Elina Pajakoski D 1897 A N N A LES U N IV ERSITATIS TU RK U EN SIS TURUN YLIOPISTON JULKAISUJA – ANNALES UNIVERSITATIS TURKUENSIS SARJA – SER. D OSA – TOM. 1897 | MEDICA – ODONTOLOGICA | TURKU 2025 MORAL COURAGE IN NURSING Refining the concept Elina Pajakoski Elina Pajakoski MORAL COURAGE IN NURSING Refining the concept TURUN YLIOPISTON JULKAISUJA – ANNALES UNIVERSITATIS TURKUENSIS SARJA – SER. D OSA – TOM. 1897 | MEDICA – ODONTOLOGIA | TURKU 2025 University of Turku Faculty of Medicine Department of Nursing Science Nursing Science Doctoral Programme in Nursing Science Supervised by Professor, Riitta Suhonen Faculty of Medicine Department of Nursing Science University of Turku Turku, Finland Professor (emerita), Helena Leino-Kilpi Faculty of Medicine Department of Nursing Science University of Turku Turku, Finland Reviewed by Professor (emerita), Hesook Suzie Kim College of Nursing University of Rhode Island Rhode Island, USA Professor, Dean, Marit Kirkevold Faculty of Health Sciences Oslo Metropolitan University Oslo, Norway Opponent Professor (emerita), Helvi Kyngäs Research Unit of Nursing Science and Health Management University of Oulu Oulu, Finland The originality of this publication has been checked in accordance with the University of Turku quality assurance system using the Turnitin OriginalityCheck service. ISBN 978-952-02-0263-7 (PRINT) ISBN 978-952-02-0264-4 (PDF) ISSN 0355-9483 (Print) ISSN 2343-3213 (Online) Painosalama, Turku, Finland 2025 To all nurses, who courageously defend what is right. 4 UNIVERSITY OF TURKU Faculty of Medicine, Department of Nursing Science Nursing Science ELINA PAJAKOSKI: Moral courage in nursing – Refining the concept Doctoral Dissertation, 155 pp. Doctoral Programme in Nursing Science September 2025 ABSTRACT The concept of moral courage in nursing belongs to the field of nursing science. It is linked to nurses’ moral actions, standing up for individual and professional values despite personal risks. In the literature, there is an increase in studies related to moral courage, with the main studies presenting partly varying definitions of moral courage and using self-assessment instruments in hospital settings, with varying constructs and contents. This doctoral study aimed to clarify and refine the concept of moral courage in nursing with the Hybrid Model of Concept Development, comprising theoretical, fieldwork and final analytical phases, including also the evaluation of the maturity of the concept. The theoretical phase comprised an integrative literature review. The fieldwork phase included a survey on nurses’ (n=205) self-assessed level of moral courage and a narrative study on nurses’(n=14) justifications for morally courageous acts and the consequences of the acts. In the analytical phase, a refined concept definition was formed. The maturity of the concept was evaluated in the theoretical and final analytical phases. Moral courage manifests itself in ethical conflicts. Nurses pondered justifications for morally courageous acts and identified the consequences of their acts for themselves, the patients and the work community. Nurses self-assessed their level of moral courage to be moderate or high. Theoretical knowledge combined with versatile examples in empirical data sets enhanced the formation of a clarified, refined definition of the concept. In the final analytical phase, the concept was evaluated as more mature than in the theoretical phase because of the clarified and refined antecedents, attributes and consequences, which were based on rich empirical data cases. The refined concept definition provided in this study strengthens the knowledge base of nursing ethics. The development of the conceptual basis of moral courage gives possibilities for developing processes that support nurses’ morally courageous acts, and that further actions are taken in the organisation to improve the situation. Additionally, the results can be used in theory development concerning the concept. KEYWORDS: Moral courage, ethics, ethical conflict, nursing, concept analysis, concept maturity, hybrid model 5 TURUN YLIOPISTO Lääketieteellinen tiedekunta, Hoitotieteen laitos Hoitotiede Elina Pajakoski: Moraalinen rohkeus hoitotyössä – Käsitteen tarkentaminen Väitöskirja,155 s. Hoitotieteen tohtoriohjelma Syyskuu 2025 TIIVISTELMÄ Käsite moraalinen rohkeus hoitotyössä kuuluu hoitotieteen alaan. Se kytkeytyy hoitotyöntekijän moraaliseen toimintaan, omien ja ammatillisten arvojen puolustamiseen eettisissä ongelmatilanteissa henkilökohtaisista riskeistä huolimatta. Moraalista rohkeutta tarkastelevien tutkimusten määrä on lisääntynyt kirjalli- suudessa, ja tutkimuksissa moraalista rohkeutta on määritelty osittain eri tavoin, käyttäen eri rakenteisia ja sisältöisiä itsearviointimittareita sairaalaympäristöissä. Väitöskirjatutkimuksen tarkoituksena oli selkeyttää ja tarkentaa käsitettä moraa- linen rohkeus hoitotyössä hybridimallia noudattavalla käsiteanalyysillä, joka koos- tuu teoreettisesta, empiirisestä ja analyyttisestä vaiheesta, sisältäen käsitteen kypsyy- den arvioinnin. Teoreettinen vaihe oli integratiivinen kirjallisuuskatsaus. Empiiri- sessä vaiheessa toteutettiin kyselytutkimus hoitotyöntekijöiden (n=205) moraalisen rohkeuden itsearvioidusta tasosta ja narratiivinen tutkimus sairaanhoitajien (n=14) perusteluista moraalisesti rohkeille teoille sekä tekojen seurauksista. Analyyttisessä vaiheessa muodostettiin tarkennettu määritelmä käsitteelle. Käsitteen kypsyyttä arvioitiin teoreettisessa ja analyyttisessa vaiheessa. Moraalinen rohkeus ilmenee eettisissä ongelmatilanteissa. Sairaanhoitajat pohti- vat perusteluita moraalisesti rohkeille teoille ja tunnistivat tekojensa seurauksia itselleen, potilaalle sekä työyhteisölle. Hoitotyöntekijät arvioivat moraalisen rohkeu- tensa tason keskitasolle tai korkeaksi. Teoreettinen tieto yhdistettynä monipuolisiin esimerkkeihin empiirisessä vaiheessa mahdollistivat käsitteen selkeyttämisen ja tarkennetun määritelmän muodostamisen. Käsite arviointiin kypsemmäksi kuin teoreettisessa vaiheessa, koska monipuolisiin empiirisiin esimerkkeihin perustuvat ennakkoehdot, ominaisuudet ja seuraukset selkeytyivät ja tarkentuivat. Tässä tutkimuksessa tehty käsitteen tarkennettu määritelmä vahvistaa hoitotyön etiikan tietoperustaa. Moraalisen rohkeuden käsitteellisen perustan vahvistaminen antaa mahdollisuuksia kehittää käytännön hoitotyöhön prosesseja, jotka tukevat hoitotyöntekijöiden moraalisesti rohkeita tekoja ja sitä, että asian kohentamiseksi tehdään organisaatioissa jatkotoimenpiteitä moraalisesti rohkeiden tekojen jälkeen. Tuloksia voi myös hyödyntää käsitteeseen liittyvässä teorianmuodostuksessa. AVAINSANAT: Moraalinen rohkeus, etiikka, eettinen ongelma, hoitotyö, käsite- analyysi, käsitteen kypsyys, hybridimalli 6 Table of Contents Abbreviations .................................................................................. 8 List of Original Publications ........................................................... 9 1 Introduction ............................................................................. 10 2 Review of the literature .......................................................... 13 2.1 Literature search .................................................................... 13 2.2 The origin of the concept of moral courage ............................ 16 2.3 The concept of moral courage defined in nursing ................... 18 2.3.1 Characteristics of moral courage in nursing ................. 20 2.3.2 Operationalisation and measurement of moral courage in nursing ....................................................... 21 2.4 Summary and gaps in knowledge .......................................... 25 3 Aims of the Study ................................................................... 27 4 Materials and Methods ........................................................... 29 4.1 Design, setting and sampling ................................................. 30 4.2 Data collection methods ......................................................... 33 4.3 Data analyses ........................................................................ 36 4.4 Ethical considerations ............................................................ 39 5 Results ..................................................................................... 42 5.1 Starting point for the refined concept definition ....................... 42 5.1.1 Moral courage as a virtue in nursing ............................ 42 5.1.2 Characteristics of morally courageous nurses ............. 43 5.1.3 Concept maturity in the theoretical phase.................... 43 5.2 Moral courage in the empirical world of nursing ..................... 45 5.2.1 Ethical conflicts as context for moral courage .............. 45 5.2.2 Justifications for morally courageous acts ................... 46 5.2.3 Morally courageous acts ............................................. 48 5.2.4 Consequences of moral courage in nursing ................ 49 5.3 A refined definition of the concept of moral courage in nursing ................................................................................... 50 5.3.1 Development of the refined concept definition ............. 51 5.3.2 The refined concept definition in the final analytical phase .......................................................................... 52 5.3.3 Maturity of the concept ................................................ 55 7 5.4 Summary of the main results .................................................. 56 6 Discussion ............................................................................... 59 6.1 Discussion of the results......................................................... 59 6.2 Validity and methodological considerations ............................ 63 6.3 Suggestions for practice ......................................................... 69 6.4 Suggestions for further research ............................................ 71 7 Conclusions ............................................................................ 72 Acknowledgements ....................................................................... 73 References ..................................................................................... 76 List of Tables, Figures and Appendices ...................................... 83 Appendices .................................................................................... 85 Original Publications ..................................................................... 95 8 Abbreviations ALLEA All European Academies ANOVA One-way analysis of variance CINAHL Cumulative Index to Nursing and Allied Health Literature ERIC Education Resources Information Centre EU European Union ICN International Council of Nurses NMCS Nurses’ Moral Courage Scale ©Numminen et al. 2019 NRS Numeric Rating Scale MCSNF Moral Courage Scale for Nursing Faculty ©Stephens & Layne 2023 MCSP Moral Courage Scale for Physicians ©Martinez et al. 2016 MEDLINE Medical Literature Analysis and Retrieval System Online NMCQ Nurses’ Moral Courage Questionnaire ©Sadooghiasl et al. 2016 OED Oxford English Dictionary PMC Professional Moral Courage Questionnaire ©Sekerka et al. 2009 TENK The Finnish National Board of Research Integrity WHO World Health Organization 9 List of Original Publications This dissertation is based on the following original publications, which are referred to in the text by their Roman numerals: I Pajakoski E, Rannikko S, Leino-Kilpi H, Numminen O 2021. Moral courage in nursing – An integrative literature review. Nursing & Health Sciences. 2021 (16); 1: 570–585. II Pajakoski E, Rannikko S, Leino-Kilpi H, Löyttyniemi E, Numminen O 2023. Nurses’ moral courage in Finnish older people care: a cross-sectional study. Nordic Journal of Nursing Research. 2023 (43); 1: 1 – 8. III Pajakoski E, Leino-Kilpi H, Stolt M, Čartolovni A, Suhonen R 2024. Nurses’ justifications for morally courageous acts: A narrative inquiry. Nursing Ethics. 2024; DOI: 10.1177/09697330241284357 IV Pajakoski E, Leino-Kilpi H, Čartolovni A, Stolt M, Suhonen R. Consequences of moral courage in nursing: A narrative inquiry. (Manuscript) The original publications have been reproduced with the permission of the copyright holders. 10 1 Introduction This doctoral study is situated in nursing science, specifically in the field of nursing ethics. It focuses on the concept of moral courage in nursing, which refers to nurses’ actions in ethical conflicts, and nurses defending what they believe to be right even at the risk of negative outcomes for themselves (Arries, 2005; Rest, 1994). Moral courage has been acknowledged as far back as in Aristotle’s virtue ethics (Aristoteles 350 BCE, 2012). The concept remains relevant in contemporary nursing, which, as a health care profession, requires high moral standards. Thus, discussions of what is good or bad and right or wrong are important in nursing, and these viewpoints are at the heart of moral courage in the field. Nurses work with patients and clients who are vulnerable due to their health issues (International Council of Nurses, 2021). Nurses have legal (Finlex 559/1994 Health Care Professionals Act, 1994) and ethical (Finnish Nurses’ Association, 2021; International Council of Nurses, 2021) obligations to provide high-quality and morally sound care for patients and clients even in the presence of ethical conflicts (WHO Regional Office for Europe, 2016). Ethical conflicts manifest when there are clashes in values between individuals or between an individual and an organisation or society (Liu et al., 2023). The essence of nursing, working for someone else’s good, adds complexity to ethical conflicts (Arries, 2005; Liu et al., 2023; Rainer et al., 2018). In ethical conflicts, nurses benefit from moral courage when acting according to their own values and the professional values of nursing despite the risk of personal negative outcomes (Barlow et al., 2018; Numminen et al., 2017; Sadooghiasl et al., 2018). The concept of moral courage is important both in the philosophical foundations and the empirical world of nursing, as it is the virtue of nurses acting courageously (Numminen et al., 2017; Sadooghiasl et al., 2018). When exploring the concept, the morally courageous individual, other people around, and the context are essential (Arries, 2005). In this doctoral study, moral courage is explored as a dispositional concept (Rodgers, 2000) because it manifests itself in human action. The manifestation seems to vary between situations, individuals, and contexts in nursing, highlighting moral courage as a context-specific concept (Arries, 2005; Papouli, 2019; Rodgers, 2000). Introduction 11 This concept analysis follows the Hybrid Model of Concept Development to clarify and refine the concept of moral courage in nursing based on earlier literature and empirical data (Morse & Lenz, 1996; Schwartz-Barcott & Kim, 2000). Refining the definition of an existing concept, such as moral courage, allows for clarifying its central elements, thus facilitating further discussions on the topic (Walker & Avant, 2019). Studying the phenomenon and concept of moral courage in nursing is important because of its relevance in contemporary nursing care and because it is a part of the theoretical knowledge base of nursing. The Hybrid Model of Concept Development was selected because it combines theoretical and empirical data, enhancing the refined concept definition with the addition of more layers and elements. The Hybrid Model handles concepts integral to nursing. It starts from a theoretical phase, comprising an integrative literature review, to identify the concept and its possible evaluation tools to form a starting point for the concept development. Then, the development continues with empirical explorations in the fieldwork phase. Finally, in the final analytical phase, theoretical and empirical knowledge are compared and combined, forming and finalising the refined concept definition. (Figure 1.) The purpose of this three-phase study was to clarify and refine the concept of moral courage in nursing. The goal was to strengthen the theoretical knowledge base of nursing with the refined concept definition, promoting a deeper understanding of the concept. (Walker & Avant, 2019) It is justified to clarify and refine this context- specific concept, as nursing and health care are changing, and nurses encounter various ethical conflicts in which they need moral courage (Liu et al., 2023). Moreover, recognising moral courage not only as an individual characteristic but as a wider phenomenon in nursing gives a broader meaning to the concept and thus justifies forming a refined definition of the concept (Rodgers et al., 2018; Schwartz- Barcott & Kim, 2000). Studying moral courage in this manner provides empirical, experience-based examples from which a refined concept definition can be derived, and nurses can identify ways to strengthen and maintain their moral courage. Additionally, the refined concept definition provides opportunities to understand and organise the knowledge on the topic, discuss it theoretically and conduct further research. (Rodgers et al., 2018; Walker & Avant, 2019) This doctoral study presents a refined definition of the concept of moral courage in nursing. The refined concept definition forms a foundation for examinations of its relationships with other concepts as part of possible theory development in the future (Kyngäs, 2020; Rodgers et al., 2018; Schwartz-Barcott & Kim, 2000). Elina Pajakoski 12 Figure 1. Study phases, approaches, and outcomes for the Hybrid Model. Refining the concept of moral courage in nursing with the Hybrid Model Phase III (2024) FINAL ANALYTICAL PHASE Summary: Comparing and combining the results of the theoretical and fieldwork phases, forming a refined concept definition. The outcome of the entire study: A refined definition of moral courage in nursing, including the antecedents, attributes, consequences, and related context and surroundings Phase I (2019–2021) THEORETICAL PHASE Identifying the concept of moral courage and its descriptions, definitions, and operationalisation in the literature to form a starting point for the concept definition and a basis for exploring moral courage in the context of nursing in the fieldwork phase. Sub-study 1: An integrative literature review (Paper I, Summary) The outcome for the Hybrid Model: The starting point for concept definition. Phase II (2020–2024) FIELDWORK PHASE Exploring moral courage and its manifestation in the empirical world of nursing. Sub-study 2: A descriptive cross-sectional survey (Paper II, Summary) Sub-studies 3 and 4: A narrative inquiry based on one interview data (Papers III and IV, Summary) The outcome for the Hybrid Model: Empirical data including nurses’ descriptions of their experiences regarding moral courage in nursing. 13 2 Review of the literature In this chapter, the origin of the concept of moral courage, its dictionary definitions and definitions in different disciplines, especially in nursing science, are presented. Earlier definitions and research findings regarding the concept are also presented. These include descriptions of what constitutes a morally courageous nurse, as well as manifestations and self-assessments of nurses’ moral courage. 2.1 Literature search The initial research literature search was conducted in 2020 in Phase I (Sub-study 1), in the theoretical phase of the Hybrid Model (Sub-chapter 4.1). The literature search was updated in 2021 and in August 2024. The search string was developed based on concept definitions in the nursing field (Numminen et al., 2017; Sadooghiasl et al., 2018), and other disciplines (Papouli, 2019; Pianalto, 2012; Sekerka et al., 2009) and through tentative searches performed by the doctoral researcher with the support of an information specialist. The databases were CINAHL (Ebsco), Cochrane Library, ERIC (Ebsco), Philosopher’s Index (Ebsco), and PubMed (MEDLINE). The search string was adjusted to technically correspond to the requirements of each database. Database- specific subject headings were used when available: nurse, nursing, and midwife. In each step, the reference lists of selected articles were searched manually to identify potential additional articles. In the initial search (2020) and the first updated search (2021), in addition to empirical papers, theoretical, concept analysis and literature review papers were included to support the theoretical phase of the Hybrid Model. The inclusion criteria were updated in the 2024 search, conducted during the Hybrid Model's final analytical phase. In the 2024 search, theoretical, concept analyses and literature review articles were excluded, and the focus was on empirical research. Adding more theoretical literature to the concept definition was irrelevant at the time of the final analytical phase. However, including new empirical knowledge supported the final analytical phase, whereas newly identified literature reviews were excluded, as they included empirical articles covered in the updated review. Although theoretical Elina Pajakoski 14 papers were excluded, it was noted that no new concept analyses were identified in the updated search in 2024. (Figure 2) Figure 2. Selection of articles. Empirical research on moral courage in nursing increased substantially after 2021, and the selected articles were published between 1998 and 2024 (Figure 3). The authors represented organisations in Europe, Asia, Australia, and America (Figure 4, Appendix 1). Review of the literature 15 Articles published between 2021–2024: only empirical articles were included. * Before 8. August.2024. Figure 3. The years when the selected articles were published. Figure 4. Countries that the authors of the articles represented. Elina Pajakoski 16 2.2 The origin of the concept of moral courage In this Sub-chapter, descriptions and definitions of moral courage are presented based on Aristotelian virtue ethics (Aristoteles 350 BCE, 2012), the Oxford English Dictionary (OED) (Oxford University Press, 2024), the Merriam-Webster Dictionary (Merriam-Webster Inc., 2024) and research conducted in disciplines other than nursing science (Caldicott, 2023; Papouli, 2019; Pianalto, 2012; Press, 2018; Sekerka et al., 2009). The concept of moral courage conjoins the two terms, moral and courage. Because only one of the two consulted dictionaries defined moral courage as a concept, the definitions of the two constituent terms are defined. (Table 1) Two widely used dictionaries that include examples of term usage were consulted. These dictionaries have existed for a rather long time, giving reason to assume validity in their definitions. (Merriam-Webster Inc., 2024; Oxford University Press, 2024) The OED defines the term moral courage and explains that it has been included in the OED since 1808 (Oxford University Press, 2024). However, the Dictionary of Nursing (Martin & MacFerran, 2008) and the Dictionary of Nursing Theory and Research (Powers & Knapp, 2011) do not define the concept. The definitions presented in Tables 1 and 2 provide the basis for understanding the concept before examining it in the context of nursing. Table 1. Dictionary definitions in the selected dictionaries. REFERENCE TERM Moral Courage Moral courage Oxford English Dictionary (2024), no page. “Of or relating to human character or behaviour considered as good or bad; of or relating to the distinction between right and wrong, or good and bad” “That quality of mind which shows itself in facing danger without fear or shrinking; bravery, boldness, valour” “The kind of courage which enables a person to remain firm in the face of odium or contempt, rather than depart from what he or she deems the right.” Merriam- Webster (2024), no page. “Of or relating to principles of right and wrong in behaviour: ethical; expressing or teaching a conception of right behaviour; conforming to a standard of right behaviour; sanctioned by or operative on one's conscience or ethical judgment; capable of right and wrong action.” “Mental or moral strength to venture, persevere, and withstand danger, fear, or difficulty” - History of the concept Moral courage has been discussed as early as in Aristotle’s Nicomachean Ethics. Aristotle described moral courage as a mean between rashness and cowardice. This meant that, despite possible negative consequences, a balance between rashness and Review of the literature 17 cowardice is found, and the morally courageous person acts accordingly. (Aristoteles 350 BCE, 2012) Despite the developments of contemporary societies after Aristotle’s time, his virtue ethics are still relevant (Papouli, 2019). Nevertheless, moral courage is not mentioned in the international (International Council of Nurses, 2021) or Finnish national (Finnish Nurses’ Association, 2021) codes of ethics for nurses, even though the content of these codes describes nurses as having the role of patient advocates. Moreover, in the EU Whistleblower Directive, whistleblowing is not described as a courageous act. The directive does, however, describe that people may choose not to “blow the whistle” because they fear negative consequences for themselves (EU, 2019), indicating a lack of moral courage. In addition to nursing, moral courage has been studied in the fields of medicine (Caldicott, 2023; Martinez et al., 2016), social work (Papouli, 2019), sociology (Press, 2018), philosophy (Pianalto, 2012) and psychology (business ethics) (Sekerka et al., 2009). These disciplines represent social- and health care and philosophy. In each of these fields, moral courage has been described with the perspective of virtue ethics and manifesting as morally courageous acts of professionals (Caldicott, 2023; Martinez et al., 2016; Papouli, 2019; Pianalto, 2012; Sekerka et al., 2009). Additionally, an instrument developed in the context of psychology has been used to measure nurses’ moral courage (Sub-section 2.3.2). Examples of how moral courage is defined in these fields are presented in Table 2, and definitions of the concept in nursing literature are presented in Sub-chapter 2.3. Table 2. Examples of definitions in other disciplines. DISCIPLINE REFERENCE DEFINITION OF MORAL COURAGE MEDICINE Martinez et al., 2016, p. 1431 “Moral courage can be defined as the voluntary willingness to stand up for and act on one’s ethical beliefs despite barriers that may inhibit the ability to proceed toward right action.” SOCIAL WORK Papouli, 2019, p. 927 “The virtue of courage is the mean between cowardice (deficiency) and rashness (excess) in the field of danger.” PHILOSOPHY Pianalto, 2012, p. 165 “Moral courage involves acting in the service of one’s convictions, in spite of the risk of retaliation or punishment” “ SOCIOLOGY Press et al. 2018, p. 181 “A form of social action that has four essential components: (1) it is animated by a strong set of personal convictions; (2) it transgresses established customs or attitudes; (3) it is carried out in the face of high social risks or costs; (4) it is normatively- driven conduct in which certain norms are accepted as binding, even as other norms are flouted and ignored.” PSYCHOLOGY Sekerka et al. 2009, p. 565 and 567 “The five dimensions [of moral courage] are moral agency, multiple values, endurance of threats, going beyond compliance, and moral goals.” “Moral courage as a part of … job, providing them with the mental strength to do what is right, even in the face of personal or professional adversity.” Elina Pajakoski 18 2.3 The concept of moral courage defined in nursing The definitions and descriptions of moral courage in the nursing field are presented based on the review of the literature. In nursing, the concept is discussed as a valued personal characteristic and a virtue, manifesting in ethical conflicts (Bickhoff et al., 2017; Gallagher, 2011; Numminen et al., 2019; Sadooghiasl et al., 2018). Nurses perform morally courageous acts on behalf of the patient’s good, to preserve the patient’s human dignity (Bickhoff et al., 2017; Numminen et al., 2017; Sadooghiasl et al., 2018). Also, doing one’s best at work and being morally responsible when encountering ethical conflicts is considered morally courageous (Numminen et al., 2017). Moral courage has been explored in nursing using qualitative descriptive and exploratory studies, cross-sectional survey studies and a small number of grounded theory, quasi-experimental, and intervention studies (Appendix 1). However, there has been imprecision and variety in the presented definitions of the concept, justifying the clarification and refinement of the concept in this study (Morse et al., 1996; Morse & Lenz, 1996). The research presented here focused on nurses, nursing students, the ethical conflicts in which moral courage manifests, morally courageous acts, and inhibitors of moral courage. Informants in the studies were nurses and nursing students (Appendix 1). Moral courage in nursing has been defined in two concept analyses from the perspective of a morally courageous nurse. The first published concept analysis was conducted to operationalise the concept and to develop an instrument for measuring nurses’ moral courage. Due to the scarce amount of literature at the time of the concept analysis, the study described what it is to be a morally courageous nurse. In the concept analysis, moral courage in nursing was defined as a virtue that manifests itself as nurses’ morally courageous acts (Numminen et al., 2017). The definition highlighted morally courageous nurses taking personal risks in various ethical conflicts as patient advocates. The attributes of the concept described the characteristics of the morally courageous nurse: “true presence”, “moral integrity”, “responsibility”, “honesty”, “advocacy”, “commitment and perseverance” and “personal sacrifice”. (Numminen et al., 2017, p. 883) The perspective of the characteristics of morally courageous nurses and the attributes were reorganised when later developing an instrument (Sub-section 2.3.2)(Numminen et al., 2017, 2019). The concept analysis identified the antecedents, attributes and consequences of the concept (Table 3). The second published concept analysis followed the Hybrid Model, combining theoretical knowledge from the literature and empirical knowledge from qualitative data. The study was set in an Islamic context, as described in the published article. (Sadooghiasl et al., 2018) Corresponding with the previously published concept analysis (Numminen et al., 2017), this concept analysis defined moral courage as a virtue of a nurse. The concept analysis identified two attributes of the concept: “moral self-actualisation” and “risk-taking”, both being related to nurses’ morally courageous acts in ethical conflicts (Sadooghiasl et al., 2018, p. 13). Based on the Review of the literature 19 definition formed in the concept analysis, the concept was operationalised and an instrument measuring nurses’ moral courage was developed (Sadooghiasl, 2016). Empirical research and concept analyses on moral courage in nursing focus on the characteristics and acts of morally courageous nurses, providing important knowledge about morally courageous nurses. The definitions provided in the concept analyses have facilitated the operationalisation of the concept in developing instruments to measure nurses’ moral courage. The basis of the definitions and descriptions of moral courage in empirical research corresponds to those in the concept analyses: moral courage is a virtue of nurses, manifesting as morally courageous acts conducted despite personal risks from the act. (Abdollahi et al., 2024; Numminen et al., 2017; Sadooghiasl et al., 2018) Ethical competence, ethical decision-making skills, responsibility, and advocacy are described as belonging to moral courage in both concept analyses (Numminen et al., 2017; Sadooghiasl et al., 2018). However, despite these similarities, there are differences between the concept analyses in the antecedents, attributes and consequences in the definitions. For example, the number and level of abstraction of antecedents and attributes differ, although risk-taking is present in both concept analyses and empirical research. Also, the presented consequences were different (Table 3). These differences and ambiguities indicate a need for clarification and refinement of the concept and evaluation of its maturity (Morse et al., 1996; Morse & Lenz, 1996). Table 3. The antecedents, attributes and consequences of the concept of moral courage in nursing in existing, reported concept analyses. NUMMINEN ET AL. 2017 (p. 883–887) SADOOGHIASL ET AL. 2018 (p. 13–16) The perspective of a morally courageous nurse ANTECEDENTS “Ethical sensitivity” “Model orientation/model acceptance” “Conscience” “Rationalism” “Overcoming fear” “Academic and professional competences” “Experience” “Spiritual beliefs” “Protective-repressive climate” ATTRIBUTES “True presence” “Moral self-actualization” “Moral integrity” “Risk-taking” “Responsibility” “Honesty” “Advocacy” “Commitment and perseverance” “Personal risk” CONSEQUENCES “Personal and professional development” “Professional care” “Feeling of empowerment” “Nurse’s peace of mind” “Right decision and right performance” Elina Pajakoski 20 2.3.1 Characteristics of moral courage in nursing Characteristics of the concept of moral courage in nursing have been identified in the literature by describing morally courageous nurses (Abdollahi et al., 2024; Li et al., 2024; Numminen et al., 2017; Sadooghiasl et al., 2018)(Sub-chapter 2.3). Next, the characteristics of morally courageous nurses will be presented to illuminate the concept, as moral courage manifests itself in nurses’ morally courageous acts. The characteristics are related to being able to overcome personal risks and having ethical competence and virtues. Morally courageous nurses can overcome the personal risk by acting morally courageously in ethical conflicts. (DeSimone, 2019; Hamric et al., 2015; Murray, 2010; Numminen et al., 2017; Peng et al., 2023) They are committed to giving good care to patients and acting in favour of promoting the clinical and ethical quality of care (Berdida & Grande, 2023; Mahboubi et al., 2023; Numminen et al., 2019; Wawersik et al., 2023; Wolf & Noblewolf, 2024). Morally courageous nurses have empathy (Heggestad et al., 2022), honesty (Jantara et al., 2023; Numminen et al., 2017; Peng et al., 2023; Wawersik et al., 2023), moral responsibility (DeSimone, 2019; Jantara et al., 2023; Numminen et al., 2017; Pakizekho & Barkhordari-Sharifabad, 2022; Roshanzadeh et al., 2021), and moral integrity (Black et al., 2014; Hauhio et al., 2021; Huang et al., 2023a; Numminen et al., 2019). Furthermore, morally courageous nurses benefit from having ethical competence (Abdollahi et al., 2021; Konings et al., 2021; Numminen et al., 2017; Wiisak, Suhonen, & Leino-Kilpi, 2022). As part of their ethical competence, morally courageous nurses have ethical sensitivity to identify ethical conflicts and the need for moral courage (Goktas et al., 2023; Khatiban et al., 2022; Luo et al., 2023; Numminen et al., 2017). After identifying ethical conflicts, nurses use their ethical decision-making skills to decide how to best act in favour of what is right (Hong et al., 2023; Khatiban et al., 2022; Luo et al., 2023; Mohammadi et al., 2022; Solgajová, 2023; Wiisak, Suhonen, & Leino‐Kilpi, 2022; Yu et al., 2023). Morally courageous nurses conduct ethical reasoning and decision-making regarding their potential morally courageous acts individually or together with colleagues or other professionals. They decide to act to advance the good of the patient, work community, society or themselves. (Wiisak, Suhonen, & Leino‐Kilpi, 2022) Nurses justify their morally courageous acts with their aim to do good at work (Bickhoff et al., 2016; Hauhio et al., 2021; Numminen et al., 2017). The acts can be conducted inside or outside the organisation, during a conflicting situation or after it. The acts identified in the literature include initiating a discussion about an ethical conflict, admitting one's own mistakes and being truly present for the patient. The first morally courageous act is often initiating a discussion of the ethical conflict (Pohjanoksa et al., 2019). Nurses can speak up to defend what is right to their closest manager (Kleemola et al., 2020; Pohjanoksa et al., 2019), managers higher up in their organisation’s hierarchy, the patient or their next-of-kin, or a trade union Review of the literature 21 representative (Kleemola et al., 2020; Pohjanoksa et al., 2019). Furthermore, nurses act morally courageously by admitting their own mistakes (Numminen et al., 2017) and by being truly present for the patient (Numminen et al., 2017). Morally courageous acts that are conducted after a conflicting situation include a written notice within or outside the organisation (Kleemola et al., 2020). However, there are situations in which nurses cannot act morally courageously even when they feel it is necessary. Inhibitors of moral courage have been described as individual and can result from a fear of negative consequences or insufficient knowledge of ethics, for example. Moreover, organisational inhibitors may include a lack of support for nurses to act morally courageously in ethical conflicts. (Namadi et al., 2023) 2.3.2 Operationalisation and measurement of moral courage in nursing Instruments for measuring moral courage have been developed based on operationalisations of the concept in military (Sekerka et al., 2009)(Table 4) and health care (Martinez et al., 2016; Numminen et al., 2019; Sadooghiasl, 2016; Stephens & Layne, 2023) contexts. As the operationalisations have been based on different definitions of the concept, it is relevant to examine the contents and structure of the instruments. The instruments used to measure the level of nurses’ moral courage are described in this section. The measured levels of moral courage are presented according to each instrument. Five instruments to measure nurses’ moral courage can be identified in the literature: the Professional Moral Courage Questionnaire ©Sekerka et al. 2009, the Nurses’ Moral Courage Questionnaire ©Sadooghiasl 2016, the Moral Courage Scale for Physicians ©Martinez et al., 2016, the Nurses’ Moral Courage Scale ©Numminen et al., 2019 and Moral Courage Scale for Nursing Faculty ©Stephens & Layne, 2023. Each instrument has sub-scales, representing attributes of moral courage (Table 4). The instruments have been used mainly to collect data in hospitals (Appendix 2). The instruments and their use are presented here in the order of their publication year. The Professional Moral Courage Questionnaire (PMC) ©Sekerka et al. (Table 4) was developed in the field of Business Ethics, and is based on empirical data from the United States Military (Sekerka et al., 2009). The PMC measures professional moral courage from the perspective of how respondents assess the contents of the items in terms of relevance to their work. The measurement is conducted based on the five dimensions (Sekerka et al., 2009) of moral courage (Table 4). A 7-point Likert scale is used: 1 is “never true” and 7 is “always true” (Sekerka et al., 2009, p. 572). The PMC has been used in the context of nursing in Iran (Abdollahi et al., 2021; Hakimi et al., 2023; Hanifi et al., 2019; Hthelee et al., 2023; Khatiban et al., 2022; Khoshmehr et al., 2020; Lotfi-Bejestani et al., 2023; Mahboubi et al., 2023; Mohammadi et al., 2022; Elina Pajakoski 22 Pakizekho & Barkhordari-Sharifabad, 2022; Pirdelkhosh et al., 2022; Safarpour et al., 2020; Taraz et al., 2019) and the USA (Edmonson, 2015). The Nurses’ Moral Courage Questionnaire (NMCQ) (Table 4) ©Sadooghiasl et al., based on a concept analysis, has been developed in nursing for measuring nurses’ moral courage (Sadooghiasl, 2016; Sadooghiasl et al., 2018). This instrument can be used to measure moral courage based on how often a person acts in a certain courageous way: responses are self-reported (Azizi et al., 2024; Sadooghiasl, 2016). The 5-point Likert scale is used: 1 is “never” and 5 is “always” (Azizi et al., 2024, p. 3). The scores of the instrument are calculated by the weight of each item, which varies from 3 to 7. The score of each item is multiplied by its weight, resulting in a scale ranging from 102 to 510 (Azizi et al., 2024, p. 3). The NMCQ has been used in Iran (Azizi et al., 2024; Ebadi et al., 2020; Kashani et al., 2023; Khodaveisi et al., 2021; Sadooghiasl, 2016). The Nurses’ Moral Courage Scale (NMCS) ©Numminen et al. (Table 4) was developed to measure nurses’ moral courage, based on a concept analysis (Numminen et al., 2017, 2019). This instrument measures moral courage according to how well the respondent considers the items to describe them, also resulting in a self-assessed level of moral courage. A 5-point Likert scale is used: 1 is “Does not describe me at all” and 5 is “Describes me very well”. (Numminen et al., 2019, p. 2446) The NMCS has been used in different languages and countries: Belgium (Konings et al., 2021), China (Hong et al., 2023; Hu et al., 2022; Huang et al., 2023a; Luo et al., 2023; Peng et al., 2023; Ruixin et al., 2024; Yang et al., 2023; Yu et al., 2023; Zheng et al., 2024), Egypt (Ali Awad & Al-anwer Ashour, 2022), Finland (Hauhio et al., 2021; Numminen et al., 2019; Wiisak, Suhonen, & Leino-Kilpi, 2022), Korea (Lee et al., 2022), the Philippines (Berdida & Grande, 2023), Saudi-Arabia (Alshammari & Alboliteeh, 2023), Türkiye (Fidan et al., 2023; Goktas et al., 2023; Yılmaz & Özbek Güven, 2024) and the United States (Wolf & Noblewolf, 2024). The Moral Courage Scale for Nursing Faculty (MCSNF) (©Stephens & Layne)(Table 4) was developed from the Moral Courage Scale for Physicians (MCSP) ©Martinez et al., which was developed based on the PMC (Sekerka et al., 2009), for measuring the overall moral courage of physicians (Martinez et al., 2016). These instruments measure moral courage according to how respondents view the relevance of the items to their work. The MCSP comprises 9 items measured with a 7- point Likert scale: 1 is “strongly disagree” and 7 is “strongly agree” (Martinez et al., 2016, p. 1433). The MCSNF comprises seven items and uses a 7-point Likert scale. The MCSNF measures the five features (Sekerka et al., 2009; Stephens & Layne, 2023) of moral courage (Table 4)(Stephens & Layne, 2023). The scores in these instruments are calculated as summary scores (Martinez et al., 2016, p. 1433): (average score across all scale items – 1) × (100/6), resulting in a scale ranging from 0 to 100. The MCSP (Gibson et al., 2020) and MCSNF (Stephens & Layne, 2023) have been used in the United States. Review of the literature 23 To conclude, the instruments measure moral courage from different perspectives: oneself-perceived relevance in the respondent’s work (PMC ©Sekerka et al., MCSP ©Martinez et al., and MCSNF ©Stephens & Layne), frequency of acting in a certain courageous way (NMCQ ©Sadooghiasl et al.), and how well the respondent perceives the items to describe them (NMCS ©Numminen et al.). Three of the instruments (PMC ©Sekerka et al., MCSP ©Martinez et al., and MCSNF ©Stephens & Layne) are based on the same concept definition (Sekerka et al., 2009), while the two developed in nursing (NMCQ ©Sadooghiasl et al. and NMCS ©Numminen et al) are each based on separate concept definitions. Table 4. The instruments used for measuring nurses’ moral courage. INSTRUMENT SUB-SCALES NUMBER OF ITEMS PERSPECTIVE OF MEASUREMENT MEASURING SCALE (MIN-MAX OF THE TOTAL SCORE) Professional Moral Courage Questionnaire (PMC) (Sekerka et al., 2009, p. 565) “Moral agency” “Multiple values” “Endurance of threats” “Going beyond compliance” “Moral goals” 15 Relevance of items in the respondent’s work, self- assessment A 7-point Likert scale (15–105) Nurses’ Moral Courage Questionnaire (NMCQ) (Azizi et al., 2024, p. 3, Sadooghiasl, 2016) “Moral self-fulfilment” “Risk-taking” “The ability to defend the right” 20 Frequency of acting courageously, self-report A 5-point Likert scale, weighted values (102–510) Nurses’ Moral Courage Scale (NMCS) (Numminen et al., 2019, p. 2446) “Compassion and true presence” “Moral responsibility” “Moral integrity” “Commitment to good care” 21 How well items describe the respondent, self- assessment A 5-point Likert scale (21–105) Moral Courage Scale for Physicians 1 (MCSP) (Martinez et al., 2016, p. 1432) “Moral agency” “Multiple values” “Endurance of threats” “Going beyond compliance” “Moral goals” 9 Agreement of relevance in the respondent’s work, self-report A 7-point Likert scale (Summary score 0– 100) Moral Courage Scale for Nursing Faculty (MCSNF) 2 (Stephens & Layne, 2023, p. 383) “Moral agency” “Multiple values” “Endurance to threats” “Measures beyond compliance” “Ethical goals” 7 Agreement of relevance in the respondent’s work, self-report A 7-point Likert scale (Summary score 0– 100) 1 Developed based on the PMC 2 Developed based on the MCSP Elina Pajakoski 24 Levels and total scores of nurses’ moral courage In the PMC (Sekerka et al., 2009), there have been two ways to report the results: as a mean of the Likert (1 – 7) and as a mean of the total score (15 – 105). Moral courage scores up to 50 represent a low level, scores between 51 and 75 represent an average level, and scores 76 and above are considered high (Lotfi-Bejestani et al., 2023). Two studies reported levels as the mean of the Likert (1 – 7): 3.87 (SD 0.68) and 6.35 (SD 0.50). The means of the total scores varied between 53.16 (SD 12.69) and 96.38 (SD 3.63), indicating average to high levels of moral courage. In the NMCQ (Sadooghiasl, 2016), the results were reported as a mean of the total score (scale 102 – 510), and the level of moral courage was higher when the scores were higher. The means varied between 407.57 (SD 53.97) and 473.33 (SD 1.64); a mean above 400 is considered a high level (Azizi et al., 2024). In the NMCS (Numminen et al., 2019), there have been two ways to report the level of moral courage: as a mean score of the Likert (1 – 5), and as a mean of the respondents’ total score (scale 21 – 105). The mean scores of the Likert (1 – 5) varied between 3.26 (SD 0.52) and 4.36 (SD 0.38), while the means of the total scores varied between 42.00 (SD not reported) and 90.70 (SD 28.89). Higher mean scores meant a higher level of moral courage. Means close to 4 and above 4 have been reported as high (Numminen et al., 2019). As for the total score, the mean of a total score above 80 has been reported as high (Fidan et al., 2023; Peng et al., 2023). In the MCSNF (Stephens & Layne, 2023) and the MCSP (Gibson et al., 2020), the results were reported as a mean of the total score (scale 0–100 in the MCSNF and 44–100 in the MCSP). In the MCSNF, the reported mean of the total score was 75.14 (SD 10.52) and in the MCSP, 88.15 (SD 9.1). As these instruments were developed based on the PMC, the reported means of total scores can be considered average and high, corresponding to the PMC. Due to the different operationalisations that the instruments are based on and the varying ways of reporting the results, drawing clear conclusions from the levels and total scores of nurses’ moral courage is challenging. However, the levels reported from all instruments were from moderate, above-mid scores to high, approaching the highest possible. This indicates that the level of nurses’ moral courage is mostly high and sometimes moderate, as measured with different instruments and countries (Appendix 2). Factors related to self-reported levels of moral courage Factors that are linked to the self-reported levels of moral courage have been found to include the characteristics of the nurse and their professional surroundings, comprising other staff and the organisation. These factors have been reported in survey studies and systematic reviews (Abdollahi et al., 2024; Li et al., 2024)(Appendix 2). Review of the literature 25 The factors regarding individual nurses include having the moral sensitivity to identify ethical conflicts (Khodaveisi et al., 2021; Mohammadi et al., 2022; Numminen et al., 2017), having encountered ethical conflicts frequently (Huang et al., 2023a; Koskinen et al., 2020; Numminen et al., 2019) and being conscious of ethical conflicts (Pakizekho & Barkhordari-Sharifabad, 2022). Having a longer experience of working in the field (Huang et al., 2023a; Khodaveisi et al., 2021; Konings et al., 2021; Mohammadi et al., 2022) has been linked to a higher level of moral courage. Additionally, being older (Konings et al., 2021; Mohammadi et al., 2022; Pirdelkhosh et al., 2022), having permanent employment (Mohadeseh et al., 2021) and having social capital (Pirdelkhosh et al., 2022) have been associated with nurses showing greater moral courage. Furthermore, having a personal interest towards nursing ethics (Konings et al., 2021), being ethically competent (Numminen et al., 2017) and having knowledge of ethics (Hauhio et al., 2021; Numminen et al., 2019) seem to support nurses’ moral courage. As for the factors of a nurse’s surroundings, support from the organisation (Berdida, 2023; Khodaveisi et al., 2021; LaSala & Bjarnason, 2010; Wiisak, Suhonen, & Leino-Kilpi, 2022) and education (Edmonson, 2010; Nouroozi et al., 2023) have been indicated to be associated with nurses having a higher level of moral courage. Also, having a supporting ethical climate (Hakimi et al., 2023; Taraz et al., 2019; Yang et al., 2023) and ethical leadership (Pakizekho & Barkhordari- Sharifabad, 2022) in the organisation seems to support nurses’ moral courage. 2.4 Summary and gaps in knowledge The concept of moral courage in nursing has been described and analysed based on different definitions and operationalisations in the literature. This indicates a need for clarification and refinement of the concept and evaluation of its maturity. (Morse et al., 1996) The increasing empirical research on moral courage in nursing has been conducted in the contexts of hospitals and universities, from the viewpoints of nurses, nurse managers, and nurse students. In the research, characteristics of nurses as morally courageous actors, such as tolerance for threats, ethical competence and responsibility, have been identified. Five instruments have been used to measure the self-assessed level of nurses’ moral courage, two of them developed in nursing (Numminen et al., 2019; Sadooghiasl, 2016). The self-assessed level has been identified as rather high. Also, related factors, such as interest in ethics, self-reported experience with ethical conflicts, and promoting or inhibiting organisational factors, have been identified. However, it is important to have caution when interpreting self- reported results because of potential social desirability bias (Van De Mortel, 2008). Elina Pajakoski 26 In summary, research on moral courage in nursing has focused on the characteristics of morally courageous nurses and nurses’ courageous acts, but the concept itself seems to lack clarity. Also, there are still gaps in knowledge regarding the concept. First, there is a gap in knowledge regarding nurses’ reasoning and decision-making regarding their potential morally courageous acts. The second gap in knowledge concerns how moral courage in nursing manifests as nurses’ morally courageous acts in varying contexts of nursing. Research thus far has focused mainly on somatic hospital settings. Therefore, research on manifestations of moral courage in other contexts, such as mental health, outpatient clinics, and primary care settings, is needed to provide a broad understanding of nurses’ morally courageous acts and the related surroundings. Because the manifestation of moral courage can vary between contexts, a variety of contexts can provide empirical examples from which new antecedents, attributes and consequences can be derived, adding to the clarity of the concept (Morse & Lenz, 1996; Schwartz-Barcott & Kim, 2000). Finally, there is a gap in knowledge about both the positive and negative consequences of nurses’ morally courageous acts for the morally courageous nurses, the patients, and the organisations, as the consequences have been mainly discussed from the perspective of the possible negative consequences for the morally courageous nurse. It is important for the sake of the ethical quality of care to understand what happens after nurses take morally courageous acts, and whether they lead to improvements. Thus, identifying all types, including the possible positive consequences, can highlight the significance of nurses’ moral courage for different stakeholders. The results of the theoretical and fieldwork phases of the Hybrid Model provide the opportunity to fill the abovementioned gaps with empirical findings and form a refined definition of moral courage in nursing in the final analytical phase. (Figure 5) Figure 5. A concise outline of the review and gaps in knowledge. Already known about moral courage  Nurses’ reasoning and decision-making concerning moral courage  Manifestations of nurses’ moral courage in varying contexts of nursing, also other than hospitals  Positive, neutral and negative consequences of nurses’ morally courageous acts for different stakeholders.  Characteristics of morally courageous nurses  Self-assessed level of nurses’ moral courage  Factors related to nurses’ moral courage  Context: nursing care in hospitals Gaps in knowledge 27 3 Aims of the Study The purpose of this three-phase study was to clarify and refine the concept of moral courage in nursing with the Hybrid Model of Concept Development (Schwartz- Barcott & Kim, 2000). The goal was to strengthen the theoretical knowledge base of nursing with the refined concept definition, facilitating further research on the concept and examination of its relationship with other concepts as part of possible future theory development. First, the theoretical phase of the Hybrid Model, detailed in Sub-study 1 (Paper I and Summary), aimed to identify the descriptions, definitions and operationalisations of the concept of moral courage in nursing in the literature, forming a starting point for the refined concept definition. Second, the fieldwork phase of the Hybrid Model, comprising Sub-studies 2, 3, and 4, aimed to explore nurses’ descriptions of moral courage as they have experienced it in the authentic environment of nursing (Papers II, III and IV). Third, the final analytical phase of the Hybrid Model (Summary) aimed to form a refined concept definition based on theoretical and empirical knowledge analysed in the theoretical and fieldwork phases. (Figure 6) The research questions were: 1. What are the descriptions, definitions, and operationalisations of the concept of moral courage in nursing in the literature? (Phase I) 2. What is moral courage in nursing based on nurses’ empirical examples? (Phase II) 3. What is the refined definition of the concept of moral courage in nursing? (Phase III) Elina Pajakoski 28 Figure 6. Designs and outcomes for the Hybrid Model of the theoretical, fieldwork and final analytical phases in this study. 29 4 Materials and Methods This chapter describes the materials and methods used in all three phases of the study to fulfil the purpose and to answer the research questions. The Hybrid Model forms the basis of the study to clarify and refine the concept of moral courage in nursing (Schwartz-Barcott & Kim, 2000). Theoretical and empirical knowledge interact in the Hybrid Model. Forming a refined concept definition for an existing concept like moral courage allows for clarifying its central elements and facilitates further research on the topic, examining the concept and its relationships with other concepts as part of future theory development (Walker & Avant, 2019). Refining the concept of moral courage in nursing is important because of its relevance in contemporary nursing care and because it is part of the theoretical knowledge base in nursing. The three-phase study comprises four sub-studies and the final analytical phase of the Hybrid Model, each phase adding to the basis of the previous phase(s). The first, theoretical phase (Sub-study 1), comprised the identification of the history and dictionary definitions of the concept and an integrative literature review identifying the descriptions, definitions and operationalisations of the concept in nursing (Summary, Paper I). The theoretical phase provided a starting point for concept clarification and refinement. The second, fieldwork phase explored moral courage in nursing with two sets of empirical data: a survey (Sub-study 2, Paper II) and a narrative inquiry (Sub-studies 3 and 4, Papers III and IV), and continued the development of the refined concept definition. The third, final analytical phase (Summary) formed the theoretical concept definition, including the evaluation of its maturity. The theoretical and fieldwork phases were revisited during the study to form the refined concept definition. (Schwartz-Barcott & Kim, 2000). (Figure 7) Elina Pajakoski 30 Figure 7. Methods of the study. 4.1 Design, setting and sampling The Hybrid Model The Hybrid Model of Concept Development (Schwartz-Barcott & Kim, 2000) forms the overarching design of this doctoral study. The Hybrid Model has foundations in the Wilsonian methods (Schwartz-Barcott & Kim, 2000; Wilson, 1970), and was Refining the concept of moral courage in nursing with the Hybrid Model Phase III (2024) Summary ANALYTICAL PHASE Comparison and combining the results of the Theoretical and Fieldwork Phases, forming the refined concept definition. Manual search: History and dictionary definitions (Summary) Final analytical phase, using a modified realist synthesis. Phase I (2019–2021) THEORETICAL PHASE An integrative literature review (Sub-study 1, Paper I)  Databases: CINAHL, Cochrane Library, ERIC, Philosopher’s Index and PubMed.  Sample: Twenty-five empirical, philosophical and theoretical scientific articles about moral courage and its manifestation.  Analysis: Whittemore & Knafl (2005) analysis framework for integrative reviews Forming the starting point for the refined concept definition. Phase II (2020–2024) FIELDWORK PHASE A descriptive cross-sectional survey (Sub-study 2, Paper II)  Sample: Registered nurses and practical nurses (N= 680, n= 205) in older people care  Data collection: Nurses’ Moral Courage Scale (NMCS),  Analysis: Statistical analyses Narrative inquiry (Sub-studies 3 and 4, Papers III and IV)  Sample: Fourteen registered nurses representing mental health and somatic fields, in-patient and out-patient units.  Data collection: individual in-depth interviews  Analyses: holistic content analysis Materials and Methods 31 selected for this study because it enhances an examination of the concept with theoretical and empirical data (Schwartz-Barcott & Kim, 2000). The purpose of the Hybrid Model is to select a concept integral to nursing and analyse it with the combined data from the literature and the empirical world of nursing. Thus, it aims to gain knowledge of the concept from empirical cases described by nurses (Schwartz-Barcott & Kim, 2000). The foundation and the analytical approaches of Wilsonian methods support the analysis in the fieldwork and the final analytical phases. However, unlike the Wilsonian methods, the cases representing the concept are derived from the empirical world of nursing. (Schwartz- Barcott & Kim, 2000; Wilson, 1970) The combination of theoretical and empirical knowledge enhances the validation of the results, as the different sets of data support and complement each other (Schwartz-Barcott & Kim, 2000). In this doctoral study, the Hybrid Model includes an integrative literature review in the theoretical phase as well as a survey and a narrative inquiry comprising two sub- studies in the fieldwork phase. In this summary, the final analytical phase was conducted by comparing and combining the results of the two earlier phases. As part of forming the refined concept definition, the maturity of the concept was evaluated in theoretical and final analytical phases using criteria for concept evaluation (Sub-chapter 4.3). The evaluation of maturity in the theoretical phase supports the selection of this concept analysis method. In the final analytical phase, the focus is on the refined concept definition developed in this study (Morse et al., 1996; Morse & Lenz, 1996). Theoretical phase I The theoretical phase comprised a manual search and an integrative literature review to identify the concept of moral courage in the literature and to form the starting point for the refined concept definition (Schwartz-Barcott & Kim, 2000). The manual search (Summary) was conducted to identify the history of the concept of moral courage and the concept’s dictionary definitions as well as definitions in different disciplines, forming a synthesis of what is already known about the topic. In Sub-study 1, an integrative literature review aimed to identify the concept of moral courage in nursing and to form a starting point for the refined concept definition (Paper I). Reviewing the literature on the concept formed an important basis for conducting a thorough concept analysis (Walker & Avant, 2019). In the later phases of the study process, the findings of the theoretical phase and newly published research articles focusing on moral courage in nursing were identified to stay up to date with research findings on the topic. Fieldwork phase II In the fieldwork phase, Sub-studies 2, 3 and 4 were conducted to explore the manifestations of moral courage in nursing. In the Hybrid Model, empirical data is Elina Pajakoski 32 collected in relevant contexts and from people who have experience and knowledge of the topic (Schwartz-Barcott & Kim, 2000). Thus, nurses themselves were asked about their moral courage. In Sub-study 2, a cross-sectional survey aimed at identifying the manifestation of nurses’ moral courage (Paper II). The level of nurses’ self-assessed moral courage and which individual background factors were related to it were analysed. The context was the care of older people in a Finnish municipality, comprising both inpatient wards and home care. The setting was selected to broaden the contexts in which moral courage is analysed because earlier research had mainly been conducted in specialised hospital settings (Hauhio et al., 2021; Numminen et al., 2019; Taraz et al., 2019). Additionally, it is known that nurses frequently encounter ethical conflicts when working with vulnerable older people (Gastmans, 2013; Kalánková et al., 2021; Kim et al., 2020), highlighting that nurses’ moral courage is important in this context (Barlow et al., 2018). A purposive sampling was conducted (Curtis et al., 2016). The participants were all nursing professionals working in selected units who considered themselves able to fill in the questionnaire in Finnish. Potential participants were reached through contact persons in each unit. The response rate was 30% with a total of 205 practical and registered nurses participating from a possible 680 (Table 5). Sub-studies 3 and 4 were based on a narrative inquiry, aiming to describe registered nurses’ justifications for whether to act morally courageously in ethical conflicts (Paper III) and the consequences of their morally courageous acts (Paper IV). Purposive sampling was conducted. A request to participate in the interview was published in the Finnish web-based discussion forum hoitajat.net (Hoitajat.net, 2023). To include a variety of empirical examples of manifestations of moral courage in nursing, registered nurses working in any context of nursing were welcomed to participate in the study. The different examples were needed to identify antecedents, attributes and consequences of the concept and to form a refined concept definition. (Morse & Lenz, 1996; Schwartz-Barcott & Kim, 2000) In this data collection, only registered nurses were included because they have a broad ethical responsibility to work in favour of the patient’s good (International Council of Nurses, 2021). Potential participants were asked to contact the doctoral researcher by phone or email. Fourteen registered nurses participated in the interviews, and the data were used in Sub-studies 3 and 4 (Papers III and IV, Table 5). Final analytical phase III The final analytical phase (Schwartz-Barcott & Kim, 2000) combined and compared the data and results from Sub-studies 1, 2, 3, and 4 with a modified realist synthesis (Gilmore et al., 2019) to form a refined definition of the concept (Schwartz-Barcott & Kim, 2000). Materials and Methods 33 Table 5. Participants of the study. SUB-STUDY 2 (PAPER II) SUB-STUDIES 3 AND 4 (PAPERS III AND IV) Frequency % Frequency Number of participants 205 14 Age (years) <30 46 22.4 0 30- <40 44 21.5 5 40- <50 52 25.4 4 ≥50 62 30.2 5 Gender Women 182 88.8 - Men 20 9.8 Other/ do not wish to tell 3 1.5 Highest degree Practical nurse 115 56.1 - Registered nurse 76 37.1 12 Other (e.g. MHSc) 14 6.8 2 Working experience in healthcare (years) 0-4,9 54 26.5 0 5-9,9 51 24.9 1 10-19,9 45 22.0 8 20- 54 26.3 5 Contexts of nursing Home care, municipal hospital wards Somatic and mental health, inpatient and outpatient care, palliative care N 205 14 4.2 Data collection methods Theoretical phase I A manual search was conducted regarding the history, dictionary definitions and definitions of the concept of moral courage in other disciplines (Summary). In Sub- study 1 (Paper I), a systematic search of the literature was conducted to collect the data for the integrative literature review (Whittemore & Knafl, 2005). The databases used in the systematic search were CINAHL (Ebsco), Cochrane Library, ERIC (Ebsco), Philosopher’s Index (Ebsco) and PubMed (MEDLINE). The main search terms were “moral courage”, “moral strength”, “moral integrity”, “moral responsibility”, “true presence”, “commitment to good care” and “nursing”. These terms were selected based on tentative searches and concept analyses of moral Elina Pajakoski 34 courage in nursing (Numminen et al., 2017; Sadooghiasl et al., 2018). Additionally, the reference lists of the selected articles were searched manually. Two researchers (Paper I) conducted the article selection independently in both the title and abstract and whole text phases. Conflicts were discussed and a consensus was reached regarding each article. (Table 6, Paper I) The quality of the selected articles was assessed independently by two researchers, and consensus was reached through discussions. Joanna Briggs Institute Critical appraisal Tools (Joanna Briggs Institute, 2017) were used, and an appropriate tool for each study design (qualitative, cross-sectional, literature review and theoretical) was selected. (Paper I) Fieldwork phase II In the fieldwork phase, two sets of empirical data were collected to explore moral courage in authentic nursing contexts (Schwartz-Barcott & Kim, 2000). In Sub-study 2, the data was collected with pen-on-paper self-assessment questionnaires (Table 6). The instrument was the Nurses’ Moral Courage Scale (NMCS) (©Numminen et al. 2019). This questionnaire was selected because it has been developed for the context of nursing to measure nurses’ moral courage from the perspective of how well the items describe the respondent, resulting in a self- assessed level of moral courage. Moreover, it has been reported that the instrument is a reliable and valid instrument for its purpose (Konings et al., 2021; Numminen et al., 2019) in different countries and cultures (Li et al., 2024). In the first section of the questionnaire, the participants were asked about individual background factors: age (years), gender, highest educational degree, work experience in health care (years), the level of knowledge base in ethics, resources of the knowledge, and participation in ethics-related activities at work (Numminen et al., 2019). As part of the questionnaire, the NMCS© comprises 21 items, divided into four sub-scales: “compassion and true presence” (5 items), “moral responsibility” (4 items), “moral integrity” (7 items) and “commitment to good care” (5 items) (Numminen et al., 2019, p. 2446). The sub-scales are based on the dimensions of moral courage and have been published in a concept analysis based on the literature. (Numminen et al., 2017, 2019). In the second section of the questionnaire, moral courage was assessed on a 5- point Likert scale: 1 was “Does not describe me at all”, 2 was “Describes me fairly little”, 3 was “Describes me on average”, 4 “Describes me fairly well” and 5, “Describes me very well” (Numminen et al., 2019, p. 2446). A higher assessment meant that the self-assessed level of moral courage was higher. Materials and Methods 35 In addition, there was a question in the Numeric Rating Scale (NRS, 1 to 10) about overall moral courage where a higher self-assessment meant a higher level of moral courage. On the scale, 10 was “I always act morally courageously when the care situation requires it” and 1 was “I never act morally courageously even though the care situation would require it” (NMCS©). Finally, in the third section of the questionnaire, there were 12 items about how easy or difficult it is to act morally courageously in situations with different persons or organisations and different types of morally courageous acts. A 5-point Likert scale similar to the 21-item first part of the questionnaire was used. (Paper II, Table 6) In Sub-studies 3 and 4, individual in-depth interviews of registered nurses were conducted to gather experience-based information on nurses’ moral courage (Lieblich et al., 1998)(Table 6). The data was used in both Papers III and IV, as it included the comprehensive narratives regarding the ethical conflicts in which nurses need moral courage, their justifications for morally courageous acts, the implemented morally courageous acts, and the consequences of the acts. The collected background information comprised the participants’ age (years), work experience in health care (years), highest degree and types of working units, describing their experience in working in nursing practice. Each interview started with a discussion on what was meant by ethical conflicts and moral courage in nursing at this point in the doctoral study. Next, the doctoral researcher requested that the participants describe ethical conflicts in which they needed moral courage but did not act courageously, as well as conflicts in which they acted morally courageously. The doctoral researcher asked probing questions after the initial narrative regarding both requests to promote discussion on the study topic. The doctoral researcher took notes about the participants’ body language, tone of voice, and the atmosphere during the interview after each interview to assist the analysis. The doctoral researcher transcribed the audio recordings after the interviews. (Papers III and IV) Final analytical phase III In the final analytical phase, the data used were those from the contents of the results of Sub-studies 1 to 4. The contents were identified from the published articles and the analysed empirical data (Table 6). Elina Pajakoski 36 Table 6. Data collection and analyses in Sub-studies 1 – 4. PHASE PAPER DATA COLLECTION ANALYSIS I I Systematic literature search (Whittemore & Knafl, 2005) The Whittemore and Knafl framework for integrative reviews (Whittemore & Knafl, 2005) Summary Data collected in Sub-study 1 Evaluation of the maturity of the concept using the criteria for concept evaluation (Morse et al., 1996) II II Pen-on-paper questionnaire: NMCS (Grove et al., 2013; Numminen et al., 2019) Statistical analyses: Descriptive statistics: frequencies, percentages, means and standard deviations Independent Samples T-test Mann Whitney U One-way analysis of variance (ANOVA) Kruskall Wallis test Cronbach's alpha (Grove et al., 2013; Rattray & Jones, 2007) III In-depth individual interviews (Lieblich et al., 1998) Holistic content analysis (Lieblich et al., 1998) IV III Summary Data collected in Sub-studies 1–4 (Schwartz-Barcott & Kim, 2000) A modified realist synthesis (Gilmore et al., 2019; Schwartz-Barcott & Kim, 2000) as part of the final analysis Evaluation of the maturity of the concept using the criteria for concept evaluation (Morse et al., 1996) 4.3 Data analyses Theoretical phase I In the theoretical phase, the data were analysed with an inductive analysis (Whittemore & Knafl, 2005) to form the starting point for the refined concept definition (Schwartz-Barcott & Kim, 2000). Additionally, the relevant contents from the manual search regarding the history, dictionary definitions and definitions in other disciplines are identified and presented in this summary. In Sub-study 1, the analysis method was selected because it enabled the identification of relevant contents from the data to form the starting point for the refined concept definition of moral courage in nursing (Schwartz-Barcott & Kim, 2000). The data in the integrative literature review was analysed inductively using the Whittemore and Knafl’s framework (Whittemore & Knafl, 2005, pp. 550–551), following the steps: 1) “data reduction”; 2) “data display”;3) “data comparison”; and 4) “conclusion drawing and verification”. (Table 6, Paper I) Materials and Methods 37 In the theoretical phase, a starting point for the refined definition of the concept of moral courage in nursing was formed. A table was created to describe explicit and implicit definitions of moral courage in nursing, examples of the uses of the concept and the identified instruments for measuring moral courage (Schwartz-Barcott & Kim, 2000). The contents were identified from the integrative review and each included article separately. The starting point included the antecedents, attributes and consequences of the concept, as they are important in concept definitions (Walker & Avant, 2019). As part of forming the refined concept definition, its maturity was evaluated. The evaluation criteria are described in the last section of Sub-chapter 4.3. Fieldwork phase II In the fieldwork phase of the Hybrid Model, descriptive and inferential statistical analyses and holistic content analyses were used to describe moral courage in the empirical world of nursing. In Sub-study 2, data was analysed statistically, using IBM SPSS Statistics for Windows, Version 26.0 (IBM Corp., 2019) and SAS version 9.4 of the SAS System for Windows software (SAS Institute Inc, 2013). Next, the categories of background variables were combined to fit the statistical analyses: the categories in the variables “Education” and “Knowledge Base in Ethics” (Numminen et al., 2019, p. 2443) were adjusted into three categories with corresponding numbers of responses, combining the two categories with the least answers, leaving the other categories as they were (Paper II). First, assumptions of normal distributions were tested using the Kolmogorov– Smirnov test. Then, the analysis began with descriptive statistics, including frequencies, percentages, means and standard deviations of background variables (Gordon, 2012). Moral courage was analysed item by item, according to four sub- scale sum variables, an overall sum variable (21 items), and an overall Numeric Rating Scale (NRS) of 0 to 10. The sum variables were formed according to those theoretically defined. (Numminen et al., 2017, 2019) Finally, the associations between moral courage and individual background variables were analysed using the Independent Samples T-test, or the corresponding non-parametric Mann Whitney U-test for variables with two categories, One-way analysis of variance (ANOVA), or the corresponding non-parametric Kruskall Wallis test for variables with three or more categories, according to the distribution of the data (Gordon, 2012). The internal consistency of the NMCS© was assessed with Cronbach’s alpha (Gordon, 2012). (Table 6, Paper II) For the Hybrid Model, Sub-study 2 provided generalisable knowledge of the manifestation of nurses’ moral courage, obtained with the self-assessment instrument (Numminen et al., 2019) selected in the theoretical phase. This knowledge formed a basis for exploring nurses’ experiences of moral courage in Elina Pajakoski 38 Sub-studies 3 and 4, as the need for new knowledge to better understand nurses’ inner meanings regarding their potential moral courage was identified from the results (Schwartz-Barcott & Kim, 2000). In Sub-studies 3 and 4, data was analysed with a holistic content analysis, based on the holistic-content perspective (Lieblich et al., 1998). The holistic content analysis was selected to illustrate and understand the manifestation of moral courage in nursing from the descriptions of registered nurses’ experiences, including the ethical conflicts in which nurses act morally courageously, their morally courageous acts, and the consequences of the acts. In the analyses, the relevant contents of each transcribed interview were approached holistically; when a participant described one situation in more than one part of the interview, all contents relevant to the situation were handled together as a whole. (Lieblich et al., 1998) Each holistic content analysis is described in detail in the respective papers (Table 6, Papers III and IV). For the Hybrid Model, Sub-studies 3 and 4 provided descriptions of the justifications and consequences regarding moral courage in nursing, forming the basis for identifying the antecedents, attributes and consequences of moral courage in nursing in the analytical phase (Schwartz-Barcott & Kim, 2000). Final analytical phase III The final analytical phase was conducted to form a refined definition of moral courage in nursing (Schwartz-Barcott & Kim, 2000). A modified realist synthesis was used in forming the refined concept definition because it enhances a systematic comparison and combination of theoretical and empirical results (Gilmore et al., 2019; Wong et al., 2014). The realist synthesis was modified by leaving the initial phases out in the realist synthesis as they were not relevant to this study. The initial phases that were left out were “identification”, “data collection” and “data analysis” (Gilmore et al., 2019, p. 3), which were all conducted in the theoretical and fieldwork phases in this study, following the methods of the Hybrid Model (Schwartz-Barcott & Kim, 2000). In this study, the phase “synthesis” (Gilmore et al., 2019, p. 3) was used to compare and combine the results of the theoretical and fieldwork phases. In the synthesis, antecedents, attributes and consequences were formed because they are central when defining concepts (Walker & Avant, 2019). In the modified realist synthesis, antecedents, attributes, and consequences of the concept were identified separately at the starting point (theoretical phase) and the after the Fieldwork Phase. (Gilmore et al., 2019; Schwartz-Barcott & Kim, 2000). The antecedents, attributes and consequences were presented in tables and compared and combined. The similarities and differences between the results of the Theoretical and Fieldwork Phases were identified, refining the combined antecedents, attributes, and consequences. Similar contents were gathered and named clearly within the Materials and Methods 39 antecedents, attributes and consequences. New antecedents, attributes and consequences were added based on the Fieldwork Phase, according to the identified new knowledge. (Gilmore et al., 2019; Schwartz-Barcott & Kim, 2000) Evaluation of the maturity of the concept in theoretical and analytical phases In the theoretical and final analytical phases, maturity was evaluated with the following criteria (Morse et al., 1996, p. 388): concept definition, characteristics (in this study, attributes), preconditions and outcomes (in this study, antecedents and consequences), and boundaries. Between mature and emerging concepts, there are partially developed concepts, as concepts are not only either mature or immature. The evaluation was conducted in the theoretical phase focusing on the definitions and descriptions of the concept in earlier literature (identified in the integrative literature review), including the antecedents, attributes and consequences of the concept. In the final analytical phase, the evaluation focused on the refined concept definition formed in this study, including the antecedents, attributes and consequences. The evaluation was conducted step by step, evaluating each criterion as its own, following the method of Morse et al (1996). The criterion “concept definition” refers to a concise, written definition of the concept, while the other criteria refer to the characteristics of the concept (antecedents, attributes, and consequences) (Morse et al., 1996, p. 388). The evaluation criteria for the maturity of the concept (Morse et al., 1996, p. 388) are: • The concept definition is clear in a mature concept but lacks clarity in an emerging one. • The characteristics are described clearly in a mature concept but are not identified or lack clarity in an emerging concept. • The preconditions and outcomes are demonstrated with empirical examples, and fully described in a mature concept, but are not identified in an emerging concept. • The boundaries of a mature concept are delineated but are not known in an emerging concept. 4.4 Ethical considerations This study is situated in the field of nursing science, especially within nursing ethics, and it was conducted following the principles of nursing (International Council of Nurses, 2021) and the principles of research integrity (ALLEA - All European Elina Pajakoski 40 Academies, 2023; TENK, 2019). The study examines and refines the concept of moral courage, the exploration in the empirical world of nursing focusing on nurses’ perceptions of their moral acting. Thus, as a personal and moral topic, it can be considered sensitive. However, it is justified to study nurses’ moral courage, as it is an essential part of nurses’ ethical conduct and nurses can promote good, safe, and ethical patient care and their work-related well-being with their moral courage (Numminen et al., 2017; Sadooghiasl et al., 2018). Furthermore, research regarding the topic is increasing, justifying a refined definition of the concept. The Hybrid Model of Concept Development was selected to facilitate the refined definition of moral courage in nursing with the combined methods of literature review and empirical studies. With the Hybrid Model, earlier research findings and purposefully selected, relevant empirical data are combined to form a definition of the concept that is relevant in nursing. It is essential to choose study participants who have experience of the studied topic, in this case nurses. Thus, it was justified to use the Hybrid Model and have nurses as participants in the fieldwork phase. Moreover, as it is not ethically possible to cause ethical conflicts for the sake of observing nurses’ acting in them, it was decided that nurses would be asked about their perceptions and experiences of the topic in authentic nursing practice. This was done with the self-assessment survey and the in-depth interviews. As for the ethical approvals and permissions to conduct the sub-studies, there was no need to seek ethical approval for Sub-study 1, as it was a literature review. In the review, the rights of the authors of the included studies were respected. All original articles were cited in the text of the report. (ALLEA - All European Academies, 2023) In Sub-studies 2 and 3, ethical approval was obtained from the Ethics Committee of the University of Turku (dated 27 January 2020 and 24 October 2022). The ethical approval for Sub-study 3 also included approval for Sub-study 4, as the use of the data in future studies was included and the participants agreed to it. In Sub-study 2, permission to use the NMCS© (Numminen et al., 2019) was received from the copyright holder. Furthermore, in Sub-study 2, permission to gather data was received from the selected organisation. For gathering the data for Sub-studies 3 and 4, permission to publish an invitation to participate in the study was received from the hoitajat.net online discussion forums. The rights of the participants of the study (Papers II, III and IV) were respected. They received written and oral information about the study, were given the contact information for the doctoral researcher and the supervisors and were encouraged to ask further questions. Also, they were informed that they had the right to withdraw from the study at any time, without an explanation, and that no negative consequences for them would ensue from the withdrawal. In Sub-study 2, voluntary informed consent was considered to have been given by completing the questionnaire (Paper II). In the data collection for Sub-studies 3 and 4, participants Materials and Methods 41 voluntarily gave their informed consent by signing a consent form after receiving information about the study. Only the doctoral researcher had access to the consent forms. (Papers III and IV) Only the background information necessary for conducting data analyses was requested. (ALLEA - All European Academies, 2023). All participants’ data were handled carefully and reported in a pseudonymised way, following the EU General Data Protection Regulation (EU, 2016). In Sub-study 2, the participants returned the completed pen-on-paper questionnaires to the contact persons in the units in sealed envelopes. After the data collection period, the doctoral researcher collected the envelopes from each unit. Thus, the researcher did not know the identity of the participating nurses. In Sub-studies 3 and 4, potential participants contacted the researchers by phone or email, thus the researcher knew their names. This direct personal information was used only to agree on the time and place of the interview, not as part of the study data. In the doctoral study, the data were handled carefully and only the doctoral researcher, supervisors and a statistician (Sub-study 2) had access to it. The data, SPSS files of the survey data and Word documents of the transcribed interview data, will be stored electronically in the University’s Seafile platform, behind secure passwords until five years after the completion of the study. After this period, the data will be securely destroyed. Publication ethics were followed when publishing each article (Papers I to IV) and this Summary (ALLEA - All European Academies, 2023). The authorship and the order of authors were discussed and agreed with all authors. The research methods were described truthfully and in detail. All results were reported truthfully and logically. All authors agreed on the final version of each manuscript and conference abstract. 42 5 Results First, the starting point for the refined concept definition, including the evaluation of its maturity (theoretical phase, Sub-chapter 5.1), and moral courage in the empirical world of nursing (fieldwork phase, Sub-chapter 5.2) are described. Then, the refined definition of the concept of moral courage in nursing is presented, including the antecedents, attributes, and consequences, and the evaluation of its maturity (final analytical phase, Sub-chapter 5.3). 5.1 Starting point for the refined concept definition The starting point for the refined concept definition was formed in the theoretical phase I (Sub-study 1), based on the existing literature. It provided a basis for exploring moral courage in nursing in the fieldwork phase. Due to the limited research during conducting this study phase, it was only possible to identify moral courage as a virtue and morally courageous nurses’ characteristics and skills. The starting point is summarised as follows: Moral courage in nursing is a virtue of nurses, and morally courageous nurses have certain characteristics. Skills for ethical conduct and acting according to individual and professional values in ethical conflicts despite potential negative outcomes are integral to moral courage in nursing. (Paper I) 5.1.1 Moral courage as a virtue in nursing Moral courage was identified as a virtue in nursing, and morally courageous nurses have certain personal characteristics. This highlights the perspective of virtue ethics, as virtues are characteristics of individuals (Arries, 2005). Nurses and nursing students sometimes need moral courage in ethical conflicts, when they encounter poor practice, a lack of professional competence or wrongdoing. Morally courageous nurses act according to personal or professional values despite a personal risk of negative consequences from the act. (Paper I) Results 43 5.1.2 Characteristics of morally courageous nurses Moral courage as a virtue in nursing has been described and defined from the perspective of nurses who act morally courageously. The characteristics of morally courageous nurses represent their personal qualities. Morally courageous nurses commit to good care and are willing to do good for others. Being a morally courageous nurse means having ethical sensitivity, moral integrity, and accountability. Ethical sensitivity refers to identifying the ethical conflict and the need for moral courage. Having moral integrity is the ability to continue standing up for one’s values in varying situations, even when encountering personal risks while accountability meant staying true to both individual and professional values and being prepared to act courageously when needed. A morally courageous nurse had the confidence to act according to their beliefs and conscience in ethical conflicts, despite the personal risk involved. Finally, moral courage being a virtue, a morally courageous nurse displays neither cowardice nor foolhardiness. (Paper I) Morally courageous nurses have ethical and professional competences, both integral to nurses’ moral courage. Thus, morally courageous nurses have knowledge about ethics and can identify ethical conflicts, make decisions and act according to them. Also, they show moral courage when admitting their own mistakes and learning from the mistakes. Finally, a morally courageous nurse has the skills to take responsibility even in difficult ethical conflicts. (Paper I) Morally courageous acts are described in Sub-chapter 5.2. 5.1.3 Concept maturity in the theoretical phase The maturity of the concept was evaluated, focusing on the results of the theoretical phase (Paper I). A starting point for the refined concept definition was formed and is reported in this Summary (Sub-chapter 5.1, Table 7). The evaluation of the maturity of the concept began with the criteria “concept definition” (Morse et al., 1996, p. 388). Similarities and differences between definitions and descriptions of the concept were found in the literature. Points of agreement include the ideas that moral courage is a virtue and that morally courageous nurses act based on values in ethical conflicts despite possible personal risks. Also, the literature was consistent on the stance that the presence of personal risk and moral responsibility are attributes of the concept (Paper I). However, there were differences (Sub-chapter 2.3) between the definitions and operationalisations of the concept (Numminen et al., 2019; Sadooghiasl, 2016; Sekerka et al., 2009), and based on the operationalisations, instruments measuring moral courage in nursing from different perspectives have been developed (Sub-section 2.3.2, Appendix 2). Earlier research on the concept lacks variety in the contexts from which empirical examples have been identified (Appendix 2). Thus, it was evaluated that a concept refinement is justified to provide Elina Pajakoski 44 a variety of empirical examples for the derivation of antecedents, attributes and consequences and to strengthen the theoretical understanding of the concept (Morse & Lenz, 1996). The differences in definitions and operationalisations indicate a lack of clarity in the “characteristics” of the concept maturity evaluation. Thus, the definition of the concept in nursing benefits from further clarification (Morse et al., 1996; Morse & Lenz, 1996). For the evaluation of “preconditions and outcomes”, there was variety and ambiguity regarding the antecedents and consequences due to the different definitions. Thus, it was evaluated that clarifying and refining the antecedents, attributes and consequences of the concept was justified. (Morse et al., 1996, p. 388; Morse & Lenz, 1996) Finally, the “boundaries” of the concept seem rather clear because the different definitions consistently state that moral courage includes overcoming risks and fears and belongs in an individual’s moral acts. Thus, without personal risk and value-based, moral acts, the concept is not moral courage in nursing. However, due to the differences in the definitions and operationalisations, the boundaries of the concept require further clarification and refinement. Based on the evaluation, the concept of moral courage in nursing appeared only partly developed, because definitions and operationalisations with different perspectives have been used. Also, the literature on nurses’ reasoning regarding moral courage was limited and exploring it in this study can provide new characteristics for the concept for better understanding it. Thus, it is justified to develop the concept using the Hybrid Model and to aim for a clarified and refined definition of the concept. (Morse et al., 1996, p. 388; Morse & Lenz, 1996) . Table 7. The antecedents, attributes and consequences of the concept in the theoretical phase. THEORETICAL PHASE ANTECEDENTS Ethical conflict Personal risk for the nurse acting Virtuous professional: empathy, responsibility, integrity Ethical competence Willpower ATTRIBUTES Being committed to personal and professional values Overcoming risk and tolerance for threats Acts based on rational decisions Moral responsibility CONSEQUENCES Promotion of patient safety Promotion of ethical care Empowerment of the nurse Reduction of moral distress Results 45 5.2 Moral courage in the empirical world of nursing In the fieldwork phase, moral courage was explored in the empirical world of nursing (Papers II, III and IV). The empirical explorations comprised nurses’ descriptions of ethical conflicts, their justifications for acting morally courageously, their morally courageous acts, the self-assessed level of moral courage and the consequences of the acts. Moral courage manifests itself in ethical conflicts, which are presented first. Nurses’ reasoning and decision-making regarding their potential morally courageous acts are described from the perspective of their justifications for acting morally courageously, and the acts and self-assessed level of moral courage are described to present the manifestation of moral courage in nursing. Finally, the descriptions of the consequences of morally courageous acts show what happens after nurses have acted morally courageously. The abovementioned results are presented as they enhance the identification of antecedents, attributes and consequences for the refined concept definition. 5.2.1 Ethical conflicts as context for moral courage Ethical conflicts are described as a context for the manifestation of moral courage in nursing (Sub-studies 1, 3, and 4), as ethical conflicts are present before moral courage manifests itself (Sub-chapter 2.3). The ethical conflicts were identified from the descriptions of participating nurses (Papers III and IV), and the conflicts concerned patients and professionals. The conflicts emerged between nurses and the organisation, colleagues, co-workers, patients, and patients’ next-of-kin. (Papers III and IV) The conflicts concerning patients included observation of poor practice, threats to patients’ rights or safety, and missed care. The nurses identified poor practices related to palliative care, medication, and rough handling of patients (Paper III). In addition, sometimes, the ethical conflict arose from the nurse’s or another professional’s mistakes or lack of competence. These conflicts were related, for example, to mistakes in medication or missed care due to the lack of competence in the unit. Furthermore, patients’ rights to hear the truth about their condition, for their privacy to be maintained, and to be respected were sometimes not actualised, causing ethical conflicts. (Papers III and IV) The ethical conflicts between professionals included inequality in dividing work tasks, challenges in collaboration, compromising a nurse’s privacy, and a lack of respect between professional groups. Inequality in dividing work tasks happened both inside a unit, where individual nurses had different amounts of tasks, and between units, when nurses from one unit had to do more work tasks because another unit lacked competence. The conflicts related to nurses’ privacy included, for example, situations when a nurse manager told other nurses about one nurse’s private Elina Pajakoski 46 health issues. Finally, a lack of respect between professionals was identified, for example, professionals other than nurses exhibiting rude behaviour and not listening or respecting nurses’ perspectives about patient care. (Papers III and IV, Table 8) Table 8. Ethical conflicts in which moral courage manifested itself (Papers III and IV). AREA OF CONFLICT CONCERNING THE PATIENT BETWEEN PROFESSIONALS MISSED CARE Insufficient number of nurses Insufficient competence of professionals Insufficient pain relief THREAT TO PATIENT’S GOOD CARE Insufficient quality of care Disagreements on the care plan between professionals The patient’s right to knowledge is not actualising Poor practice Own or someone else’s mistakes TRUTH AND PRIVACY The patient’s right to knowledge is not actualising The patient’s privacy is violated A nurse’s privacy is violated RESPECT The patient’s autonomy is not respected Lack of respect between professionals Some professionals are being bullied EQUALITY Inequity in getting correct care Work tasks are divided unequally COLLABORATION Poor collaboration Tense atmosphere Challenges in communication 5.2.2 Justifications for morally courageous acts Nurses identified that they needed moral courage in ethical conflicts and decided on justifications for acting morally courageously. These justifications are presented, from abstract to more concrete: the foundations, bases, and perspectives of justifications. The justifications were based on internal responsibility, following professional ethics, or the emotions that an ethical conflict had triggered. The justifications with the three abovementioned bases had individual, contextual, and organisational perspectives. (Paper III) As for the foundation of justifications, nurses’ willingness to do good and their identity as patient advocates formed a foundation for deciding to act morally courageously in ethical conflicts. They decided to act morally courageously in ethical conflicts or after the conflicts, aiming to do what was right based on their individual and professional values. The nurses aimed to promote good care, Results 47 functioning care processes, and equity among patients and professionals with morally courageous acts. (Paper III) The bases of justifications for morally courageous acts were internal responsibility, professional ethics, and emotions. Nurses pondered different solutions and possible acts in ethical conflicts, acknowledging the contradictions between different acts. As for internal responsibility, nurses got the confidence to justify their acts from their own beliefs and conscience, while professional ethics as a basis of justifications provided external motivation for acting morally courageously. Furthermore, the nurses who based their justifications on emotions got the strength and confidence to act morally courageously from emotions, such as anger at wrongness in ethical conflicts. The justifications with all the abovementioned bases have individual, contextual or organisational perspectives (Paper III, Figure 8). This highlights the context- specific nature of moral courage in nursing: the nurses had different justifications in different situations, resulting in various manifestations of moral courage. Figure 8. Nurses’ justifications for acting morally courageously. However, sometimes nurses did not act morally courageously despite identifying the need to do so. The perspectives of nurses’ justifications for not acting morally courageously correspond with the justifications for acting morally courageously: individual, contextual and organisational, but resulting in no morally courageous act. (Paper III) The individual justifications had to do with fears of personal negative Perspectives of justification for acting morally courageously: Individual, Contextual and Organisational The bases of justifications for morally courageous acts: Internal responsibility, Professional ethics and Emotions Foundation for justifications: Nurse's identity and the aim of doing good Elina Pajakoski 48 consequences that outweighed their aim to do good. The contextual justifications were related to the severity and other attributes of the situation. Finally, organisational justifications had to do with hierarchy and poor collaboration between professionals. (Paper III, Figure 9) Figure 9. Nurses’ justifications for not acting morally courageously even when there was a need to do so. 5.2.3 Morally courageous acts Nurses’ morally courageous acts were identified in Sub-studies 2, 3 and 4. Nurses decided to act and acted morally courageously during and after the ethical conflicts they encountered, acting based on individual and professional values. They aimed to do good for their patients and their work community, focusing the acts either inside or outside the organisation. (Papers II, III and IV, Table 9) The nurses described that, inside the organisation, they had courageously talked to their colleagues, nurse leaders and other professionals, such as physicians, about the ethical conflicts (Table 9). In Sub-study 2, the mean score of self-assessed moral courage was high, 4.16 on the Likert scale of 1 to 5 (Paper II). Moreover, the nurses self-assessed that bringing up an ethical conflict for discussion was the easiest way (mean 4.26 on the 1 to 5 Likert scale) of acting morally courageously. Additionally, the nurses filed written notifications within their organisation. In Sub-study 2, this was the second easiest way (mean 3.67 on the 1 to 5 Likert scale) of acting morally courageously (Paper II). Outside their organisation, the nurses contacted trade unions, local politicians or professionals working elsewhere (Papers II and III). The participants’ mean score of the self-assessed easiness of morally courageous acting outside the organisation was 3.06 on the 1 to 5 Likert scale (Paper II). In addition to the abovementioned morally courageous acts, the nurses described that they courageously admitted their own mistakes and were truly present for their patients (Papers III and IV, Table 9). Nurses’ justifications Individual: fear of negative consequences Contextual: severity and timing of the situation Organisational: hierarchy and poor collaboration between professionals. No morally courageous act Results 49 Table 9. Nurses’ morally courageous acts. NURSES’ MORALLY COURAGEOUS ACTS TAKING PERSONAL RISKS IN FAVOUR OF WHAT WAS RIGHT BASED ON VALUES MORALLY COURAGEOUS ACTS INSIDE THE ORGANISATION OUTSIDE THE ORGANISATION SPEAKING UP (A SPOKEN CONTACT) During the situation x After the situation x x To the person involved x A person not involved x x FILING A WRITTEN NOTICE (A WRITTEN CONTACT) Own organisation x Trade union x Local authorities x Politicians x Healthcare professionals in other organisations x ADMITTING OWN MISTAKES x REPORTING SOMEONE ELSE'S MISTAKES x x BEING TRULY PRESENT TO THE PATIENT x x = The morally courageous act was taken inside/ outside the organisation 5.2.4 Consequences of moral courage in nursing The consequences were identified based on nurses’ descriptions of their experiences in Sub-study 4 (Paper IV). Nurses’ morally courageous acts had consequences for the acting nurse, the patients, and the work community. There were direct consequences which immediately ensued from morally courageous acts, and indirect consequences, which ensued after additional acts were conducted based on the initial morally courageous act. Similar consequences resulted in situations when an ethical conflict was resolved as when a conflict remained unresolved. However, some consequences only ensued when a conflict was resolved or when a conflict remained unresolved. The consequences were both positive and negative. For example, to improve collaboration between professionals, collaborative meetings were organised, and to improve the individuality of care, care plans were altered based on nurses’ morally courageous acts. Furthermore, improved competence of professionals, which had been reached by offering continuous education in the organisations, was a positive consequence for the work community. (Paper IV, Table 10) Elina Pajakoski 50 Table 10. Consequences of nurses’ morally courageous acts (Paper IV). CONSEQUENCES OF NURSES’ MORALLY COURAGEOUS ACTS For the ethical conflict For the nurse For the patient For the work community THE CONFLICT WAS RESOLVED Solving the conflict in collaboration 1 Development of professionals’ competence or skills 2 Being pleased 1 Being empowered 1 Actualisation of rights 1, 2 Mental wellbeing 1,2 Improved quality of care 2 Improved collaboration 2 Improved competence 2 Improved atmosphere 2 THE CONFLICT REMAINED UNRESOLVED Other solutions were required 2 The ethical conflict lengthened. 2 More problems were identified 1 Being discouraged 2 Anxiety 2 BOTH WHEN THE CONFLICT WAS RESOLVED AND STAYED UNRESOLVED Support from other professionals 1 Mixed feelings 1 Being treated badly by others 2 Losing job 2 Direct consequence 1 Indirect consequence 2 5.3 A refined definition of the concept of moral courage in nursing The refined definition of the concept of moral courage in nursing was formed in the final analytical phase of the Hybrid Model, comparing and combining the results of the theoretical phase and the fieldwork phases (Schwartz-Barcott & Kim, 2000). First, the antecedents, attributes and consequences were identified separately from the theoretical and fieldwork phases (Sections 5.1.3 and 5.3.1, Table 11). Identifying the antecedents was an important part of forming the refined concept definition in this study, as they must be present for a concept to be developed and defined. The attributes of the concept represent abstract components that are always present in the concept, while the consequences link the concept with the context, illuminating its use. (Morse et al., 1996) In this Sub-chapter, the development of the refined concept definition after the fieldwork phase (Sub-section 5.3.1), and the refined concept definition, formed in the final analytical phase, including the antecedents, attributes, and consequences (Sub-section 5.3.2) are presented. In Sub-section 5.3.3, an evaluation of the maturity of the concept is presented. Results 51 5.3.1 Development of the refined concept definition The development of the refined concept definition was continued in the fieldwork phase through identifying antecedents, attributes and particularly consequences based on the results from the empirical data and comparing them with the ones identified in the theoretical phase. Based on the comparison, some of the antecedents, attributes and consequences were the same as identified in the theoretical phase, confirming the results of the theoretical phase. As part of combining the results of the theoretical and fieldwork phases, the antecedents, attributes and consequences were derived from the results of the fieldwork phase. These additions clarify the boundaries of the concept. Furthermore, some of the characteristics of the concept were combined in the final analytical phase, the combinations clarifying and refining the descriptions of the antecedents, attributes and consequences. (Table 11) Table 11. Steps in forming the refined concept definition. THEORETICAL PHASE FIELDWORK PHASE FINAL ANALYTICAL PHASE A N TEC ED EN TS Ethical conflict Ethical conflict Ethical conflict Other people are present (human contact required) Human contact Personal risk for the nurse acting Personal risk for the nurse acting Personal risk for the nurse acting Virtuous professional: empathy, responsibility, integrity Empathy, responsibility Virtuous professional Nurse’s identity as a patient’s advocate Nurse’s identity Willpower Willpower Ethical/ moral competence Moral competence Moral competence A TTR IB U TES Being committed to personal and professional values Being committed to personal and professional values Moral responsibility Moral responsibility Moral responsibility Overcoming risk/ tolerance for threats Overcoming fear and taking personal risks in favour of the patient Tolerance of risks Confidence An act based on a rational decision The ability to act courageously according to a value-based rational decision Ethical conduct Emotions Emotions C O N SEQ U EN C ES Promotes patient safety Improved patient safety Improved patient safety Promotes ethical care Actualisation of patient’s rights Ethical care: actualised patient rights Correct care Correct care for the patient Promotes patient’s and nurses’ mental well-being Patients’ and nurses’ improved or maintained mental well-being The nurse becomes empowered The nurse becomes empowered Empowerment: the nurse has the confidence to act courageously in the future Reduces nurse’s moral distress Nurse is pleased Support from others Others support the nurse Nurse being discouraged Nurse’s moral distress Nurses’ moral distress Being treated badly by others Others treat the nurse badly Improved competence Improvements in the unit Improved collaboration Improved atmosphere Resolved ethical conflict Resolved ethical conflict Elina Pajakoski 52 The antecedents added in the fieldwork phase were other people being present (human contact) and the nurse’s identity as a patient advocate. As part of combining the results of the theoretical and fieldwork phases, the antecedents “nurse’s identity as a patient advocate” and “willpower” were combined, as willpower belongs to the identity of nurses as patient advocates. The attributes added in the fieldwork phase were confidence and emotions regarding ethical conflicts. Furthermore, in the final analytical phase, attributes were combined when appropriate: commitment to values was merged with moral responsibility, as responsibility involves commitment, and tolerance of risks was merged with confidence, as confidence is involved in tolerance. The combination of results continued with deriving new consequences from the fieldwork phase (Paper IV). The added consequences related to the patient were the actualisation of patients’ rights, correct care and promotion of patients’ well-being, while nurse-related consequences were nurses’ mental well-being, support from others, being discouraged, moral distress and being treated badly by others. Added consequences related to the work community were improved competence, collaboration and atmosphere, which were combined in the final analytical phase, and resolved ethical conflicts. (Table 11) 5.3.2 The refined concept definition in the final analytical phase Based on the results of the theoretical and fieldwork phases, the refined definition of the concept of moral courage in nursing was formed from the combined antecedents, attributes and consequences. The refined definition is presented below. Antecedents, attributes and consequences of the concept The antecedents precede the concept of moral courage in nursing. This means that if one of them is missing, the ensuing concept might not be moral courage. The antecedents are ethical conflict, human contact, personal risk, virtuous professional, nurse’s identity as a patient advocate, moral competence and willpower. Ethical conflict, human contact and personal risk were highlighted as a preceding context for moral courage in nursing, while virtuous professionals, nurse’s identity as a patient advocate, moral competence and willpower form preceding factors related to nurses. (Table 12) Moral courage in nursing is virtuous nurses’ value-based, responsible conduct, manifesting in ethical conflicts in the presence of personal risks and resulting in good care for the patients and positive and negative outcomes for the acting nurse and the work community. Results 53 Table 12. Descriptions of the antecedents. ANTECEDENT DESCRIPTION Ethical conflict Value clashes between the nurse and the organisation, colleagues, co-workers, patients, and their next-of-kin Human contact Other people are present: professionals, patient(s), patient’s next of kin. Personal risk for the nurse acting Risk of negative outcomes for the acting nurse Virtuous professional Empathy Responsibility Integrity Nurse’s identity Identifying oneself as a patient’s advocate Having willpower Moral competence Ethical sensitivity Ethical decision-making skills The attributes of the concept identified based on the results of the theoretical and fieldwork phases were commitment to values, ethical conduct, moral responsibility, tolerance of threats, confidence and emotions. Commitment to values includes both individual and professional values, and tolerance of threats illustrates this commitment, comprising the willingness to take personal risks through value-based acts. Ethical conduct emphasises moral courage as a concept representing virtuous moral acting, comprising ethical sensitivity, rational reasoning, value-based decisions and courageous acts. Moral responsibility, confidence and emotions illuminate moral courage as a concept representing the characteristics of the moral actor, in this case, a nurse. Moral responsibility involves conscience and responsible moral acts, and confidence involves beliefs about what is right and what is wrong and conscience. Emotions involve the willingness to do good and anger and negative feelings when encountering wrongness. (Table 13) Elina Pajakoski 54 Table 13. Descriptions of the attributes. ATTRIBUTE DESCRIPTION Moral responsibility Conscience Commitment to personal and professional values Tolerance of risks Willingness to take personal risks in favour of what is right Risk-taking Confidence Ethical conduct Ethical sensitivity, identifying ethical conflicts Rational reasoning as part of ethical decision-making Value-based decision Courageous act based on a value-based decision Emotions Willingness to do good Anger because of the encountered wrongness Feeling bad because of the encountered wrongness The consequences of the concept are positive and negative, and they are related to the patient, the morally courageous nurse and the organisation. The consequences highlight the good for the patient: improved safety, actualised rights, correct care and improved or maintained mental well-being. Furthermore, the good for the acting nurses is represented in empowerment, maintained mental well-being and support from other professionals. Negative consequences for the acting nurse are moral distress and bad treatment from others. The positive consequences for the organisations are improved moral and clinical competence, collaboration and atmosphere, and a resolved ethical conflict. (Table 14) Table 14. Descriptions of the consequences. CONSEQUENCE DESCRIPTION Improved patient safety Correct care for the patient Ethical care Actualised patient rights Patients’ and nurses’ mental well-being Improved mental well-being Maintained mental well-being Empowerment The nurse has the confidence to act courageously in the future Others support the nurse Support from colleagues, leaders and other professionals Nurse’s moral distress Moral distress when the conflict remains unresolved despite efforts to act morally courageously Others treat the nurse badly Bullying Getting angry Improvements in the unit Moral and clinical competence Collaboration between professionals Perceived atmosphere Resolved ethical conflict Resolved issues regarding the ethical conflict Results 55 5.3.3 Maturity of the concept The maturity of the concept of moral courage in nursing was evaluated (see Sub- chapter 4.3) after forming the refined concept definition (Sub-chapter 5.3). The antecedents, attributes and consequences were described and demonstrated in the empirical data in the fieldwork phase (Papers II, III and IV), and the theoretical phase (Paper I) supported the findings. The evaluation of maturity was conducted according to the criteria for concept evaluation (Morse et al., 1996; Morse & Lenz, 1996). The evaluation focused on the refined concept definition and the refined antecedents, attributes and consequences of the concept. First, the criteria “concept definition” (Morse et al., 1996, p. 388) was evaluated. The presented refined definition enhances the understanding of the concept and its characteristics. This adds clarity to the concept, which appears more mature than before the refined definition was formed in this study. Second, the “characteristics” of the concept were evaluated. The fieldwork phase added new attributes, confidence and emotions, and confirmed the attributes identified in the theoretical phase. The attributes were combined in the final analytical phase (Sub- section 5.3.1). The new attributes and refinement in the final analytical phase add to the clarity of the “characteristics” of the concept. (Morse et al., 1996, p. 388). Third, the criterion “preconditions and outcomes” was evaluated (in this study, the terms antecedents and consequences are used). The antecedents and consequences include perspectives of the morally courageous nurse, the patient and the work community, highlighting the wide significance of moral courage in nursing. Concepts related to human actions, such as moral courage, appear more mature when they have well- described antecedents and consequences. Thus, adding new antecedents and consequences (Sub-chapter 5.3.1, Table 11) contributed to the clarity of the concept, and the concept appears more mature (Morse et al., 1996, p. 389). Finally, the refined concept definition added new knowledge of the concept regarding its “boundaries” identified in the theoretical phase (Sub-section 5.1.3). The dispositional concept manifests as different human acts in changing situations, although the concept itself is the same. The boundaries of the concept, presented in the theoretical phase, remained the same in the final analytical phase. However, the combined theoretical and empirical explorations provided refined characteristics of the concept, clarifying the boundaries. (Morse et al., 1996, p. 389). The refined definition formed in this study has both similar and new characteristics compared to the previously published concept analyses (Numminen et al., 2017; Sadooghiasl et al., 2018). Based on the evaluation, the concept of moral courage in nursing is more mature after the refined definition (Sub-chapter 5.3) was formed in this doctoral study. This can be identified in the clarified and refined antecedents, attributes and consequences, which are based on the integrative literature review and the rich cases from the empirical world of nursing. The identified new antecedents, attributes and consequences (Sub-section Elina Pajakoski 56 5.3.1) were refined in the final analytical phase (Table 11), adding to the clarity and maturity of the concept (Morse et al., 1996; Morse & Lenz, 1996). 5.4 Summary of the main results A refined definition of the concept of moral courage in nursing (Sub-chapter 5.3) and an evaluation of the maturity of the concept (Sub-section 5.3.3), are presented in Figure 10 and Figure 11. In the theoretical phase, moral courage was identified as a virtue and a valued personal characteristic of a nurse, the perspective staying the same throughout the study process (Figure 11). The fieldwork phase provided a wider context for the refined definition of the concept, as the concept was explored in a variety of contexts. The empirical exploration enhanced the formation of a refined concept definition, acknowledging not only the morally courageous nurse but also the surroundings as part of the definition. The inclusion of the surroundings adds to the refinement and delineation of the concept and its boundaries (Morse et al., 1996). (Figure 11) Figure 10. A visual presentation of the concept of moral courage in nursing. The final analytical phase formed the refined concept definition (Table 11, Figure 10), including the antecedents, attributes and consequences of the concept. The refined definition is summarised as follows: Moral courage in nursing, manifesting in ethical conflicts in the presence of personal risks, is virtuous nurses’ value-based, responsible conduct, resulting in good care for the patients and positive Manifests itself in ethical conflicts in the presence of personal risks for the virtuous and competent nurse who has willpower. Value- and emotions- based morally responsible conduct despite personal risks. Ensuing good care for patients, positive and negative outcomes for the acting nurse and improvements in the organisation Moral courage in nursing Results 57 and negative outcomes for the acting nurse and the work community (Figure 10). The refined concept definition was evaluated as more mature than at the starting point for the concept definition because new antecedents, attributes and consequences were added based on the empirical exploration, and they were combined when appropriate as part of the refinement of the concept in the final analytical phase. Although more mature, the very core of the concept remains as it was at the starting point: The nature of moral courage is value-based, and personal risk is always present. (Figure 11) Elina Pajakoski 58 Figure 11. Main results of the study. Main results in each phase of the Hybrid Model Phase I, THEORETICAL PHASE: An integrative literature review (Paper I)  The origin of the concept in Aristotelian virtue ethics: A virtue in nursing  Starting point for the refined concept definition o Moral courage as a virtue in nursing, manifesting in the presence of personal risk o Characteristics and skills of the morally courageous nurse  Characteristics: willingness to do good, moral integrity, ethical sensitivity, and confidence.  Skills: ethical and clinical competence, ethical decision-making skills, moral responsibility Phase II, FIELDWORK PHASE: A descriptive cross-sectional survey (Paper II, Summary) and Narrative studies (Papers III and IV, Summary)  Ethical conflicts as context o Between nurses and the organisation, other professionals, patients and patient’s next of kin.  Justifications for morally courageous acts o Foundation: Nurse’s identity and aim to do good o Bases: Internal responsibility, Professional ethics and Emotions o Perspectives: Individual, contextual and organisational  Morally courageous acts o Inside the organisation: taking personal risks, speaking up, filling a notice, admitting one’s own and reporting others’ mistakes.  Consequences of nurses’ morally courageous acts o Direct and indirect consequences for the patient, the morally courageous nurse and the work community  New antecedents, attributes and consequences were added Phase III, ANALYTICAL PHASE: Summary  Refined definition: Moral courage in nursing, manifesting in ethical conflicts in the presence of personal risks, is virtuous nurses’ value-based, responsible conduct, resulting in good care for the patients and positive and negative outcomes for the acting nurse and the work community.  Antecedents: ethical conflict, human contact, personal risk for the acting nurse, virtuous professional, nurse’s identity as a patient advocate, moral competence, willpower  Attributes: moral responsibility, ethical conduct, tolerance of risks, and emotions  Consequences: Improved patient safety, patients’ actualised rights, improved mental well-being, nurses’ empowerment, moral distress, others treating the nurse badly, improved ethical and clinical competence and atmosphere in the unit.  Maturity: In the fieldwork phase, new antecedents, attributes and consequences were added, and the results of the theoretical phase were confirmed. The final analytical phase combined and refined the concept definition. The refined definition added clarity to the concept, indicating increased maturity. 59 6 Discussion This study achieved its purpose of clarifying and refining the concept of moral courage in nursing. In this Chapter, first, the results are discussed in relation to the literature regarding moral courage in nursing (6.1). Second, the strengths and limitations of all phases, sub-studies and the entirety of the Hybrid Model are discussed (6.2). Finally, suggestions for healthcare organisations, nursing education (6.3), and further research (6.4) are presented. 6.1 Discussion of the results This study provides a clarified and refined definition of the concept of moral courage in nursing. The antecedents, attributes, and consequences of the concept were derived from theoretical and empirical data. The combination of theoretical and empirical data supported the development of this dispositional concept because moral courage manifests as human acts in various situations, and it is explored as a theoretical concept in the Hybrid Model. As part of the development of the concept, novel empirical findings on self- reported moral courage in nursing were provided. First, the justifications that nurses had for acting or not acting morally courageously illuminate their inner reasoning regarding potentially acting morally courageously. This insight contributed to deriving clarified and new antecedents and attributes for the concept. Second, the direct and indirect consequences of morally courageous acts that the nurses described highlight the importance of moral courage in nursing for different stakeholders, which enhanced clarification and widened the perception of the consequences of the concept. Third, the refined concept definition includes the context, which broadens the perspective of the definition. The significance of the results is twofold: first, they provide a refined definition of the concept for the benefit of nursing practice and nursing science. Second, they add to the theoretical knowledge base in the field of nursing ethics. The results of Sub-studies 1–4 have been discussed explicitly in Papers I–IV. Next, the results are discussed concerning the starting point for the concept definition (theoretical phase), moral courage in the empirical world of nursing (fieldwork phase) and the refined definition of the concept (final analytical phase). Elina Pajakoski 60 The starting point Due to the scarcity of empirical research available at the time that the integrative literature review was conducted, the descriptions of moral courage in nursing lacked clarity. Thus, the limited data was supported by including articles focusing on the earlier identified attributes and close concepts, such as moral strength (Numminen et al., 2017; Sadooghiasl et al., 2018). At the starting point (Paper I, Summary), moral courage was described as a virtue in nursing, comprising the characteristics of morally courageous nurses. These results are supported by the increased research focused on moral courage in nursing published after the theoretical phase was conducted (Abdollahi et al., 2024; Li et al., 2024). Identifying the starting point for the concept definition was a crucial step in the Hybrid Model, justifying the clarification and refinement of the concept and enhancing the identification of the perspectives of exploration in the fieldwork phase (Schwartz-Barcott & Kim, 2000). Moral courage in the empirical world of nursing The empirical exploration of moral courage in nursing added to the results of the theoretical phase, beginning with the ethical conflict, illuminating nurses’ reasoning and ending with the consequences of nurses’ morally courageous acts. The identified justifications and consequences, especially, were novel findings, contributing to the maturity of the concept (Morse et al., 1996). The complexity of the concept of moral courage can be identified from the varying contexts, ethical conflicts, and people present. Moral courage is strongly related to standing up for values in the presence of other people and personal risks, with earlier research (Haahr et al., 2019; Kleemola et al., 2020; Liu et al., 2023; Numminen et al., 2017; Sadooghiasl et al., 2018) supporting the complex ethical conflicts presented in this study. Moreover, the identified ethical conflicts add to the demonstrations of the antecedents of the concept. The identified justifications for morally courageous acts provided clarity to the antecedents and attributes in the refined concept definition (Morse et al., 1996). The justifications based on internal responsibility, professional ethics and emotions add to the knowledge base regarding reasoning for moral courage (Khatiban et al., 2022; Wiisak, Suhonen, & Leino‐Kilpi, 2022). Emotions as justifications highlight moral courage as a virtue (Arries, 2005), with the perspective of virtue ethics remaining the same as at the starting point. However, discussions in the literature have included critiques regarding the perspective of virtue ethics in nursing. It has been argued that people do not always do the right thing despite being virtuous. (Newham, 2015) Thus, to emphasise the perspective of virtue ethics, it is worth acknowledging that moral courage is the medium between the two extremes of foolhardiness and Discussion 61 cowardice (Arries, 2005; Pianalto, 2012). Being morally courageous involves taking necessary risks, but not being foolhardy when a risk is not worth taking (Arries, 2005). This was identified in the justifications to not act, for example, when encountering wrongdoing (Paper III). At the other end of the continuum is cowardice, when a person does not act courageously although they identify the need to do so. This means that one nurse can act morally courageously in some situations but lack the courage to act in others, which amounts to cowardice. In these cases, it is necessary to acknowledge that even courageous and responsible nurses can encounter situations in which doing the right thing according to values is impossible due to individual, contextual or organisational reasons. (Namadi et al., 2023)(Paper III). The participating nurses described that they consciously decided to act morally courageously when encountering ethical conflicts, despite the risk of personal negative outcomes. This highlights an attribute of moral courage (Sub-chapter 5.3), the tolerance of risks, which has also been presented in earlier research (Numminen et al., 2017; Sadooghiasl et al., 2018). The identified morally courageous acts, including initiating discussions, admitting mistakes, being truly present with the patients and completing written notices, are supported by earlier research (Kleemola et al., 2020; Pohjanoksa et al., 2019). These empirical examples add clarity to the attribute of ethical conduct. In the empirical world, the different types of acting morally courageously illuminate the various situations and the skills nurses need to act courageously. Also, to identify the boundaries of the concept of moral courage in nursing (Morse et al., 1996), it is important to identify the difference between a morally courageous act in the presence of personal risk, and general ethical conduct without personal risk (Numminen et al., 2017; Sadooghiasl et al., 2018). As for the consequences of the concept, this study explored nurses’ descriptions of what happens in the empirical world of nursing after their morally courageous acts and whether improvements are made based on the acts. This adds to the earlier identified whistleblowing process (Wiisak, 2023), providing positive and negative consequences to the refined concept definition. Identifying both negative and positive consequences demonstrates the significance of moral courage in nursing to the nurses themselves, the patients, and healthcare organisations. (Paper IV) Moreover, it is important that after a morally courageous act, such as whistleblowing, the matter is handled in the organisation and necessary further actions are taken. This is also outlined in the EU directive regarding the protection of whistleblowers as well as the Finnish law (EU, 2019; Finlex 1171/2022 Laki Euroopan unionin ja kansallisen oikeuden rikkomisesta ilmoittavien henkilöiden suojelusta, 2022). However, at the organisational and even societal level, it is important to acknowledge the possible “double effect” (Kearns, 2022) of morally courageous acts: although the acts aim for good, there can be negative consequences to the Elina Pajakoski 62 organisation, for example as in the form of damage to reputation when a negative matter is brought to public attention. These negative consequences ensue despite the good intentions of the acting nurse and illuminate the complexity of the process of morally courageous acting. (Kearns, 2022) The refined concept definition A refined concept definition of moral courage in nursing was presented. New refined antecedents, attributes, and consequences were derived from nurses’ descriptions of their experiences regarding moral courage in nursing. This added to the starting point of the refined concept definition, which was formed in the theoretical phase and to the definitions from earlier concept analyses and literature (Abdollahi et al., 2024; Li et al., 2024; Numminen et al., 2017; Sadooghiasl et al., 2018), in which an individual, morally courageous nurse is prominent. The empirical findings (Papers II, III and IV) broadened the contexts from which practical examples were derived from nurses’ descriptions. This facilitated the clarification and refinement of the concept definition, resulting in new knowledge of this dispositional concept, and the concept appears more mature. (Morse et al., 1996, p. 388; Morse & Lenz, 1996) Next, the antecedents, attributes and consequences of the concept of moral courage in nursing are discussed. The antecedents represent both the context and the nurse. As nursing is conducted among people, moral courage in nursing manifests itself through human contact (Arries, 2005). Ethical conflicts also manifest when there are value clashes between people (Liu et al., 2023). Thus, in the refinement of the concept, it was justified to acknowledge the contexts and people involved in the events in which moral courage manifests. As for the antecedents, certain contextual matters, such as ethical conflict and personal risk, and people, such as virtuous nurses, must be present for moral courage to manifest. The antecedents presented in this study add to the earlier published concept analyses (Numminen et al., 2017; Sadooghiasl et al., 2018). The attributes highlight the virtues of a nurse (Arries, 2005). Moral courage not only means following certain rules, for example, a code of ethics (International Council of Nurses, 2021), but it also involves representing an individual’s responsible, ethical conduct, including value-based decisions and acting accordingly despite the risk of personal negative outcomes (Arries, 2005; Falcó‐Pegueroles et al., 2021). Attributes of the pre-existing definitions (Numminen et al., 2017; Sadooghiasl et al., 2018) include, for example, responsibility and tolerance of risks. However, in the attributes of this refined definition, ethical conduct represents a wide perspective, including the surroundings and the people involved. Also, emotions, derived from the participating nurses’ (Paper III) justifications, represent a new angle Discussion 63 of the attributes. Finally, the perspective of virtue ethics corresponds with the existing definitions and literature (Abdollahi et al., 2024; Li et al., 2024; Numminen et al., 2017; Sadooghiasl et al., 2018). The presented consequences highlight the actualised aim of doing good (Newham, 2015), which represents the very core of moral courage in nursing. (Numminen et al., 2017; Sadooghiasl et al., 2018). The presented consequences link the concept with the context of nursing and add to its maturity, as new explicit examples have been given in this study (Morse et al., 1996). Moreover, the positive direct and indirect consequences for different stakeholders were prominent, illuminating how essential moral courage is in nursing (Paper IV). To conclude, the theoretical and empirical explorations have provided new perspectives and knowledge of this dispositional concept. The refined definition of the concept of moral courage in nursing appears more mature than it was before this doctoral study. 6.2 Validity and methodological considerations The rigour, strengths and limitations were considered throughout the study process and are reported in detail in Papers I–IV. Next, the strengths and limitations are described concerning Phases I, II and III and the Hybrid Model as a whole. Theoretical phase I In Sub-study 1 (Paper I), to ensure the validity of the study, the steps of the method were followed systematically in the integrative literature review (Whittemore & Knafl, 2005) and reported according to the PRISMA guidelines (Page et al., 2021). In the steps of the integrative review (Whittemore & Knafl, 2005), validity was ensured by selecting the correct and precise search terms with support from a library information specialist. Also, relevant databases were selected, refined inclusion and exclusion criteria were used, different types of scientific articles were included, and the data were analysed rigorously (Oliver, 2012). Theoretical, philosophical, and empirical papers were included to promote the validity of the results with as broad data as possible (Oliver, 2012) despite limited research on moral courage in nursing during the time of conducting the database search (Paper I). Furthermore, the validity of the article selection and quality appraisal was aimed at by two researchers (Paper I), individually selecting the articles. (Page et al., 2021) The validity of the data analysis was ensured by systematically following the steps in the review process (Whittemore & Knafl, 2005) and regularly discussing the analysis within the research team. Elina Pajakoski 64 The reliability of the integrative review was assessed according to the criteria of qualitative research, as the data analysis was qualitative. Dependability of the review was sought by describing the steps of the review process and data analysis clearly, thus explaining how the results and conclusions were reached. Confirmability was pursued by ensuring that the original articles were cited appropriately and that the review process and decisions in it were described in detail. (Holloway & Wheeler, 2014, pp. 302–303) With the aim of study credibility, the researcher’s role, activities, and assumptions of the study topic were monitored. For example, the data was analysed inductively despite the researcher having earlier assumptions about the definitions and descriptions of the concept. (Holloway & Wheeler, 2014, p. 311) The limitations in Phase I (Paper I) were related to article selection, quality appraisal and the results. In the article selection, having a wide range of databases (Paper I, Sub-chapter 2.1) supported the identification of all relevant articles. However, there were 14 articles selected in the title and abstract phase that were inaccessible despite efforts to retrieve them. It is possible that those articles could have provided relevant information (Paper I). Nevertheless, the versatile results facilitated the formation of the starting point for the refined concept definition. In the quality appraisal, the selected tools from the Joanna Briggs Institute (Joanna Briggs Institute, 2017) did not include a tool for concept analysis, which can be considered a limitation in the review. However, quality appraisal tools appropriate for the methods in each concept analysis were used, these being literature reviews and qualitative studies. As for the results, empirical research focusing on moral courage in nursing was limited during the time of conducting the integrative review, which can be considered a limitation. However, articles focusing on the dimensions of moral courage were identified, enhancing a detailed description of the concept. Fieldwork phase II The survey in Sub-study 2 (Paper II) aimed to provide knowledge of the manifestation of moral courage in nursing, collected with a self-assessment instrument and derived from a new context for both the instrument and exploration of moral courage. The validity was ensured throughout the study process: sampling, selecting the instrument for data collection, collecting the data, and analysing and reporting it. The purposive sampling from the care settings for older people in a large city in Finland was used to gain a versatile sample (Roberts et al., 2006) from this context, providing a new perspective for exploration. This aim was reached and the validity of the results strengthened, as the background factors of the participants represented the target population: nurses in the care for older people in primary care hospital wards and home care in the Finnish care settings (Paper II)(Roberts et al., 2006). The Discussion 65 aim of broadening the perspectives from the earlier studies on moral courage in nursing was one justification for the exploration of moral courage in this context (Hauhio et al., 2021; Numminen et al., 2019; Taraz et al., 2019). Moreover, nurses frequently encountering ethical conflicts when working with older people (Gastmans, 2013; Kalánková et al., 2021; Kim et al., 2020) justified selecting this context and highlighted the significance of nurses’ moral courage in the care of older people (Barlow et al., 2018). As for the measurement, the operationalisation of the concept in the instrument (NMCS ©Numminen) provided clear items, promoting the clarity of the self- assessment instrument and the validity of the results (Waltz et al., 2010). The internal consistency of the instrument in this study was measured using Cronbach’s alpha, and it was satisfactory at 0.94 for the 21-item NMCS. Also, it corresponds with earlier studies using the instrument (Huang et al., 2023a; Lee et al., 2022; Numminen et al., 2021; Rattray & Jones, 2007; Waltz et al., 2010)(Paper II). The limitations in Sub-study 2 were related to the relatively low response rate and possible social desirability bias (Van De Mortel, 2008). The response rate was 30%, which can be considered a limitation, although it corresponds with contemporary surveys (Weigold et al., 2019). Although the estimated sample size of 270, which was calculated based on the confidence interval width from the article reporting the validation of the instrument (Numminen et al., 2019), was not reached, the sample size allowed for conducting statistical analyses (Paper II). Also, the possibility of social desirability bias can be seen as a limitation. It is possible that some participants answered according to what they thought the aim was instead of how they acted (Van De Mortel, 2008). However, this research stands on the assumption that participants answer to the best of their knowledge. While the survey provided self-assessed knowledge of moral courage in the empirical world of nursing, it alone cannot capture the entirety of the meanings and manifestations of the concept. Thus, to add new perspectives and to strengthen the credibility of the concept development, the Hybrid Model continued with narrative studies. The narrative studies in Sub-studies 3 and 4 (Papers III and IV) aimed to add experience-based knowledge from nurses about their moral courage to clarify and refine the concept definition. In the narrative studies, trustworthiness was evaluated according to dependability, credibility, confirmability and transferability (Holloway & Wheeler, 2014, pp. 298–303). In Papers III and IV, the narrative studies were assessed explicitly following the recommendations for narrative methodology (Lieblich et al., 1998). Trustworthiness in Sub-studies 3 and 4 is related to the systematic use of the methods and their suitability for finding answers to the research questions. To promote the trustworthiness of the sub-studies, the narrative inquiries were Elina Pajakoski 66 conducted following the process systematically (Holloway & Wheeler, 2014; Lieblich et al., 1998). Furthermore, selecting a suitable data collection method, individual in-depth interviews, strengthened the trustworthiness of the narrative studies. Dependability was pursued by describing the context, data, analysis and results clearly and logically, to ensure that the choices made and the conclusions reached can be followed through the reports. (Holloway & Wheeler, 2014, pp. 302– 303) The credibility of the narrative studies was strengthened by listening to the experiences of the participants with an open mind and providing them an opportunity to freely talk about their experiences in the interviews. Also, the participants reflected on both situations when they acted morally courageously and when they did not, the perspectives complementing each other. Moreover, the credibility and confirmability of the reporting of the results were supported by the authentic quotes of the participants, illuminating the relationship between the data and the results (Papers III and IV). Furthermore, the confirmability of the results was sought through reporting the used methods step by step. (Holloway & Wheeler, 2014, p. 303) Transferability was assessed by whether the results could be used or a similar type of study conducted in other contexts. Different types of nursing contexts are represented in the data, strengthening the transferability of the results (Holloway & Wheeler, 2014, p. 303). Also, the empirical examples from the different contexts, from which the refined definition was derived, strengthen the theoretical understanding of the concept. This justifies the broadening of the contexts in the concept definition (Morse & Lenz, 1996). However, it must be acknowledged that the study was conducted in Finland, and there can be cultural and organisational differences in registered nurses’ work between countries, for example, when considering the relatively high number of registered nurses in Finland (Tynkkynen et al., 2023). In Sub-studies 3 and 4, the limitations were related to the complexity of the holistic illustrations and the results comprising self-reflections of nurses. The doctoral researcher’s interpretations in the holistic analysis and the complexity of the topic posed challenges to reporting the findings logically and with a small number of concepts. (Lieblich et al., 1998) The exploration focusing on self-reflections can be seen as a limitation because of possible social desirability bias (Bergen & Labonté, 2020). However, the aim was to understand the topic based on experiential knowledge and the topic concerned individuals’ inner thoughts. Thus, it was justified to ask nurses themselves about their moral courage, contributing to forming the refined concept definition (Lieblich et al., 1998; Schwartz-Barcott & Kim, 2000). Discussion 67 Final analytical phase III In the final analytical phase (Summary), the results of Phases I and II were synthesised with a modified realist synthesis (Gilmore et al., 2019; Wong et al., 2014). The validity and consistency of the modified realist synthesis were pursued to ensure by describing the synthesis in detail and deriving the refined definition of the concept logically from the results of the theoretical and fieldwork phases (Schwartz-Barcott & Kim, 2000; Wong et al., 2014). The quality of the final analytical phase was assessed with the perspectives of “extensiveness of the database”, “depth of analysis”, “development of argument”, “validity”, “level of abstractness”, and “contribution to knowledge” (Morse & Lenz, 1996, p. 271). The data in the theoretical and fieldwork phases provided theoretical and empirical perspectives, supporting each other. Moreover, the survey and narrative studies in the fieldwork phase provided different types of data from varying nursing contexts, the narrative studies adding depth to the analysis. The abovementioned extensive data strengthens the validity of the final analytical phase of the Hybrid Model (Morse & Lenz, 1996; Schwartz-Barcott & Kim, 2000). The analysis provided new and combined antecedents, attributes and consequences of the concept, and refined the ones identified in the theoretical phase, illustrating the “depth of the analysis”. All phases were conducted rigorously, and methods were used and described logically to support the “development of argument” of the refined concept definition (Morse & Lenz, 1996, p. 271). Furthermore, the validity of the analytical phase was promoted by explicitly describing the antecedents, attributes and consequences (Schwartz-Barcott & Kim, 2000). The boundaries of the concept were delineated with the antecedents, attributes and consequences, clarifying the theoretical understanding of the concept and strengthening the “epistemological principle” of evaluating concept analyses (Morse & Lenz, 1996, p. 257). As for “the level of abstractness”, the concept was explored, deriving a variety of examples from the empirical world of nursing, which strengthened the theoretical understanding of the concept and added to the “level of abstractness”. However, as a limitation, although the examples derived from the empirical world provide a variety of contextual and situational uses of the concept, the complex examples posed challenges for expressing them as abstract consequences of the concept. Finally, the refined definition provided new knowledge, including a variety of perspectives, for the theoretical understanding of the concept. (Morse & Lenz, 1996, p. 271) This increases the maturity of the concept and strengthens the “contribution to the knowledge” in the field of nursing ethics (Morse & Lenz, 1996, p. 271). The evaluation of the concept’s maturity was conducted systematically following the criteria (Morse et al., 1996) to promote the credibility of the evaluation. The clarified and refined antecedents, attributes and consequences of the concept Elina Pajakoski 68 supported the systematic evaluation. In the method (Morse et al., 1996), the criteria are described, but they leave space for interpretation. As a limitation, this posed challenges to meticulously evaluating the concept's maturity. Thus, the presentation of the evaluation was descriptive. Another limitation is that it was not possible to evaluate the maturity of the refined concept definition formed in this study from the perspective of its use in literature, although the perspective was included in the theoretical phase. Thus, these two evaluations are different: the first evaluated the concept that is defined and described in the literature, and the latter evaluated a new, refined definition. Nevertheless, the evaluation provided a clear presentation of how the concept has developed in this study, clarifying the understanding of the concept and its maturity. (Morse et al., 1996) The Hybrid Model The process of the Hybrid Model (Schwartz-Barcott & Kim, 2000) was followed systematically throughout the doctoral study to promote the credibility and rigour of the study. The theoretical and fieldwork phases formed a foundation for the final analytical phase, in which the results were combined and compared, forming the refined concept definition. The empirical studies provided a variety of empirical examples, facilitating the refinement of the concept definition and fulfilling the purpose of this doctoral study. The broad illustrations of the empirical examples strengthen the validity of the Hybrid Model, as new perspectives supporting the clarity of the theoretical understanding of the concept were identified. (Morse & Lenz, 1996; Schwartz-Barcott & Kim, 2000) A critique of the Hybrid Model has been presented when only one empirical data is used in the analysis, thus lacking in data and generalisability (Morse & Lenz, 1996). In this study, however, this matter was avoided with two sets of empirical data: a survey with better generalisability and interview data, of which two narrative studies were conducted. These results provided new perspectives and nurse populations to the empirical case examples. The Hybrid Model facilitated the development of a broad and refined concept definition in the process of theoretical, fieldwork and analytical phases. This process provided different perspectives on the concept, with the Hybrid Model appearing suitable for the development of this dispositional concept. However, in the future, it would be justified to examine the suitability of this method and potentially other methods for developing dispositional concepts, to ensure the quality of the theoretical and conceptual work in the field of nursing science. (Rodgers et al., 2018) The limitations in the Hybrid Model were related to the scarce research on moral courage in nursing during the theoretical phase and the relatively small empirical samples. As an extensive literature review is an important basis for concept Discussion 69 analysis (Morse & Lenz, 1996; Schwartz-Barcott & Kim, 2000), the limited research on moral courage during the theoretical phase can be considered a limitation. However, the amount of literature increased during the study process, and the updated literature review strengthened the credibility of the study. Moreover, the two sets of data in the fieldwork phase supported the theoretical phase and added novel perspectives to the knowledge base. The relatively small samples in the fieldwork phase (Sub-study 2, 205 and Sub-studies 3 and 4, fourteen) are limitations. Nevertheless, the survey data allowed for statistical analyses, and the interview data was rich, enhancing the analysis as two separate perspectives. Thus, the results derived from the data provided extensive descriptions and examples of the concept and facilitated the refined concept definition. (Morse & Lenz, 1996; Schwartz- Barcott & Kim, 2000) 6.3 Suggestions for practice The refined definition of the concept of moral courage in nursing formed in this study strengthened the theoretical knowledge base on moral courage in nursing. The concept development provides a conceptual basis for nursing as part of healthcare and research in the field of nursing. Thus, the results of this study can be used in different ways in healthcare organisations and the education of nurses. Next, the uses of the results are presented, first regarding healthcare organisations and then education. Healthcare The refined concept definition clarifies the understanding of moral courage in nursing. This understanding provides possibilities to develop processes and organisational structures related to moral courage in healthcare organisations, from the perspectives of nurses, nurse leaders and organisations. With the understanding of moral courage in nursing and the examples given in this study, nurses can identify their strengths and required development points regarding their moral courage. Also, the justifications for acting morally courageously presented in this study can provide possibilities for nurses to develop their argumentation skills regarding moral courage. Finally, the positive consequences in the refined concept definition can provide motivation and confidence for nurses to act morally courageously in ethical conflicts. For nurse leaders, the understanding of moral courage, based on its refined definition, provides possibilities to develop processes to support professionals in their moral courage. Moreover, the identified consequences of moral courage in nursing provide possibilities for nurse leaders to facilitate discussions on ethical Elina Pajakoski 70 issues both among nurses and within multi-professional care teams. Finally, the new understanding of moral courage in nursing provides possibilities for nurse leaders to discuss possible continuous education with nurses and to identify skills that could be strengthened. At the organisational level in social and healthcare organisations, the refined concept definition, the identified justifications and morally courageous acts provide opportunities to develop processes to promote professionals’ moral courage and ethical conduct. The processes can support nurses’ moral courage, multi- professional cooperation concerning moral courage and the well-being of professionals when they encounter ethical conflicts in their work. Furthermore, the presented consequences provide possibilities for developing processes that could facilitate further actions in organisations after morally courageous acts are conducted. These further actions would signify that the issues are resolved, and similar issues could be avoided in the future. Finally, by identifying the consequences described in this study, organisations and care teams could aim to prevent the negative consequences of morally courageous acts that nurses might suffer. Education of nurses The refined definition of the concept of moral courage in nursing formed in this doctoral study improves the understanding of the concept in the basic and continuing education of nurses. In basic nursing education, firstly, the descriptions of morally courageous acts and the refined definition of the concept provide possibilities to develop nursing ethics curricula, aiming to promote moral courage among future nurses. Secondly, the justifications for morally courageous acts, the described acts and their consequences provide examples on which nursing students can reflect in their theoretical studies and practicums. Additionally, these examples provide possibilities to develop ethics simulations as part of curricula design, to support nursing students in gaining the skills to justify courageous acts and their moral courage. In continuous education, the empirical results provide examples for learning decision-making related to potential morally courageous acts in ethical conflicts. Additionally, the antecedents and attributes provide possibilities to identify relevant content for developing continuous education. Finally, the consequences provide examples of the possibilities that can arise when nurses act morally courageously. This can strengthen nurses’ confidence in defending what is right based on values in complex ethical conflicts. Discussion 71 6.4 Suggestions for further research This study clarifies and refines the concept of moral courage in nursing. The results can be used in further research on the topic (Table 15). Based on the refined definition of the concept, comprising the nurse and the context, possible new instruments measuring moral courage in the nursing context can be developed. Empirical research could also focus on nurses or nurse managers reflecting on their colleagues’ morally courageous acts. This might limit possible social desirability bias. Also, the empirical findings indicate that while the matter was often handled in the organisation after a morally courageous act, sometimes no further actions were taken. The processes and organisational structures can be developed to support individual nurses in their moral courage and ethical conduct at the organisational level. Also, the processes could facilitate further actions after morally courageous acts have been conducted, to ensure that the matter is handled and improved, if possible. These processes could identify moral courage as a whistleblowing act, which can be conducted individually or as a collective act of courageous professionals, aiming to avoid the slippery slope of silently agreeing with the identified wrongness. Thus, the processes developed in further research can strengthen the significance that nurses’ morally courageous acts have on the nurses themselves, patients, work communities and societies. Finally, this doctoral study identifies negative consequences that ensued for morally courageous nurses, while there were also positive consequences. Thus, in further research, it could be explored whether it is possible, and how, to prevent these negative consequences from happening. As for the research methods, the development of instruments could be conducted using the appropriate instrument development methods. Potential processes in healthcare organisations could be developed with action research to ensure the processes apply to the organisations. Finally, further research could aim for theory development on moral courage in nursing, based on the refined definition presented in this doctoral dissertation. Table 15. Topics and methods for further research. RESEARCH TOPIC RESEARCH METHODS CONTEXT POTENTIAL MEASUREMENTS OF MORAL COURAGE IN NURSING Instrument development Healthcare DEVELOPMENT OF ORGANISATIONAL STRUCTURES AND PROCESSES PROMOTING MORAL COURAGE Action research in collaboration with healthcare organisations Healthcare THEORY DEVELOPMENT OF MORAL COURAGE IN NURSING Theoretical work Healthcare 72 Conclusions The refined concept definition of moral courage in nursing was presented. Moral courage in nursing, manifesting in ethical conflicts in the presence of personal risks, is virtuous nurses’ value-based, responsible conduct, resulting in good care for the patients, and positive and negative outcomes for the acting nurse and the work community. The refined definition includes both the nurse and the context, and it is thus wider than a personal characteristic. Most of the attributes of the refined concept definition had already been established at the starting point. The attributes added in the fieldwork phase were confidence and emotions. In the final analytical phase, a combination of the results of earlier phases and the antecedents, attributes and consequences of the concept was conducted. The combination of theoretical and empirical data in the concept development supported the link of understanding the concept in both theoretical research and the empirical world of nursing. The evaluated increased maturity of the concept contributes to the knowledge base regarding moral courage in the field of nursing ethics. Nursing education and healthcare organisations can implement these results when supporting nurses’ moral courage and multi-professional cooperation in ethical conflicts. The results can be implemented in the development of processes facilitating nurses’ morally courageous acts and processes that potentially prevent personal negative consequences, which are always a risk when acting morally courageously. The results warrant consideration of acknowledging the significance of moral courage in nursing in healthcare organisations. The direct and indirect consequences indicate the importance of taking further actions following morally courageous acts. Further actions, such as organising collaborative meetings, developing individual care plans and providing continuous education, are needed to improve the matter in question after morally courageous acts are conducted in healthcare organisations. In that way, morally courageous acts can lead to even more widespread positive consequences, although it is important to acknowledge and try to prevent the possible double effect of moral courage, negative consequences for the acting nurse and the organisation. 73 Acknowledgements A journey to a doctoral degree can be long and meandering, sometimes even lonely. However, one thing is sure: I could not have done this without all the wonderful and wise people around me. I am grateful for all the help and support I have received during this journey. This doctoral study was conducted in the Doctoral Programme in Nursing Science (DPNurs), as part of the University of Turku Graduate School (UTUGS), at the Faculty of Medicine, University of Turku, Finland. I feel privileged to belong to this academic community and wish to express my gratitude to everyone involved. In addition, I want to thank the Department of Nursing Science, which has also been an important part of my academic journey. Next, I want to thank a crucial group of people in my doctoral study: all 219 registered and practical nurses who participated. You voluntarily gave your time and thoughts to this study, providing it with rich and informative data. I am grateful for your contribution. Also, I want to thank the contact people in Sub-study 2 for facilitating the data collection in your units. Your help was significant. I was fortunate to receive funding for my doctoral research, which was a great support for conducting the study and writing up this summary book. A warm thank you to all funders: Emil Aaltonen Foundation, Akavan sairaanhoitajat ja Taja ry, DPNurs, the Finnish Association of Nursing Research, the Finnish Work Environment Fund, Laura Bassi Foundation and the University of Turku. I wish to express my deepest gratitude to my excellent supervisors, Professor Riitta Suhonen and Professor (emerita) Helena Leino-Kilpi. Riitta, your presence and guidance have been calming and patient, and at the same time, you have been pushing me forward, which I am very grateful for. Your insights into the study topic and methodological expertise have been endless. Thank you for asking exactly the right questions and helping me to find the best possible solutions in my doctoral study. My deepest gratitude to you. Helena, you have been involved since the very beginning of my research career, and you are one of the biggest reasons why I chose this path and this study topic. Your wide knowledge and understanding of nursing science, ethics, moral courage in nursing and concept analysis have given me many learning opportunities. Thank you for sharing your knowledge and insights; it has Elina Pajakoski 74 been amazing support for me. For both of my supervisors, thank you for believing in me, often more than I have believed in myself. Finally, thank you for not making this journey too easy for me; you have supported me in exactly the right way so that I have been able to learn many new things and do my best. I wish to thank my follow-up committee members and co-authors. Professor (acting) Minna Stolt, you have supported me with your guidance since my master’s studies. Thank you for your continuous support and your interest in my research. Associate Professor Anto Čartolovni, thank you for your support and guidance. Your expertise in the field of ethics has always been a great source of inspiration for me. I am grateful for my supervisors during my master’s thesis and co-authors in Papers I and II, Olivia Numminen and Sunna Rannikko. I want to warmly thank you for guiding me in my first steps as a researcher. Your help and support were important to me in becoming a doctoral researcher and continuing my journey in academia. Also, many thanks to the statistician and co-author in Paper II, Eliisa Löyttyniemi, for sharing your expertise and teaching me to better understand the world of statistics. I wish to express my gratitude to my pre-examiners, Professor (emerita) Hesook Suzie Kim and Professor Marit Kirkevold. I am grateful to you for taking the time to read my dissertation manuscript and for giving valuable and encouraging feedback, which helped me to grow as a researcher. Also, my esteemed opponent, Professor (emerita) Helvi Kyngäs, I thank you for accepting the invitation to be my opponent. Naturally, this journey would not have been like it was without all the peer support I received from many fellow doctoral researchers, friends, and my sister. I wish to express my gratitude to the members of the two DPNurs seminar groups that I have belonged to over the years. It has been a great pleasure to get to know you and your research topics. The inspiring discussions and supportive atmosphere were always pushing me forward, and I have learned so much from you all. In addition to the seminars, I have been privileged to be part of a group of doctoral researchers organising writing retreats. Many times, I have managed to write and think about my dissertation from a different angle during our writing retreats. So, my heartfelt gratitude goes to Saija Inkeroinen, Hanna-Kaisa Pellikka, Jonna Puustinen, Mari Mynttinen and Pia Kukkonen for your endless support and all the laughs. Thank you so much, I appreciate our time together. Also, I wish to thank Tina Hiltunen, Eva Paakkanen, Jaana Lojander and Elina Laitonen for sharing the first steps in academia with me since our master’s studies. I am grateful for all the peer support and discussions. A warm thank you to Johanna Wiisak for the inspiring discussions about our study topics. Also, I wish to express my gratitude to Camilla Långstedt. Towards the end of my doctoral journey, I got crucial peer support from you. I will always remember how valuable it was to share the journey and the final steps with you. Acknowledgements 75 Finally, the greatest gratitude goes to my beloved family. Thank you for believing in me and for being patient when I retreated to my work desk to work on my doctoral study and to write my thesis. Thank you for taking care of daily tasks and listening to me ponder many different parts of my doctoral study, even when I repeated the same themes. And most importantly, thank you for showing your love for me before and during this process. Vihti, 25.6.2025 Elina Pajakoski 76 References Abdollahi, R., Ghasemianrad, M., Hosseinian-Far, A., Rasoulpoor, S., Salari, N., & Mohammadi, M. (2024). Nurses’ moral courage and related factors: A systematic review. Applied Nursing Research, 75, 151768. https://doi.org/10.1016/j.apnr.2024.151768 Abdollahi, R., Iranpour, S., & Ajri-Khameslou, M. (2021). Relationship between resilience and professional moral courage among nurses. Journal of Medical Ethics and History of Medicine. https://doi.org/10.18502/jmehm.v14i3.5436 Ali Awad, N. H., & Al-anwer Ashour, H. M. (2022). Crisis, ethical leadership and moral courage: Ethical climate during COVID-19. Nursing Ethics, 29(6), 1441–1456. https://doi.org/10.1177/09697330221105636 ALLEA - All European Academies. (2023). The European Code of Conduct for Research Integrity. ALLEA - All European Academies. https://doi.org/10.26356/ECoC Alshammari, M. H., & Alboliteeh, M. (2023). Moral courage, burnout, professional competence, and compassion fatigue among nurses. Nursing Ethics, 30(7–8), 1068–1082. https://doi.org/10.1177/09697330231176032 Aristoteles 350 BCE. (2012). Aristotle’s Nicomachean Ethics (R. C. (transl. ) Bartlett & S. D. (transl. ) Collins, Eds.). University of Chicago Press. Arries, E. (2005). Virtue ethics: An approach to moral dilemmas in nursing. Curationis, 28(3), 64–72. https://doi.org/10.4102/curationis.v28i3.990 Azizi, Z., Naghizadeh, M. M., & Bijani, M. (2024). The relationship between moral courage, team work, and safe nursing care in clinical nurses: A multicenter cross-sectional study in Iran. BMC Nursing, 23(1), 411. https://doi.org/10.1186/s12912-024-02097-3 Barlow, N. A., Hargreaves, J., & Gillibrand, W. P. (2018). Nurses’ contributions to the resolution of ethical dilemmas in practice. Nursing Ethics, 25(2), 230–242. https://doi.org/10.1177/0969733017703700 Berdida, D. J. E. (2023). The mediating roles of moral courage and moral resilience between nurses’ moral distress and moral injury: An online cross-sectional study. Nurse Education in Practice, 71, 103730. https://doi.org/10.1016/j.nepr.2023.103730 Berdida, D. J. E., & Grande, R. A. N. (2023). Moral Distress, Moral Resilience, Moral Courage, and Moral Injury Among Nurses in the Philippines During the COVID-19 Pandemic: A Mediation Analysis. Journal of Religion and Health. https://doi.org/10.1007/s10943-023-01873-w Bergen, N., & Labonté, R. (2020). “Everything Is Perfect, and We Have No Problems”: Detecting and Limiting Social Desirability Bias in Qualitative Research. Qualitative Health Research, 30(5), 783–792. https://doi.org/10.1177/1049732319889354 Bickhoff, L., Levett-Jones, T., & Sinclair, P. M. (2016). Rocking the boat—Nursing students’ stories of moral courage: A qualitative descriptive study. Nurse Education Today, 42, 35–40. https://doi.org/10.1016/j.nedt.2016.03.030 Bickhoff, L., Sinclair, P. M., & Levett-Jones, T. (2017). Moral courage in undergraduate nursing students: A literature review. Collegian, 24(1), 71–83. https://doi.org/10.1016/j.colegn.2015.08.002 Black, S., Curzio, J., & Terry, L. (2014). Failing a student nurse: A new horizon of moral courage. Nursing Ethics, 21(2), 224–238. https://doi.org/10.1177/0969733013495224 Bruun, A. M. G., Valeberg, B. T., & Leonardsen, A.-C. L. (2022). Moral Courage: Student Registered Nurse Anesthetist Experiences on the Operating Team. AANA Journal, 90(2), 121–126. References 77 Caldicott, C. V. (2023). Revisiting Moral Courage as an Educational Objective. Academic Medicine, 98(8), 873–875. https://doi.org/10.1097/ACM.0000000000005239 Curtis, E., Comiskey, C., & Dempsey, O. (2016). Importance and use of correlational research. Nurse Researcher, 23(6), 20–25. https://doi.org/10.7748/nr.2016.e1382 DeSimone, B. B. (2019). Curriculum Redesign to Build the Moral Courage Values of Accelerated Bachelor’s Degree Nursing Students. SAGE Open Nursing, 5, 237796081982708. https://doi.org/10.1177/2377960819827086 Ebadi, A., Sadooghiasl, A., & Parvizy, S. (2020). Moral courage of nurses and related factors. Iranian Journal of Nursing Research, 15(2), 24–34. Edmonson, C. (2010). Moral courage and the nurse leader. Online Journal of Issues in Nursing, 15(3). https://doi.org/10.3912/OJIN.Vol15No03Man05 Edmonson, C. (2015). Strengthening moral courage among nurse leaders. Online Journal of Issues in Nursing, 20(2). https://doi.org/10.3912/OJIN.Vol20No02PPT01 EU. (2016). REGULATION (EU) 2016/679 OF THE EUROPEAN PARLIAMENT AND OF THE COUNCIL of 27 April 2016 on the protection of natural persons with regard to the processing of personal data and on the free movement of such data, and repealing Directive 95/46/EC (General Da. https://eur- lex.europa.eu/legal-content/EN/TXT/HTML/?uri=CELEX:32016R0679&from=EN EU. (2019). Directive (EU) 2019/1937 of the European Parliament and of the Council of 23 October 2019 on the protection of persons who report breaches of Union law. EU. https://eur- lex.europa.eu/legal-content/EN/TXT/?uri=CELEX:32019L1937 Falcó‐Pegueroles, A., Rodríguez‐Martín, D., Ramos‐Pozón, S., & Zuriguel‐Pérez, E. (2021). Critical thinking in nursing clinical practice, education and research: From attitudes to virtue. Nursing Philosophy, 22(1), e12332. https://doi.org/10.1111/nup.12332 Fidan, Ö., Çunkuş Köktaş, N., & Şanlialp Zeyrek, A. (2023). The relationship between moral courage and lovingkindness–compassion levels in critical care nurses: A cross-sectional study. Australian Critical Care, S1036731423000644. https://doi.org/10.1016/j.aucc.2023.04.009 Finlex 559/1994 Health Care Professionals Act. (1994, 2011). 559/1994. Finlex. https://www.finlex.fi/en/laki/kaannokset/1994/en19940559 Finlex 1171/2022 Laki Euroopan unionin ja kansallisen oikeuden rikkomisesta ilmoittavien henkilöiden suojelusta. (2022). 1171/2022. Finlex. https://www.finlex.fi/fi/laki/alkup/2022/20221171#Pidm46263580809808 Finnish Nurses’ Association. (2021). Code of Ethics for Nurses. https://sairaanhoitajat.fi/en/profession- and-skills/professional-ethics-and-collegiality/ Gallagher, A. (2011). Moral Distress and Moral Courage in Everyday Nursing Practice. Online Journal of Issues in Nursing, 16(2), 1. https://doi.org/10.3912/OJIN.Vol16No02PPT03 Gastmans, C. (2013). Dignity-enhancing nursing care: A foundational ethical framework. Nursing Ethics, 20(2), 142–149. https://doi.org/10.1177/0969733012473772 Gibson, E. (2018). Student courage: An essential for today’s health education. Nursing Forum, 53(3), 369–375. https://doi.org/10.1111/nuf.12254 Gibson, E., Duke, G., & Alfred, D. (2020). Exploring the relationships among moral distress, moral courage, and moral resilience in undergraduate nursing students. Journal of Nursing Education, 59(7), 392–395. https://doi.org/10.3928/01484834-20200617-07 Gilmore, B., McAuliffe, E., Power, J., & Vallières, F. (2019). Data Analysis and Synthesis Within a Realist Evaluation: Toward More Transparent Methodological Approaches. International Journal of Qualitative Methods, 18, 160940691985975. https://doi.org/10.1177/1609406919859754 Goktas, S., Aktug, C., & Gezginci, E. (2023). Evaluation of moral sensitivity and moral courage in intensive care nurses in Turkey during the COVID ‐19 pandemic. Nursing in Critical Care, 28(2), 261–271. https://doi.org/10.1111/nicc.12820 Gordon, R. A. (2012). Applied statistics for the social and health sciences. Routledge. Grove, S. K., Burns, N., & Gray, J. (2013). The practice of nursing research: Appraisal, synthesis, and generation of evidence. (7th ed.). Elsevier/Saunders cop. Haahr, A., Norlyk, A., Martinsen, B., & Dreyer, P. (2019). Nurses experiences of ethical dilemmas: A review. Nursing Ethics, 1–15. https://doi.org/10.1177/0969733019832941 Elina Pajakoski 78 Hakimi, H., Mousazadeh, N., Sharif-Nia, H., Nazari, R., & Dehghani, M. (2023). The predictive factors of moral courage among hospital nurses. Philosophy, Ethics, and Humanities in Medicine, 18(1), 13. https://doi.org/10.1186/s13010-023-00141-9 Hamric, A. B., Arras, J. D., & Mohrmann, M. E. (2015). Must we be courageous? Hastings Center Report, 45(3), 33–40. https://doi.org/10.1002/hast.449 Hanifi, N., Moqaddam, M., & Ghahremani, Z. (2019). Factors Related to Moral Courage of Nursing Students in Zanjan. Preventive Care In Nursing and Midwifery Journal, 9(1), 22–28. https://doi.org/10.29252/pcnm.9.1.22 Hauhio, N., Leino-kilpi, H., Katajisto, J., & Numminen, O. (2021). Nurses ’ self-assessed moral courage and related socio- demographic factors. Nursing Ethics. https://doi.org/10.1177/0969733021999763 Heggestad, A. K. T., Konow-Lund, A.-S., Christiansen, B., & Nortvedt, P. (2022). A vulnerable journey towards professional empathy and moral courage. Nursing Ethics, 096973302210740. https://doi.org/10.1177/09697330221074013 Hoitajat.net. (2023). Hoitajat.net. https://hoitajat.net/ Holloway, I., & Wheeler, S. (2014). Qualitative Research in Nursing and Healthcare (3rd ed.). Wiley- Blackwell. Hong, N., Qichao, N., Dong, C., Chunling, T., Dong, P., Xinyu, L., Yu, S., Shilong, L., & Yuhuan, Z. (2023). A study on different types of moral courage and coping styles of clinical nurses: Based on potential profile analysis. BMC Nursing, 22(1), 418. https://doi.org/10.1186/s12912-023-01590-5 Hthelee, L. H. H., Sadooghiasl, A., & Kermanshahi, S. M. (2023). Moral distress and moral courage among Iraqi nurses during the COVID-19 pandemic: A cross-sectional study. Journal of Medical Ethics and History of Medicine, 16, 19. https://doi.org/10.18502/jmehm.v16i19.14618 Hu, K., Liu, J., Zhu, L., & Zhou, Y. (2022). Clinical nurses’ moral courage and related factors: An empowerment perspective. BMC Nursing, 21(1), 321. https://doi.org/10.1186/s12912-022-01093- 9 Huang, M., Dong, W., Zhao, Q., & Mo, N. (2023a). Factors associated with the moral courage of nurses in China: A cross‐sectional study. Nursing Open, nop2.1672. https://doi.org/10.1002/nop2.1672 Huang, M., Dong, W., Zhao, Q., & Mo, N. (2023b). Moral courage of master’s students of nursing during COVID-19. Nursing Ethics, 30(4), 585–597. https://doi.org/10.1177/09697330221146250 IBM Corp. (2019). IBM SPSS Statistics for Windows, Version 26.0. Armonk [English]. IBM Corp. https://www.ibm.com/mysupport/s/topic/0TO500000001yjtGAA/spss- statistics?language=en_US International Council of Nurses. (2021). THE ICN CODE OF ETHICS FOR NURSES [Dataset]. International Council of Nurses. https://www.icn.ch/sites/default/files/2023-06/ICN_Code-of- Ethics_EN_Web.pdf Jantara, R. D., Barlem, J. G. T., Jantara, A., Rocha, L. P., Rocha, S. S. da, & Stigger, D. A. da S. (2023). Analysis of moral courage and related factors among undergraduate nursing students: A scoping review. Revista Brasileira de Enfermagem, 76(suppl 3), e20220225. https://doi.org/10.1590/0034- 7167-2022-0225 Joanna Briggs Institute. (2017). CRITICAL APPRAISAL TOOLS JBI’s critical appraisal tools assist in assessing the trustworthiness, relevance and results of published papers. https://joannabriggs.org/ebp/critical_appraisal_tools Kalánková, D., Stolt, M., Scott, P. A., Papastavrou, E., & Suhonen, R. (2021). Unmet care needs of older people: A scoping review. Nursing Ethics, 28(2), 149–178. https://doi.org/10.1177/0969733020948112 Kashani, M., Bozorgzad, P., Masror Roudsary, D., Janani, L., Asghari, H., Asgari, M., & Babamohamadi, H. (2023). The relationship between moral courage and providing safe care in nurses: A cross-sectional study. Journal of Education and Health Promotion, 12(1), 352. https://doi.org/10.4103/jehp.jehp_977_22 Kearns, A. J. (2022). The principle of double effect and external whistleblowing in nursing. Nursing Outlook, 70(6), 807–819. https://doi.org/10.1016/j.outlook.2022.09.001 Khatiban, M., Falahan, S. N., & Soltanian, A. R. (2022). Professional moral courage and moral reasoning among nurses in clinical environments: A multivariate model. Journal of Medical Ethics and History of Medicine. https://doi.org/10.18502/jmehm.v14i20.8180 References 79 Khodaveisi, M., Oshvandi, K., Bashirian, S., Khazaei, S., Gillespie, M., Masoumi, S. Z., & Mohammadi, F. (2021). Moral courage, moral sensitivity and safe nursing care in nurses caring of patients with COVID‐19. Nursing Open, 8(6), 3538–3546. https://doi.org/10.1002/nop2.903 Khoshmehr, Z., Barkhordari-Sharifabad, M., Nasiriani, K., & Fallahzadeh, H. (2020). Moral courage and psychological empowerment among nurses. BMC Nursing, 19(1), 1–7. https://doi.org/10.1186/s12912-020-00435-9 Kim, M., Oh, Y., & Kong, B. (2020). Ethical Conflicts Experienced by Nurses in Geriatric Hospitals in South Korea: “If You Can’t Stand the Heat, Get Out of the Kitchen”. International Journal of Environmental Research and Public Health, 17(12), 4442. https://doi.org/10.3390/ijerph17124442 Kleemola, E., Leino-Kilpi, H., & Numminen, O. (2020). Care situations demanding moral courage: Content analysis of nurses’ experiences. Nursing Ethics. https://doi.org/10.1177/0969733019897780 Konings, K. J. P., Gastmans, C., Numminen, O. H., Claerhout, R., Aerts, G., Leino-Kilpi, H., & de Casterlé, B. D. (2021). Measuring nurses’ moral courage: An explorative study. Nursing Ethics. https://doi.org/10.1177/09697330211003211 Koskinen, S., Pajakoski, E., Fuster, P., Ingadottir, B., Löyttyniemi, E., Numminen, O., Salminen, L., Scott, P. A., Stubner, J., Truš, M., & Leino-Kilpi, H. (2020). Analysis of graduating nursing students’ moral courage in six European countries. Nursing Ethics. https://doi.org/10.1177/0969733020956374 Kyngäs, H. (2020). Theory Development from the Results of Content Analysis. In H. Kyngäs, K. Mikkonen, & M. Kääriäinen (Eds.), The Application of Content Analysis in Nursing Science Research (pp. 73–84). Springer International Publishing. https://doi.org/10.1007/978-3-030- 30199-6_7 LaSala, C., & Bjarnason, D. (2010). Creating workplace environments that support moral courage. Online Journal of Issues in Nursing, 15(3), 1. https://doi.org/10.3912/OJIN.Vol15No03Man04 Lee, B., Oh, Y., Lee, E., & Nam, K. A. (2022). Validation of the Korean Version of Nurses’ Moral Courage Scale. International Journal of Environmental Research and Public Health, 19(18), 11642. https://doi.org/10.3390/ijerph191811642 Li, H., Guo, J., Ren, Z., Bai, D., Yang, J., Wang, W., Fu, H., Yang, Q., Hou, C., & Gao, J. (2024). Moral courage level of nurses: A systematic review and meta-analysis. BMC Nursing, 23(1), 530. https://doi.org/10.1186/s12912-024-02082-w Lieblich, A., Tuval-Mashiach, R., & Zilber, T. (1998). Narrative Research. SAGE Publications, Inc. https://doi.org/10.4135/9781412985253 Lindh, I., Severinsson, E., & Berg, A. (2007). Moral responsibility: A relational way of being. Nursing Ethics, 14(2), 129–140. https://doi.org/10.1177/0969733007073693 Lindh, I., Severinsson, E., & Berg, A. (2008). Exploring student nurses’ reflections on moral responsibility in practice. Reflective Practice, 9(4), 437–448. Lindh, I.-B., Severinsson, E., & Berg, A. (2009). Nurses’ moral strength: A hermeneutic inquiry in nursing practice. Journal of Advanced Nursing (Wiley-Blackwell), 65(9), 1882–1890. https://doi.org/10.1111/j.1365-2648.2009.05047.x Liu, Y., Wang, X., Wang, Z., Zhang, Y., & Jin, J. (2023). Ethical conflict in nursing: A concept analysis. Journal of Clinical Nursing, 32(15–16), 4408–4418. https://doi.org/10.1111/jocn.16563 Lotfi-Bejestani, S., Atashzadeh-Shoorideh, F., Ghafouri, R., Nasiri, M., Ohnishi, K., & Ghadirian, F. (2023). Is there any relationship between nurses’ perceived organizational justice, moral sensitivity, moral courage, moral distress and burnout? BMC Nursing, 22(1), 368. https://doi.org/10.1186/s12912-023-01536-x Luo, Z., Tao, L., Wang, C. C., Zheng, N., Ma, X., Quan, Y., Zhou, J., Zeng, Z., Chen, L., & Chang, Y. (2023). Correlations between moral courage, moral sensitivity, and ethical decision-making by nurse interns: A cross-sectional study. BMC Nursing, 22(1), 260. https://doi.org/10.1186/s12912- 023-01428-0 Mahboubi, M., Salamat, A., Ebrazeh, A., Sayar, S., Abbasi, Z., & Hamooleh, M. M. (2023). Perspectives of nurses working at COVID-19 wards on professional moral courage: A descriptive study. J Res Dev Nurs Midw, 20(1), 28–30. Martin, E., & MacFerran, T. A. (2008). A dictionary of nursing: Over 10000 entries (5. ed). Oxford Univ. Press. https://doi.org/10.1093/acref/9780199211777.001.0001 Elina Pajakoski 80 Martinez, W., Bell, S. K., Etchegaray, J. M., & Lehmann, L. S. (2016). Measuring Moral Courage for Interns and Residents: Scale Development and Initial Psychometrics. Academic Medicine, 91(10), 1431–1438. https://doi.org/10.1097/ACM.0000000000001288 Merriam-Webster Inc. (2024). Merriam-Webster Dictionary. https://www.merriam-webster.com/ Mohadeseh, R., Mohaddeseh, M., Azam, M., & Mahboobeh, K. (2021). Correlation of Moral Courage and Organizational Commitment in Operating Room Nurses. Siriraj Medical Journal, 73(3), 183– 190. https://doi.org/10.33192/Smj.2021.24 Mohammadi, F., Tehranineshat, B., Ghasemi, A., & Bijani, M. (2022). A Study of How Moral Courage and Moral Sensitivity Correlate with Safe Care in Special Care Nursing. The Scientific World Journal, 2022, 1–8. https://doi.org/10.1155/2022/9097995 Morse, J. M., & Lenz, E. R. (1996). Concept Analysis in Nursing Research: A Critical Appraisal. Scholarly Inquiry for Nursing Practice, 10, 253–277. Morse, J. M., PhD, C. M., Hupcey, J. E., & Cerdas, M. (1996). Criteria for concept evaluation. Journal of Advanced Nursing, 24(2), 385–390. https://doi.org/10.1046/j.1365-2648.1996.18022.x Murray, C. J. S. (2010). Moral courage in healthcare: Acting ethically even in the presence of risk. Online Journal of Issues in Nursing, 15(3). https://doi.org/10.3912/OJIN.Vol15No03Man02 Namadi, F., Shahbaz, A., & Jasemi, M. (2023). Nurses’ Lived Experiences of Moral Courage Inhibitors: A Qualitative Descriptive Study. SAGE Open Nursing, 9, 237796082311573. https://doi.org/10.1177/23779608231157326 Nash, W., Mixer, S. J., McArthur, P. M., & Mendola, A. (2016). The moral courage of nursing students who complete advance directives with homeless persons. Nursing Ethics, 23(7), 743–753. https://doi.org/10.1177/0969733015583926 Newham, R. A. (2015). Virtue ethics and nursing: On what grounds? Nursing Philosophy, 16(1), 40– 50. https://doi.org/10.1111/nup.12063 Nouroozi, A., Etemadifar, S., Deris, F., & Davoodvand, S. (2023). The effect of assertiveness-based empowerment on professional commitment and moral courage of nurses working in Shahrekord educational hospitals. Journal of Multidisciplinary Care, 12(3), 111–116. CINAHL. https://doi.org/10.34172/jmdc.1230 Numminen, O., Katajisto, J., & Leino-Kilpi, H. (2019). Development and validation of Nurses’ Moral Courage Scale. Nursing Ethics, 26(7/8), 2438–2455. https://doi.org/10.1177/0969733018791325 Numminen, O., Konings, K., Claerhout, R., Gastmans, C., Katajisto, J., Leino-Kilpi, H., & Dierckx de Casterlé, B. (2021). Validation of the Dutch-language version of Nurses’ Moral Courage Scale. Nursing Ethics, 1–14. https://doi.org/10.1177/0969733020981754 Numminen, O., Repo, H., & Leino-Kilpi, H. (2017). Moral courage in nursing: A concept analysis. Nursing Ethics, 24(8), 878–891. https://doi.org/10.1177/0969733016634155 Oliver, P. (2012). Succeeding with your literature review: A handbook for students. McGraw-Hill Open University Press. Oxford University Press. (2024). Oxford English Dictionary. https://www.oed.com/ Page, M. J., McKenzie, J. E., Bossuyt, P. M., Boutron, I., Hoffmann, T. C., Mulrow, C. D., Shamseer, L., Tetzlaff, J. M., Akl, E. A., Brennan, S. E., Chou, R., Glanville, J., Grimshaw, J. M., Hróbjartsson, A., Lalu, M. M., Li, T., Loder, E. W., Mayo-Wilson, E., McDonald, S., … Moher, D. (2021). The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. BMJ, n71. https://doi.org/10.1136/bmj.n71 Pakizekho, S., & Barkhordari-Sharifabad, M. (2022). The relationship between ethical leadership, conscientiousness, and moral courage from nurses’ perspective. BMC Nursing, 21(1), 164. https://doi.org/10.1186/s12912-022-00941-y Papouli, E. (2019). Aristotle’s virtue ethics as a conceptual framework for the study and practice of social work in modern times. European Journal of Social Work, 22(6), 921–934. https://doi.org/10.1080/13691457.2018.1461072 Peng, M., Saito, S., Guan, H., & Ma, X. (2023). Moral distress, moral courage, and career identity among nurses: A cross-sectional study. Nursing Ethics, 30(3), 358–369. https://doi.org/10.1177/09697330221140512 Pianalto, M. (2012). Moral courage and facing others. International Journal of Philosophical Studies, 20(2), 165–184. https://doi.org/10.1080/09672559.2012.668308 References 81 Pirdelkhosh, M., Mohsenipouya, H., Mousavinasab, N., Sangani, A., & Mamun, M. A. (2022). Happiness and Moral Courage Among Iranian Nurses During the COVID-19 Pandemic: The Role of Workplace Social Capital. Frontiers in Psychiatry, 13, 844901. https://doi.org/10.3389/fpsyt.2022.844901 Pohjanoksa, J., Stolt, M., Suhonen, R., Löyttyniemi, E., & Leino-Kilpi, H. (2019). Whistle-blowing process in healthcare: From suspicion to action. Nursing Ethics, 26(2), 526–540. https://doi.org/10.1177/0969733017705005 Powers, B. A., & Knapp, T. R. (Eds.). (2011). Dictionary of nursing theory and research (4th ed). Springer Pub. Co. Press, E. (2018). Moral Courage: A Sociological Perspective. Society, 55(2), 181–192. https://doi.org/10.1007/s12115-018-0231-4 Rainer, J., Schneider, J. K., & Lorenz, R. A. (2018). Ethical dilemmas in nursing: An integrative review. Journal of Clinical Nursing, 27(19–20), 3446–3461. https://doi.org/10.1111/jocn.14542 Rakhshan, M., Mousazadeh, N., Hakimi, H., & Hosseini, F. A. (2021). Iranian nurses’ views on barriers to moral courage in practice: A qualitative descriptive study. BMC Nursing, 20(1), 221. https://doi.org/10.1186/s12912-021-00728-7 Rattray, J., & Jones, M. C. (2007). Essential elements of questionnaire design and development. Journal of Clinical Nursing, 16(2), 234–243. https://doi.org/10.1111/j.1365-2702.2006.01573.x Rest, J. R. (1994). Background: Theory and Research. In Moral Development in the Professions: Psychology and Applied Ethics (1st Edition). Mahwah: Taylor and Francis. Roberts, P., Priest, H., & Traynor, M. (2006). Validity and Reliability in Research. Nursing Standard, 20(44), 41–45. Rodgers, B. L. (2000). Philosophical Foundations of Concept Development. In Concept Development in Nursing (2nd ed., pp. 7–38). Saunders. Rodgers, B. L., Jacelon, C. S., & Knafl, K. A. (2018). Concept Analysis and the Advance of Nursing Knowledge: State of the Science. Journal of Nursing Scholarship, 50(4), 451–459. https://doi.org/10.1111/jnu.12386 Roshanzadeh, M., Vanaki, Z., Sadooghiasl, A., Tajabadi, A., & Mohammadi, S. (2021). Explaining Courage in Ethical Decision-making by Nursing Managers: A Qualitative Content Analysis. Journal of Holistic Nursing And Midwifery, 31(4), 254–262. https://doi.org/10.32598/jhnm.31.4.2141 Ruixin, Z., Shan, H., Yongli, T., Chen, J., Qianzhu, C., & Xue, W. (2024). The influence of psychological resilience and nursing practice environment on nurses’ moral courage: A cross‐ sectional study. Nursing Open, 11(4), e2163. https://doi.org/10.1002/nop2.2163 Sadooghiasl, A. (2016). Designing and psychometric properties testing of Moral Courage Questionnaire for Nurses. Teheran University of Medical Sciences. Sadooghiasl, A., Parvizy, S., & Ebadi, A. (2018). Concept analysis of moral courage in nursing: A hybrid model. Nursing Ethics, 25(1), 6–19. https://doi.org/10.1177/0969733016638146 Safarpour, H., Ghazanfarabadi, M., Varasteh, S., Bazyar, J., Fuladvandi, M., & Malekyan, L. (2020). The association between moral distress and moral courage in nurses: A cross-sectional study in Iran. Iranian Journal of Nursing and Midwifery Research, 25(6), 533. https://doi.org/10.4103/ijnmr.IJNMR_156_19 SAS Institute Inc. (2013). SAS/ACCESS® 9.4. [Computer software]. https://support.sas.com/en/software/sas-access.html Schwartz-Barcott, D., & Kim, H. S. (2000). An Expansion and Elaboration of the Hybrid Model of Concept Development. In Concept Development in Nursing (2nd ed., pp. 129–159). Saunders. Sekerka, L. E., Bagozzi, R. P., & Charnigo, R. (2009). Facing Ethical Challenges in the Workplace: Conceptualizing and Measuring Professional Moral Courage. Journal of Business Ethics, 89(4), 565–579. https://doi.org/10.1007/s10551-008-0017-5 Solgajová, A. (2023). Strengthening moral courage in nurses. Central European Journal of Nursing and Midwifery, 14(3), 905–906. https://doi.org/10.15452/cejnm.2023.14.0013 Stephens, T. M., & Layne, D. (2023). A National Survey of Nursing Faculty Resilience, Moral Courage, and Purpose. Journal of Nursing Education, 62(7), 381–386. https://doi.org/10.3928/01484834- 20230509-01 Elina Pajakoski 82 Taraz, Z., Loghmani, L., Abbaszadeh, A., Ahmadi, F., Safavibiat, Z., & Borhani, F. (2019). The relationship between ethical climate of hospital and moral courage of nursing staff. Electronic Journal of General Medicine, 16(2), 1–6. https://doi.org/10.29333/ejgm/93472 TENK. (2019). The ethical principles of research with human participants and ethical review in the human sciences in Finland. In Finnish National Board in Research Integrity. https://www.tenk.fi/sites/tenk.fi/files/Ihmistieteiden_eettisen_ennakkoarvioinnin_ohje_2019.pdf Tynkkynen, L.-K., Keskimäki, I., Karanikolos, M., Litvinova, Y., & Maresso, A. (ed. ). (2023). Finland Health system summary. European Observatory on Health Systems and Policies. https://eurohealthobservatory.who.int/publications/i/finland-health-system-summary Van De Mortel, T. F. (2008). Faking it: Social desirability response bias in self-report research. In AUSTRALIAN JOURNAL OF ADVANCED NURSING (Vol. 25, Issue 4, pp. 40–48). Walker, L. O., & Avant, K. C. (2019). Strategies for theory construction in nursing (Sixth edition). Pearson. Waltz, C. F., Strickland, O., & Lenz, E. R. (2010). Measurement in nursing and health research (4th ed). Springer Pub. Wawersik, D. M., Boutin, E. R., Gore, T., & Palaganas, J. C. (2023). Perspectives on developing moral courage in pre-licensure education: A qualitative study. Nurse Education in Practice, 70, 103646. https://doi.org/10.1016/j.nepr.2023.103646 Weigold, A., Weigold, I. K., & Natera, S. N. (2019). Response Rates for Surveys Completed With Paper-and-Pencil and Computers: Using Meta-Analysis to Assess Equivalence. Social Science Computer Review, 37(5), 649–668. https://doi.org/10.1177/0894439318783435 Whittemore, R., & Knafl, K. (2005). The integrative review: Updated methodology. Journal of Advanced Nursing, 52(5), 546–553. https://doi.org/10.1111/j.1365-2648.2005.03621.x WHO Regional Office for Europe. (2016). Strengthening people-centred health systems: A European framework for action on integrated health services delivery Conceptual overview and main elements. September, 12–15. Wiisak, J. (2023). Whistleblowing for wrongdoing in healthcare. University of Turku. Wiisak, J., Suhonen, R., & Leino‐Kilpi, H. (2022). Reasoning for whistleblowing in health care. Scandinavian Journal of Caring Sciences, scs.13109. https://doi.org/10.1111/scs.13109 Wiisak, J., Suhonen, R., & Leino-Kilpi, H. (2022). Whistle-blowers – morally courageous actors in health care? Nursing Ethics, 29(6), 1415–1428. Wilson, J. (1970). Thinking with Concepts (1st ed.). Cambridge University Press. https://doi.org/10.1017/CBO9781139173421 Wolf, L. A., & Noblewolf, H. S. (2024). Moral courage of emergency nurses in care-limited environments: A mixed-methods study. Nursing Ethics, 09697330241265415. https://doi.org/10.1177/09697330241265415 Wong, G., Greenhalgh, T., Westhorp, G., & Pawson, R. (2014). Development of methodological guidance, publication standards and training materials for realist and meta-narrative reviews: The RAMESES (Realist And Meta-narrative Evidence Syntheses – Evolving Standards) project. Health Services and Delivery Research, 2(30), 1–252. https://doi.org/10.3310/hsdr02300 Yang, Q., Zheng, Z., Ge, L., Huang, B. X., Liu, J., Wang, J., Lu, K., Huang, Y., & Zhang, J. (2023). The impact of resilience on clinical nurses’ moral courage during COVID-19: A moderated mediation model of ethical climate and moral distress. International Nursing Review, 70(4), 518– 526. https://doi.org/10.1111/inr.12871 Yılmaz, Ş., & Özbek Güven, G. (2024). The relationship between nurses’ moral courage and whistleblowing approaches. Nursing Ethics, 09697330241230686. https://doi.org/10.1177/09697330241230686 Yu, Q., Wang, H., Tian, Y., Wang, Q., Yang, L., Liu, Q., & Li, Y. (2023). Moral courage, job-esteem, and social responsibility in disaster relief nurses. Nursing Ethics, 096973302311745. https://doi.org/10.1177/09697330231174540 Zheng, H., Luo, L., Tan, X., Cen, Y., Xing, N., Huang, H., & Cai, Y. (2024). Moral courage and its influencing factor among oncology specialist nurses: A multi‐centre cross‐sectional study. Nursing Open, 11(1), e2096. https://doi.org/10.1002/nop2.2096 83 Tables, Figures and Appendices Tables Table 1. Dictionary definitions in the selected dictionaries ............... 16 Table 2. Examples of definitions in other disciplines ........................ 17 Table 3. The antecedents, attributes and consequences of the concept of moral courage in nursing in existing, reported concept analyses ................................................. 19 Table 4. The instruments used for measuring nurses’ moral courage ............................................................................. 23 Table 5. Participants of the study. .................................................... 33 Table 6. Data collection and analyses in Sub-studies 1 – 4 ............. 36 Table 7. The antecedents, attributes and consequences of the concept in the theoretical phase ........................................ 44 Table 8. Ethical conflicts in which moral courage manifested itself (Papers III and IV) ..................................................... 46 Table 9. Nurses’ morally courageous acts ....................................... 49 Table 10. Consequences of nurses’ morally courageous acts (Paper IV) .......................................................................... 50 Table 11. Steps in forming the refined concept definition ................... 51 Table 12. Descriptions of the antecedents ......................................... 53 Table 13. Descriptions of the attributes.............................................. 54 Table 14. Descriptions of the consequences ..................................... 54 Table 15. Topics and methods for further research ........................... 71 Figures Figure 1. Study phases, approaches, and outcomes for the hybrid model ...................................................................... 12 Figure 2. Selection of articles ............................................................ 14 Figure 3. The years when the selected articles were published ........ 15 Figure 4. Countries that the authors of the articles represented. ....... 15 Figure 5. A concise outline of the review and gaps in knowledge ..... 26 Figure 6. Designs and outcomes for the hybrid model of the theoretical, fieldwork and final analytical phases in this study .................................................................................. 28 Figure 7. Methods of the study ......................................................... 30 Figure 8. Nurses’ justifications for acting morally courageously ........ 47 Figure 9. Nurses’ justifications for not acting morally courageously even when there was a need to do so .......... 48 Elina Pajakoski 84 Figure 10. A visual presentation of the concept of moral courage in nursing ............................................................................56 Figure 11. Main results of the study .....................................................58 Appendices Appendix 1. Articles included in the review of the literature ....................85 Appendix 2. Self-assessed levels and total scores of moral courage in different studies ..............................................................93 Ap pe nd ic es A pp en di x 1. A rti cl es in cl ud ed in th e re vi ew o f t he li te ra tu re . 1 I ni tia l s ea rc h in 2 02 0, 2 Fi rs t u pd at in g se ar ch in 2 02 1, 3 Fi na l u pd at in g se ar ch in 2 02 4 AU TH O RS , Y EA R, CO UN TR Y DE SI G N, S ET TI NG , PA RT IC IP AN TS M ET HO D, A NA LY SI S M AI N RE SU LT S A bd ol la hi R , e t a l. 20 21 , I ra n 3 A de sc rip tiv e co rre la tio na l s tu dy 37 5 nu rs es w or ki ng in te ac hi ng ho sp ita ls Su rv ey , P M C St at is tic al a na ly se s Th e m ea n of m or al c ou ra ge w as 6 .3 5 (s ca le 1 to 7 ) A li A w ad , N . H . e t a l. 20 22 , E gy pt 3 A cr os s- se ct io na l s tu dy 23 5 nu rs es Su rv ey , N M C S St at is tic al a na ly se s M or al c ou ra ge w as re po rte d as h ig h (m ea n 72 .0 9 on th e sc al e of 2 1- 10 5) . C ris is le ad er sh ip a nd e th ic al le ad er sh ip h ad p os iti ve c or re la tio ns w ith m or al c ou ra ge . A ls ha m m ar i M H & A lb ol ite eh M 2 02 3, Sa ud i-A ra bi a 3 C or re la tio na l, cr os s- se ct io na l 68 4 nu rs es Su rv ey , N M C S, S ta tis tic al an al ys es M or al c ou ra ge n eg at iv el y in flu en ce d co m pa ss io n fa tig ue a nd m ed ia te d bu rn ou t a nd p ro fe ss io na l c om pe te nc e re la te d to co m pa ss io n fa tig ue . A zi zi Z e t a l. 20 24 , Ira n 3 D es cr ip tiv e cr os s- se ct io na l 37 5 nu rs es Su rv ey , M C Q , S ta tis tic al an al ys es M or al c ou ra ge a ve ra ge le ve l: 42 2. 37 ± 5 2. 92 . M or al c ou ra ge p ar tly ex pl ai ne d sa fe n ur si ng c ar e. Be rd id a DJ E & G ra nd e R A N . 2 02 3, Ph ili pp in es 3 C or re la tio na l c ro ss -s ec tio na l Sn ow ba ll sa m pl in g 41 2 nu rs es Su rv ey , N M C S M ed ia tio n an al ys is M or al d is tre ss , m or al re si lie nc e, m or al c ou ra ge a nd m or al in ju ry w er e in te rc on ne ct ed a nd in flu en ce d ea ch o th er . M or al c ou ra ge a nd m or al re si lie nc e w er e po si tiv el y co rre la te d w ith e ac h ot he r. B er di da D JE , 2 02 3, Ph ili pp in es 3 C or re la tio na l c ro ss -s ec tio na l Sn ow ba ll sa m pl in g 41 2 nu rs es S am a da ta a s ab ov e Su rv e, N M C S St at is tic al a na ly se s M or al d is tre ss im pa ct ed n eg at iv el y on m or al c ou ra ge , w hi le m or al re si lie nc e po si tiv el y in flu en ce d m or al c ou ra ge . M or al re si lie nc e an d m or al c ou ra ge m ed ia te d be tw ee n m or al d is tre ss a nd m or al in ju ry . B ic kh of f, L. e t a l. 20 16 , A us tr al ia 1 Q ua lit at iv e de sc rip tiv e, U ni ve rs ity in A us tra lia , 9 nu rs in g st ud en ts , 1 n ur si ng gr ad ua te . Se m i-s tru ct ur ed in te rv ie w s, Th em at ic a na ly si s M ai n th em es : “ Pa tie nt a dv oc at e id en tit y” , “ kn ow in g th ei r m or al c od e an d pr ev io us li fe e xp er ie nc es ”; “C on se qu en ce s to th e pa tie nt a nd th e nu rs in g st ud en t”; “T he im pa ct o f k ey in di vi du al s” (B ic kh of f e t a l., 20 16 , p . 3 7) . B ic kh of f e t a l. 20 17 , A us tr al ia 1 Li te ra tu re re vi ew , 15 re se ar ch a rti cl es Th em at ic a na ly si s St ud en ts w is he d to a dv oc at e fo r p at ie nt s bu t s om et im es la ck ed m or al c ou ra ge . Su pp or t f ro m m en to rs p ro m ot ed th ei r m or al c ou ra ge . 85 AU TH O RS , Y EA R, CO UN TR Y DE SI G N, S ET TI NG , PA RT IC IP AN TS M ET HO D, A NA LY SI S M AI N RE SU LT S B la ck , S . e t a l. 20 14 , UK 1 H er m en eu tic s tu dy , H ea lth ca re o rg an is at io ns , 19 m en to rs w ho h ad m en to re d nu rs in g st ud en ts R ef le ct iv e in te rv ie w s, H er m en eu tic d is co ve ry o f m ea ni ng Ke y th em es : “ Ex pe rie nc in g m or al s tre ss ”, “d em on st ra tin g m or al in te gr ity ”, “E ns ui ng m or al re si du e” . ( Bl ac k et a l., 2 01 4, p . 2 29 ) B ru un , A . M . G . e t a l. 20 22 . N or w ay 3 Q ua lit at iv e, c rit ic al in ci de nt te ch ni qu e W rit te n na rra tiv es Th em at ic a na ly si s Th em es : “ Ke ep in g th e pa tie nt s af e” a nd “E st ab lis hi ng a c on st ru ct iv e w or k en vi ro nm en t”. (B ru un e t a l., 2 02 2, p p. 1 22 –1 23 ) D eS im on e, B . B . 2 01 9. Th e U SA 3 C ur ric ul um d ev el op m en t, on e- gr ou p pr e- a nd p os t-t es t st ud y Im pl em en tin g th e co ur se Su rv ey St at is tic al a na ly se s M or al c ou ra ge v al ue s of s tu de nt s ch an ge d po si tiv el y af te r t he co ur se . N o di re ct c or re la tio n be tw ee n m or al c ou ra ge a nd th e co ur se w as id en tif ie d. Ed m on so n, C . 2 01 5, Th e U SA 1 In te rv en tio n de ve lo pm en t In te rv en tio n de ve lo pm en t an d ev al ua tio n (P M C ) St at is tic al a na ly se s Th e ed uc at io na l i nt er ve nt io n ha d m ar gi na l t o si gn ifi ca nt im pr ov em en ts in th e pa rti ci pa nt s’ m or al c ou ra ge . Es co la r- Ch ua , R . L . 20 18 . P hi lip pi ne s 1 D es cr ip tiv e co rre la tio na l s ur ve y, In v ar io us c lin ic al a re as , 2 93 nu rs in g st ud en ts Su rv ey (P M C ), St at is tic al a na ly se s Th e st ud en ts w er e m or al ly c ou ra ge ou s. Id en tif yi ng e th ic al m or al ly d is tre ss in g si tu at io ns p ro m ot ed m or al co ur ag e. G al la gh er A 2 01 1, U K 1 Th eo re tic al a rti cl e Th eo re tic al a rti cl e Sp ea ki ng u p in e th ic al c on fli ct s is a w ay o f a ct in g co ur ag eo us ly . N ur se s be ne fit fr om s up po rt fro m th e or ga ni sa tio n. Fi da n, Ö . e t a l. 20 23 . Tu rk ey 3 A co rre la tio na l d es cr ip tiv e cr os s- se ct io na l s tu dy 16 8 IC U n ur se s in T ur ke y Su rv ey (N M C S) St at is tic al a na ly se s M or al c ou ra ge w as re po rte d to b e at th e le ve l o f 8 0. 29 (m ea n on a sc al e 21 to 1 05 ). M or al c ou ra ge a nd c om pa ss io n an d lo vi ng ki nd ne ss w er e po si tiv el y co rre la te d. G ib so n, E . 2 01 8 Th e U SA . 1 C on ce pt a na ly si s Th e W al ke r a nd A va nt co nc ep t a na ly si s At tri bu te s: “p er si st en ce ”, “b ra ve ry ”, “o ve rc om in g fe ar ”, “s el f- ad vo ca cy ”. C on se qu en ce s: “m or al d is tre ss ”, “c rit ic is m ”, “e m po w er m en t”, “s el f- kn ow le dg e” . ( G ib so n, 2 01 8, p p. 3 71 –3 72 ) G ib so n 20 20 U SA 1 Th eo re tic al a rti cl e Th eo re tic al a rti cl e A m or al ly c ou ra ge ou s nu rs e ac ts b as ed o n et hi ca l p rin ci pl es . Pe rs on al e xp er ie nc es a re re la te d to o ne ’s m or al c ou ra ge . I t i s po ss ib le to le ar n m or al c ou ra ge a nd to p ro m ot e it w ith ro le -p la yi ng an d si m ul at io n. G ib so n 20 20 U SA 20 21 2 D es cr ip tiv e co rre la tio na l s tu dy 88 n ur si ng s tu de nt s Su rv ey , St at is tic al a na ly se s M or al c ou ra ge a nd m or al d is tre ss w er e as so ci at ed , b ut m or al co ur ag e di d no t d ec re as e m or al d is tre ss . G ok ta s S. e t a l. 20 23 , Tu rk ey 3 D es cr ip tiv e cr os s- se ct io na l 36 2 nu rs es in in te ns iv e ca re u ni ts Su rv ey , N M C S, St at is tic al a na ly se s M ea n m or al c ou ra ge s co re : 8 2. 08 (s ca le 2 1- 10 5) Elina Pajakoski 86 AU TH O RS , Y EA R, CO UN TR Y DE SI G N, S ET TI NG , PA RT IC IP AN TS M ET HO D, A NA LY SI S M AI N RE SU LT S H ak im i, H. e t a l. 20 23 , Ira n 3 O bs er va tio na l c ro ss -s ec tio na l st ud y 26 7 nu rs es in s ix h os pi ta ls in Ir an Su rv ey , P M C St at is tic al a na ly se s Th e m ea n sc or e of m or al c ou ra ge w as 8 7. 07 (s ca le 1 5- 10 5) H am ric 2 01 5, th e U SA 1 A ph ilo so ph ic al p ap er A ph ilo so ph ic al p ap er M or al c ou ra ge in cl ud es d oi ng w ha t i s rig ht fo r t he p at ie nt s, re qu iri ng ra tio na l r ea so ni ng . M or al c ou ra ge c an b e hi nd er ed b y hi er ar ch y. H an ifi N . e t a l. 20 19 , Ira n 2 C ro ss -s ec tio na l 20 8 nu rs in g st ud en ts in Z an ja n, Ira n Su rv ey , P M C St at is tic al a na ly se s M ea n m or al c ou ra ge 8 5 (ra ng e 15 -1 05 ) H ar di ng ha m 2 00 5 C an ad a 1 A ph ilo so ph ic al p ap er A ph ilo so ph ic al p ap er M or al in te gr ity is re la te d to o ne ’s b eh av io ur a nd v al ue s. H um an co m m un ic at io n an d re as on in g ar e im po rta nt in d ea lin g w ith e th ic al co nf lic ts . H au hi o N . e t a l. 2 02 1, Fi nl an d 3 C ro ss -s ec tio na l 48 2 re gi st er ed n ur se s Su rv ey , N M C S, s ta tis tic al an al ys es M ea n m or al c ou ra ge V AS 8 .2 0 an d 1- 5 Li ke rt 4. 09 . H eg ge st ad , A . K . T . e t al . 2 02 2 N or w ay 3 Lo ng itu di na l q ua lit at iv e (a fo llo w - up s tu dy ) Se ve n un de rg ra du at e nu rs in g st ud en ts In te rv ie w w ith a th em at ic gu id e an d op en -e nd ed qu es tio ns . Th em at ic a na ly si s Th em es : “ Vu ln er ab le s tu de nt s st rik in g a pr of es si on al b al an ce ”; “T he im po rta nc e of g oo d ro le m od el s” ; “ St ru gg lin g w ith s ho w in g m or al co ur ag e” . ( H eg ge st ad e t a l., 2 02 2, p p. 4 –6 ) H on g, N . e t a l. 20 23 , C hi na 3 A cr os s- se ct io na l s tu dy 31 4 nu rs es w or ki ng in a te rti ar y- le ve l h os pi ta l i n C hi na Su rv ey , N M C S St at is tic al a na ly se s Th e sc or e of m or al c ou ra ge w as 4 2. 00 (s ca le 2 1- 10 5) H th el ee L H H , e t a l. 20 23 , I ra n 3 A cr os s- se ct io na l s tu dy 16 8 nu rs es Su rv ey , P M C St at is tic al a na ly se s H ig h le ve l o f m or al c ou ra ge (o ve r 3 9 sc or e) : 1 67 n ur se s, 9 9, 40 % o f th e pa rti ci pa nt s. H u K . e t a l. 20 22 , C hi na 3 C ro ss -s ec tio na l s tu dy 22 6 nu rs es Su rv ey , N M C S St at is tic al a na ly se s Th e m ea n of th e N M C S (m or al c ou ra ge ) w as 3 .9 0 (L ik er t 1 to 5 ) N ur se s w ith h ig he r c op in g sc or es h ad h ig he r m or al c ou ra ge . H ua ng M . e t a l. 20 24 , C hi na 3 A m od ifi ed D el ph i s tu dy 20 e xp er ts (n ur si ng e du ca tio n, nu rs in g et hi cs , p hi lo so ph y, a nd bi oe th ic s) fr om C hi na A lit er at ur e re vi ew a nd tw o D el ph i r ou nd s (a su rv ey ), St at is tic al an al ys es . A tra in in g pl an fo r m or al c ou ra ge , c om pr is in g ei gh t t he m es a nd 3 3 ite m s H ua ng M . e t a l. 20 23 , C hi na 3 A de sc rip tiv e qu al ita tiv e st ud y 10 n ur se s In te rv ie w s D ed uc tiv e co nt en t an al ys is C at eg or ie s: “p ro ce ed w ith ou t h es ita tio n” ; “ th e ou tc om e of p ra ct is in g m or al c ou ra ge ”; an d “d ev el op a nd m ai nt ai n m or al c ou ra ge ”. (H ua ng et a l., 2 02 3b , p . 5 89 ) 87 Appendices AU TH O RS , Y EA R, CO UN TR Y DE SI G N, S ET TI NG , PA RT IC IP AN TS M ET HO D, A NA LY SI S M AI N RE SU LT S H ua ng M . e t a l. 20 23 , C hi na 3 C ro ss -s ec tio na l s tu dy 58 3 nu rs es fr om fi ve h os pi ta ls Su rv ey , N M C S St at is tic al a na ly se s Th e m ea n of th e N M C S (m or al c ou ra ge ) w as 3 .6 4 (L ik er t 1 to 5 ) K as ha ni M .e t a l. 20 23 , Ira n 3 A cr os s- se ct io na l s tu dy 17 2 nu rs es Su rv ey , N M C Q , St at is tic al a na ly se s Th er e w as a s ig ni fic an t c or re la tio n be tw ee n m or al c ou ra ge a nd s af e nu rs in g ca re . K el ly 1 99 8 US A 1 G ro un de d th eo ry 22 n ew ly g ra du at ed n ur se s In -d ep th in te rv ie w s C on st an t c om pa ra tiv e cl as si fic at io n of p at te rn s an d th em es H av in g co nf id en ce , b ei ng e th ic al ly c om m itt ed a nd g oo d et hi ca l cl im at e pr om ot ed m or al in te gr ity . L ea rn in g te am w or k an d ga in in g co nf id en ce b en ef ite d fro m s up po rt. K ha tib an M . e t a l. 20 22 , I ra n 3 C ro ss -s ec tio na l 22 4 nu rs es in fi ve h os pi ta ls in Ir an Su rv ey , P M C St at is tic al a na ly se s M ea n sc or e 56 .1 6 (S ca le 1 5 - 7 5) K ho da ve is i, M . e t a l. 20 21 , I ra n 3 C ro ss -s ec tio na l 52 0 nu rs es in fi ve h os pi ta ls in Ira n. Su rv ey , N M C Q St at is tic al a na ly se s M ea n sc or e 47 3. 33 (S ca le 1 02 -5 10 ) K ho sh m eh r e t a l. 20 20 Ira n 2 D es cr ip tiv e co rre la tio na l 18 0 nu rs es Su rv ey , P M C St at is tic al a na ly se s M or al c ou ra ge a nd p sy ch ol og ic al e m po w er m en t w er e po si tiv el y co rre la te d w ith e ac h ot he r. Be in g ol de r a nd h av in g m or e w or k ex pe rie nc e w er e re la te d to a hi gh er le ve l f og m or al c ou ra ge . K le em ol a, E . e t a l. 20 20 , F in la nd 2 Q ua lit at iv e de sc rip tiv e 28 6 nu rs es , w or ki ng w ith c hi ld re n an d ad ol es ce nt s. Su rv ey , a ns w er s fro m op en -e nd ed q ue st io ns Si tu at io ns in cl ud ed : c ol le ag ue s, p hy si ci an s, p at ie nt s, o rg an is at io n, nu rs es th em se lv es , r el at iv es , a nd m an ag er s. Ac tio ns : “ ve rb al c om m un ic at io n” , “ im m ed ia te a ct io n” , “ w rit te n no tif ic at io n” , “ fa ilu re to a ct ” ( Kl ee m ol a et a l., 2 02 0, p . 7 ). K on in gs , K . J . P . e t a l. 20 21 . B el gi um a nd F in la nd 3 A fo rw ar d- ba ck w ar ds tr an sl at io n m et ho d A no n- ex pe rim en ta l, de sc rip tiv e cr os s- se ct io na l 55 9 nu rs es in tw o ho sp ita ls in Be lg iu m Tr an sl at io n of th e qu es tio nn ai re N M C S Su rv ey St at is tic al a na ly se s Th e m ea n m or al c ou ra ge in th e N M C S 3. 77 (L ik er t-s ca le 1 to 5 ) K os ki ne n S. e t a l. 20 20 Sp ai n, F in la nd , Ic el an d, G er m an y, Li th ua ni a, a nd Ir el an d 2 C ro ss -s ec tio na l 15 03 g ra du at in g nu rs in g st ud en ts in s ix E ur op ea n co un tri es . Su rv ey , N M C S: V AS ov er al l m or al c ou ra ge St at is tic al a na ly se s VA S m or al c ou ra ge (s ca le 0 to 1 00 ) To ta l 7 7. 8, F in la nd 7 3. 49 , G er m an y 79 .9 , I ce la nd 7 6. 0, Ir el an d 79 .7 , Li th ua ni a 77 .4 , S pa in 8 2. 0 Elina Pajakoski 88 AU TH O RS , Y EA R, CO UN TR Y DE SI G N, S ET TI NG , PA RT IC IP AN TS M ET HO D, A NA LY SI S M AI N RE SU LT S La ab s, C . 2 01 1 Th e U SA . 1 Q ua lit at iv e de sc rip tiv e 82 n ew ly g ra du at ed n ur se s Sh or t a ns w er o nl in e su rv ey C on ve nt io na l c on te nt an al ys is A pe rs on w ith m or al in te gr ity is h on es t, an d tru st w or th y an d ca n ov er co m e th e th re at o f n eg at iv e ou tc om es fr om a n ac t. La Sa la & B ja rn as on 20 10 U SA 1 Th eo re tic al p ap er Th eo re tic al p ap er A m or al ly c ou ra ge ou s nu rs e ac ts b as ed o n et hi ca l p rin ci pl es , e ve n if th er e ar e pe rs on al ri sk s fro m th e ac t. H av in g cl ea r v al ue s an d re w ar di ng e th ic al ly s ou nd a ct io ns p ro m ot e nu rs es ’ m or al c ou ra ge . Le e, B . e t a l. 20 22 , K or ea 3 Sc al e va lid at io n st ud y Su rv ey , K -N M C S St at is tic al a na ly se s Th e m ea n le ve l o f m or al c ou ra ge w as 3 .2 6 (L ik er t s ca le 1 to 5 ) C ul tu re s in K or ea a nd F in la nd a re d iff er en t i n nu rs in g. T hu s, 9 it em s w er e ex cl ud ed fr om th e Ko re an v er si on . Li nd h, I. -B . e t a l.. 2 00 8 N or w ay & S w ed en . 1 Q ua lit at iv e ex pl or at or y 14 n ur si ng s tu de nt s in S w ed en R ep ea te d fo cu s gr ou p in te rv ie w s in te rp re ta tiv e co nt en t an al ys is Th em es : “ Be in g av ai la bl e fo r t he p at ie nt ”, “S hi el di ng th e pa tie nt ”, “B ei ng c on fro nt ed w ith th e vo ic e of c on sc ie nc e” . ( I. Li nd h et a l., 2 00 8, p. 4 40 ) Li nd h, I. -B . e t a l. 20 09 , N or w ay & S w ed en 1 Q ua lit at iv e st ud y w ith a he rm en eu tic a pp ro ac h 8 nu rs es in S w ed en In di vi du al in te rv ie w s Th em es : “ Th e ac tio n le ve l a s ‘h av in g co ur ag e to a ct o n on e’ s co nv ic tio ns ’”, “T he re la tio na l l ev el a s ‘b ei ng a tte nt iv e an d re co gn iz in g vu ln er ab ilit y’ ”, “T he e xi st en tia l l ev el a s ‘fa ci ng th e un pr ed ic ta bl e’ ”. (I. - B. L in dh e t a l., 2 00 9, p . 1 88 5) Li nd h, I. -B . e t a l. 20 07 , Sw ed en 1 Q ua lit at iv e st ud y 14 n ur si ng s tu de nt s in S w ed en Fo cu s gr ou p in te rv ie w s Q ua lit at iv e th em at ic an al ys is M or al re sp on si bi lit y is a re la tio na l w ay o f b ei ng . Th em es w er e: “B ei ng g ui de d by in ne r c om pa ss ” an d “S tri vi ng to d o go od ” ( I. Li nd h et a l., 2 00 7, p p. 1 33 –1 34 ). Lo tfi -B ej es ta ni , S . e t al . 2 02 3. Ira n an d Ja pa n 3 D es cr ip tiv e co rre la tio na l 50 0 nu rs es w or ki ng in m en ta l he al th w ar ds in h os pi ta ls Su rv ey , P M C St at is tic al a na ly se s M or al c ou ra ge h ad a m ea n le ve l o f 5 3. 16 (s ca le 1 5- 10 5) M or al c ou ra ge a nd m or al s en si tiv ity w er e po si tiv el y co rre la te d. W hi le nu rs es h ad m or al c ou ra ge , t he y al so h ad m or al d is tre ss w he n th ey w er e no t a bl e to a ct c ou ra ge ou sl y. Lu o Z. e t a l. 20 23 , C hi na a nd A us tr al ia 3 A cr os s- se ct io na l s tu dy . 13 34 n ur se in te rn s Su rv ey (N M C S) St at is tic al a na ly se s M or al c ou ra ge h ad a m ea n le ve l o f 7 5. 88 (s ca le 2 1- 10 5) Th er e w as a p os iti ve c or re la tio n be tw ee n m or al c ou ra ge a nd e th ic al de ci si on -m ak in g sk ills M ah bo ub i e t a l. 20 23 , Ira n 3 A cr os s- se ct io na l s tu dy 20 0 nu rs es w or ki ng in C O VI D -1 9 un its Su rv ey , P M C St at is tic al a na ly se s Th e m ea n sc or e of m or al c ou ra ge w as 5 6. 25 (s ca le 1 5- 10 5) 89 Appendices AU TH O RS , Y EA R, CO UN TR Y DE SI G N, S ET TI NG , PA RT IC IP AN TS M ET HO D, A NA LY SI S M AI N RE SU LT S M el ne ch en ko 2 00 3 C an ad a 1 Th eo re tic al p ap er Th eo re tic al p ap er Tr ue p re se nc e m ea ns th at n ur se s ar e th er e fo r t he p at ie nt s an d un de rs ta nd th ei r n ee ds . B ei ng tr ul y pr es en t r eq ui re s m or al c ou ra ge an d co m m itm en t t o va lu es a nd e th ic al p rin ci pl es . M oh am m ad i, F. e t a l. 20 22 , I ra n 3 A de sc rip tiv e st ud y 52 4 IC U n ur se s Su rv ey , P M C St at is tic al a na ly se s M or al c ou ra ge h ad a m ea n le ve l o f 9 6. 38 (s ca le o f 1 5- 10 5) . T he re w as a p os iti ve c or re la tio n be tw ee n m or al s en si tiv ity a nd m or al co ur ag e. A ls o, a p os iti ve c or re la tio n w as id en tif ie d be tw ee n m or al co ur ag e sa fe c ar e. M ur ra y 20 10 U SA 1 Th eo re tic al p ap er Th eo re tic al p ap er N ur se s ne ed m or al c ou ra ge w he n th ey d ef en d w ha t t he y th in k is rig ht d es pi te th e ris k of p er so na l n eg at iv e ou tc om es . S tre ng th en in g fa ct or s fo r m or al c ou ra ge w er e ed uc at io n, a rra ng in g di sc us si on s re ga rd in g et hi cs , h av in g ro le -m od el s an d co m pe te nc e in ra tio na l re as on in g. N am ad i F . e t a l. 20 23 , Ira n 3 A Q ua lit at iv e D es cr ip tiv e St ud y 15 n ur se s In -d ep th in te rv ie w s. D at a an al ys is : G ra ne he im an d Lu nd m an ’s m et ho d In di vi du al a nd o rg an is at io na l i nh ib ito rs N as h, W . e t a l. 20 16 . Th e U SA 1 Q ua lit at iv e de sc rip tiv e 15 n ur si ng s tu de nt s in a p ub lic un iv er si ty Su rv ey , q ue st io nn ai re s. Th em at ic c on te nt a na ly si s Th em es : “ Fe ar o f b eh av in g in in ap pr op ria te w ay s” ; “ Fe ar o f di sc us si ng a h om el es s pe rs on ’s d yi ng a nd d ea th ”; “C ha lle ng e of ex pl ai ni ng th e AD ’s c on te nt a nd re co rd in g th e ho m el es s pe rs on s’ w is he s” (N as h et a l., 2 01 6, p p. 7 49 –7 50 ) N ou ro oz i A . e t a l. 20 23 , I ra n 3 A qu as i-e xp er im en ta l s tu dy 70 n ur se s, in te rv en tio n an d co nt ro l g ro up s Im pl em en tin g th e as se rti ve ne ss -b as ed pr og ra m . S ur ve y, St at is tic al a na ly se s Th e in te rv en tio n st re ng th en ed n ur se s’ m or al c ou ra ge . N um m in en , O . e t a l. 20 17 , F in la nd 1 A co nc ep t a na ly si s ba se d on th e lit er at ur e R od ge r’s e vo lu tio na ry co nc ep t a na ly si s At tri bu te s: “t ru e pr es en ce ”, “m or al in te gr ity ”, “re sp on sib ilit y” , “ ho ne st y” , “a dv oc ac y” , “ co m m itm en t a nd p er se ve ra nc e” , a nd “p er so na l r isk ”. An te ce de nt s: “e th ica l s en sit ivi ty ”, “c on sc ie nc e” , a nd “e xp er ie nc e” . C on se qu en ce s: “p er so na l a nd p ro fe ss io na l d ev el op m en t “ an d “e m po w er m en t”. (N um m in en e t a l., 2 01 7, p p. 8 83 –8 87 ) N um m in en e t a l 2 01 9 Fi nl an d 1 A sc al e de ve lo pm en t s tu dy 48 2 nu rs es (+ 1 29 n ur se s in p ilo t) Su rv ey , ( N M C S) St at is tic al a na ly se s M or al c ou ra ge w as a ve ra ge 4 .0 7 (1 to 5 s ca le ). Th e N M C S w as p ro ve d va lid . N um m in en O . e t a l. 20 21 , F in la nd a nd B el gi um 2 A sc al e va lid at io n st ud y, o n- ex pe rim en ta l, cr os s- se ct io na l ex pl or at or y de si gn . 55 9 nu rs es Su rv ey St at is tic al a na ly se s N M C S to ta l w as 3 .7 7 (1 to 5 s ca le ) Elina Pajakoski 90 AU TH O RS , Y EA R, CO UN TR Y DE SI G N, S ET TI NG , PA RT IC IP AN TS M ET HO D, A NA LY SI S M AI N RE SU LT S N un th aw on g, J . e t a l. 20 20 , T ha ila nd 1 Sc al e de ve lo pm en t s tu dy Ps yc ho m et ric de te rm in at io n. St at is tic al a na ly se s M or al c ou ra ge is o pe ni ng d is cu ss io ns a nd d oi ng w ha t i s rig ht in e ac h si tu at io n. T he re c an b e ch al le ng es b ut th ey h av e to b e ta ke n ca re o f. Pa ki ze kh o, S ., & B ar kh or da ri- Sh ar ifa ba d, M . 2 02 2, Ira n 3 A cr os s- se ct io na l d es cr ip tiv e st ud y 18 0 nu rs es w or ki ng in h os pi ta ls Su rv ey (P M C ) St at is tic al a na ly se s Th e m ea n sc or e of m or al c ou ra ge w as 7 7. 01 1 (s ca le 1 5- 10 5) M or al c ou ra ge a nd n ur se s’ c on sc ie nt io us ne ss w er e si gn ifi ca nt ly re la te d. E th ic al le ad er sh ip h ad s ig ni fic an tly in cr ea se d m or al c ou ra ge . Pe ng , M . e t a l. 2 02 3, C hi na a nd J ap an 3 A cr os s- se ct io na l s tu dy 78 1 nu rs es fr om tw o te rti ar y ho sp ita ls Su rv ey (N M C S) St at is tic al a na ly se s M or al c ou ra ge h ad a m ea n sc or e of 8 2. 02 (s ca le 2 1- 10 5) M or al c ou ra ge a nd m or al d is tre ss h ad a p os iti ve c or re la tio n w ith ea ch o th er . M or al c ou ra ge w as p os iti ve ly c or re la te d w ith c ar ee r id en tit y. Pi rd el kh os h, M . e t a l. 20 22 , I ra n 3 A cr os s- se ct io na l s tu dy 16 9 nu rs es w or ki ng in C O VI D -1 9 w ar ds Su rv ey (P M C ) St at is tic al a na ly se s M or al c ou ra ge h ad a m ea n sc or e of 9 0. 24 (s ca le 1 5- 10 3) H ig he r s oc ia l c ap ita l m ea nt h ig he r m or al c ou ra ge . R ak hs ha n, M . e t a l. 20 21 , I ra n 3 A qu al ita tiv e de sc rip tiv e st ud y 19 n ur se s w or ki ng in h os pi ta ls in Ira n Se m i-s tru ct ur ed , i n- de pt h in te rv ie w s. C on ve nt io na l c on te nt an al ys is . Th em es : “ or ga ni za tio na l f ai lu re ”; “d et er re nt p er so na l i de nt ity ”; “d ef ea te d pr of es si on al id en tit y” . ( R ak hs ha n et a l., 2 02 1, p . 4 ) R os ha nz ad eh . e t a l. 20 21 , I ra n 3 Q ua lit at iv e st ud y N in et ee n nu rs e m an ag er s w or ki ng in h os pi ta ls in Ir an In -d ep th in te rv ie w s Q ua lit at iv e co nt en t an al ys is C at eg or ie s: “o bl ig at io n” a nd “d ec is iv en es s” . ( R os ha nz ad eh e t a l., 20 21 , p p. 2 57 –2 58 ) R ui xi n Z. e t a l. 20 24 , C hi na 3 A cr os s- se ct io na l s tu dy 58 6 nu rs es Su rv ey , N M C S St at is tic al a na ly se s Av er ag e sc or e of m or al c ou ra ge w as 7 9. 00 (s ca le 2 1- 10 5) . H ig he r le ve l o f m or al c ou ra ge h ad a p os iti ve c or re la tio n w ith p sy ch ol og ic al re si lie nc e an d th e co nt ex t o f n ur si ng p ra ct ic e. Sa do og hi as l, A . e t a l. 20 18 , I ra n 1 C on ce pt a na ly si s ba se d on lit er at ur e an d qu al ita tiv e em pi ric al da ta H yb rid m od el c on ce pt an al ys is In -d ep th in te rv ie w s. C on ve nt io na l c on te nt an al ys is At tri bu te s: “M or al s el f-a ct ua liz at io n” , “ R is k- ta ki ng ” An te ce de nt s: “M od el o rie nt at io n/ m od el a cc ep ta nc e” , “ R at io na lis m ”, “A ca de m ic a nd p ro fe ss io na l c om pe te nc ie s” , “ Sp iri tu al b el ie fs ” C on se qu en ce s: “P ro fe ss io na l c ar e” , “ N ur se ’s p ea ce o f m in d” , “ R ig ht de ci si on a nd ri gh t p er fo rm an ce ”. (S ad oo gh ia sl e t a l., 2 01 8, p p. 1 3– 15 ) Sa fa rp ou r, H . e t a l. 20 20 , I ra n 3 A cr os s- se ct io na l s tu dy 21 7 nu rs es Su rv ey , P M C St at is tic al a na ly se s M or al c ou ra ge h ad a m ea n sc or e of 5 9. 47 (s ca le o f 1 5 to 1 05 ) H ig he r m or al c ou ra ge m ea nt s ig ni fic an tly lo w er m or al d is tre ss . 91 Appendices AU TH O RS , Y EA R, CO UN TR Y DE SI G N, S ET TI NG , PA RT IC IP AN TS M ET HO D, A NA LY SI S M AI N RE SU LT S Si m m on ds e t a l 2 01 3 C an ad a 1 Q ua lit at iv e cr iti ca l n ar ra tiv e 14 in tra pa rtu m n ur se s In te rv ie w s, q ua lit at iv e an al ys is . G oo d te am w or k pr om ot ed m or al re sp on si bi lit y, b ut h ie ra rc hy in hi bi te d it. N ur se s w ith m or al re sp on si bi lit y ad vo ca te d fo r p at ie nt s an d w er e co m m itt ed to g oo d ca re . C le ar v al ue s in th e or ga ni sa tio n pr om ot ed nu rs es ’ m or al re sp on si bi lit y. St ep he ns T M . 2 02 3, Th e U SA a nd C an ad a 3 D es cr ip tiv e co rre la tio na l s tu dy 69 0 nu rs es in th e U SA a nd C an ad a Su rv ey , M C SN F St at is tic al a na ly se s M or al c ou ra ge h ad a m ea n sc or e of 7 5. 14 (s ca le 0 to 1 00 ) a nd it w as m od er at el y co rre la te d w ith m or al re si lie nc e. Ta ra z, Z . e t a l. 20 19 , Ira n. 1 D es cr ip tiv e co rre la tio na l s tu dy 15 6 nu rs es in u ni ve rs ity h os pi ta ls in Ir an . Su rv ey St at is tic al a na ly se s PM C M or al c ou ra ge w as p os iti ve ly c or re la te d w ith e th ic al c lim at e. M or al c ou ra ge h ad a m ea n le ve l o f 3, 87 (O n th e sc al e of 1 to 5 ) W iis ak , J . e t a l. 20 22 , Fi nl an d 3 D es cr ip tiv e co rre la tio na l s tu dy 45 4 nu rs es in F in la nd Su rv ey , N M C S St at is tic al a na ly se s Th e m ea n of to ta l m or al c ou ra ge (N M C S) w as 4 .3 4 (L ik er t s ca le 1 to 5) Th er e w er e po si tiv e co rre la tio ns b et w ee n ea si ne ss o f i ni tia tin g di sc us si on a bo ut th e pr ob le m a nd to ta l m or al c ou ra ge a nd m or al in te gr ity . W ol f L A & N ob le w ol f H S . 2 02 4 Th e U SA 3 A m ix ed -m et ho ds s tu dy 10 1 (s ur ve y) 8 (in te rv ie w s) Su rv ey (N M C S) a nd in te rv ie w s St at is tic al a nd s itu at io na l an al ys es . M os t o f t he re sp on de nt s (7 0% ) r ep or te d th at th ey w ou ld a ct m or al ly co ur ag eo us ly if th ey e nc ou nt er ed a n et hi ca l c on fli ct . Th ey fo un d de fe nd in g in di vi du al v al ue s fa irl y ea sy o r v er y ea sy . Ya ng Q . e t a l. 20 23 , C hi na 3 A cr os s- se ct io na l s tu dy 33 0 nu rs es Su rv ey , N M C S St at is tic al a na ly se s M or al c ou ra ge h ad a n in di re ct re la tio ns hi p w ith re si lie nc e. E th ic al cl im at e ha d a m ed ia tin g ef fe ct (1 5% ) b et w ee n re si lie nc e an d m or al co ur ag e. Y ılm az S & G üv en G Ö . 2 02 4 Tü rk iy e 3 A de sc rip tiv e co rre la tio na l s tu dy 58 2 nu rs es Su rv ey , N M C S St at is tic al a na ly se s Th e av er ag e m or al c ou ra ge s co re w as 8 4. 03 . Le ve l o f m or al c ou ra ge a nd w hi st le bl ow in g le ve ls h ad a s ig ni fic an t re la tio ns hi p (p < .0 5) . Yu , Q . e t a l. 2 02 3, C hi na 3 C ro ss -s ec tio na l s tu dy 71 6 di sa st er -re lie f n ur se s in ho sp ita ls in C hi na Su rv ey , N M C S, S ta tis tic al an al ys es Th e m ea n sc or e of m or al c ou ra ge w as 8 2. 47 (s ca le 2 1- 10 5) a nd th e m ea n on th e Li ke rt sc al e (1 to 5 ) w as 3 .9 3. Jo b es te em a nd s oc ia l r es po ns ib ilit y w er e po si tiv el y co rre la te d w ith m or al c ou ra ge . Zh en g H. e t a l. 20 24 , C hi na 3 An e xp lo ra to ry , d es cr ip tiv e st ud y 39 0 nu rs es Su rv ey , N M C S, S ta tis tic al an al ys es In di vi du al a ttr ib ut es a nd e th ic s ed uc at io n w er e re la te d to th e le ve l o f m or al c ou ra ge . H av in g m or e m or al c ou ra ge m ea nt b ei ng le ss m or al ly di st re ss a nd m or e et hi ca lly s en si tiv e. Elina Pajakoski 92 A pp en di x 2. S el f-a ss es se d le ve ls a nd to ta l s co re s of m or al c ou ra ge in d iff er en t s tu di es . AU TH O RS A ND Y EA R CO NT EX T LE VE L AN D T O TA L SC O RE O F M O R A L C O U R A G E M EA N O F TH E SU M V A R IA B LE M EA N O F TH E TO TA L SC O R E PM C L ik er t 1 – 7 , m ea n (S D ), to ta l s co re 1 5- 10 5 A bd ol la hi e t a l., 2 02 1 H os pi ta l 6. 35 (0 .5 0) - H ak im i e t a l., 2 02 3 H os pi ta ls - 87 .0 7 (1 5. 52 ) H an ifi e t a l., 2 01 9 U ni ve rs ity (s tu de nt s) - 85 (1 2. 66 ) H th el ee e t a l., 2 02 3 H os pi ta l - 56 .8 3 (5 .0 1) K ho sh m eh r e t a l., 2 02 0 H os pi ta l - 90 .6 9 (1 1. 21 ) K ha tib an e t a l., 2 02 2 H os pi ta ls - 56 .1 6 (1 0. 18 ) Lo tfi -B ej es ta ni e t a l., 2 02 3 H os pi ta ls - 53 .1 6 (1 2. 69 ) M ah bo ub i e t a l., 2 02 3 H os pi ta ls - 56 .2 5 (7 .0 2) M oh am m ad i e t a l., 2 02 2 H os pi ta ls - 96 .3 8 (3 .6 3) Pa ki ze kh o & B ar kh or da ri- Sh ar ifa ba d, 2 02 2 H os pi ta ls - 77 .0 11 (1 5. 33 1) Pi rd el kh os h et a l., 2 02 2 H os pi ta ls - 90 .2 4 (1 2. 74 ) Sa fa rp ou r e t a l., 2 02 0 H os pi ta l - 59 .4 7 (8 .9 6) Ta ra z et a l., 2 01 9 H os pi ta l 3. 87 (0 .6 8) - N M C Q L ik er t 1 – 5 , m ea n (S D ), to ta l s co re 1 02 -5 10 A zi zi e t a l, 20 24 H os pi ta ls - 42 2. 37 (5 2. 92 ) K ho da ve is i e t a l., 2 02 1 H os pi ta ls - 47 3. 33 (1 .6 4) K as ha ni e t a l., 2 02 3 H os pi ta ls - 40 7. 57 (5 3. 97 ) Eb ad i e t a l., 2 02 0 H os pi ta ls - 41 2. 42 (4 2. 65 ) Appendices 93 AU TH O RS A ND Y EA R CO NT EX T LE VE L AN D T O TA L SC O RE O F M O R A L C O U R A G E M EA N O F TH E SU M V A R IA B LE M EA N O F TH E TO TA L SC O R E N M C S Li ke rt 1 – 5 , m ea n (S D ), To ta l s co re 2 1- 10 5 Al i A w ad & A l-a nw er A sh ou r, 20 22 Is ol at ed h os pi ta ls - 72 .0 9 (7 .7 3) B er di da & G ra nd e, 2 02 3 H os pi ta ls 4. 36 (0 .3 8) - Fi da n et a l., 2 02 3 U ni ve rs ity h os pi ta l - 80 .2 9 (1 3. 16 ) G ok ta s et a l., 2 02 3 H os pi ta ls - 90 .7 0 (2 8. 89 ) H au hi o et a l., 2 02 1 U ni ve rs ity h os pi ta l 4. 10 (0 .4 98 ) - H on g et a l., 2 02 3 A te rti ar y ho sp ita l - 42 .0 0 (n ot re po rte d) H u et a l., 2 02 2 A te rti ar y ho sp ita l 3. 90 (0 .6 7) - H ua ng e t a l., 2 02 3 H os pi ta ls 3. 64 (0 .6 92 ) - K on in gs e t a l., 2 02 1 H os pi ta ls 3. 77 (0 .5 37 ) - Le e et a l., 2 02 2 1 H os pi ta ls 3. 26 (0 .5 2) - Lu o et a l., 2 02 3 H os pi ta ls - 75 .8 8 (1 4. 52 ) N um m in en e t a l., 2 01 9 U ni ve rs ity h os pi ta l 4. 07 (0 .4 93 ) - N um m in en e t a l., 2 02 1 H os pi ta ls 3. 77 (0 .5 37 ) - Pe ng e t a l., 2 02 3 Te rti ar y ho sp ita ls - 82 .0 2 (1 6. 19 ) R ui xi n et a l., 2 02 4 H os pi ta l 3. 76 (n ot re po rte d) 79 .0 0 (n ot re po rte d) W iis ak e t a l., 2 02 2 Va rio us h ea lth ca re o rg an is at io ns 4. 34 (0 .4 7) - Y ılm az & G üv en , 2 02 4 In - a nd o ut pa tie nt u ni ts - 84 .0 3 (1 2. 29 ) Yu e t a l., 2 02 3 D is as te r r el ie f u ni ts 3. 93 (0 .7 1) 82 .4 7 (1 4. 85 ) Zh en g et a l., 2 02 4 H os pi ta ls - 81 .4 2 (1 4. 72 ) M C SP L ik er t 1 – 7 , m ea n (S D ), to ta l s co re 4 4- 10 0 G ib so n et a l. 20 20 U ni ve rs ity (s tu de nt s) - 88 .1 5 (9 .1 ) M CS NF L ik er t 1 – 7 , m ea n (S D ), to ta l s co re 0 -1 00 St ep he ns & L ay ne , 2 02 3 U ni ve rs ity (f ac ul ty ) - 75 .1 4 (1 0. 52 ) Elina Pajakoski 94 Elina Pajakoski D 1897 A N N A LES U N IV ERSITATIS TU RK U EN SIS ISBN 978-952-02-0263-7 (PRINT) ISBN 978-952-02-0264-4 (PDF) ISSN 0355-9483 (Print) ISSN 2343-3213 (Online) Pa in os al am a, T ur ku , F in la nd 2 02 5