The predictive role of moral courage in guilt feelings and occupational hardiness among NICU nurses
- Open Access
- 31.01.2026
- Research
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Abstract
Introduction
The survival rate of premature and low birth weight infants has increased in recent decades due to technological advances and improvements in neonatal intensive care [1]. Providing the necessary basic care to sustain life and support normal growth and development typically requires hospitalization in the neonatal intensive care unit for a period ranging from several days to several months, depending on the degree of prematurity or medical conditions [2]. According to the World Health Organization report, about 9.5–10% of births were preterm in 2020, which corresponds to roughly 13–14 million babies. Preterm birth remains a major global health issue, and outcomes vary widely by setting. In many low-income countries, survival of very preterm infants (< 32 weeks) is substantially lower than in high-income countries, underscoring the importance of advanced neonatal care and public health interventions [3].
These conditions make neonatal intensive care units among the most complex and demanding clinical environments. Providing care in neonatal intensive care units can be very stressful for the healthcare team, as managing premature infants with special and complex needs is a very difficult task and poses many challenges in care [4]. Neonatal nursing, involving close collaboration with families in distress, has a significant emotional impact on nurses, and there is a need to develop interventions to support and educate nurses in this aspect of their work [5]. Neonatal nursing care for newborns with fragile physiology and often in high-stress environments increases the risk of burnout [6].
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Considering the likelihood of errors occurring in such a complex environment, the tendency to experience pathological guilt may arise in nurses and harm their health [7]. Guilt is an emotional state, and the sense of failing in dealing with a task and performing a wrong action is inferred from it [8, 9]. In the nursing profession, due to the responsibility for the lives of others, in situations where an error or mistake occurs in patient care, the feeling of guilt can be acute and significant [7]. Healthcare providers can be regarded as ‘second victims’ after adverse events, often experiencing guilt, shame, and grief [10]. Nurses who experience pathological guilt may compromise their healthy and purposeful life [7]. When nurses experience persistent or excessive guilt, their well-being and sense of professional purpose may be undermined, potentially jeopardizing the quality of care they provide [11].
Nurses face numerous stressors, including long hours, the need to remain focused, and the emotional demands of caring for patients [12]; therefore, guilt among nurses can arise from work challenges, the high stress of patient care, burnout, and bereavement from patient death. Excessive or pathological guilt is often linked to depressive symptoms, and greater levels of pathological guilt are associated with more severe depression [13].
Meanwhile, occupational hardiness, a trait increasingly recognized as important for coping with stress, is thought by many to help healthcare workers resist job-related stress [14]. When occupational hardiness increases, well-being and self-esteem tend to rise, highlighting the importance of measuring and evaluating this construct in healthcare environments [15]. Professional hardiness is one of the personality traits that enables nurses to withstand difficulties and maintain their mental health [16]. Hardiness indicates that the individual can, to a large extent, control themselves or situations, trust in their abilities and talents, and not give up on striving toward their goals [17].
Nurses with higher levels of occupational hardiness tend to feel committed to their roles, adopt solution-focused coping strategies, and perceive stressful events as manageable and meaningful. This helps them experience less psychological tension when dealing with unexpected and unpleasant events and maintain their mental health [18]. In contrast, individuals with low professional hardiness feel less control over events and circumstances around them, and unexpected changes in life will be more challenging for them. Therefore, they will experience more stressful conditions and severe anxiety [19].
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Nurses frequently encounter ethical tensions in neonatal intensive care units, and the suffering caused by these challenges has motivated the nursing profession to identify effective strategies for addressing them. In this context, experts increasingly recognize moral courage as a powerful approach to managing ethical difficulties and consider it an essential component of nursing practice across all areas and levels [20, 21]. Moral courage means acting based on moral values despite difficulties during moral dilemmas [21]. Low levels of moral courage in nurses may result in ethical neglect, reduced attention to patient dignity, and an increased risk of clinical errors [22].
In contrast, moral courage leads to internal satisfaction for nurses and acts as a protective shield for patients [23]. Improving the level of moral courage and ethical sensitivity in nurses can increase the quality of care and enhance patient safety [20]. Due to the special conditions of patients in neonatal intensive care units and the existence of ethical challenges—such as complex care processes, multidisciplinary interactions, and emotionally demanding decision-making—the need for moral courage in these units is particularly evident, as these factors can affect team performance and neonatal care outcomes [24].
Although previous studies have examined moral courage, guilt, and occupational hardiness among nurses working in adult hospital units, evidence focusing specifically on NICU nurses remains limited. This gap is noteworthy given the high levels of stress and ethical challenges reported among NICU nurses. Therefore, the present study aimed to examine whether moral courage predicts guilt feelings and occupational hardiness among nurses working in neonatal intensive care units.
Methods
Design and setting
We conducted a descriptive–analytical study in the neonatal intensive care units (NICUs) of three tertiary, university-affiliated hospitals in Shiraz, Iran—Namazi (4 NICU wards), Hazrat Zeinab (4 NICU wards), and Hafez (2 NICU wards). All units provide similar levels of intensive neonatal care and operate across morning, afternoon, and night shifts.
Participants
Eligible participants were registered nurses working in the NICUs of three tertiary hospitals, each with at least one year of NICU work experience. Additional inclusion criteria included willingness to participate and absence of severe physical illnesses or self-reported psychological disorders.
Sampling
We used a quota sampling strategy to ensure proportional representation across the hospitals based on the number of active NICU wards in each center. Therefore, approximately 40% of the sample was allocated to Namazi (4 wards), 40% to Hazrat Zeinab (4 wards), and 20% to Hafez Hospital (2 wards). The final distribution of participants closely matched this planned proportion.
Sample size and attrition
A priori sample size was calculated using G*Power based on a correlation of r = 0.25 between moral sensitivity and moral courage [20] with α = 0.05 and 90% power, yielding a minimum of 164 participants. To account for potential attrition, the target sample was increased to 180. After excluding six questionnaires with more than 20% missing responses, 174 completed questionnaires were retained for analysis, which exceeded the required number.
Instrumentation
Demographic questionnaire
A researcher-designed demographic form collected data on age, gender, marital status, education level, work experience, and employment status. Faculty members specializing in neonatal and pediatric intensive care nursing reviewed and approved its face validity. Participants self-reported any history of severe physical illness or psychological disorders.
Professional moral courage questionnaire
The Professional Moral Courage Questionnaire was originally developed by Sekerka et al. (2009). This 15-item questionnaire assesses moral courage on a 5-point Likert scale (1 = never true to 5 = always true), yielding a total score between 15 and 75. Scores of 15–25 indicate low, 26–50 moderate, and 51–75 high moral courage. The original tool demonstrated acceptable validity and reliability with Cronbach’s alpha above 0.80 [25]. In Iran, it reported a content validity index of 0.81 and a Cronbach’s alpha of 0.85 [26].
Guilt questionnaire
The Guilt Questionnaire by Kugler and Jones (1992), and the Occupational Hardiness Questionnaire by Moreno-Jiménez et al. (2014). This 45-item tool measures guilt across three subscales using a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree), with total scores ranging from 45 to 225. Scores of 45–75 indicate low guilt, 76–150 moderate guilt, and above 150 high guilt. Original reliability values ranged from 0.78 to 0.86 [27] and in Iran, validity and test–retest reliability (0.68–0.79) were confirmed [28].
Occupational hardiness questionnaire
This 17-item instrument evaluates control, challenge, and commitment using a 4-point Likert scale (1 = strongly disagree to 4 = strongly agree). Total scores range from 17 to 68. Scores of 45 and above indicate occupational hardiness. Original validation reported Cronbach’s alpha between 0.74 and 0.80 for subscales and 0.86 for the total score [29]. Furthermore, Lucino-Moreno and colleagues in 2020 conducted the validation of this questionnaire in a sample of 212 police officers in Spain. They found appropriate validity results and confirmed the reliability with Cronbach’s alpha coefficient ranging between 0.81 and 0.87 [30]. In Iranian studies, reliability coefficients ranged from 0.75 to 0.88, with a total alpha of 0.78 [31].
The questionnaires were administered in hard-copy paper format. Nurses who met the inclusion criteria were randomly selected within each hospital. All questionnaires were completed in a single session, and only those with fully completed items were included in the final analysis.
Data collection
Following ethical approval (IR.SUMS.NUMIMG.REC.1402.142) and institutional permissions, we obtained written informed consent from participants. Data were collected across all shifts using the three self-administered questionnaires.
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Ethical considerations
Approval was granted by the Ethics Committee of Shiraz University of Medical Sciences. Assigning codes to questionnaires ensured confidentiality and anonymity and secure data storage. All procedures adhered to relevant ethical guidelines.
Statistical analysis
Data were analyzed using SPSS version 23. Descriptive statistics were used to summarize the demographic characteristics and main study variables. Spearman’s rank correlation test was applied to examine the relationships among the quantitative variables (moral courage, guilt feelings, and occupational hardiness). In addition, Multiple Linear regression analysis was conducted to assess predictive relationships. A p-value of < 0.05 was considered statistically significant.
Findings
The demographic characteristics of the study sample are presented in Tables 1 and 2. A total of 174 nurses working in neonatal intensive care units participated in the study. The quantitative variables, including age and work experience, are summarized in Table 1.
Table 1
Determination of quantitative demographic variables of nurses working in neonatal intensive care units
Variable | Number | Minimum | Maximum | Mean | SD |
|---|---|---|---|---|---|
Age | 174 | 22 | 56 | 31.44 | 6.28 |
Work Experience | 174 | 1 | 27 | 7.90 | 6.04 |
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Most participants were in their early thirties, with an average work experience of approximately 8 years.
The qualitative demographic characteristics, including marital status, educational level, work shift, hospital affiliation, and employment type, are presented in Table 2.
Table 2
Determination of qualitative demographic variables of nurses working in neonatal intensive care units
Variable | Category | Number | Percentage |
|---|---|---|---|
Marital status | Single | 75 | 43.2 |
Married | 99 | 56.8 | |
Education | Bachelor’ Degree | 155 | 89.1 |
Master’s Degree | 19 | 10.9 | |
Work shift | Morning | 4 | 2.3 |
Afternoon | 5 | 2.9 | |
Rotating | 165 | 94.8 | |
Hospital | Namazi | 69 | 39.7 |
Hazrat Zeinab | 66 | 37.9 | |
Hafez | 39 | 22.4 | |
Employment type | Temporary | 52 | 29.9 |
Project-based | 15 | 8.6 | |
Contractual | 19 | 10.9 | |
Official | 88 | 50.6 |
The majority of nurses were married, held a bachelor’s degree, worked in rotating shifts, and were employed on a permanent basis. All participating nurses in this study were female. In terms of hospital distribution, most participants were working at Namazi Hospital.
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Table 3 shows the mean scores of the main study variables) moral courage, guilt feelings, and occupational hardiness (among nurses working in neonatal intensive care units, providing a summary of their overall levels.
Table 3
Mean scores of moral Courage, Guilt, and occupational hardiness in nurses working in neonatal intensive care units
Variable | Minimum | Maximum | Mean | SD |
|---|---|---|---|---|
Moral courage | 15 | 75 | 58.75 | 7.44 |
Guilts | 45 | 163 | 118.08 | 29.27 |
Occupational Hardiness | 17 | 68 | 48.74 | 7.83 |
Result Showed, the mean score of moral courage in neonatal intensive care units was 58.75 (SD = 7.44), indicating a high level. The mean guilt score was 118.08 (SD = 29.27), and the mean occupational hardiness score of the participants was 48.74 (SD = 7.83), which reflects a high level. The normality of moral courage, guilts and occupational hardiness was not confirmed (Shapiro–Wilk test: p < 0.001, p < 0.001 and p < 0.001, respectively). Therefore, the relationship between variables was examined using Spearman correlation.
Table 4 presents the relationships between the main study variables) moral courage, guilt feelings, and occupational hardiness (among nurses working in neonatal intensive care units. The table provides a summary of the correlation coefficients, indicating the strength and direction of associations between these variables.
Table 4
Examination of the relationship between moral courage, guilt, and occupational hardiness in nurses working in neonatal intensive care units
Variable | Spearman Correlation | P-Value |
|---|---|---|
Guilts
Moral courage | r = -0.03 | 0.72 |
Occupational Hardiness
Moral courage | r = 0.40 | P < 0.001 |
Guilts
Occupational Hardiness | r = 0.04 | 0.61 |
Correlation analyses among the main study variables are presented in Table 4. Moral courage was positively and significantly correlated with occupational hardiness (r = 0.40, P < 0.001), but its correlation with guilts was negative and non-significant (r = -0.03, P = 0.72). The relationship between guilts and occupational hardiness was weak and non-significant (r = 0.04, P = 0.61). These findings indicate that moral courage is associated with higher occupational hardiness, providing the rationale for further regression analyses to examine its predictive role.
To comprehensively examine potential predictive effects, regression analysis was conducted to assess the impact of both guilt feelings and occupational hardiness on moral courage. This approach allows us to determine whether each variable independently contributes to moral courage, regardless of the significance of the bivariate correlations.
Table 5
Multiple linear regression analysis predicting moral courage based on guilt feelings and occupational hardiness
Predictor Variable | B (Unstandardized Coefficient) | SE(B) | β (Standardized Coefficient) | t | p-value | 95% CI for B | VIF |
|---|---|---|---|---|---|---|---|
(L, U) | |||||||
Constant | 37.42 | 3.99 | 9.37 | P < 0.001 | (29.53, 45.30) | ||
Guilts | -0.01 | 0.02 | -0.04 | 0.59 | 0.56 | (-0.026,0.048) | 1.03 |
Occupational Hardiness | 0.41 | 0.07 | 0.43 | 5.86 | P < 0.001 | (0.27,0.54) | 1.03 |
Model Summary | |||||||
R = 0.43, R²=0.19, Adjusted R²=0.17 F (2, 171) = 17.56, P < 0.001 | |||||||
Prior to conducting the regression analyses, all model assumptions were checked. Linearity between the independent variables and the dependent variable was examined through scatterplots and partial regression plots. The normality of residuals was confirmed using both visual inspection of P–P plots and the Shapiro–Wilk test (p > 0.05). Homoscedasticity was verified by inspecting standardized residuals versus predicted values. Multicollinearity was not a concern, as all Variance Inflation Factor ((VIF ≈ 1) values were below 2. These diagnostic results indicated that the data met the assumptions required for multiple regression analysis. Results in Table 5 showed that the regression model predicting moral courage based on guilt feelings and occupational hardiness was significant (F (2,171) = 17.56, p < 0.0001) and explained 17% of the variance. Occupational hardiness was a significant positive predictor of moral courage (B = 0.41, β = 0.43, p < 0.0001), whereas guilt feelings did not show a significant predictive effect (B=-0.01, β=-0.04, p = 0.56).
To complement the correlation analyses, scatter plots were used to illustrate the relationship between moral courage and each of the predictor variables, including guilt feelings and occupational hardiness (Fig. 1).
Fig. 1
Scatter plot of the relationship between moral courage and guilt in nurses working in neonatal intensive care units (n = 174)
Fig. 2
Scatter plot of the relationship between moral courage and occupational hardiness in nurses working in neonatal intensive care units (n = 174)
Based on the correlation coefficient (r = 0.40 and P < 0.0001), the relationship between moral courage and occupational hardiness in nurses working in neonatal intensive care units is positive and significant. In other words, as moral courage increases in nurses, their occupational hardiness will also increase (Fig. 2).
Discussion
The present study was descriptive-analytical research conducted to examine the relationship between moral courage, guilt feeling, and occupational hardiness in nurses working in neonatal intensive care units in three hospitals.
All nurses participating in the study were female. The youngest participant was 22 years old, and the oldest was 56 years old, with the average age of the nurses being 31.44 years. In the study by Ziaoldini [18], the average age of participating nurses was reported as 31.4, which aligns closely with our sample. The shortest work history in this study was one year, and the longest was 27 years, with an average of 7.9 years. Furthermore, 43.2% of the participants were single, and 56.8% were married. In the study by Montazeri et al., the majority of nurses (58.6%) were married [32], which is comparable to our findings. Regarding education, 89.1% had a bachelor’s degree, and 10.9% had a master’s degree. Similar studies reported the majority of nurses with a bachelor’s degree, consistent with our results [32‐34].
In the present study, 2.3% of the nurses working in NICUs had fixed morning shifts, 2.9% had fixed evening shifts, and the majority, 94.8%, worked in rotating shifts. Khajavandi et al. also reported most nurses with rotating shifts [35]. In terms of employment status, 50.6% of the nurses were permanently employed, 29.9% were on project-based contracts, 10.9% were contractual, and 8.6% were employed on a temporary basis. Consistent with similar studies, most nurses were permanently employed [32, 35].
The mean score of moral courage was 58.75 ± 7.44, indicating a high level. Abedi et al. (2020) reported that 76% of nurses in Tehran had high moral courage [33], and Namadi et al. (2019) found a mean of 86.09 ± 15.62 [34], also high. Mazlan et al. (2023) and Ruixin et al. (2024) reported similarly high levels [36, 37]. These results align with our findings, suggesting that nurses with strong moral courage are more capable of facing professional challenges and adhering to ethical principles [38]. However, some studies reported moderate levels of moral courage, such as Montazeri et al. (2022) with a mean of 74.24 ± 12.22 [32] and Aminizadeh et al. (2017) with 42.71 ± 9.67 [39]. Differences between these studies and ours may reflect variations in organizational culture, managerial support, job security, and fear of rejection.
In the present study, the mean guilt feeling score was 60.52 ± 9.17, which was at a low level. Almasi et al. (2023) also reported a low mean guilt feeling (56.53 ± 9.21) among nurses [11], consistent with our findings. Low guilt among NICU nurses may be due to conscientious care, responsibility, and confidence when working with fragile infants, which reduces error rates and feelings of guilt. In contrast, Dolatshad et al. (2020) reported high guilt scores in a pediatric reference hospital [12], likely due to the high emotional strain and critically ill patients in that setting.
The mean occupational hardiness score among NICU nurses in our study was 48.74 ± 7.83, reflecting a high level. Ziaaddini (2019) reported a similar high score of 50.19 ± 5.16 [18], and Salimi and Bashirganbadi (2017) found 76.83 ± 7.83 [40], also high. The relatively high hardiness observed may reflect professional adaptation, recognition of strengths, and coping strategies, which support resilience under workplace stress [16].
The results indicated a negative but non-significant relationship between moral courage and guilt feelings (r = -0.070, P = 0.360), suggesting that while increased moral courage may reduce guilt, this effect was not statistically significant, possibly due to the limited sample size. Conversely, a positive and significant relationship was found between moral courage and occupational hardiness (r = 0.40, P < 0.0001), indicating that higher moral courage is associated with greater occupational resilience.
In summary, moral courage among NICU nurses is high and positively related to occupational hardiness, while its relationship with guilt feelings is not statistically significant in this sample. These findings emphasize the importance of supporting moral courage and resilience in nursing practice.
Limitations of the study
Because data were collected exclusively from neonatal intensive care units of three hospitals in one city, the findings may not be generalizable to nurses in other cities or regions. Variations in organizational culture, management practices, socioeconomic contexts, and healthcare resources across different geographical areas may influence nurses’ moral courage and occupational hardiness. Therefore, caution should be exercised in applying these findings to broader populations. Additionally, the use of self-reported measures raises the possibility of social desirability bias, particularly for sensitive constructs (e.g., guilt, moral courage), which could bias observed associations.
Final conclusion
This study examined the relationships between moral courage, guilt feelings, and occupational hardiness among nurses working in neonatal intensive care units. The results indicated high levels of moral courage and occupational hardiness among these nurses, and a positive relationship between moral courage and occupational hardiness. In contrast, the relationship between moral courage and guilt feelings was not significant. These findings highlight the importance of moral courage in supporting resilience and coping among NICU nurses and provide a basis for further research in this field.
Acknowledgements
This study was approved by the Ethics Committee of the Shiraz University of Medical Sciences, Shiraz, Iran (IR.SUMS.NUMIMG.REC.1402.142). The authors would like to thank the Research Deputy of the University for the Financial Support, and to the nurses in Neonatal Intensive Care Units.
Declarations
Ethics approval and consent to participate
To conduct this research, approval was obtained from the Research Deputy and Ethics Committee of Shiraz University of Medical Sciences under project ethics code with the number (IR.SUMS.NUMIMG.REC.1402.142). Ethical considerations were meticulously adhered to throughout the study, and informed consent was obtained from each participant. All methods outlined in this paper were conducted in compliance with the pertinent guidelines and regulations stipulated by the Research Deputy and Ethics Committee of Shiraz University of Medical Sciences.
Consent for publication
Not applicable.
Ethical considerations
In order to conduct this research, Research Deputy and Ethics Committee of Shiraz University of Medical Sciences obtained the permission to implement the project with the following code (IR.SUMS.NUMIMG.REC.1402.142). After obtaining the necessary permissions from all related departments, sampling was done. Prior to conducting the study, the necessary explanations about the confidentiality of the achieved information and its neutral interference in therapy process, discharge and follow-ups was reassured.
Competing interests
The authors declare no competing interests.
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