Investigate the state of critical thinking and its impact on moral courage and moral sensitivity; evidence from nurses’ perspective

Critical thinking is one of the types of thinking in the field of education, which is of special importance [1]. The skill of critical thinking is essential in today’s society, and a deficiency in this skill can limit individuals from effectively participating in communities [2]. Nowadays, critical thinking is not only accepted as a vital aspect of nursing but also suggested to be a distinctive way of processing information within the nursing field. This process is dependent on individual skills like intelligence, knowledge, creativity, experience, understanding, and logic [3]. Critical thinking is a complex mental process that seems to require cognition at high levels of learning and is used in nursing practice for clinical decision-making [4]. Nurses should have the skill to make decisions in high-risk clinical scenarios and a predisposition to enhance critical thinking skills [5]. A nurse with a keen interest in critical thinking can enhance her abilities, apply her expertise, and efficiently complete her duties by making precise and prompt judgments. One of the fundamental aspects of successful decision-making is intelligence [6]. Some studies show that nurses’ critical thinking can directly affect the safety and improvement of the patient’s condition [7, 8]. Therefore, they must be able to understand changes in patients’ conditions, carry out nursing interventions independently, accurately follow medical orders, and prioritize nursing actions [7, 8]. Furthermore, critical thinking application leads to the improvement of problem-solving efficiency, nursing judgment skills, and clinical service quality [9]. Gaining critical thinking skills in nursing is associated with positive outcomes such as patient-centered care, creativity, evidence-based practice, and professionalization in the field [10]. Nurses who apply critical thinking abilities while providing care exhibit increased assurance in their decision-making and are capable of justifying their choices [10]. Therefore, utilizing this skill is effective in making accurate clinical judgments and managing patients in critical and stressful situations [11]. This is why it is necessary to measure and examine the critical thinking status of nurses. Although today the importance of critical thinking and its impact on the quality of nursing care is not hidden from all educational officials and planners; The results of some studies show that nurses’ critical thinking ability is not at an optimal level [12‐14]. The use of critical thinking seems to be a crucial element in helping nurses maintain professional ethics standards when dealing with challenging ethical dilemmas [15]. In this regard, it should be mentioned that before performing an ethical action, nurses must determine whether that action is reasonable and meaningful or not [16]. In this situation, they should follow a critical thinking process to make a decision [17]. Critical thinking is very important for nurses because it enables ethical action in ethical situations [18]. In the field of nursing practice, nurses with critical thinking are needed to be able to demonstrate expertise by helping with accurate evaluation and judgment in the process of solving nursing problems as the subject of ethical decision making [19].

Nurses are encountering intricate ethical and spiritual dilemmas more frequently as a result of their professional position and responsibilities [20]. Ethical dilemmas arise from the excessive treatment of terminally ill patients, unnecessary medical examinations, fraudulent behavior in test administration and reporting, inadequate care, unequal power dynamics among staff, lack of support from the organization, and the pain and distress caused by aggressive diagnostic and therapeutic interventions aimed at fulfilling the organization’s needs [21, 22]. Also, the lack of number of nurses, the unequal power of the health team members, and the ineffectiveness of managers in such moral situations, caused nurses to face inappropriate moral conditions in hospital environments [23]. This is because nurses are often faced with conflicting values ​​and beliefs of other health care providers to do the right thing, and these challenges affect the delivery of quality nursing care [24]. In this situation, nurses, as moral agents, need moral courage and breadth of vision to properly manage moral dilemmas and professional commitment to patients [25]. Recent research in England and Ireland has demonstrated inadequacies in the healthcare delivery system [26]. High mortality rates and cases of patient neglect were observed in a hospital in England during a different research investigation [24]. In a study by Black, around 34% of nurses opted not to report the injury to the patient, despite being informed about it [27]. Considering the silence of health workers in front of these problems, the question comes to mind, why is there no courage to say that these things are not correct [26]. When a person is not able to perform the correct moral action, moral courage helps him to strive to achieve the ultimate goal regardless of the consequences and take the right action which is not easy to do, considering the moral principles [28]. Nurses with strong moral courage can apply ethical principles effectively in various clinical scenarios [28]. High moral courage from nurses leads to making the best decisions according to ethical principles in different clinical situations [29]. Conversely, nurses with low moral courage may lead to neglect patients’ emotions and feelings, lack of attention to their privacy, disregard for their self-esteem, and clinical mistakes [30]. In relation to moral courage, it should be explained that learning critical thinking can be the foundation for creating this courage [31]. Nurses who have the ability to think critically by applying logic and reasoning, posing key questions and analyzing all the information needed in the work environment, gain the courage to overcome fear and do the right thing based on moral beliefs, despite the existence of potential threats [29].

Effective moral behavior hinges on the comprehension of moral principles and the cultivation of moral sensitivity [32]. Moral sensitivity allows individuals to discern moral complexities and view them through an ethical perspective [33]. This sensitivity, which is a combination of a person’s awareness of moral dimensions such as tolerance, calmness, responsibility, and giving importance to moral issues, is reflected in a person’s concerns about acting for others and helps people to distinguish between right and wrong actions [9]. The moral sensitivity of nurses often plays an important role in fulfilling their professional responsibility and making ethical decisions. In other words, it is the first component to comply with ethics in nurses’ medical care and is considered as one of the criteria of nurses’ professional competence. Various studies show the effect of moral sensitivity on improving the moral performance of nurses and improving the therapeutic relationship between nurses and patients; For this reason, nursing education organizations should pay attention to this important goal in their planning [33]. The framework of nursing activity includes the commitment to care and being sensitive to the physical and emotional needs of patients. As a result, moral sensitivity and sense of responsibility in those who provide clinical care to patients based on ethical values ​​is of particular importance [34]. Moral sensitivity requires caregivers to be aware of and interpret the behaviors and verbal and non-verbal signs of patients to understanding their needs. Moral sensitivity and sense of responsibility are of particular importance for nurses, who provide care based on personal moral values [27, 28, 32]. In this regard, critical thinking, as the ability to think in a clear and logical way, can help the sensitivity of nurses in the moral dimension. The study conducted by Kim (2015) indicated that nurses in their work environment, by using logical judgment and solving problems derived from critical thinking, can face and manage ethically problematic situations more sensitively [35]. Also, the findings of Je’s study (2021) indicated that critical thinking can help nurses make ethical decisions in clinical situations [36].

Despite examining the variables of critical thinking, moral courage and moral sensitivity separately in past studies, the relationship between this type of thinking and the above ethical considerations among nurses has not been widely reported in the relevant literature. Considering the importance of critical thinking, moral courage, and moral sensitivity in increasing the performance and quality of nursing services, as well as conducting few studies in the field of simultaneous investigation of these three variables, therefore, this study aims to determine the state of critical thinking and its effect on moral sensitivity and moral courage. It was conducted in nurses working in hospitals covered by Jiroft University of Medical Sciences in southern Iran in 2024. It should be mentioned that this study is different from the few previous studies in terms of methodology and the use of regression analysis. Thus, in addition to examining the correlation between the main variables of the research using the correlation coefficient, in the present study, regression analysis was used to test the effect of critical thinking on moral courage and moral sensitivity. An issue that has not been paid much attention to in previous studies. The findings of this study, while helping to expand the knowledge about the investigated variables in the field of nursing, increase the knowledge of managers and policymakers of the health system about the impact of critical thinking on moral sensitivity and moral courage in the nursing community. Also, according to the main goal of this research, the findings can be the basis for planning to improve the sensitivity and moral courage of nurses.

The average age of the nurses participating in the study was 30.41 ± 8.15 years and most of them (62.60%) were in the age group of less than 30 years. The average work experience was 5.87 ± 4.29 years and most of them (77.14%) in the group had less than 10 years of work experience. 66.49% were female and the rest were men. Most of the studied nurses were in the project-based employment status (63.89%) and married (68.57%) (Table 1).

The average score of critical thinking, moral courage, and moral sensitivity of the studied nurses was 188.16 ± 8.22 out of 450, 62.32 ± 7.45 out of 105, and 71.55 ± 6.39 out of 100, respectively, which indicates the level of critical thinking was weak and the level of moral courage and moral sensitivity of nurses was moderate (Table 2).

Based on the results, a statistically significant correlation was observed between critical thinking with moral courage (r = 0.574 and P < 0.001) and moral sensitivity of nurses (r = 0.611 and P < 0.001). In this way, probably the nurses who had critical thinking had more moral courage and greater moral sensitivity (Table 3).

The results of multiple linear regression analysis to determine the simultaneous effect of different dimensions of critical thinking and demographic variables on the moral courage and moral sensitivity of the nurses showed that the significant variables in the model, which were determined using the Enter method, in the order of importance were truth-seeking, inquisitiveness, analyticity, systematicity, self-confidence, cognitive maturity, open-mindedness, employment status, age and work experience (for moral courage), and truth-seeking, inquisitiveness, analyticity, systematicity, self-confidence, cognitive maturity, open-mindedness, work experience, age, employment status, and gender (for moral sensitivity).

The β values ​​related to the influencing variables that indicate the priority of influencing moral courage and moral sensitivity are given in Table 4. Also, this test showed that the coefficient of determination of the processed model (R² Adjusted) for moral courage and moral sensitivity is equal to 0.69 and 0.73, respectively. This means that 69% and 73% of the changes in the moral courage and moral sensitivity scores of nurses can be explained by the variables in the model. The linear equation of the score of moral courage and moral sensitivity of nurses can be explained by the variables in the model. This equation was obtained based on multiple regression analysis as follows:

Based on the findings of the study, the average score of critical thinking was significantly different based on the variables of age (p = 0.004), gender (p = 0.01), and employment status (p = 0.01). Thus, the average score of nurses’ critical thinking increased with age. Also, critical thinking was more in female nurses (189.05 ± 8.63 out of 450) and with permanent employment status (189.26 ± 7.42 out of 450) than others. Also, the mean score of moral courage of nurses was significantly different based on the variables of age (p = 0.02) and work experience (p = 0.04). So that the average score of moral courage of nurses increased with increasing age and work experience. Also, the moral courage of married nurses (62.88 ± 7.05 out of 105) and with permanent employment status (63.12 ± 7.88 out of 105) was higher than others. Finally, the average moral sensitivity score of the examined nurses was significantly different based on the variables of age (p = 0.03), gender (p = 0.04), marital status (p = 0.03), work experience (p = 0.007), and employment status (p = 0.04). In this way, the average moral sensitivity of nurses increased with age and work experience. Also, the moral sensitivity of female nurses (71.93 ± 6.34 out of 100), married nurses (72.08 ± 6.47 out of 100) and with permanent employment status (72.16 ± 6.35 out of 100) was higher than others (Table 5).

Based on the results, the critical thinking of the studied nurses was estimated at a weak level. In Hasanpour et al.‘s study (2016), the average critical thinking score of nurses was lower than the desired level [42]. In the review study by Ebadi et al. (2012), the results of the studies have shown that the level of critical thinking skills of graduate nurses is low [12]. The findings of the study by Babamohammadi et al. (2018) also indicated that the critical thinking score of nurses in internal surgery and special departments was weak [13]. The results of Karimi et al.‘s study (2013) also indicated the weak critical thinking ability of most clinical nurses [14]. Also, in the study of Kerman Saravi et al. (2011), the level of critical thinking of first year, fourth year nursing students and clinical nurses was reported to be weak [43]. The review of studies in the review article by Khandan et al. (2020) also shows that nursing students have a weak ability to understand critical thinking and their attitude is shaky [44]. Therefore, the results of all the mentioned studies are the same as the results of this part of the findings of the present study. In this regard, it can be stated that the reasons are the lack of professional independence of nurses in Iran and the reliance on the implementation of medical orders, as well as the absence or lack of nursing care based on the nursing process, which requires the ability to think logically; It has led to the weak ability of critical thinking in nurses. The educational approaches in schools and pre-university settings, along with the standard university programs, could be inhibiting the advancement of critical thinking abilities. Also, maybe the way of teaching in schools and before entering the university and the common educational programs being implemented during the university study period are such that it hinders the development of critical thinking.Based on part of the results of the study by Davari Dolatabadi and Ziaeirad (2021), the average critical thinking score of nurses had a favorable level [45]. The results of the study by Jafari et al. (2019) showed high critical thinking in the nurses participating in the study [46]. The results of the studies mentioned are incongruent with the findings of this part of the current study, and this inconsistency may be linked to factors such as the distinct research setting, tools employed, and participant entry and exit conditions.

The findings of the present study also showed that the average moral courage of the investigated nurses is at a moderate level. Studies by Mohammadi et al. (2014) [39], Hoseini et al. (2019) [47], Aminizadeh et al. (2017) [48], Moosavi et al. (2017) [49], Taraz et al. (2019) [50], Hannah et al. (2011) [51], and Safarpour et al. (2020) [52] have reported the level of moral courage in nurses at a moderate level. Therefore, the results of the mentioned studies are in line with the results of this part of the findings of the present study. Factors such as limitations in management and organization, poor institutional leadership, and non-adherence to professional standards are among the reasons for the moderate moral courage displayed by nurses. The majority of nurses demonstrate honesty in their work; however, various obstacles such as organizational structures often compel individuals to inhibit their ethical inclinations before taking action. On the other hand, the results of the study by Khajevandi et al. (2020) indicated that the average moral score of the nurses under study was high [53]. Namadi et al.‘s study (2019) has shown that the moral courage of nurses has a favorable level [54]. Mahdaviseresht et al.‘s study (2014) also reported the level of moral courage of nurses as favorable [40]. The results of these mentioned studies are inconsistent with the results of this part of the findings of the present study. The reasons for the difference in the moral courage of nurses in different studies can be considered to be the difference in organizational culture, the support of nurses and managers of the organization, the importance of job retention and the fear of being rejected. Also, this difference in the results can be caused by the environmental factors of the nurses’ workplace and different tools for measuring moral courage.

According to the results of this study, the average moral sensitivity of nurses was also at the moderate level. The results of studies by Izadi et al.(2013) [55], Chaloner(2007) [56], Abbaszadeh et al.(2010) [57], Hassanpoor et al.(2011) [58], Jaafarpour and Khani (2012) [59], Kobrai et al. (2021) [60], Mostafavian et al. (2019) [61], and Sharifi et al. (2020) [62], and Hosseinabadi et al. (2020) [63] showed that nurses have a moderate level of moral sensitivity. Therefore, the results of the mentioned studies are consistent with the results of this part of the present research. However, some studies have reported different results. Zuzelo (2007) in a study he conducted in the United States, reported the moral sensitivity of nurses as high [64]. Filipova (2009) showed that nurses do not have enough moral sensitivity to make decisions [65]. In the study of Kim et al. (2005), the mean moral sensitivity score of average nurses was reported to be high [66]. In the explanation of this part of the study, it can be stated that the average level of moral sensitivity of nurses indicates the relative importance given by nurses to complying with ethical principles in providing care to patients. In this regard, Ahn (2010) stated that nurses usually have a sense of responsibility and moral sensitivity, but the main moral difference between them is in adhering to this sensitivity in challenging situations [67]. Therefore, it is very important for nurses to become familiar with the principles of nursing ethics. The moral sensitivity of nurses is likely to be impacted by a combination of factors, including cultural influences, working environment conditions, educational background, ethics training, nursing workload, and patient volume.

Another part of the findings of the present study showed that there is a positive and significant correlation between critical thinking and moral courage and moral sensitivity of the studied nurses. This means that nurses with high critical thinking had higher moral courage and moral sensitivity. Based on the findings of Lim’s (2016) study, moral sensitivity and critical thinking were among the factors affecting perceived moral trust in nursing students under study [68]. Taghavi et al.‘s study (2022) showed a positive correlation between moral sensitivity and moral courage [69]. According to the results of Dehghani et al.‘s study (2017), one of the most important factors that facilitate compliance with ethics in nursing is the ability to think critically [15]. However, in the study of Ahn and Yeom (2014), a negative correlation was observed between moral sensitivity and critical thinking [70], which is contrary to the results of the present study; One of the reasons for this difference can be the target population and sample of the two studies. Also, Ahn and Yeom (2014) focused on final-year nursing students who, according to the authors, had not yet completed their ethics courses [70].

Marquis and Huston (2012) have listed critical thinking skills as one of the skills needed by supervisors [71]. In the clinical field, nurses are frequently confronted with unpredictable, urgent, and anxiety-inducing situations, requiring prompt, brave, and ethical decision-making. In the clinical field, nurses are faced with unpredictable, urgent, and anxiety-provoking situations every moment, which require immediate, timely, and courageous decision-making taking into account ethical criteria. Therefore, nurses must have critical thinking skills to overcome these problems and make brave decisions [71]. Unfortunately, nursing graduates are not able to think and make independent and appropriate decisions to solve patients’ problems and face critical cases, and most of the time they are unquestioning executors of doctors’ orders, which can lead to providing undesirable care to patients. Currently, there is a need for nurses who can provide multidimensional and specialized care in diverse and often unfamiliar environments, nurses who can deal with these complex changes with high levels of thinking and reasoning power. In addition, the uncertain and changing conditions of patients require that nurses are decision-makers with enough courage to be able to respond to the needs of their patients [72].

One of the limitations of this study is the quantitative methodology and data collection through questionnaires, which can affect the findings’ limitations and weak generalizability. Conducting qualitative research related to the study’s topic and also the use of structural equations modeling in examining the relationships between three variables can partially address this limitation, as it may reveal new dimensions of hidden and unexpressed findings. Another limitation of the present study is its cross-sectional design, so caution should be taken in generalizing the results.

The low level of critical thinking of nurses in this study indicates that the nurses under investigation have not received the necessary and sufficient training in the field of skills and knowledge of the concept of critical thinking. On the other hand, the existence of restrictive rules and guidelines has prevented the development of critical thinking and its components, including increasing decision-making power, self-confidence and growth, as well as the ability to analyze information in nurses. Nurses who do not use critical thinking skills in their care have less self-confidence in the decision-making process and cannot defend their decisions. Also, the average levels of variables of moral courage and moral sensitivity in the studied nurses indicate that moral issues are relatively important for nurses in facing the problems of patients. It can be manifested by nurses through supporting, promoting, and maximizing health and ability, preventing illness and injury, facilitating recovery, and alleviating the pain and suffering of patients. Finally, the positive and significant correlation between the variables of the research indicates that nurses who have critical thinking skills have more sensitivity and precision in their clinical and care decisions in dealing with patients and have the courage to make decisions. They have more suitable ways to improve the health level of patients.