Volume 31, Issue 4 (9-2021)                   J Holist Nurs Midwifery 2021, 31(4): 254-262 | Back to browse issues page

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Roshanzadeh M, Vanaki Z, Sadooghiasl A, Tajabadi A, Mohammadi S. Explaining Courage in Ethical Decision-making by Nursing Managers: A Qualitative Content Analysis. J Holist Nurs Midwifery. 2021; 31 (4) :254-262
URL: http://hnmj.gums.ac.ir/article-1-1741-en.html
1- Assistant Professor, Department of Nursing, Nursing School of Brojen, Shahrekord University of Medical Sciences, Shahrehkord, Iran.
2- Professor, Department of Nursing, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran , vanaki_z@modares.ac.ir
3- Assistant Professor, Department of Nursing, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
4- Assistant Professor, Department of medical emergency, Sabzevar University Of Medical Sciences, Sabzevar, Iran
5- MSN, Department of Nursing, Nursing School of Brojen, Shahrekord University of Medical Sciences, Shahrehkord, Iran
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ecision-making is a key part of the management process, and managers are constantly involved in making various decisions [1]. Different decision-making situations sometimes present managers with challenges. In this regard, the principles based on which managers can make decisions have a decisive role in this process and its outcomes [2]. Given that ethical values are the basis for other values in an organization, they can guide managers to make decisions [3].
Maintaining ethical values is essential in health organizations that ensure the health of individuals. In this context, decision-makers of these systems can play an essential role in spreading the ethical climate in organizations, thus respecting human and moral values [5, 4]. Given the multidimensional roles of nursing managers, they need to make the right decisions when encountering different situations [6]. They should incorporate ethical principles and values into decision-making under different circumstances, characterized as ethical decision-making [7]. 
One of the factors that have an essential role in making decisions is the courage of managers to adhere to ethical principles [8]. Moral courage can be defined as insisting on ethical beliefs and values when exposed to different circumstances [9]. Many decisions might not be made at all for fear of jeopardizing their position, assets, and power [10, 11]. Moral courage plays an important role in shaping a manager’s personality, and it is an essential attribute for ethical behavior in an organization [12]. Courage makes a manager fearless and ethical, and it is like an indicator by which moralists can be distinguished from realists [13].
Managers with enough courage to make their decisions in accordance with ethical principles create positive results for the whole system [9]. A courageous nursing manager, while paying attention to the organization’s ethical principles, can make decisions with sufficient knowledge of the conditions of the system operators while taking into account the interests of clients and staff [14, 15]. The ethical atmosphere that follows the ethical decisions made in the organization increases the satisfaction of the staff and increases the quality of care. As a result, clients’ satisfaction with receiving services increases, and their complaints and dissatisfaction with health organizations improve. Following these conditions, health systems can move towards achieving their goals and therefore increase the success of the system [13, 16]. It should also be noted that managers who do not dare to make their decisions in the challenging conditions of the health system cannot make the right decisions, and, in many cases, ethics are not considered. Sometimes managers succeed in making a decision, but due to the existing limitations, they lack enough courage to implement it, making the decision ineffective [9, 17].
The challenge regarding managers’ ethical decision-making is that they often have enough knowledge to make ethical decisions under different circumstances [14], but their decisions do not have ethical consequences [12]. 
Ethical decision-making in managers is influenced by a lot of conditions and factors, many of which are related to the decision-making environment that consists of organizational constraints or requirements. Many factors are also ambiguous [15, 16]. One of the factors that may play an essential role in making ethical decisions by managers is the manager’s courage in making decisions [11]. In other words, only being aware of ethics cannot be a sufficient guarantee of ethical decision-making, and managers need other factors, including courage, awareness of ethical principles, and creativity to make ethical decisions [17]. Edmonson emphasized the importance of courage in managers and stated that courage is a multidimensional concept that can be manifested under various personal and professional factors [18]. Savel points to the challenges that nursing manager’s face in making ethical decisions and states that managers’ lack of awareness of ethical principles and lack of operational strategies for ethical decision-making in various clinical settings can challenge managers [19]. Also, when managers cannot make ethical decisions due to organizational barriers, they will suffer from moral distress [19]. Courageous individuals also make decisions that are in the best interests of others and aimed at achieving a moral outcome [20, 21].
A review of various studies indicates the importance of courage in the ethical performance of managers, but this concept has been studied more in nurses. Although many aspects of decision-making are shared between managers and nurses in ethical terms, managers have been more responsive to patients, senior executives, and staff due to their multilateral accountability, and thus ethical decision-making becomes more apparent to them. Considering that courage plays an essential role in ethical decision-making by managers and that this issue has received less attention from nursing managers, also, because it is impossible to explain the experiences of nursing managers through quantitative studies, so a qualitative study was used to conduct this study, this study aimed to explore the experiences of nursing managers about courage in ethical decision-making.
Materials and Methods
Based on the question of the present study, we used a conventional content analysis approach. The content analysis approach allows us to understand better the experiences of nursing managers’ courage in ethical decision-making.
Sampling was taken purposefully from nursing managers at three levels: head nurses, supervisors, and matrons who were either in managerial positions at the time of research or previously had management experience. In the process of sampling, in addition to collecting the consent of managers for participating in the research, they needed to have the ability to express their experiences. The research setting was Tehran and Shahrekord hospitals. To achieve maximum variation in sampling, nursing managers were selected with regard to maximum variation in age, gender, managerial experience, different levels of management, and the type of selected hospitals. Finally, 19 interviews with 19 nursing managers were taken until the data saturation was reached.
Semi-structured, in-depth, face-to-face interviews were used to collect data from individuals. The interview duration was 45 to 90 minutes, and the average duration of an interview was 57.77 minutes. The location and time of the interview were selected by the participants’ choices and for their convenience. At the beginning of the interview, the aim of the study was explained to the participants, and after receiving demographic information from the participants, the main questions of the interview were openly asked. Then based on the participant’s answers, the interview was continued with further questions to obtain more information about the participants’ experience regarding the considered concept. All interviews were recorded and conducted in the Persian language. Before the interview, the interview guide was prepared, and the interview process was started accordingly. Some of the interview questions were as follow:
1. Please share your experiences of ethical making decisions in different situations.
2. Please explain your experience and perception of courage in your decision-making.
3. Please explain the characteristics of courage in decision-making in your view as a nursing manager. Share your experiences in this field.
4. Do you have experience in having the courage to make ethical decisions? 
The interview process continued until no new categories were obtained; in other words, the data were saturated. To analyze data, we applied content analysis by use of Graneheim and Lundman [22]. Based on the stages of this method, the collected data were implemented by the researcher; also, the interview text was studied several times to obtain a comprehensive understanding of the content of the text. Then, the meaning units of the text and its initial coding were extracted. The codes were compared and, based on their similarities and differences, and their content was categorized. MAXQDA software version 10 was used to manage the data.
For the study to be rigorous, Lincoln and Guba criteria were considered [23]. For credibility, methods like a member check were used so that the text of the interview was returned to the participants after the coding, and the researcher wants to make sure that has gotten the correct understanding. The process of coding and analyzing data was also monitored by a professional research team that had sufficient experience in qualitative research, management, and ethics. Maximum variation was also observed in the sampling of nursing managers. To increase the fittingness, the researcher tried to document all stages of the research, including data collection, analysis, and the classification of categories and subcategories that are fully measurable by others.
The characteristics of the study participants are presented in Table 1.

The results disclosed two categories of decisiveness and obligation and 8 subcategories (Table 2).

Category 1: Decisiveness
Clearness in expressing decisions

Clear speaking from the perspective of nursing managers meant being able to express their views and opinions, even if they were contrary to the views of senior managers, without fear of losing their position. Also, managers must be honest in their interactions with superiors and other subordinates in the organization. The existence of openness in organizational interactions between the manager and others causes transparency in relationships, and the exchange of views and opinions does not take place in an aura of ambiguity. The explicit expression also makes others feel assertive in their decisions and behavior. One participant (Head nurse at governmental hospital, female, 37 years) stated:
“I had a staff member who was older than me and did not obey me because he was a man and had a lot of experience. One day I said emphatically that Sir ... if you cannot carry out my orders, you must change your unit. After that, his behavior changed, and the problem was solved”.
The ability of the manager to make decisions in critical and complex situations
Nursing managers must be able to make decisions in different situations. In many cases, managers are faced with situations that they have not experienced before or are critical situations and do not have much opportunity to make decisions. So the ability of the manager to make decisions according to ethical principles is essential. For example, a manager should be able to make good decisions in the face of delinquent or rogue staff in the department. Also, in the face of critical situations such as accidents where the volume of hospital visits is high, the manager’s power in making immediate decisions is of particular importance. One participant (Supervisor at governmental hospital, male, 32 years) stated: 
“One night, I was a supervisor. A child needed intubation, and I called everyone, but no one cooperated, and the anesthesiologist was not available. The head of the hospital could not do anything and gave me the authority. The situation was complicated, and I was alone. ... I immediately called several nearby hospitals ... and one of them accepted, and I took the child by ambulance, and the doctor did the intubation”.
From the perspective of nursing managers, authority means a kind of independence with self-confidence that managers experience in different situations of ethical decision making. The manager’s authority to make independent decisions and not to regret the decisions made, and to have self-confidence in making decisions in accordance with ethical principles is crystallized. A powerful manager can act independently with confidence in making decisions and therefore make decisions decisively in different situations according to ethical principles. One participant (Head nurse at governmental hospital, female, 39 years) stated: 
“I had a staff member in the emergency ward who did not work well. Of course, I was patient. One day the shift became very busy, and I said go to the triage and get to work. ... He quickly changed his clothes and wanted to leave his shift. I stood in front of him and said that if you leave your shift, this is the last time you will take a shift in this hospital and get back to triage quickly. When he saw my authority, he returned and started working”.
Category 2: Obligation
Decision-making as a religious responsibility

Nursing managers considered decision-making as a religious responsibility and stated that they felt responsible before God and should seek God’s approval in the process of moral decision-making. They also consider God to be in charge of their actions and therefore commit themselves to the observance of moral principles in decision-making. One participant (Head nurse at non-governmental hospital, female, 43 years) stated:
“I had a patient who had been discharged by a doctor because he could not afford it. The hospital director said the hospital was non-governmental, and we could not do anything. The patient’s bed was moved to the corridor. As a Muslim, my commitment did not allow me to let go, and I stood on top of him and took a pulse oximeter from another section. He died two hours later, though”. 
Follow the decision process 
One of the duties of committed and responsible managers is to follow the process of their decisions until the desired results are achieved. In this regard, managers have expressed issues such as continuous follow-up of claims and actions to solve the problem. Pursuing the decisions can be due to the sense of commitment and responsibility that the manager has towards making ethical decisions in different situations and makes continuous efforts and follow-up to achieve ethical results in the field of decisions made. One participant (Supervisor at non-governmental hospital, male, 40 years) stated:
“We had a patient who had just gotten out of the operation room. During the shift change, I realized that he was as pale as a wall. I asked his nurse about his blood pressure, and she said that Mr, such and such measures had been taken and had said that he was alright. I realized that she didn’t care that much, so I told her to take his blood pressure anyway. His pressure was low, so we checked his bandage and saw that it was soaked in blood. I immediately called the doctor out of his meeting to tend to the patient”.
Being responsible 
One of the main characteristics of ethical managers is their responsibility. Nursing managers state that being accountable for the decisions a manager makes and also not blaming others for the results of decision-making and monitoring and pursuing decisions directly to achieve the goal is one of the issues that are considered in the ethical decision-making process by committed managers. In fact, a manager’s sense of responsibility ensures that the ethical decisions made are enforceable and that mistakes are prevented. One participant (Supervisor at governmental hospital, female, 24 years) stated:
“One night a female nurse came to my room and said that my head nurse gives me too many shifts and does not observe justice ... I told myself that I was checking the shift; otherwise I was wrong! ... I checked the whole program until 4 in the morning, and then I proved to him with evidence that he had not misunderstood”.
Making compensatory decisions 
One of the essential issues for nursing managers is the decisions they make to make up for past wrong decisions. In other words, managers try to correct the mistakes of the decisions made and correct the mistakes and negative points of the decisions made by making new decisions. This action is an ethical process in managers’ decision-making and reduces the achievement of unethical results. One participant (Supervisor at governmental hospital, Male, 32 years) stated:
“When I entered the ward, I saw two of the staff arguing loudly. I also wrote a negative score for both of them in the notebook without asking them anything. I later found out that one of them was not at fault, and I apologized to him and tried not to evaluate anyone without asking and getting information”.
Making preventive decisions
One of the actions of committed managers is to try to prevent wrong decisions. Nursing managers state that when faced with adverse outcomes, they try to prevent mistakes in future decisions. Strictness in the decision-making process, modification of the work process, review of the situation, and analysis of the results of past decisions by managers are considered as measures for preventive decision-making. It should also be said that managers, according to ethical principles, try to make decisions that prevent mistakes, and therefore preventive decisions are an essential part of the performance of ethical managers. One participant (Head nurse at governmental hospital, female, 43 years) stated:
“When I got to the bed, I saw a patient who had fallen out of bed and... it is not right to blame him here. Considering that it had been repeated several times in the previous week... I checked and saw that there was no defect in the nurse, and he was lowering the bed guard with the patient due to lack of awareness. Therefore, to prevent this, we decided to train with the patient”.
Examination of the experiences of nursing managers in the field of courage indicated two categories of obligation and decisiveness. The decisiveness category includes subcategories of clearness in expressing decisions, the ability of the manager to make decisions in critical and complex situations, and authority. In analyzing the concept of courage, Numminen et al. pointed out features such as responsibility and personal commitment and perceiving commitment as an intrinsic motivating force that drives people toward their goal [17]. Moosavi and Izadi introduced one of the concepts of moral courage, namely ethical performance traits, which means courageous action [24]. In their instruments, Abadi et al. referred to the concept of breaking social norms as a part of moral courage [25]. It must be said that the assertiveness and commitment in this study are in line with the studies of the concept of courage in moral decision-making. 
Edmonson viewed managers’ training for assertiveness and openness of speech, and confidence in decision-making as effective in their courage [18]. Cipriano considered the role of empowerment and authority necessary in ethical decision-making and argued that ethical knowledge alone could not guarantee moral action [26]. In the meantime, the concept that contributes to ethical performance is the ability and authority of individuals along with their commitment. Lachman et al. stated that self-esteem is influenced by factors, such as physical and psychological abilities, which can lead to authority in decision-making, and assertive individuals can show their courage because of their confidence in their abilities [27]. Also, Hawkins and Morse saw moral courage as a factor that enables nurses to resist and oppose practices that endanger patients [28]. In analyzing the results, it must be said that the concept of courage cannot be made clear without concepts such as self-esteem and assertiveness, and courageous individuals can independently determine their performance, which can increase their confidence in a rotating fashion.
The obligation category includes subcategories of decision making as a religious responsibility, follow the decision process, being responsible, making compensatory decisions, and making preventive decisions. Numminen et al. and Moosavi and Izadi argued that moral courage is one of the moral concepts to pay attention to, and nurses need the inner strength to act as a guide to deal with ethical decision-making when faced with challenges [17, 24]. In this regard, it must be said that having a sense of commitment is an intrinsic factor that serves as a precursor to moral courage and reduces moral error in decision-making. Clarke stated that people’s attitudes and perspectives are a decisive internal factor that makes people behave courageously in different situations. In this regard, the environmental and nurturing conditions of individuals, by influencing their attitude and value system, can affect their commitment and, therefore, their courage [29]. Given that Iran has an Iranian and Islamic culture and the role of religion in their culture is strong, the role and importance of religious principles as a basis for ethical principles in the creation of individual commitment cannot be ignored. 
Engelhardt viewed the decision-making process and the manager›s sensitivity to the results of the decisions as part of their professional commitment and stated that managers must have carefully considered the decision-making process to ensure the right decisions and outcomes, considering the preventive measures needed to reduce ethical error [11]. Hoseini and Ebadi argued that courageous managers are sensitive to the outcomes of decisions due to their internal commitment and are constantly seeking to refine their decision-making processes [30]. In general, it should be said that the manager›s sensitivity to the correctness of the decisions made is an influential factor in preventing ethical error in decision-making and that the brave managers consider the prevention and compensation cycle in their decisions, and their main goal is to improve decision-making.
According to the results, some courageous managers can make firm decisions and prioritize collective interests over individual resources through a sense of commitment and internal and professional responsibility. It should also be said that the commitment of Muslim managers can be regarded as a religious responsibility, thus guarantee their adherence to ethical principles when making decisions.
Given that commitment and assertiveness are intrinsic characteristics of individuals, strategies can be used to enhance these concepts and consequently the courage of managers to make decisions. Educating and sensitizing managers to ethical issues and challenges and enhancing their insights into ethical issues using problem-solving and role-playing methods can play an essential role in promoting managers› commitment and responsibility. Also, using methods to enhance managers› self-confidence and taking specialized management courses to empower them to make decisions can enhance their assertiveness. Moreover, health systems need to reduce the organizational and professional constraints on ethical decision-making so that managers can make the right decisions with courage.
In this study, we concluded that from the perspective of nursing managers, a brave manager in making ethical decisions is a manager who commits to make a decision and the determination to make their decision a reality. 
Due to limitations, the study of ethical concepts in individuals and the expression of their experiences was difficult because they usually interpret and express ethics according to their attitudes and knowledge. Individuals also refer to their positive experiences and refuse to talk about their futile experiences or those that were not in accordance with ethical principles. This is one of the challenges of studying ethical concepts, and the researcher has worked hard to write neutral and indirect questions about the managers› ethical experiences. Moreover, the usage of a qualitative approach limits the generalizability of the findings.

Ethical Considerations
Compliance with ethical guidelines

Tarbiat Modares University approved the study (IR.MODARES.REC.2018.025). This study adhered to the principles of the Helsinki Declaration [31]. The ethical principles of autonomy, confidentiality, and anonymity were considered for the participants. To enter the study, all participants were asked to provide oral and written informed consent, and their participation in the study was optional. The participants were assured of the confidentiality of the interviews and their anonymity. The text of the interviews was also implemented anonymously with a code. The anonymity of the citations was also taken into account in the presentation of the results.

This study was funded by Tarbiat Modares University.

Author's contributions
Writing the original draft: Mostafa Roshanzadeh; Designing the study process: Zohreh Vanaki and Afsaneh Sadooghiasl; Data collection and analysis: Mostafa Roshanzadeh; Reviewing the final edition: Ali Tajabadi and Mostafa Roshanzadeh; Article translation and final linguistic editing: Somayeh Mohammadi and Ali Tajabadi; Final revision: All authors.

Conflict of interest
The authors declared no conflicts of interest.

The authors would like to thank and appreciate all the nursing managers who participated in this study and Tarbiat Modares University and Shahrekord University of Medical Sciences.

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Article Type : Applicable | Subject: Special
Received: 2021/11/29 | Accepted: 2021/07/26 | Published: 2021/10/1

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