Background: 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. In a complex nursing practice, ethical considerations are integral. Moral courage is needed throughout nurses’ career. Aim: To analyse graduating nursing students’ moral courage and the factors associated with it in six European countries. Research design: A cross-sectional design, using a structured questionnaire, as part of a larger international ProCompNurse study. In the questionnaire, moral courage was assessed with a single question (visual analogue scale 0–100), the questionnaire also covered several background variables. Participants and research context: The sample comprised graduating nursing students (n = 1796) from all participating countries. To get a comprehensive view about graduating nursing students’ moral courage, the views of nurse managers (n = 538) and patients (n = 1327) from the same units in which the graduating nursing students practised were also explored, with parallel questionnaires. Ethical considerations: Ethical approvals and research permissions were obtained according to national standards in every country and all participants gave their informed consent. Results: The mean of graduating nursing students’ self-assessed moral courage was 77.8 (standard deviation 17.0; on a 0–100 scale), with statistically significant differences between countries. Higher moral courage was associated with many factors, especially the level of professional competence. The managers assessed the graduating nursing students’ moral courage lower (66.5; standard deviation 18.4) and the patients slightly higher (80.6; standard deviation 19.4) than the graduating nursing students themselves. Discussion and conclusions: In all countries, the graduating nursing students’ moral courage was assessed as rather high, with differences between countries and populations. These differences and associations between moral courage and ethics education require further research.

Moral courage and understanding of its meaning are essential when nurses face ethical conflicts in their practice. This integrative review aimed to explore moral courage in nursing and possible associated individual and organizational factors. A database search in January 2020 identified 1308 scientific articles of which 25 were selected for the review. Inductive analysis with clear steps for defining and synthesizing themes in research reviews revealed three categories concerning moral courage in nursing: definition and descriptions of moral courage, characteristics of the morally courageous nurse, and skills and acts of the morally courageous nurse. Individual and organizational factors, such as positive personal experiences, commitment to ethical principles, supportive work environment and teamwork, were associated with moral courage in nursing, contributing to a more comprehensive description of nurses' moral courage. Findings indicate that in nursing practice, there is a need for promoting multi‐professional collaboration and discussion of ethical dilemmas to provide opportunities to enhance moral courage. Developing care environments in which hierarchy does not inhibit nurses' moral courage seems justified. Further research on moral courage with varying methodologies and multi‐disciplinary and international approaches is needed.

Nurses need moral courage in their ethical decision-making. As a personal characteristic, moral courage varies between individuals. The aim of this study was to analyse nurses’ self-assessed moral courage, morally courageous acts and associated individual factors in older people care in one large city in Finland. The data of this cross-sectional study were collected with the ‘Nurses’ Moral Courage Scale’ (NMCS) and the main analyses were conducted with multi-way ANOVA. A total of 205 nurses responded. Respondents’ self-assessed moral courage was 4.16 on a Likert scale of 1 to 5. Higher moral courage was associated with a higher knowledge base in ethics, more frequent encountering of ethical conflicts and having several sources for knowledge of ethics, suggesting that providing ethics education for nurses in the care of older people is important. The STROBE checklist was used as the reporting guideline for the manuscript.