Nowadays, advances in medical science have placed nurses in difficult situations in their workplaces that require ethical decision-making. These situations have created an increasing need for discussion and exchange of views on ethical issues and decision-making (Sorokin et al., 2016). Nurses are the principal group of service providers in health care systems (Freund et al., 2015) and have a significant impact on the quality of health care (Oldland et al., 2020). They often face challenging ethical issues in clinical settings (Harrison et al., 2016) and as moral agents, they need moral courage to properly manage ethical problems and have a professional commitment to their patients (Mahdaviseresht et al., 2015).
Moral courage is one of the most important topics in nursing professions and has a long history (Hawkins and Morse, 2014). The concept of moral courage was introduced by Florence Neningel. It is, among all the personal characteristics and competencies, the basic principle for being a good nurse. It is a trait that allows a person to act based on moral principles (Numminen et al., 2019). Moral courage means acting based on moral values. A person who has moral courage, despite the difficulties and dangers, in times of moral challenges and dilemmas, decides and acts constantly, consciously and voluntarily, despite all the negative consequences of her/his decisions(Hamric et al., 2015, Numminen et al., 2019, Numminen et al., 2017). Nurses, based on their profession nature, need moral courage to emphasize humanitarian care and resist doing immoral things (Lindh et al., 2010). Moral courage helps the nurse to provide acceptable care for the patient, the family, and the community in addition to having the qualities of a good person (Fry et al., 2010).
Moral courage is a trait that leads to a reduction of moral distress (Hoseini et al., 2019, Lachance, 2017, Taraz et al., 2019, Woods, 2014), personal and professional development (Dinndorf-Hogenson, 2015, Lamiani et al., 2017), motivation, acquisition of skills, and maintenance of the body of knowledge in the nurse (Sekerka et al., 2009). In its absence, the provision of nursing care is affected and may lead to immoral behavior (Lamiani et al., 2017). Nurses' courageous decisions to achieve ethical goals can prevent ethical conflicts (Santos et al., 2018). Also, having moral courage in the face of moral challenges can maintain moral frameworks and prevent moral chaos (Lachance, 2017). Murray (2010) states that strengthening moral courage can play an important role in the prevention of the undesirable consequences of moral challenges that typically arise in therapeutic settings (Murray, 2010). However, the findings of most previous studies showed a low level of moral courage in nurses (Aminizadeh et al., 2017, Taghaddosi et al., 2020) and some reported it as moderate (Aminizadeh et al., 2017, Hoseini et al., 2019, Taraz et al., 2019). Studies have shown that personal and professional factors (Suhonen et al., 2011) along with organizational culture and leadership style (Escolar-Chua, 2018) can affect nurses' moral courage. Nurses try to adhere to their moral principles and values in situations such as protecting the patient, giving bad news, caring for an infected patient, and inappropriate care by immoral coworkers. But fear of negative reactions from co-workers, losing a job, widespread emotional reactions, and violence cause them to avoid moral action. As a result, they experience depression, guilt, and anger and they may feel being worthlessness and powerlessness (Gallagher, 2011, Lachman, 2012).
Ethical courage is an essential issue in nurses' behavior, as its impact may be seen in the quality of care provided by them (Numminen et al., 2017). Despite the studies conducted, a lack of moral courage is common among nurses and should be enhanced by developing courage and adherence to ethical principles in them (Mohammadi et al., 2014). But its promotion requires the identification of relevant factors (Watson, 2003). Limited studies have been conducted to identify barriers to the formation of moral courage in nurses. Studies on moral courage have often examined this concept through assumptions and in the form of quantitative studies. However, the use of quantitative approaches to identify individuals' beliefs and values about phenomena that are somehow related to human interactions do not have the necessary flexibility and depth (Grove and Gray, 2018). In this regard, qualitative research is mainly used to identify human emotions and perceptions (LoBiondo-Wood et al., 2017). Qualitative research provides an opportunity to answer questions centered on social experience. They are based on the assumption that acquiring knowledge about human beings is impossible without describing and explaining their beliefs and perceptions in their cultural and social contexts (Speziale et al., 2011).Therefore, the use of qualitative methods gives depth and richness to the findings that are not comparable to quantitative research methods (Polit and Beck, 2017). Considering the importance of moral courage and the need to promote it in the nurses along with the need to recognize its formation’s barriers in the culture and context of the nursing, the present study was conducted to explain the barriers to moral courage formation of nurses working in hospitals in Iran. Current study aimed to explore the barriers to the formation of moral courage in nurses who work in hospitals.