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Moral Courage in Intensive Care Nurses: Exploring the Predictors of a Professional Virtue
Ali Akbari, Alireza Arman, Alireza Nikbakht Nasrabadi,
Volume 17, Issue 0 (12-2024)
Abstract
Moral courage is essential for intensive care unit (ICU) nurses to navigate complex ethical dilemmas and advocate for patient rights. Despite its importance, the factors that influence the expression of moral courage remain poorly understood. This review aims to identify key predictors of moral courage in ICU nurses, offering valuable insights to enhance ethical decision-making and improve patient care in critical care settings. This review followed the Cochrane systematic review principles and adhered to PRISMA guidelines. A comprehensive literature search was conducted using both English and Persian keywords related to "moral courage," "ICU nurses," and "predictors." International databases such as PubMed, Scopus, and Web of Science were searched, along with grey literature from Google Scholar. No time frame restrictions were applied. Inclusion criteria included observational studies that focused on predictors of moral courage in ICU nurses, while studies such as clinical trials, reviews, opinion pieces, and those lacking primary data were excluded. Two authors independently screened and extracted data, resolving discrepancies through consensus with a third author. The Newcastle-Ottawa Scale (NOS) was used to assess study quality, and relevant data were systematically organized into an extraction table. A total of 136 articles were initially identified, with 24 observational studies included after screening. The final selection consisted of 4 cross-sectional studies and 8 cohort studies. Key predictors of moral courage in ICU nurses were identified, including age, gender, professional experience, ethical training, and workplace support. Older and female nurses were more likely to demonstrate moral courage, while nurses with more years of experience and formal ethical training exhibited a stronger ability to confront ethical challenges. Additionally, a supportive work environment and personal ethical beliefs were found to significantly influence the likelihood of nurses advocating for patients and addressing unethical practices. These findings emphasize the importance of both individual and organizational factors in fostering moral courage. This review identifies age, gender, professional experience, ethical training, and workplace support as significant predictors of moral courage in ICU nurses. These findings highlight the critical role of individual characteristics and organizational support in promoting ethical behavior and moral courage in critical care settings.

Barriers to Reporting Medication Errors Among Nurses in Iran: A Narrative Review
Faezeh Rostamian, Fatemeh Khosravi,
Volume 17, Issue 0 (12-2024)
Abstract
Reporting medication errors is essential for improving patient safety and enhancing the quality of nursing care. By identifying and reducing medical and treatment errors, reporting helps foster better care practices. However, various barriers prevent nurses from reporting errors, allowing mistakes to persist in clinical environments. This study aims to identify the barriers to medication error reporting among nurses in Iran through a narrative review. This narrative review involved searching articles from several databases, including ScienceDirect, PubMed, SID, Scopus, CINAHL, Magiran, and Google Scholar, using keywords such as "nurses," "barriers to reporting," "causes of non-reporting," "medication errors," "drug mistakes," "Iran," and their English equivalents. Research articles in both Persian and English, published between 2011 and 2024, which focused on barriers to medication error reporting among nurses in Iran and offered full-text access, were selected for review. Initially, 67 articles were identified. After reviewing the titles, abstracts, and in some cases, full texts, 23 articles were selected and analyzed based on their alignment with the research aim. The review revealed that barriers to reporting medication errors among nurses in Iran are influenced by individual, organizational, and cultural factors. Individual barriers include fear of legal and professional consequences, concerns about negative impacts on performance evaluations, and fear of being labeled incompetent. Organizational barriers consist of workload pressures, lack of time, inefficient reporting systems, and a lack of support from managers and colleagues. Additionally, a weak safety culture in hospitals and insufficient training on the importance of error reporting further hinder the reporting process. The findings of this study indicate that barriers to reporting medication errors among nurses in Iran are primarily due to individual, organizational, and cultural factors. To address these barriers, it is crucial for hospital administrators and healthcare system officials to provide appropriate training and foster a supportive environment that encourages error reporting. Regular training sessions, coupled with positive, non-judgmental feedback on error reporting, can enhance nurses' trust in the reporting system. Strengthening reporting systems and cultivating a safety culture with active involvement from both nurses and administrators will not only improve the quality of nursing care but also reduce medication errors.
 

Moral Sensitivity Among Nurses in Cardiac Critical Care Units of Selected Hospitals Affiliated with Isfahan University of Medical Sciences in 2024
Safoura Dorri, Seyed Ali Rasooli, Hamideh Hakimi,
Volume 17, Issue 0 (12-2024)
Abstract
Moral sensitivity, defined as the ability to recognize and assess the ethical complexities of clinical situations and make appropriate ethical decisions, is a crucial skill for nurses. Despite its importance, various studies report varying levels of moral sensitivity among nurses, suggesting a gap in this competency. Nurses’ continuous exposure to ethical dilemmas can lead to adverse outcomes, including psychological and moral distress, decreased job satisfaction, and compromised care quality. As moral sensitivity can differ across healthcare settings and may change over time, studies assessing its levels across different periods are essential. This study aims to assess the level of moral sensitivity among nurses in hospitals affiliated with Isfahan University of Medical Sciences in 2024. This cross-sectional descriptive study was conducted with 200 nurses working in cardiac intensive care units (CICUs) of four large hospitals affiliated with Isfahan University of Medical Sciences. Participants were selected using a random sampling method. Data were collected using a demographic information form and the Lutzen Moral Sensitivity Questionnaire. Data analysis was performed using SPSS version 26, employing descriptive statistics such as means and standard deviations. The findings revealed that the average moral sensitivity score among the nurses was moderate (60.17±13.04). When analyzing the different dimensions of moral sensitivity, the highest score was observed in the dimension of "honesty and benevolence" (15.30 ± 4.48), while the lowest score was found in the dimension of "professional knowledge" (3.25 ± 1.88). The mean scores for the remaining dimensions were as follows: "respect for patient autonomy" (7.44 ± 2.13), "awareness of how to communicate with patients" (15.18 ± 3.41), "experiencing ethical problems and dilemmas" (7.74 ± 2.03), and "applying ethical concepts in ethical decision-making" (11.95 ± 3.35). The study revealed that nurses demonstrated a moderate level of moral sensitivity, with the lowest scores in the dimension of professional knowledge. This suggests that nurses may not be sufficiently involving patients in their treatment and care decisions. Given these findings, it is critical for healthcare policymakers and nursing managers to implement continuous assessment and feedback systems to accurately evaluate nurses' moral sensitivity and professional knowledge. By identifying the weaknesses and educational needs of nurses, targeted training programs can be developed, ultimately enhancing nurses' moral sensitivity and improving the quality of care.
 

Nurses’ Attitudes About Euthanasia: A Systematic Review
Shabnam Rasoulpoor, Reza Nematollahi Maleki, Neda Tagizadeh,
Volume 17, Issue 0 (12-2024)
Abstract
Euthanasia, defined as the intentional ending of a patient's life to relieve intractable suffering, presents complex ethical, legal, and emotional challenges for healthcare professionals, particularly nurses. Nurses play a pivotal role in end-of-life care, making their attitudes toward euthanasia crucial for understanding its implications in clinical practice. This review aims to synthesize existing literature on nurses' attitudes about euthanasia to identify key influencing factors and areas requiring further exploration. This study was conducted using the PRISMA 2020 guideline with no time limitation (by December 2024). Eligible articles were selected following a search in various databases (Scopus, Web of Science, PubMed, ScienceDirect, Embase, and Google Scholar) using keywords and operators of “AND” & “OR.” The search strategy included “Perceptions” OR “Attitudes” OR “Nurse” AND “Euthanasia.” Data extraction and risk-of-bias assessment were performed independently by two reviewers (SR and NT). Studies were evaluated with the Appraisal Tool for Cross-Sectional Studies (AXIS Tool). A total of 21 studies were included in the review. The review revealed that nurses’ attitudes toward euthanasia vary widely depending on legal frameworks, cultural norms, religious beliefs, and personal values. In countries where euthanasia is legalized, such as Belgium and the Netherlands, nurses often report greater acceptance and willingness to participate in the process, emphasizing their role in ensuring patient autonomy and dignity. Conversely, in regions where euthanasia is illegal, nurses frequently express ethical concerns, moral distress, and reluctance to support the practice. Common themes include the need for clear guidelines, ethical training, and emotional support systems for nurses dealing with euthanasia-related situations. Nurses’ attitudes about euthanasia are influenced by a complex interplay of cultural, legal, and personal factors. While some nurses view euthanasia as an extension of compassionate care, others experience ethical dilemmas and professional conflict. This highlights the need for robust ethical frameworks, specialized training, and supportive resources to help nurses navigate the challenges associated with euthanasia in their practice.

Elucidating the Lived Experiences of Operating Room Nurses Regarding Moral Intelligence: A Hermeneutic Phenomenological Study
Masoomeh Salehi, Behzad Imani, Shirdel Zandi,
Volume 17, Issue 0 (12-2024)
Abstract
The diversity of work environments, regulations, and prevailing atmospheres uniquely influence individuals' moral intelligence. Given the significant role of operating room nurses in patient care and the importance of moral intelligence in enhancing the quality of these services, this study aimed to elucidate the experiences of operating room nurses regarding moral intelligence at Hamadan University of Medical Sciences. A hermeneutic phenomenological study was conducted in hospitals affiliated with Hamadan University of Medical Sciences, Iran, from May to October 2023. Twelve operating room nurses were purposefully selected. Data was collected through in-depth semi-structured interviews and analyzed using van Manen's method. The study's rigor was ensured through four criteria: credibility, dependability, confirmability, and transferability. Three main themes related to moral intelligence were identified by examining the experiences of operating room nurses. These themes include: moral sensitivity (inner guidance, recognizing the rightness or wrongness of actions, having a work ethic), the ability to make sound decisions (ability to make sound judgments, moral courage), and ethical behavior towards patient interests (providing ethical care, preserving patient dignity, ability to work as a team). Operating room nurses with high moral intelligence are sensitive to the rightness or wrongness of actions, guided by inner ideals and professional commitment to doing what is right. They make sound judgments when faced with challenges and defend them courageously, making sound decisions. By providing ethical care, working as a team, and protecting human dignity, they demonstrate ethical behavior towards patient interests.

Investigating the Factors Influencing Moral Courage in Nurses: A Systematic Review
Morteza Javanmardi , Seyede Elahe Karimipour , Zahra Bakhshizadeh , Mohammad Hossein Taklif, Negin Farid,
Volume 17, Issue 0 (12-2024)
Abstract
Moral courage, encompassing the ability to act ethically in the face of adversity and uphold ethical principles, is crucial for nurses. This systematic review aimed to investigate the factors influencing moral courage among nurses. A comprehensive literature search was conducted using keywords such as "moral courage," "ethics," "nurses," and "courage" in major databases, including PubMed/Medline, Web of Science Core Collection, Scopus, Google Scholar, Irandoc, SID, and Magiran. The search included publications in both English and Persian with no time limitations. After excluding duplicates and screening the initial 2577 studies, 21 studies met the inclusion criteria. The review adhered to the PRISMA guidelines for reporting systematic reviews, ensuring ethical considerations were maintained throughout the selection, extraction, and analysis processes. The review revealed that moral courage in nurses is influenced by a multifaceted array of factors. Individual factors such as age, gender, work experience, and type of employment (e.g., permanent vs. temporary) were found to influence moral courage. Higher education, particularly possessing a master's degree or higher, and participation in medical ethics training were significantly associated with increased moral courage. Ethical sensitivity, defined as the ability to recognize and appreciate ethical dilemmas, was a significant facilitator of moral courage. A supportive work environment, characterized by factors such as strong ethical leadership, open communication, and adequate resources, was found to positively influence moral courage. Conversely, ethical distress experienced in challenging clinical situations can negatively impact moral courage. This review demonstrates that moral courage among nurses is influenced by a complex interplay of individual, professional, and environmental factors. Enhancing moral courage requires a multi-pronged approach, including strengthening nursing education with a robust emphasis on ethics training, fostering a supportive and ethically sound work environment, and implementing strategies to mitigate ethical distress. These interventions can significantly contribute to improved clinical practice and enhanced patient care.

Investigating the Relationship Between Moral Intelligence and Clinical Competence of Nurses and Nursing Students: A Systematic Review
Zahra Abdollahi, Marzieh Barahooei Noori, Mohammad Hossein Khani, Mohammad Hossein Taklif, Negin Farid,
Volume 17, Issue 0 (12-2024)
Abstract
Moral intelligence encompasses an individual's ability to discern right from wrong, possess ethical values, and demonstrate ethical behavior in practice. Clinical competence, a crucial aspect of nursing practice, encompasses a combination of knowledge, skills, and attitudes, including adherence to ethical principles. This systematic review aimed to investigate the relationship between moral intelligence and clinical competence among nurses and nursing students. A comprehensive literature search was conducted using keywords related to "moral intelligence," "clinical competence," "nurses," and "nursing students" in major international databases, including Web of Science Core Collection, PubMed/Medline, Scopus, and Google Scholar, as well as national databases such as Irandoc, SID, and Magiran. The search included publications in Persian and English with no time limitations. After removing duplicates and screening the initial 150 identified studies, five studies met the inclusion criteria. Ethical considerations, including minimizing bias in the selection, extraction, and analysis of evidence, were adhered to throughout the review process. The abstract adheres to PRISMA guidelines for reporting systematic reviews. The review revealed a significant positive correlation between moral intelligence and clinical competence across various dimensions. Studies demonstrated that higher levels of moral intelligence were associated with improved clinical competence, including ethical reasoning and clinical self-efficacy. Factors such as age, work experience, educational status, and individual rank were found to influence this relationship. Additionally, some studies indicated that moral intelligence could predict clinical competence scores, while others demonstrated that it could be a significant predictor of clinical competence alongside other factors such as Grade Point Average (GPA). This systematic review provides evidence for a significant positive relationship between moral intelligence and clinical competence among nurses and nursing students. Enhancing moral intelligence through targeted educational interventions can contribute to improved clinical competence and ultimately enhance the quality of patient care. Future research should focus on developing and evaluating educational programs designed to enhance moral intelligence in nursing education and practice.

Factors Affecting Compassion Fatigue in Critical Care Nurses: A Systematic Review
Hedayat Jafari, Fatemeh Ahmadi, Mobina Abedinpour,
Volume 17, Issue 0 (12-2024)
Abstract
Compassion fatigue refers to the physical and emotional exhaustion experienced by healthcare professionals due to prolonged exposure to job-related stress and the emotional demands of caring for others. Compassionate care is vital for achieving better patient outcomes, but various factors during healthcare delivery can compromise it. This study examines the factors influencing compassion fatigue among critical care nurses. This systematic review was conducted by searching databases including SID, Magiran, Irandoc, Iranmedex, Civilica, Science Direct, Web of Science, Embase, PubMed, Scopus, ProQuest, and Google Scholar. Keywords used in the search included “compassion fatigue,” “critical care,” “intensive care,” “nurses,” “compassion satisfaction,” and “burnout.” After removing duplicates, studies were screened based on inclusion and exclusion criteria, and their quality was assessed using the Critical Appraisal Checklist for Analytical Cross-Sectional Studies. Ultimately, 23 studies met the criteria and were included in the systematic review (qualitative synthesis). The studies included in this review were conducted between 2012 and 2024, with a total of 5,820 participants. The review found that both workplace structural factors and demographic characteristics of nurses, such as age, sex, marital status, nationality, educational level, resilience, length of shifts, experience in critical care settings, place of work, position within the unit, and nurse-to-patient ratios, are causes and predictors of compassion fatigue. Leadership and administrative support in clinical settings, as well as the coping strategies employed by nurses, were identified as factors that mitigate the impact of compassion fatigue among critical care nurses. This systematic review highlights the profound impact of compassion fatigue on nurses and emphasizes the roles of workplace environment and demographic factors in its development. The findings underscore the importance of supportive leadership and effective coping strategies in reducing compassion fatigue and enhancing compassion satisfaction among critical care nurses. By addressing these factors, healthcare organizations can reduce burnout, improve nurse well-being, and enhance patient care and clinical outcomes.
 

Moral Sensitivity in Psychiatric Nurses: A Qualitative Content Analysis
Fariba Borhani, Mariye Jenabi Ghods, Ladan Fattah Moghadam, Tahereh Gilvari, Amirreza Rafiei Javazm, Mahshad Naserpour, Mohammad Javad Hosseinabadi ‑farahani,
Volume 17, Issue 0 (12-2024)
Abstract
Moral sensitivity is a fundamental characteristic of professional ethics in nursing, significantly influencing patient care. This qualitative study aimed to explore the concept of moral sensitivity among psychiatric nurses. The study employed a qualitative approach using content analysis. Participants included 15 psychiatric nurses working at Razi Psychiatric Hospital in Iran, selected through purposive sampling based on defined inclusion and exclusion criteria. After obtaining ethical approval, data were collected through semi-structured, in-depth interviews. The interviews were audio-recorded, transcribed, and managed using MAXQDA software. Data analysis was conducted following Granheim and Lundman’s five-step method (2004), and the trustworthiness of the findings was ensured using Guba and Lincoln’s criteria. The findings revealed three main categories and six subcategories:
  1. Ethical Knowledge (comprising clinical experience and education, and professional development).
  2. Ethical and Legal Conflicts (including discrepancies between ethical principles and legal frameworks, and challenges in ethical decision-making within complex legal situations).
  3. Ethical Atmosphere (encompassing individual ethics and organizational ethics).
Based on these findings, it is recommended that these insights be integrated into nursing education, research, and management to enhance care for patients with psychiatric disorders.

The Relationship Between Ethical Culture and Job Commitment of Nurses Working in Educational and Medical Centers of Hamadan University of Medical Sciences
Mehran Saadatmand, Abolfazl Ghani Honar,
Volume 17, Issue 0 (12-2024)
Abstract
Promoting an ethical culture is crucial for ensuring job commitment and competent clinical care among nurses. Ethical culture encompasses shared understandings and perceptions that guide ethical conduct within an organization. Job commitment reflects an individual's psychological and emotional attachment to their job. This study aimed to investigate the relationship between ethical culture and job commitment among nurses working in educational and medical centers affiliated with Hamadan University of Medical Sciences. This descriptive correlational study included 170 nurses selected from teaching hospitals in Hamadan using the Morgan table and based on inclusion criteria. Data were collected using demographic questionnaires, the Gobel et al. Ethical Culture Questionnaire, and the Schaufeli Job Commitment Questionnaire. Data analysis was performed using SPSS version 22 software. A significant and positive correlation was found between ethical culture and nurses' job commitment (r=0.42, p<0.05). Ethical culture was significantly higher among nurses with more work experience and female nurses compared to their counterparts. Additionally, job commitment was significantly higher among male nurses and those with formal employment status. The findings demonstrate a strong positive correlation between ethical culture and job commitment among nurses. Enhancing ethical culture within healthcare settings through effective leadership, clear ethical guidelines, and open communication channels can significantly improve job satisfaction and, ultimately, patient care. Further research is needed to explore the specific factors that contribute to ethical culture within different healthcare contexts.

The Impact of Professional Ethics Training on the Spiritual Care Competence of Emergency Nurses
Milad Kazemi Najm, Tahereh Toulabi, Abbas Abbaszadeh, Rasoul Mohammadi, Nasrin Imanifar,
Volume 17, Issue 0 (12-2024)
Abstract
Nurses, as the largest group of healthcare workers globally, are responsible for providing holistic care to patients. Holistic care encompasses physical, mental, social, and spiritual dimensions. This study aimed to determine the effect of professional ethics training on the spiritual care competence of emergency nurses. This two-group field trial study with a pre-test and post-test design was conducted with 84 nurses working in the emergency departments of Lorestan University of Medical Sciences. Participants were selected through stratified random sampling. The intervention group participated in four workshops. The study tool was the Spiritual Care Competency Questionnaire. Data analysis was performed using SPSS, employing descriptive statistics (mean, median, and percentage) and inferential statistical tests, including repeated measures ANOVA, independent t-tests, and Fisher’s exact test.
The study included two groups: intervention (n = 42) and control (n = 42). Most participants in both groups were women. A significant difference was observed in the average total spiritual care competence scores and its dimensions (excluding the self-knowledge subscale) over different time points in the intervention group (P < 0.001). However, for the self-knowledge subscale, no significant difference was found in the average scores between the control and intervention groups at different time points. The results of this study demonstrated that professional ethics training improves nurses' spiritual care competence. By conducting workshops, training programs, and in-service courses on professional ethics and spiritual care, the quality of nursing care can be enhanced, ultimately improving patient safety. It is recommended that healthcare policymakers and nursing managers prioritize professional ethics as the foundation of all nursing practices. Employing innovative and engaging methods, such as the scenario-based approach used in this study, can further support the development of professional ethics in nursing.

Attitudes Towards Euthanasia Among Intensive Care Nurses
Maryam Ghaffari, Reza Shabanloei, Mozhgan Behshid,
Volume 17, Issue 0 (12-2024)
Abstract
Euthanasia, often referred to as mercy killing or an "easy death," remains a deeply controversial issue, particularly in Islamic countries where it is both ethically and legally prohibited. Nurses working in intensive care units (ICUs) are more likely than other healthcare professionals to encounter situations related to end-of-life care, given the critical condition of the patients they serve. Consequently, their attitudes toward euthanasia hold significant ethical and professional implications. This descriptive-analytical study was conducted to explore the attitudes of ICU nurses toward euthanasia in a context where it is culturally and legally forbidden. A total of 194 nurses from eight hospitals affiliated with Tabriz University of Medical Sciences participated. Data collection instruments included a demographic questionnaire and Holloway’s Attitudes Toward Euthanasia Scale. Data were analyzed using descriptive statistics, t-tests, and ANOVA. The mean attitude score towards euthanasia was 71.95 ± 4.99 out of a possible 120. Overall, 74% of participants scored below 75, reflecting a generally negative attitude toward euthanasia, while 26% scored above 75, indicating a more favorable view. No statistically significant association was found between attitudes toward euthanasia and any demographic variables (p ≥ 0.05). Despite the legal and religious restrictions against euthanasia in Iran, a portion of ICU nurses demonstrated a positive attitude toward the practice. Given the potential impact of these attitudes on patient care, nursing managers and educational authorities should address even minimal levels of support for euthanasia. Targeted training and ethical guidance are essential to ensure that patient care remains aligned with legal and moral standards, particularly in ethically sensitive clinical situations.
 

The Effect of Spiritual Intelligence Training on Nurses' Spiritual Care Competency in Patient Care: A Review Study
Mina Kafash Mohammadjani, Mandana Kazemi, Fatemeh Mahboob Bashari,
Volume 17, Issue 0 (12-2024)
Abstract
Spiritual intelligence, defined as the capacity to effectively utilize religious and spiritual resources, plays a crucial role in providing high-quality nursing care. This study aimed to investigate the effect of spiritual intelligence training on nurses' competency in caring for patients. This review study utilized a comprehensive search strategy, including Persian and English keywords (Spirituality, Spiritual Intelligence, Spiritual Care, and Nursing) within the PubMed, Scopus, Google Scholar, and SID databases, covering the period from 2017 to 2023. A total of 21 full-text articles (in English and Persian) were selected and analyzed. The findings revealed that 45% of the nurses assessed exhibited below-average levels of spiritual care competency. Most studies demonstrated a significant positive correlation between spiritual intelligence and nurses' competence in providing spiritual care. Spiritual intelligence fostered the development of nurses' beliefs, personality traits, and a strong desire for personal and professional growth, ultimately enhancing the quality of nursing care. Furthermore, male gender, place of residence, and religious adherence emerged as predictors of nurses' spiritual care competency. Studies consistently highlighted the increased importance of spiritual dimensions during illness and hospitalization, emphasizing the critical need for nurses to provide comprehensive spiritual care.Based on this review, it is evident that ethical challenges exist within nursing care, and some nurses may not adequately address the spiritual needs of their patients. Therefore, promoting spirituality in nursing care through spiritual intelligence training is essential to enhance the quality of nursing practice.
 

Pediatric Nurses' Adherence to Codes of Ethics: A Narrative Review
Naiire Salmani,
Volume 17, Issue 0 (12-2024)
Abstract
Codes of ethics serve as essential guides for nurses in all medical settings to implement ethical principles, and they are especially important in pediatric wards. Given the vulnerability of sick children, it is crucial for pediatric nurses to provide care grounded in ethical codes and guidelines. This study aimed to review pediatric nurses' adherence to these codes of ethics. This review study was conducted by searching for articles using keywords such as “nurse,” “care,” “codes of ethics,” and “children” (and their Persian equivalents) through databases including Google Scholar, PubMed, Scopus, and SID from 2013 to 2024. A total of 1537 articles were retrieved initially. After reviewing the full-text English or Persian articles, 23 were assessed for quality, and 10 were selected for analysis. Pediatric nurses' adherence to ethical codes encompasses several key principles, including respecting the patient's family, establishing trust-based relationships, maintaining the privacy of sick children, demonstrating patience, taking responsibility for errors in patient care, and ensuring non-discrimination between sick children and families. To effectively adhere to codes of ethics in pediatric care, nurses must provide ethical care that is both patient-centered and family-focused, using ethical principles as a foundation for their practice.

The Relationship Between Moral Foundations and Organizational Culture Among Nurses at Vali-e Asr Hospital in Borujen in 2023
Fatemeh Badr, Mostafah Roshanzadeh, Somayeh Mohammadi, Mina Shirvani, Samaneh Dehghan Abnavi,
Volume 17, Issue 1 (3-2024)
Abstract
Considering the important role of health organizations and the behavior and performance of nurses in achieving organizational goals, the moral foundations of nurses can significantly influence their behaviors and decisions and shape the organizational culture and atmosphere. Therefore, the present descriptive-analytical study aimed to investigate the relationship between moral foundations and organizational culture among 200 nurses selected using the census method at Shahrekord University of Medical Sciences in 2023. Data were collected through a demographic information form along with questionnaires to measure moral foundations and organizational culture. Data were analyzed using SPSS software version 16 via descriptive statistics (percentage, mean, and standard deviation) and analytical tests (t-test, analysis of variance (ANOVA), correlation coefficient, and linear regression). Pearson’s correlation coefficient revealed a significant relationship between the mean scores of moral foundations and organizational culture among nurses (r=0.61, P<0.001). The coefficient of determination (R2=0.372) showed approximately 37% of the variance in organizational culture can be predicted by moral foundations. Among the dimensions of moral foundations, loyalty to the group, respect for authority, and purity significantly predicted organizational culture (P<0.001). The mean score of moral foundations among nurses was acceptable at 98.55±15.8, while the mean score of organizational culture was favorable at 105.74±25.7. Based on the findings from the present study it can be concluded that by creating a moral atmosphere and promoting moral values such as loyalty to the group, respect for authority, and purity in nurses, the organizational culture can be enhanced

Association of Moral Reasoning with Clinical Belongingness and Their Influential Factors among ICU Nurses
Simin Kokabi Asl, Sareh Zekavat, Somayeh Rostamkhan, Abolfazl Dehbanizadeh, Mahsa Ghaemizadeh, Milad Amiri,
Volume 17, Issue 1 (3-2024)
Abstract
The intensive care unit (ICU) is a challenging and stressful environment where nurses encounter difficult ethical decisions daily. Therefore, this study aimed to determine the correlation between moral reasoning and clinical belongingness among Iranian ICU nurses. This cross-sectional, descriptive-analytical study was conducted on 126 nurses working in the adult ICUs of hospitals in Yasuj, Iran in 2023 using census sampling. Questionnaires measuring clinical belongingness and moral reasoning were used to collect data. Data were analyzed using independent samples t-test, ANOVA, regression, and Pearson’s correlation coefficient via SPSS-26 software. The findings revealed that the mean scores for clinical belongingness and moral reasoning among the nurses were 109.68 ± 13.75 and 36.07± 5.50, respectively, indicating good clinical belongingness and moderate moral reasoning. Moreover, a statistically significant relationship was identified between the place of service and clinical belongingness (p = 0.02), while no significant relationship was found between clinical belongingness and moral reasoning (p>0.05). Although no significant relationship was established between clinical belongingness and moral reasoning, certain demographic characteristics showed a significant predictive relationship with nurses' clinical belongingness. Accordingly,  it is recommended that nursing officials and managers utilize these findings to improve moral reasoning and the sense of belonging to the clinical environment among nurses.

The Experience of Moral Distress from the Perspective of Emergency Medicine Physicians and Nurses in the Emergency Department: A Qualitative Study
Leila Masoudiyekta, Ehsan Hassanpour Pazevar , Alireza Parsapour, Ehsan Shamsi Gooshki, Mohammd Jalili, Amirahmad Shojaei,
Volume 18, Issue 1 (3-2025)
Abstract
Moral distress constitutes a significant challenge for healthcare professionals, arising when individuals find themselves unable to act in accordance with their personal and professional values due to both internal and external pressures. Healthcare professionals may face scenarios that prompt them to question the ethical acceptability of their decisions and treatment practices, often feeling powerless in the face of perceived unethical changes. This study sought to explore the experiences of moral distress encountered by emergency medicine physicians and nurses in the emergency department. This study was conducted using qualitative content analysis. Data were collected through semi-structured interviews with 25 healthcare providers selected via purposive sampling. Data analysis was conducted using MAXQDA 2018 software. The results indicated that the experiences of moral distress among emergency medicine physicians and nurses in the emergency department can be classified into four primary categories including those related to: 1. patient rights, 2. medical staff and colleagues, 3. management, and 4. professionals. Notably, factors such as overcrowding, inadequate staffing, discrepancies between salaries and workloads, and poor management of human and physical resources emerge as significant contributors to moral distress in the emergency department of Imam Khomeini Hospital. To improve patient care quality, it is essential to implement strategies that enhance triage processes, prioritize human resources, align resources with patient needs, monitor patient attendance, and develop a comprehensive protocol for staff.

The Relationship Between Moral Courage and Occupational Stress in Nurses: A Cross-Sectional Study in Urmia, Iran
Reza Abdollahi, Haleh Ghavami,
Volume 18, Issue 1 (3-2025)
Abstract
Due to the inherently demanding nature of their profession, nurses face significant job-related stress that can adversely affect their lives and the quality of nursing care. Moral courage may serve as a key factor influencing occupational stress among nurses. Accordingly, this study aimed to examine the relationship between moral courage and occupational stress among nurses. This descriptive-analytical cross-sectional study was conducted in 2024 with 120 nurses from emergency departments of educational and therapeutic hospitals in Urmia, Iran, who were selected via two-stage sampling. Data were collected through a demographic information form, Sekerka’s Moral Courage Scale, and Gray-Toft and Anderson’s Nursing Stress Scale. Data were analyzed using Pearson correlation coefficient, multiple linear regression, independent t-test, and one-way ANOVA in SPSS software version 23. The results showed the mean scores for professional moral courage and occupational stress were 85.93 ± 15.68 and 10.77 ± 0.23, respectively. Moreover, there was a significant negative relationship between moral courage and occupational stress in nurses (r = -0.33 and P< 0.05).  Specific dimensions of moral courage, such as moral factor, threat tolerance, and moral purpose, had a significant negative effect on occupational stress (P< 0.05). These findings suggested that moral courage plays a significant role in mitigating occupational stress among nurses, which can influence their performance and, consequently, the quality of nursing care. Therefore, by fostering an environment that promotes moral courage, nursing managers can play a vital role in decreasing and mitigating the occupational stress experienced by nurses as well as enhancing the quality of care.

Ethical Challenges in Elderly Care: A Narrative Review
Zahra Khalilzadeh-Farsangi, Samaneh Fallah-Karimi,
Volume 18, Issue 1 (3-2025)
Abstract
With increasing life expectancy and a growing elderly population worldwide, elder care has become a major priority for health systems. These care services are accompanied by numerous ethical challenges, and neglecting them can negatively affect the dignity, rights, and quality of life of older adults. This study aimed to address the question: “What ethical challenges are faced in elder care?” Accordingly, a systematic review was conducted guided by PRISMA guidelines. To identify relevant studies, PubMed, Scopus, Web of Science, SID, and Google Scholar were searched for the period 2013–2025, using the keywords “Ethical Challenges”, “Elderly Care”, “Nursing”, and their Persian equivalents. Inclusion criteria were original articles (qualitative, quantitative, experimental, or quasi-experimental) with a direct focus on ethical challenges in elder care, written in Persian or English, and with full-text availability. Exclusion criteria included letters to the editor and conference abstracts. The quality of the studies was assessed using the appraisal tool proposed by Gifford. In total, 31 eligible articles were included in the final analysis. The results indicated that ethical challenges in elder care can be classified into four main categories, including autonomy, justice, beneficence, and non-maleficence. Subthemes included privacy preservation, shared decision-making, end-of-life care, equitable resource allocation, and the prevention of physical and psychological harm. The findings underscored the necessity of strengthening ethics education and informing policymaking in elder care.

The Relationship Between Moral Injury and Moral Courage in Nurses Working in Intensive Care Units
Samaneh Fallah-Karimi, Zahra Khalilzadeh-Farsangi, Azizollah Arbabisarjou, Fatemeh Etemadinia,
Volume 18, Issue 1 (3-2025)
Abstract
Nurses working in intensive care units are frequently exposed to complex ethical issues and difficult decision-making, placing them at high risk for moral injury. Such injury can negatively affect their professional performance and mental health. Accordingly, this study aimed to explore the relationship between moral injury and moral courage among nurses working in intensive care units. This descriptive cross-sectional study was conducted in 2024. The study population consisted of 150 nurses working in intensive care units. Data were collected through Sekerka’s Moral Courage Questionnaire and the Moral Injury Symptom Scale for Health Professionals. Data were analyzed using descriptive statistics, Pearson’s correlation coefficient, and the independent samples t-test via SPSS software version 22. The findings revealed a significant inverse relationship between moral injury and moral courage (r = -0.64, p < 0.001). Moreover, moral courage levels were higher among registered nurses compared to nurses in the compulsory service program. Besides, a direct relationship was observed between age and moral courage, suggesting that moral courage increases with age. The results of this study highlight the importance of designing and implementing effective educational programs to reduce moral injury and promote moral courage among this group of nurses.

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