Moral courage in health sciences students: a systematic review of challenges, influencing factors, and consequences

Abstract

Background

Moral courage is the critical bridge between ethical knowledge and ethical action in healthcare. While health sciences students often possess high moral sensitivity, they frequently struggle to act on their values due to the “theory-practice gap” and the pressures of clinical hierarchies. The suppression of moral courage not only compromises patient safety but is also closely associated with moral distress and professional burnout among trainees.

Objectives

This systematic review aims to critically analyze the global evidence regarding the prevalence of moral courage among health sciences students and to identify the barriers, facilitators, and consequences associated with moral courage in educational settings.

Methods

This systematic review was conducted in accordance with PRISMA guidelines and registered in PROSPERO (CRD420251057915). A comprehensive search was performed across PubMed, Embase, Web of Science, the Cochrane Library, and Google Scholar to identify relevant studies published from 2000 to March 2025. The methodological quality of the included studies was assessed using the Joanna Briggs Institute (JBI) critical appraisal tools.

Results

A total of 21 studies, comprising 4,719 participants from diverse cultural contexts, were included. The findings reveal a disciplinary divergence in moral courage: nursing students generally exhibited moderate-to-high levels, whereas medical and dental students reported lower levels, often constrained by rigid hierarchies. The primary barriers identified were the “hidden curriculum,” fear of negative evaluation, and hierarchical power dynamics. Conversely, key facilitators included positive role modeling, a strong sense of moral agency, and supportive peer environments.

Conclusion

Students largely perceive the deficit in moral courage as a systemic issue rather than an individual failure. Current educational models often prioritize compliance over advocacy, creating a perceived conflict between academic survival and ethical action for trainees. To foster active moral agents, medical education must reframe moral courage as a trainable “non-technical skill” and implement systemic reforms to dismantle the culture of silence in clinical environments.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12909-026-09619-4.

Introduction

In the rapidly evolving landscape of modern healthcare, ethical competence is a critical determinant of patient safety and clinical quality. As healthcare systems face increasing complexity, driven by technological advancements, resource scarcity, and global health crises, professionals are frequently confronted with high-stakes ethical dilemmas. While moral sensitivity enables clinicians to recognize these conflicts, it is moral courage that empowers them to act. Defined as the capacity to overcome fear and stand up for core values despite the risk of reprisal [1, 2], moral courage serves as the final barrier against medical error and patient harm [3]. Recent literature underscores that the absence of moral courage does not merely result in silence; it is strongly associated with moral injury and burnout. This phenomenon has become increasingly prevalent among healthcare workers globally in the post-pandemic era [4, 5].

The cultivation of moral courage is particularly precarious during professional training. Health sciences students undergo a rigorous socialization process where they transition from the idealistic environment of the classroom to the hierarchical reality of clinical practice. Here, they encounter a profound Theory-Practice Gap [6]. While formal curricula emphasize advocacy and transparency, the hidden curriculum can implicitly teach that conformity and obedience to superiors are the keys to academic survival [7]. A substantial proportion of trainees, ranging from 40% to 60% in various educational settings, witness unethical behaviors or unprofessional conduct by supervisors but choose to remain silent [8, 9]. This perceived systemic suppression frequently leads students into a state of moral distress. In such situations, trainees often report knowing the right action but feeling institutionally powerless to execute it [10].

Given the high likelihood that students will encounter unethical behavior during their clinical training, moral courage represents an essential clinical competency. However, it remains unclear how often trainees actually deploy this courage when faced with real-world ethical dilemmas. Current educational models frequently fall short in equipping students with the “non-technical skills” required to navigate power gradients and ethical conflicts effectively [6, 11].

While existing research establishes that moral courage is vital for patient advocacy and professional integrity, the literature remains fragmented. Previous reviews have predominantly focused on practicing nurses and nursing students [9, 12] or specific isolated interventions [13], failing to provide a comprehensive synthesis across the broader spectrum of health sciences students. However, emerging primary studies indicate that the struggle for moral courage extends deeply into other clinical disciplines. For instance, medical students frequently grapple with steep hierarchical power dynamics during clinical clerkships. This dynamic often results in reported silence regarding medical errors or unprofessional conduct by attending physicians [14, 15]. Similarly, dental students face unique ethical dilemmas, such as the pressure of clinical quotas, overtreatment, and balancing patient autonomy, which severely test their ethical resilience [16, 17]. Allied health and pharmacy students also encounter significant interprofessional barriers when attempting to advocate for patient safety. Understanding the unique ecosystem of barriers (e.g., hierarchical fear, evaluation anxiety) and facilitators (e.g., resilience, role modeling) specific to the student population is essential. This understanding is a critical step toward bridging the gap between ethical knowing and ethical doing.

To address this gap, this systematic review aims to analyze the global evidence regarding moral courage in health sciences students. Specifically, this study seeks to identify the challenges that inhibit moral courage, the influencing factors that promote it, and the consequences of moral courage for both the student’s professional identity and the healthcare system. The findings may inform the development of evidence-based pedagogical strategies that transform students from passive observers into active moral agents.

Methods

Protocol and registration

We conducted a systematic review of papers published from 2000 to March 12, 2025, to examine the literature regarding moral courage in health sciences students. This study was conducted in accordance with the PRISMA guidelines [18]. The study protocol was reviewed and approved by the Ethics Committee of Golestan University of Medical Sciences (approval number: IR.GOUMS.REC.1403.470). Following a preliminary search, the systematic review protocol was developed and registered in PROSPERO [19] under registration number CRD420251057915.

Literature search

To collect relevant data, a comprehensive search was conducted across international databases, including PubMed, Embase, Web of Science, and the Cochrane Library. The search strategy was structured to combine terms relating to health sciences education (e.g., “health sciences students” OR “nursing students” OR “medical students”) AND terms related to moral courage (e.g., “moral courage” OR “courage”). These terms were applied to the titles and abstracts of records. Additionally, a subject-based search using Medical Subject Headings (MeSH) was performed in PubMed. To ensure comprehensive coverage, the reference lists of eligible studies were manually screened, and supplementary searches were conducted in Google Scholar using the main keywords. Furthermore, the “Cited by” and “Related articles” features were examined to identify additional relevant studies. Detailed search strategies employed across the databases are provided in [Supplementary Table 1].

Study selection and Data extraction

Following the retrieval of records, all citations were imported into EndNote (Version 20, Clarivate Analytics), and duplicates were removed by one reviewer (K.K.). Subsequently, two independent reviewers (S.M. and A.A.) screened the titles and abstracts to identify studies meeting the inclusion criteria. In cases of disagreement, consensus was reached through discussion. When necessary, a third reviewer (K.K.) was consulted to reach a final decision. The full texts of all potentially eligible studies were then retrieved and assessed. Review articles, theses, conference abstracts without full texts, and studies published outside the defined time frame were excluded.

Key data, including the title, first author, publication year, location, study design, sample size, target population, instruments used, and main findings, were independently extracted by two reviewers (S.M. and A.A.). These extracted data were then entered into a Microsoft Excel 2016 spreadsheet for analysis. Due to the methodological heterogeneity of the measurement tools across the primary studies, direct numerical synthesis was not feasible. Therefore, the reported “levels” of moral courage were extracted and categorized. This categorization was based strictly on the specific cut-off points and qualitative interpretations provided by the original authors of each study. Any discrepancies between the reviewers during the screening and data extraction stages were resolved through consultation with the third reviewer (K.K.).

Methodological quality assessment

All included studies underwent quality assessment using the Joanna Briggs Institute (JBI) Critical Appraisal Tools. Specific tools were utilized for each study type, including cross-sectional [20], quasi-experimental [21], and qualitative designs [22]. Each appraisal item was rated as “Yes”, “No”, “Unclear”, or “Not Applicable” (NA). To determine the overall quality, the proportion of “Yes” responses was calculated. Studies with ≥ 75% “Yes” responses were classified as having a low risk of bias (high quality). Those scoring between 50% and 74% were categorized as moderate risk, and those with < 50% as having a high risk of bias (low quality) [Supplementary Tables 2–4]. Based on these criteria, 18 studies were classified as high quality, 1 study as moderate quality, and 2 studies as low quality. Visual representations of the quality scores across the different study designs are provided in the supplementary files. All steps of the review process were conducted in strict adherence to PRISMA guidelines to ensure transparency and reproducibility.

Results

Search results

The article selection process is illustrated in [Figure 1]. The initial search across electronic databases identified a total of 1,568 records. Specifically, these included 577 from PubMed, 407 from Web of Science, 550 from Embase, and 32 from the Cochrane Library. Additionally, one record was identified through a manual search in Google Scholar. After removing 611 duplicates, 957 records remained for screening. Of these, 907 were excluded based on title and abstract screening, as they did not meet the eligibility criteria. Consequently, the full texts of 50 articles were assessed for eligibility. Thirty articles were subsequently excluded for the following reasons: failing to address moral courage (n = 13) or not focusing on the target population of health sciences students (n = 17). Ultimately, 21 studies, comprising a total of 4,719 students, fulfilled the inclusion criteria and were included in this systematic review. The characteristics of the included studies are presented in [Table 1].

Fig. 1.

PRISMA flow diagram of the systematic literature search and study selection process

Table 1.

Study characteristics of the selected articles

First Author	Publication year	Country	Study population	Sample size (N)	gender	Age (Mean or range)	Study Design	Facilitating and motivating factors	Barriers to moral courage	Key Results
Bickhoff et al. (23)	2016	Australia	Nursing students	10	F / M	20–52	Qualitative	Patient advocate identity; consequences to the patient and to the participant; the impact of key individuals	Fear of potential consequences Includes fear of failing, deliberate exclusion from learning opportunities, and bullying	60% of participants were confident to speak up against unethical behavior; 40% depended on severity.
Curtis et al. (24)	2014	United Kingdom	Nursing students	19	NR	NR	Qualitative	Discussion about values and learning; individual moral responsibility; moral virtue of compassion experiences	The reality of practice pressures; The sustainability of professional ideals; Subsequent personal and professional dissatisfaction; Moral distress; Approaching the completion of their education	Students are at risk of failing professional expectations due to lack of emotional support and resilience training.
DeSimone et al. (25)	2019	USA	Nursing students	29	F / M	21–39	Qualitative	Respectfulness; Responsibility-Compassion; Honesty; Fairness	Inexperience; Limited Ethical Knowledge; Lack of Ethical Confidence; Fear of Retaliation; Fear of Litigation	78% felt competent in ethical decision-making; highest skill reported was cultural competence (82%).
Escolar et al. (26)	2018	Filipin	Nursing students	293	F / M	> 18	Qualitative	Exposure to morally distressing situations; Moral sensitivity; Commitment to the profession; Desire to act in the patient’s best interest; Supportive educational environment	Perceived inexperience and low hierarchical status; Feelings of powerlessness; Lack of professional competence; Lack of support from supervisors and mentors; Fear of negative consequences; Difficulty speaking up; Unfavorable work environment; Moral distress; Cultural and educational factors	Students often ignored distress to avoid conflict. High moral sensitivity (> 4/6) and perceived courage (> 5/7) reported.
Heggestad et al. (7)	2022	Norway	Nursing students	7	F / M	20–32	Qualitative	Empathy and compassion; Role models; Professional socialization; Supportive clinical environments; Ethics education; Personal values and integrity; Experience and reflection; Organizational support	Lack of role models; Vulnerability and insecurity; Hidden curriculum; Fear of negative consequences; Lack of mutual respect and support; Over-reflection and apprehension; Conflicting values and organizational culture	Difficulty showing courage in unethical situations due to poor role modeling and supervision.
Koskinen et al. (27)	2021	Finland-Germany- Iceland-Ireland- Lithuania- Spain	Nursing students	1796	F / M	18–60	Cross-sectional	Professional competence; Ethics education; Supportive student–mentor relationships; Role modeling by educators; Advocacy and willingness to act; Positive ethical climate; Personal attributes; Experience and achievement; Perception of nursing’s value	Lack of professional competence; Low professional hierarchy; Lack of supervisor support; Fear of negative consequences; Inadequate ethics education; Negative organizational climate; Moral distress; Poor mentor–student relationship	77.8% of nursing students demonstrated moral courage.
Mohammadi et al. (28)	2022	Iran	Nursing students	400	F / M	19–35	Cross-sectional	Moral Sensitivity; Safe Nursing Care; Work Experience and Age; Support from Supervisors and Facilitators; Professional Values; Organizational and Peer Support	Fear of being reprimanded by hospital managers; Hostile or unsupportive work environments; Heavy workload and overcrowded wards; Lack of time and resources; Conflicting opinions with physicians and absence of physicians in the ward; Working with incompetent colleagues; Violation of patient privacy and confidentiality	High moral courage and resilience in students caring for COVID-19 patients. Direct correlation between resilience and courage.
Gibson et al. (29)	2020	USA	Nursing students	45	F / M	22.15 (Mean)	Qualitative	Supportive mentoring / supervision; Sense of responsibility / professional identity; Confidence in ethics / professional skills; Ethics education and training; Supportive environments; Reflective practice / moral awareness; Role models and leadership	Fear of negative consequences; Power dynamics / organizational constraints; Lack of supervisor / mentor support; Inadequate ethics education; Internal rationalization / self-doubt; Cultural / social norms; Ongoing moral distress	Mild moral distress reported. Courage correlated with resilience, age, and prior degrees.
Talebian et al. (30)	2023	Iran	Nursing students	175	F / M	24.8 (Mean)	Cross-sectional	Religious orientation; Moral sensitivity; Ethics education / training; Supportive mentoring / role models; Personal / professional values; Supportive environments	Fear of negative consequences; Lack of support from supervisors or mentors; Power dynamics and hierarchical structures; Unsupportive or intimidating learning environments; Internal doubt and lack of confidence; Cultural and social norms; Moral distress	Average moral courage level (Mean = 58.74). Significant positive correlation with religious orientation (r = .62).
Xiao et al. (31)	2024	china	Nursing students	50	F / M	25.5 (Mean)	Quasi-experimental	Integrated moral and medical education; Enhanced professional practice ability; Ethics-focused curriculum; Role modeling and mentorship; Opportunities for reflection and discussion; Increased satisfaction and engagement; Assessment and feedback	Fear of negative consequences; Hierarchical power dynamics; Lack of supervisory or mentor support; Intimidation or being ignored; Organizational culture and routine; Insufficient ethics education; Low professional competence or confidence	Intervention group showed significantly higher moral courage and nursing skills compared to control group (P<.001).
Yi et al. (32)	2024	China	Nursing students	467	NR	NR	Cross-sectional	1. High moral sensitivity; Strong professional identity; Supportive ethical climate; Personal characteristics; Ethics education / training; Leadership / role models	Organizational constraints / moral distress; Fear of negative consequences; Lack of psychological empowerment; Weak moral sensitivity / professional identity; Hostile / unsupportive environments; Compassion fatigue; Practical considerations / rationalization	Positive correlation between moral courage, professional identity, and sensitivity. Negative correlation with compassion fatigue.
Huang et al. (33)	2023	China	Nursing students (Master’s degree)	10	F / M	24.3 (Mean)	Qualitative	Sense of responsibility; Professional identity; Support systems; Personal values and beliefs; Role models; Education and training; Experience sharing; Organizational support; Resilience	Lack of managerial support; Unfavorable work environment; Fear of job loss or retaliation; Lack of experience; Fear of negative consequences; Insufficient moral education or training; Moral distress; Conflicting values; Isolation policies; Resource constraints	High moral courage maintained during COVID-19 pandemic despite ethical challenges.
Bruun et al. (34)	2022	Norway	Nurse anesthetist students	40	NR	NR	Qualitative	Knowledge of situation / ethics; Emotional control / risk management; Assertive communication; Education and preparation; Supportive supervisors / team dynamics; Advocacy for safety / colleagues; Personal values / integrity; Reflective practice	Organizational constraints / culture; Fear of negative consequences; Moral distress / powerlessness; Lack of peer / administrative support; Conflicting loyalties / value conflict 6. Insufficient ethical education	Narratives revealed 20 situations of moral courage vs. 18 situations of failed courage.
Kroszynski et al. (14)	2024	Israel	Medical students	239	F / M	< 29	Cross-sectional	Well-being & Low Burnout; Professional Efficacy; Educational Interventions; Reflective Practice; Supportive Environments; Personal/Moral Development	Unsafe learning environment; Burnout; Not fully addressing students’ learning needs; Academic burnout (e.g., exhaustion); Reduced professional efficacy; Hesitation to share concerns, limitations, mistakes, or feelings of incapability	Only 10% reported high moral courage toward others, while 54% reported high courage toward self.
Ribeiro et al. (35)	2021	Brazil	Medical students	13	F / M	23.8 (Mean)	Cross-sectional	Structured ethics education and rights-based leadership; Reflection and honest self-assessment; Cognitive and emotional strategies; Supportive environments and peer support; Personal characteristics and moral development; Ongoing education and practice; Leadership and organizational culture	1. External circumstances that constrain decision-making, such as a hierarchical clinical environment or the lack of structure and organization in the healthcare system; Conflict between students’ current attitudes and moral decisions with the desired or idealized attitudes of the doctor they intend to become; Moral dilemmas related to the conflict between ethical principles that students need to balance during moral decision-making	Need for improved emotional support and opportunities to habituate moral thought to prevent loss of compassion.
caldicott et al. (36)	2005	USA	Medical students	327	NR	NR	Qualitative	Ethical Education and Training; Institutional Support for Speaking Up; Protection Against Discrimination and Ethical Violations	Deliberate lies and deception in the context of medical care (communication); Discriminatory treatment of patients (justice); Students’ reluctance to speak up about ethically troubling behaviors	Analysis of 688 cases showed that 12% of students explicitly feared speaking up. This fear was significantly higher in Surgery (p<.025) and OB/GYN (p<.01). Common issues included deception and patient rights.
Kelly et al. (37)	2009	Canada	Medical students	100	NR	NR	Qualitative	Ethics education that goes beyond recognition; Encouraging open discussion of ethical issues; Innovative evaluation models; Role modeling and supportive clinical environments; Practical, scenario-based ethics training; Opportunities for reflection and debriefing; Integration of ethics into clinical training	Organizational culture and hierarchy; Fear of reprisal or negative consequences; Lack of support and role models; Normalization of unethical acts; Loss of independent thinking; Inadequate ethics education and training; Emotional distress and moral distress	High Moral Sensitivity (100%) but very low Moral Courage action (4%).
Martinez et al. (38)	2016	USA	Medical students (interns and residents)	352	F / M	NR	Cross-sectional	Moral Agency; Multiple Values; Endurance of Threats; Going Beyond Compliance; Moral Goals	Lower Status/Experience; Hierarchical/Organizational Barriers; Lack of Empowerment; Fear of Negative Consequences; Loss of Independent Thinking; Lack of Empathy	Residents scored higher than interns. Courage positively associated with empathy and speaking up about safety.
Borracci et al. (39)	2020	Argentina	Medical students (resident)	87	NR	29 (Mean)	Cross-sectional	Multiple Values; Endurance of Threats; Going Beyond Compliance; Moral Goals	Medical Hierarchy and Power Dynamics; Concerns About Evaluations and Career Advancement; Conforming Pressures in the Clinical Environment; Risk of Ostracism and Lateral Violence; Organizational Climate and Lack of Support; Social Desirability Bias	Strong correlation between instruments; reliable measurement of moral courage construct in residents.
Tehrani et al. (40)	2020	Iran	Dental students	80	F / M	25 (Mean)	Cross-sectional	Moral sensitivity & reasoning; Moral motivation; Supportive teaching & role modeling; Professional responsibility; Ethics education & practice; Supportive systems; Emotional strength; Peer/organizational support	Moral distress / powerlessness; Fear of negative consequences; Lack of peer / organizational support; Rationalization / self-doubt; Insufficient moral sensitivity / identity; Organizational / social norms; Lack of confidence / self-efficacy	Dental students scored higher in moral sensitivity/integrity than dentists. Mean courage score: 13.47.
Mosavi et al. (6)	2025	Iran	Dental students	180	F / M	23.3 (Mean)	Qualitative	Prioritizing moral values over other considerations and taking responsibility for the moral outcomes of one’s actions; Creating educational environments that actively engage students in moral dilemmas; Implementing innovative teaching approaches	Disregarding professional responsibility (Negligence in commitment to professional values, Indifference toward unprofessional behaviors, Conflict of values and interests) ; Unsupportive behaviors of clinical teachers in moral dilemmas (Worrying about negative feedback from clinical teachers, Irresponsible behaviors of clinical teachers)	Mean score 43.61. Highest score in moral reasoning, lowest in moral motivation. Students lacked tools for dilemmas.

Abbreviations: F, female; M, male; NR, not reported

The table summarizes the study design, sample size, participants’ field of study, country, and other relevant characteristics of the included articles

Characteristics of the chosen articles

The detailed characteristics of the included studies are presented in [Table 1]. Geographically, the studies were conducted across diverse regions [Figure 2]:

Fig. 2.

Geographic distribution of the number of published studies on moral courage among students in medical sciences

• Asia: Iran (n = 4) [6, 28, 30, 40], China (n = 3) [31–33], Israel (n = 1) [14], and the Philippines (n = 1) [26].

• Europe: Norway (n = 2) [7, 34], the United Kingdom (n = 1) [24], and one multicenter study conducted across Finland, Germany, Iceland, Ireland, Lithuania, and Spain [27].

• The Americas: The United States (n = 4) [25, 29, 36, 38], Argentina (n = 1) [39], Brazil (n = 1) [35], and Canada (n = 1) [37].

• Oceania: Australia (n = 1) [23].

Regarding the study population, twelve studies investigated 3,301 nursing students [7, 23–33]. Furthermore, six studies examined 1,118 medical students [14–39], two studies assessed 260 dental students [6, 40], and one study focused on 40 student registered nurse anesthetists [34]. In terms of study design, the review included 10 qualitative studies (involving 1,060 participants), 10 cross-sectional studies (involving 3,082 participants), and 1 quasi-experimental study (involving 50 participants).

Methodological quality assessment

The comprehensive results of the quality assessment are presented in [Supplementary Table 5], while the item-by-item scores for individual studies are reported in [Supplementary Tables 2–4]. Based on the Joanna Briggs Institute (JBI) critical appraisal tools, the majority of studies (n = 18) were classified as having a low risk of bias [7, 23–26, 28–34], 36– [6]. Only one study was rated as having a moderate risk of bias [27], and two studies were considered to have a high risk of bias [14, 35]. A visual summary of the risk of bias assessment is provided in [Figure 3].

Fig. 3.

Quality of studies based on the type of questions in the JBI critical appraisal checklist. JBI, Joanna Briggs Institute

Facilitating factors of moral courage

The thematic analysis of the included studies highlighted four primary domains facilitating moral courage among health sciences students [Table 1]:

• Ethics Education and Knowledge: The most frequently reported facilitator was related to educational interventions. This domain encompasses structured ethics curricula, continuous training, and the development of ethical knowledge. These elements collectively equip students with the tools to recognize and address moral conflicts.

• Supportive Environment: The second domain pertains to the organizational and social context. Key factors included supportive clinical environments, robust peer support systems, and organizational backing.

• Moral Sensitivity and Agency: Internal psychological factors were also prominent. Studies frequently cited “moral sensitivity,” “moral reasoning,” and “moral agency” as essential prerequisites for moral courage.

• Role Modeling and Leadership: Finally, the presence of positive role models, effective mentorship, and strong leadership emerged as critical external motivators for students to exhibit moral courage.

Barriers to moral courage

Conversely, the primary barriers to moral courage included [Table 1]:

• Fear of Negative Consequences: This was the most significant barrier reported across studies. Students frequently expressed fears regarding retaliation, poor evaluations, loss of learning opportunities, job insecurity, or academic failure.

• Hierarchy and Lack of Support: The second major barrier involved organizational dynamics, specifically hierarchical power structures (e.g., medicine’s strict hierarchy) and a lack of support from supervisors or mentors. An unsupportive or hostile clinical climate was a recurrent theme.

• Psychological and Ethical Distress: “Moral distress” was a primary barrier in this domain. Additionally, pressure to conform (conformity) and the “loss of independent thinking” were noted as factors suppressing moral courage.

• Educational Deficiencies: Inadequate ethics education and insufficient practical training were cited as foundational barriers.

• Individual Factors: Inexperience, lack of professional competence, and low self-efficacy or confidence were consistently identified as personal obstacles to acting courageously.

Overview of moral courage

The reviewed studies utilized a variety of instruments to assess moral courage. These predominantly relied on the Nurses’ Moral Courage Scale (NMCS) for nursing populations. Alternatively, the Professional Moral Courage (PMC) Scale or context-specific vignettes were used for medical and dental students. Recognizing this heterogeneity, the “levels” of moral courage described below reflect the self-reported scores. These scores were interpreted according to the specific validation criteria of each study’s instrument. The reviewed studies indicate that the level of moral courage varies across different health disciplines:

• Nursing Students: Moral courage ranged from moderate to high. Of the twelve studies, seven [25–28, 31–33] reported high levels, while five [7, 23, 24, 29, 30] indicated moderate levels.

• Medical Students: In contrast, moral courage among medical students was generally low to moderate. Among the six studies, two [35, 37] indicated low moral courage, while four [14, 36, 38, 39] reported moderate levels. Findings suggest that rigid hierarchies and fear of repercussions significantly dampen moral courage in this group. However, residents tended to show slightly higher levels than interns.

• Dental Students: Moral courage was generally moderate. Tehrani et al. [40] reported medium-to-high scores, whereas Mosavi et al. [6] highlighted that students felt ill-equipped to navigate ethical dilemmas.

• Nurse Anesthetist Students: Moral courage was reported as moderate. While students demonstrated courage in specific situations, organizational constraints often limited their ability to act [34].

Discussion

This systematic review synthesized evidence from 21 studies to analyze the moral landscape of health sciences students. Overall, our findings indicate that while students perceive peer support and positive role modeling as primary facilitators of moral action, they consistently identify the hidden curriculum, fear of negative evaluation, and hierarchical power dynamics as primary barriers. These perceptions highlight what has been described in the literature as the moral performance gap. Students often report high moral sensitivity, yet perceive that their transition to moral action is structurally inhibited. Mosavi et al. [6] framed this perceived disconnect not merely as a lack of skill, but as a compromised sense of moral agency. In this context, students report that they possess the cognitive competence to identify ethical breaches but perceive a lack of professional power to intervene.

Institutionalized vulnerability and the survival paradox

The literature consistently identifies fear of reprisal as the primary perceived inhibitor of moral courage. However, a deeper analysis reveals that students often frame this hesitation not as individual timidity, but as a rational response to institutionalized vulnerability. As Caldicott et al. [36] highlighted, trainees frequently perceive a direct tradeoff between academic survival and patient interests. This dynamic creates a perceived conflict where students report that the hidden curriculum implicitly rewards compliance over courageous advocacy.

Critically, this review identifies that students’ experiences of suppression are highly context-dependent. For example, Caldicott et al. [36] noted that the fear of speaking up was not uniform. Instead, it was reported to be significantly heightened in high-stakes, high-hierarchy rotations, such as surgery and obstetrics/gynecology, compared to pediatrics. This variation indicates that students perceive a greater necessity for, and difficulty in exercising, moral courage within specific departmental microcultures. Furthermore, Martinez et al. [38] observed an association between this sense of vulnerability correlates directly with hierarchical rank, with interns reporting more inhibition than residents. This indicates that students perceive the medical hierarchy as a structural barrier that heavily discourages action among the most junior members of the healthcare team.

Importantly, while these specific examples highlight medical trainees, our synthesis reveals that this perceived vulnerability is not exclusive to medical students. Rather, it is commonly reported across health sciences education. Nursing students similarly experience feelings of vulnerability when confronting senior ward staff or hospital managers [28]. Likewise, dental students report a comparable sense of powerlessness when challenging the authority of clinical instructors who evaluate their practical requirements [6]. Thus, the perceived tension between academic standing and ethical action appears to affect multiple disciplines, even though the specific hierarchical actors exerting the pressure may differ.

Professional identity formation: the logic of care vs. cure

The synthesis of findings suggests a divergence in how students perceive their professional identity formation and structural barriers between disciplines. Nursing students, as noted by Bickhoff et al. [23], often report internalizing a patient advocate identity early in their training. This identity often serves as a moral anchor, compelling them to act despite perceived risks. However, they frequently describe their primary barrier to moral courage as manifesting within ward dynamics, such as the fear of alienating senior nurses or physicians in a team-based setting [27, 28].

In contrast, medical students frequently report feeling socialized into an environment where they perceive that clinical competence and hierarchical deference are prioritized over ethical advocacy. For medical students, the perceived structural barrier is highly hierarchical. They feel their academic progression heavily relies on subjective evaluations from attending physicians. Students report that this intense evaluative pressure makes them particularly susceptible to the perceived risks of speaking up compared to other disciplines [39]. This perceived structural difference may explain why Heggestad et al. found that medical students were more prone to a gradual desensitization to ethical issues when they lacked role models to validate their moral intuitions.

Furthermore, our review highlights a distinct perceived structural reality for dental students. Unlike medical or nursing students who operate within large ward hierarchies, dental students report navigating ethical dilemmas tied to their specific educational framework. For instance, they often describe challenges related to fulfilling rigid clinical procedural quotas. For these students, perceived barriers to moral courage are frequently linked to the conflict between patient autonomy (e.g., overtreatment) and the academic pressure to complete graduation requirements. Facilitators for this group often rely heavily on ethical guidance from individual clinical instructors rather than broad team support [6, 40].

Mechanisms of Resilience: Internal and External Buffers

If the organizational structure is perceived to fail to support moral courage, what sustains it? Our analysis points to specific protective buffers.

• Cultural Buffer: In contexts with strong religious frameworks, Talebian et al. [30] found that religious orientation acts as an internal scaffold. This provides students with a foundational source of authority that can supersede perceived organizational pressure.

• Psychological Buffer: During the extreme stress of the COVID-19 pandemic, Mohammadi et al. [28] identified a strong link between resilience and moral courage. This suggests that moral courage is psychologically demanding. Consequently, it may be more difficult to exhibit for students with either less personal sense of agency or for whom perceived or actual career risks are greater.

Educational implications: from passive knowledge to active agency

The persistent gap between knowing and doing challenges current educational models. Theoretical ethics classes often fail to replicate the high-pressure reality of clinical dilemmas. Xiao et al. [31] and DeSimone demonstrate that efficacy lies in immersive ethical rehearsal. While we acknowledge that the inherent social disincentives and intrinsic difficulties of moral courage will always remain in real clinical settings, we hypothesize that simulation can provide a psychologically safe environment for students to effectively practice identifying ethical content and formulating their responses. Just as students simulate cardiac arrest management to build procedural proficiency, we propose that they must simulate speaking up to build habitual ethical responses.

We argue that moral courage must be reframed from an optional virtue to a non-technical skill (NTS), assessed with the same rigor as diagnostic reasoning. However, building ethical resilience at the student level is likely futile if the clinical environment remains punitive. Our findings suggest that the penalization of advocacy—often manifesting as poor academic evaluations, ostracization, or public reprimand by superiors—is deeply ingrained in traditional healthcare hierarchies. Addressing these deeply entrenched systems requires a top-down institutional shift rather than relying solely on individual student initiative. Reformation must begin with faculty development, training clinical instructors to actively reward, rather than punish, questioning behavior. Furthermore, institutions must establish structural safety nets, such as secure, anonymous reporting mechanisms and strictly enforced zero-retaliation policies. Without these systemic reforms, demanding moral courage from vulnerable students risks asking them to assume significant professional risk.

Limitations

This systematic review has several limitations. First, the heterogeneity of the measurement tools across the included studies restricted the feasibility of a quantitative meta-analysis. Second, the reliance on self-reported questionnaires in the majority of studies may introduce reporter bias. This not only risks students overestimating their own moral courage in hypothetical scenarios, but it also introduces student bias regarding the actual facilitators and barriers to moral courage. Consequently, the data heavily relies on their subjective perceptions. Third, the geographic distribution of studies was uneven, and the restriction to English and Persian languages may have excluded relevant data from other cultural contexts.

Conclusion

This review concludes that students largely perceive the deficit in moral courage as a reflection of perceived systemic barriers rather than individual deficiency. However, it is important to note that this perception—attributing moral hesitation to external systemic barriers rather than personal shortcomings—is not unique to health sciences students and is frequently at the root of general moral hesitation. The rigid hierarchies and punitive micro-cultures of certain specialties are perceived to force students to choose between their conscience and their career.

Therefore, cultivating moral courage requires a dual evolution: educating students to build ethical resilience, while simultaneously reforming clinical environments to dismantle the perceived culture of silence that penalizes advocacy. Crucially, mitigating these systemic barriers is desirable not because it makes exhibiting moral courage “easier”—as courage inherently implies acting amidst difficulty—but because it is fundamentally desirable to minimize the occurrence of clinical problems that require its exercise in the first place.

To broaden this field, we recommend that future researchers move beyond descriptive, cross-sectional studies reliant on self-reported data. Future scholarship should prioritize interventional research to empirically evaluate the effectiveness of immersive ethical rehearsals and simulation-based training. Additionally, longitudinal studies tracking students as they transition from academic training into independent clinical practice are essential to understand how moral courage is sustained or eroded over a professional lifespan.

Authors' contributions

Kosar Kordkatuli: Conceptualization, Methodology, Project Administration, Supervision, Systematic search, Study selection, Writing – Original Draft, Writing – Review & Editing. Sare Manouchehr: Investigation, Screening, Data curation, Risk of bias assessment, Writing – Review & Editing. Kosar Bayat: Investigation, Screening, Data curation, Writing – Review & Editing. Amirali Alizadeh: Investigation, Screening, Data curation, Writing – Review & Editing. Soheyla Kalantari: Conceptualization, Methodology, Writing – Review & Editing. All authors have read and approved the final manuscript.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Data availability

All data generated or analyzed during this study are included in this published article [and its supplementary information files].

Declarations

Ethics approval and consent to participate

The Ethics Committee of Golestan University of Medical Sciences reviewed and approved the study protocol (approval number: IR.GOUMS.REC.1403.470).

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.