Explicating the process of moral courage in clinical nurses: a grounded theory study

Shirmohammad  Davoodvand; Somayeh  Mohammadi; Shahriyar  Salehi; Mostafa  Roshanzadeh

doi:10.18502/jmehm.v18i11.19960

Shirmohammad Davoodvand Assistant Professor, Department of Adults and Geriatric Nursing, School of Nursing and Midwifery, Shahrekord University of Medical Sciences, Shahrekord, Iran.
Somayeh Mohammadi Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran.
Shahriyar Salehi Associate Professor, Department of Adults and Geriatric Nursing, School of Nursing and Midwifery, Shahrekord University of Medical Sciences, Shahrekord, Iran.
Mostafa Roshanzadeh Assistant professor, Nursing Department, Shahrekord University of Medical Sciences, Shahrekord, Iran.

DOI: https://doi.org/10.18502/jmehm.v18i11.19960

Keywords: Medical ethics; Decision-making; Moral courage; Clinical nurses.

Abstract

Moral courage in nurses is the product of a complex process and can be enhanced by identifying the steps through which nurses make morally courageous decisions. This qualitative study aimed to explicate the process of moral courage in clinical nurses and present a descriptive model. The study was conducted in Shahrekord University of Medical Sciences in 2022 using the grounded theory approach. Twenty-one clinical nurses were selected through purposive and theoretical sampling. Data were analyzed using Strauss and Corbin's 2015 approach and data management was supported by MAXQDA software (version 11). The core variable identified was moral excellence. When faced with a misalignment between authority and responsibility, nurses experience ambiguity in ethical decision-making. The nurses in this study employed spirituality, legality, and self-sacrifice strategies, which helped them to manage system expectations. In this model, moral courage ultimately gravitates toward managing system expectations—a deviant mechanism failing to yield positive outcomes due to organizational infrastructures and conditions. Therefore, it is recommended that healthcare organizations address *Corresponding Author Mostafa Roshanzadeh Address: Shahrekord University of Medical Sciences, Shahr-e Kord, Iran. Postal Code: 88 71 68 34 85 Tel: (+98) 93 97 95 25 22 Email: roshanzadeh.m@skums.ac.ir Received: 6 Feb 2025 Accepted: 30 Aug 2025 Published:14 Oct 2025 Citation to this article: Davoodvand S, Mohammadi S, Salehi S, Roshanzadeh M. Explicating the process of moral courage in clinical nurses: a grounded theory study. J Med Ethics Hist Med. 2025; 18: 11. factors contributing to ambiguity in nurses' decision-making, such as lack of operational protocols for ethical decisions, mismatched expectations and responsibilities, and deficiencies in professional autonomy.