Moral courage, moral sensitivity and safe nursing care in nurses caring of patients with COVID‐19

Abstract Aim Evaluation the moral courage, moral sensitivity and safe nursing care in nurses caring of infected patients by the COVID‐19. Design This study employed cross‐sectional research. Methods 520 nurses caring for COVID‐19 patients in 5 hospitals were selected via convenience sampling. They completed questionnaires online. Data were analysed by SPSS software version 22. Results Findings showed that moral courage has a strong and direct correlation with moral sensitivity (p < .001, r = 0–.70) and safe nursing care (p < .001, r = 0–.74). Variables of moral sensitivity, safe nursing care, work experience, age and employment status can predict 64.76% of the variance in moral courage in these nurses. Nursing care of patients with COVID‐19 have reported high moral courage in recent months, and in spite of the numerous tensions and stresses in terms of caring these patients during this relative long period, they are still diligent in providing safe and high sensitive care to these patients.


| INTRODUC TI ON
Nurses are one of the most important members among the caregiver teams whose beliefs and attitudes have a tremendous impact on the performance and quality of care (Shahriari et al., 2013). Caregiving is the essence of nursing; it is also the main exclusive focus on nursing performance (Blasdell, 2017;Gregg & Magilvy, 2004), so that nursing is a care profession with six principles of compassion, trust, commitment, competence, relationship and courage Thorup et al., 2012). In the meantime, moral courage plays a significant role in providing systematic and high-quality care (Numminen et al., 2019), due to encountering with dying and poor patients, entails invasive care, tackling with the newfound diseases and emergencies which all emerge courage a sensitivity for caregivers as the nurses (Bickhoff et al., 2016;Hawkins & Morse, 2014;Numminen et al., 2019;Sadooghiasl et al., 2018).

| BACKG ROU N D
Moral courage is defined as courage to act according to one's own ethical values and principles even at the risk of negative consequences for the individual (Sadooghiasl et al., 2018). Moral courage helps caregivers to provide professional care to the patient, families and society in addition to having human qualities. (Hamric et al., 2015) Nurses, due to their professional nature, need moral courage to provide principled care to avoid the eventual committing immoral acts (Gallagher, 2011). Moral courage causes caregivers to adhere to the principles and values of professional ethics in some situations such as protecting the patient's privacy, giving bad news and caring for an infected patient (Gallagher, 2011;Gregg & Magilvy, 2004). But sometimes the fear of receiving unfriendly reactions from co-workers, losing a job, violence and reduction in wages and on the contrary some benefits make them refuse to engage in moral acts and consequently experience moral distress, depression, guilt and anger, powerless and worthless feelings (Lachman et al., 2012;Shareinia et al., 2018). Therefore, to provide safe care, in addition to moral courage, health care providers need to be aware of ethical principles and have moral sensitivity (Lachman et al., 2012). Moral sensitivity definitions as the nurses' knowledge of patients' vulnerability and predict the results of moral decision-making in patients, it enables them to make a moral decision for patients (Amiri et al., 2020). Therefore, moral sensitivity is one of the main pillars of nursing professional competence that leads to the development of patience, calmness and caregivers responsibility . Studies show that caregivers with moral courage and moral sensitivity commitment provide safe care for patients and they are sensitive to the physical and psychological needs of patients and actively identify the needs and problems of patients and find a way to solve these problems and provide safe care . Therefore, there is a close relationship between moral courage with moral sensitivity and safe care, that, especially in the new crisis of COVID-19, can affect the performance of nurses caring for patients with COVID-19. In the meantime, the new emerging disease COVID-19 started in China and then, it became pandemic in all countries and caused over 8.3 million people in the world to get infected by this disease in the past 3 months, over 224,000 of whom have lost their life following this issue (Coronavirus, 2019;Lai et al., 2020). Iran outbreak of COVID-19 is complex, at the beginning of the pandemics Iran was the third country with the highest number of reported COVID-19 cases after China and Italy, whereas it has been heavily hit by the virus and now facing the third wave of the COVID-19 outbreak compared with other countries that are currently facing the fourth wave. Although the majority of Iranians wear masks, inappropriate economic situation causes very few restrictions on work, activity and travel all around the cities of Iran; therefore, large number of people use public transportation every day, and the streets are crowded. In addition, all employees spend their time at work in person every day as the telecommunication is rare to occur (Nemati et al., 2020). These factors have been the remarkable causes of infection so that about 530,500 people in Iran have been infected with COVID-19 and over 30,500 of them have lost their lives (Education, 2020;Nemati et al., 2020). World Health Organization (WHO), in January 2020, introduced COVID-19 pandemic as a Public Health Emergency of International Concern (PHEIC) (Liu et al., 2020). According to reports from the same organization, nurses are the first health advocates against the crisis caused by the COVID-19, who experience severe stress and psychological distress. As an inclusive group in the health care system, nurses play a significant role for the evolution and care development, treatment, improvement and health promotion in these patients.
In addition, dealing with critically poor and dying patients with COVID-19, who have high contagious ability since there is no definitive treatment, exposes the nurses with numerous ethical tensions and challenges to provide safe care (Numminen et al., 2019).
In regard with this difficulty, studies have examined the stress and anxiety of nurses taking care of the mentioned patients with COVID-19. Accordingly, Stuijfzand et al., (2020) state that healthcare professionals during epidemic and pandemic (Severe Acute Respiratory Syndrome(SARS), Middle East respiratory syndrome coronavirus (MERS), Ebola Virus Disease) experience a great deal of mental health problems including psychological distress, insomnia, alcohol/drug misuse and symptoms of post-traumatic stress disorder (PTSD), depression, anxiety, anger and burnout (Stuijfzand et al., 2020). Also, Lehmann et al. (2015) represent that health care professionals reported Depression, stress, social isolation and job fatigue during Ebola outbreak. Social isolation has been largely reported due to parental stress and concerns related to the disease transmission amongst the children and other family members. On the other hand, although job stress and fatigue can affect nurse`s tolerance, they have overcome these work pressures and tensions with team working and observing the principles of infection control (Lehmann et al., 2015). A study which has already been conducted by Liu et al., (2020) confirms that compared to the other medical staff members nurses caring COVID-19 patients experience higher levels of anxiety and depression because not only should they struggle with various difficulties in the performance of their professional duties, but as a member of their families they also should shoulder their daily responsibilities (Liu et al., 2020). Similarly, the study of Roy (2020) showed that nurses are experiencing high degrees of stress, anxiety, depression and post-traumatic stress disorder (PTSD) in the COVID-19 crisis. Therefore, it seems to be necessary to conduct a study to investigate the relationship between moral courage, moral sensitivity and safe care in nurses of patients with COVID-19 in Iranian society.

| Study design and setting
This study is a cross-sectional research. The conducted investigation is based on the strengthening the reporting of observational studies in epidemiology statement (STROBE), that is checklist for observational research (Appendix S1), from March to June 2020. The two following aims were examined in study "evaluation of moral courage, moral sensitivity and safe care in nurses who take care of COVID-19 patients" and "investigating the relationship between moral courage, moral sensitivity, safe care and demographic characteristics in nurses who take care of COVID-19 patients."

| Participants and sampling
Sample size has been estimated 520 samples in this study according to the past study of Labrague, et al. With β = 80% and α = 0.05 and taking into account the 10% drop in each group (Labrague & De los Santos, 2020). The participants were selected via convenience sampling. Ultimately Nurses who worked in the infectious ward and provided care to COVID-19 patients in 5 hospitals affiliated with University of Medical Sciences in the west of Iran. They were invited and selected via convenience sampling to participate in the study. The inclusion criteria were: being willing to participate, being one of the members of the hospitals where have been devoted to COVID-19 patients, and having at least 1 month of work experience in the particular wards for patients with COVID-19. The participants who failed to answer more than half of the items on their questionnaires or did not return their questionnaires were excluded. The participants were asked to complete and submit the questionnaires -a personal (demographic) characteristics questionnaire, an occupational burnout scale, resilience scale, and, if they were parents, the parenting stress scale -online. The researchers sent emails and reminder messages to the participants, so that the majority of the questionnaires (90%) were completely gathered in June. 420 of the subjects completed and returned the questionnaires via e-mail or a social network. Thus, the response rate was 77.88%, the nurses' reasons for not being participated in this study were high prevalence of COVID-19 in Iran, heavy workload and intensive shifts, also infected with COVID-19.

| Demographic information questionnaire
The questionnaire included age, gender, marital status, employment status and work experience, the average number of monthly shifts, shift work, financial condition and education.

| Nurses' moral courage questionnaire
This questionnaire was designed and validated by Sadoughi et al. in 2015. This 20-item questionnaire consists of three dimensions of moral self-fulfilment (9 questions), risk-taking (8 questions), and the ability to defend the right (3 questions), which is graded according to the five-point Likert scale from always (score 1) to never (score 5). The score of each item is obtained by multiplying the Likert score by the value of the item. The questionnaire has a minimum score of 102 and a maximum score of 510. In this questionnaire, low moral courage was considered 102-238, medium moral courage 239-374 and high moral courage 375-510. Content validity obtained by determining the content validity index is (CVI = 0.87), its internal consistency by calculating Cronbach's alpha coefficient is 0.88 and its consistency equals 0.87 by doing the test-re-test and calculating the intra-class correlation coefficient (Sadooghiasl, 2016). Assessing the patient's psychological needs (4 questions), the third part is the Assessing the patient's physical needs (7 questions), and the fourth part is the assessment of the nurse's teamwork (5 questions); Answers to all questions are scored on a 5-point Likert from never (1 point) to forever (5 points). The weight of questions 14, 18, 19, 20 and 32 is equal to 1; the weight of questions 2, 3,4,5,7,10,11,12,13,15,16,17,21,26 and 30 is 2. The weight of questions 1,6,8,9,23,24,25,27,29 and 31 is 3, and the weight of questions 28 and 22 is 4; therefore, the obtained number was multiplied by the weight of the question, and the final number was used for the analysis. A score of 1 to 4 indicates poor performance; a score of 2 to 4 indicates moderate performance, and a score of 1 to 4 shows good performance. The calculated reliability of this tool using Alpha Cronbach's method was 0.97 that indicates its optimal reliability (Rashvand et al., 2017).

| Statistical methods
In this study, the collected data will be analysed with SPSS software version 22. For this purpose, descriptive statistics (frequency, percentage, mean and standard deviation) were used. Chi-square and independent t test were also used to investigate the relationship be-

| Ethics approval and consent to participate
The study design was approved by the Ethics Committee of the Hamadan University of Medical Sciences (Umsha.rec.1399.524).
Also at the beginning of study the researcher introduced herself and explained the goals of the study and assured that all information would remain confidential and that they could withdraw from the study at any time. Finally, the written informed consent was obtained from all the participants after providing them with sufficient information on the study.

| Demographic information
Participants in this study were in the age ranging from 25 to 56 years with a mean age of 39.04 ± 2.13. Also, most of the nurses participating in this study (68.14%) 276 had a bachelor's degree in nursing, contractual employment 205 (50.61%), had 10 years of experience with an average of 34 shifts per month. Findings also showed that there is a statistically significant relationship between moral courage and work experience, age and employment status (Table 1).

| Moral courage, moral sensitivity and safe nursing care in nurses
Nurses participating in this study reported a moral courage score of 473.33 ± 1.64, a moral sensitivity score of 178.61 ± 98 1.98 and a safe nursing care score of 298.53 ± 2.27 in caring of patients with COVID-19 (Table 2).

| The relationship between moral courage, moral sensitivity and safe nursing care in nurses
Findings in this study revealed that there is a strong and direct correlation between moral courage with moral sensitivity (r = .91, p < .001) and moral courage with safe nursing care (r = .89, p < .001) in nurses caring of patients with COVID-19. Also, the reports showed a close correlation between the score of moral sensitivity and safe nursing care (r = .84, p < .001) ( Table 3).

| Predictors of moral courage in nurses caring for patients with COVID-19
The variable of moral sensitivity, safe nursing care, work experience, age and marital status with which had a p-value of smaller than 0.25 were entered into multiple linear regressions with the backward technique. These variables remained in the model and accounted for about 64.76% of the moral courage variance in the nurses who provided care to COVID-19 patients (Table 4).  (Ohnishi et al., 2019). But other studies have also reported that the moral sensitivity of nurses in caring for patients is moderate or even weak (Borhani et al., 2013;Izadi et al., 2013). Possible causes of this discrepancy can be cultural and organizational differences and, above all, the differences in the type of disease and care departments. That is due to the type and physical and mental condition of patients that can affect moral sensitivity in nurses in a way that nurses caring for patients in intensive and psychiatric wards have reported more moral sensitivity than the nurses in other units (Ohnishi et al., 2019;Mahdaviseresht et al., 2015). On the other hand, the sudden occurrence of COVID-19 and its high contagious power caused some nurses to be reluctant to continue working in hospitals and even leave hospitals, but nurses who are still in the hospitals and have taken care of these patients, probably more carefully and precisely and considering all the characteristics and conditions of these patients, have tended to take care of them by observing professional principles; consequently, they have a higher moral sensitivity in care.

| D ISCUSS I ON
The safe care score of the nurse participating in this study was  (Nouhi et al., 2016). In the line with this study, other studies show that nurses in different wards, especially intensive care units for adults and infants, pay more attention to the principles of safe care throughout the work (Baykara et al., 2015;Lützén et al., 2003;Mathur & VanderWeele, 2020). This similarity is probably because patients with COVID-19 are usually hospitalized to intensive care units in the hospital with symptoms of respiratory distress and heart problems. On the other hand, the unknown nature of this disease has caused nurses to be more careful when caring and to follow the principles of safe care more.
The findings of this study also indicate that work experience and age are directly related to the level of moral courage of nurses participating in this study. Other studies in line with the findings of this study showed that increasing age and work experience augment the moral courage in nurses, and then they show more courage in performing care (Navidian et al., 2014;Parker, 2014).
This relationship is probably due to the promotion of individual's awareness about organizational conditions, gaining professional and practical competence, and learning courageous behaviours from other colleagues Murray, 2010;Numminen et al., 2019). On the other hand, the moral courage of nurses had a statistically significant relationship with their employment status.
Nurses with contractual employment reported less moral courage,

| Limitations
One of the major limitations of the present study was the relative low return rate of the questionnaires via e-mail which could have been due to the hectic work schedules of nurses in the crisis. Moreover, the variables addressed in the present study were measured over a 6-month period -it is suggested that future studies assess moral courage, moral sensitivity and safe nursing care in nurses who care for COVID-19 patients in the coming months and years in other societies and larger samples in order to acquire a more accurate understanding of nurses' moral courage in this crisis. Health administrators and policy makers can use these findings to develop more comprehensive plans for the current and future crises.

| CON CLUS ION
In the present study, the nurses who care for COVID-19 patients reported high levels of moral courage, sensitivity and safe care nursing. Also, the results showed that nurses' moral courage correlates with their sensitivity, safe nursing care, work experience, age and marital status: these variables predicted 64.76% of the subjects' moral courage variance. The nurse managers and policy makers of health organizations should examine and use the findings of this study in order to provide appropriate environments for nurses, also to develop more comprehensive plans for support of nurses for the current and future crises.

| RELE VAN CE TO CLINI C AL PR AC TI CE
Moral courage promotes the moral sensitivity of nurses in clinical practice, and consequently, nurses who have the courage and moral sensitivity, take care of patients, even patients with infectious diseases and without definitive treatment, better and safer. Therefore, to increase moral sensitivity and moral courage and improve safe nursing care, nursing managers should pay attention to the following points in clinical practice. First, it is important to educate nurses about codes and moral sensitivity. Second supporting them to develop moral courage in nurses, so that, they can provide safe nursing care.

ACK N OWLED G M ENTS
The present article is extracted from a research project registered personnel who participated in the study, and all the other individuals who cooperated with them.

CO N FLI C T O F I NTE R E S T
No conflict of interest is declared by the authors.

E TH I C A L A PPROVA L
The institutional review board of the Hamadan University of Medical Science located in the west of Iran provided ethics approval (approval number: 1399.524). Also at the beginning of each interview, the researcher introduced herself and explained the goals of the study and assured that all information would remain confidential and that they could withdraw from the study at any time. The researchers provided the opportunity for participants to inform the researcher about their withdrawal from the study at any stage of the research and assured. Finally, the written consent was obtained from study participants.

DATA AVA I L A B I L I T Y S TAT E M E N T
The written consent was obtained from study participants for publishing data.