral courage. Among the dimensions of moral sensitivity, the highest and lowest mean scores were obtained in “trust in medical knowledge and principles of care” and “respect to autonomy,” respectively. “Trust in medical knowledge and principles of care” means using the physician’s knowledge and expertise to solve the patient’s care problems, and “respect to autonomy” refers to strategies adopted to limit the patient’s independence, despite the nurse’s awareness of the self-selection principle.[40] This is a thought-provoking finding since this dimension refers to the principle of autonomy. The low level of respect to autonomy in students shows that nursing students have not obtained the right understanding and attitude toward the patient’s right to autonomy. This situation shows the necessity of nursing education based on moral education and the main values of nursing to improve students’ knowledge and moral thinking.[41,42]

In this study, nursing students’ moral courage ability was at a moderate level. The results of a review by Bickhoff et al.[43] showed that nursing students lacked the necessary moral courage to intervene or negotiate when faced with the weak actions of others. However, Koskinen et al.[19] reported high moral courage in nursing students. Moreover, Chua et al.[6] stated in their research that despite nursing students’ capacity for moral courage, most faced conditions that prevented moral courage from manifesting.

In this study, among the dimensions of moral courage, the highest and lowest mean scores were in “moral agency” and “multiple values,” respectively. The “moral agency” dimension indicates one’s responsibility when faced with a moral dilemma. The significance of this feature is that the individual is voluntarily involved with ethical issues and can make ethical decisions. “Multiple values” means one’s ability to integrate his/her values with professional values and use these integrated values when making ethical decisions.[41] Ethical dilemmas can challenge one’s deepest values because morally disturbing situations frequently occur in the clinical setting; therefore, awareness and clarification of values are required when confronted with such situations.[5,6] Similarly, Hanifi et al.’s study[3] reported the highest and lowest scores in the moral courage dimension in moral agency and multiple values, respectively. However, Chua et al.[6] stated the highest score in the moral goals dimension and the lowest score in the moral agency dimension. The difference in the results of the studies can be caused by the influence of moral courage from individuals’ previous life experiences,[19] the level of students’ awareness of moral codes, the consequences of manifesting moral courage for students,[7] the instructor’s supportive role for the student,[40] the influence of personal and organizational values on decision-making, ethical behavior,[6] and the ethical climate of the workplace and organization.[24]

The findings of the study showed a significant relationship between moral courage and the variables of “interest in the field of nursing,” “obtaining information about the field of nursing before choosing it,” and “clinical work experience.” However, no relationship was observed between moral courage and the variables of gender, marital status, academic semester, and place of residence. The moral courage score of students who had obtained knowledge about this profession before choosing nursing, students who were currently satisfied with studying in this field, and those with clinical experience was significantly higher than others. The findings of the study by Koskinen et al.[19] likewise showed a positive relationship between nursing students’ level of moral courage with longer work experience in healthcare and having career goals in the nursing field.

It is expected that with the increase in the academic year, nursing students will be empowered in moral courage; however, the failure to achieve this goal can occur due to various reasons such as organizational culture, collective decision to ignore the issue,[24] hierarchies in clinical departments, students’ lack of self-confidence, lack of professional competence (knowledge and skills), and fear of consequences and loss of nurses’ cooperation.[3,6] To clarify the moral courage incapability, more detailed investigation and further studies are required.

One of the critical limitations of this study was the sampling during the COVID-19 pandemic, which caused special mental and psychological conditions such as stress and fear of infection and death for the healthcare team, including the students. Another limitation of this study was data collection through self-reports.

Conclusion

This study suggested that moral reasoning ability plays a more important role in developing students’ moral courage than moral sensitivity and demographic characteristics. Considering that moral skills can be learned and developed with practice and internalized, educating students about moral issues throughout their studies, focusing on this feature, is of particular importance. Selecting various methods of moral empowerment of students, such as holding regular educational workshops to provide opportunities to discuss moral issues, can help to create and develop moral sensitivity, moral reasoning, and consequently moral courage.

Conflicts of interest

Nothing to declare.

Funding Statement

Isfahan University of Medical Sciences