Moral Courage and Organizational Commitment among Nurses in a Level I Hospital

Moral Courage and Organizational Commitment among Nurses in a Level I Hospital

Krishaleen Mae T. Tamayo, MANM., Joan P. Bacarisas, DM, MAN., and Resty L. Picardo, DM, JD, MAN

 University of Visayas, College of Allied Health Sciences

DOI: https://doi.org/10.51244/IJRSI.2025.120600165

Received: 15 June 2025; Accepted: 23 June 2025; Published: 23 July 2025

ABSTRACT

Moral courage builds trust, responsibility, and ethical leadership, boosting organizational commitment.  It encourages people to speak up for what they believe in, especially in the face of adversity, which can lead to a more just and equal workplace and boost employees’ sense of belonging and commitment. In the field of nursing, there is a scarcity of studies where organizational commitment is predicted by personal characteristics and moral courage. This quantitative research made use of the descriptive, correlational (predictive) design to assess whether the dimensions of moral courage predicts organizational commitment among nurses in a Level I hospital in Wao, Lanao del Sur for the second quarter of 2025. Findings of the study revealed that majority were aged 18 to 35 years old and females. Just over half were single and majority were Roman Catholics and had bachelor’s degree. Half of the respondents had served the organization for three years below and just over half of the nurses were ranked as Nurse I. There was a high adherence and tendency in terms of the overall moral courage of the nurses.  In terms of compassion and true presence and moral responsibility, there were high adherence and tendency. In terms of moral integrity, there was a very high adherence and tendency while in terms of commitment to good care, this was rated as moderate adherence and tendency. Overall, the organizational commitment of the nurses was high. Affective, continuance, and normative commitment were high. The personal characteristics of age, sex, marital status, religion, educational attainment, years of experience, and position did not predict moral courage. Marital status and position predicted organizational commitment. However, age, sex, religion, educational attainment, and years of experience did not predict organizational commitment. Commitment to good care predicted organizational commitment. To address the findings of the study an organizational commitment enhancement plan is proposed.

Keywords: Descriptive, correlational (predictive) design; Moral courage; Organizational commitment; Nurses.

INTRODUCTION

In addition to being an essential component of human existence, morality is a subfield of practical philosophy that encompasses the search for right and wrong, as well as the determination of what constitutes good and bad behavior in a set of actions under specific circumstances.  In the past, in the present, and in the future, the nursing profession is one of the sciences that has encountered a great deal of illuminating ethical situations.  As a result of the fact that the body of ethics includes the ability to differentiate between what is good and what is harmful, the moral competency of the nursing profession may be considered to be equivalent to professional competency. As a matter of fact, on a daily basis, nurses are confronted with a number of ethical challenges that require resolution.  Sensitivity to moral issues and an awareness of ethical principles are both necessary components for the identification of ethical difficulties.  Although moral awareness and knowledge are necessary, they are not sufficient on their own.  It is essential for nurses to have the moral courage to act in accordance with what is regarded as ethically correct, given that their personal beliefs and standards are in line with the values that are generally recognized in the healthcare industry.

Moral courage is the courage to act in accordance with moral principles in the face of moral conflict, even though one may experience negative consequences (Fubin et al., 2023), and in the field of nursing, moral courage defined as the nurse’s ability to adhere to professional ethical guidelines and to act in strict compliance with those guidelines, even if there is a foreseeable or real negative impact on yourself as a result (Numminen et al., 2017). Research by Safarpour et al. (2020) showed that nurses with higher level of moral courage experience lower frequencies of moral distress. High level of moral courage enables nurses to effectively respond to challenging situations and uphold their professional values. Additionally, high moral courage enables them to openly oppose unethical practices, protect patients’ rights and make the right decisions. Low level of moral courage may lead to nurses being unable to adhere to ethical principles, leading to an increase in the frequency of moral distress, thereby reducing the quality of care, and ultimately leading to unethical behavior (Khodaveisi et al., 2021). As the backbone of the healthcare system, nurses require a supportive environment to meet their needs (Safarpour et al., 2020).

Somehow, having a high moral courage would indirectly mean that the nurse is with high organizational commitment. Moral courage in nurses, which is defined as the capacity to behave ethically despite the danger of personal repercussions, is essential for organizational commitment because it enhances their dedication to patient care and upholds ethical standards, which eventually results in an improvement in the quality of treatment and a more favorable work environment. According to Hakimi (2023), having moral courage is a crucial characteristic for nurses to handle ethical quandaries, stay true to their professional obligations towards patients, and uphold ethical principles. This concept can be influenced by various factors including personal, professional, organizational, and leadership considerations. One of the researchers had been a nurse working in the hospital and has experienced issues regarding moral courage and organizational commitment. In terms of moral courage, because of the many patients that nurses’ care, they appear to do their job as plainly doing only what is ordered by the doctor. The element of moral courage seemed to disappear as care becomes hurried and impersonalized. Patient-advocacy is lost in the long-run and moral courage seem to disappear. They no longer matter for as long as the nurse is able to work for 8 hours and was able to carry out the doctor’s orders. Issues relating to organizational commitment can be readily seen from the track records of turnover intentions, especially for nurses. Nurses resigning almost every month is a clear indication that they lack commitment to the hospital and this may be greatly influenced by the fact that nurses seek better pay by going abroad. All these instances led the researcher to establish a baseline information on moral courage and organizational commitment as there had been no baseline data in the hospital yet. On top of this knowledge gap, the study moves forward to assessing whether the dimensions of moral courage predicts organizational commitment serving as the methodological gap of the study.

The researchers intend to address these gaps by devising a strategy for the strengthening of commitment while simultaneously addressing the issue of moral courage. Not only will this output be valuable to the nursing practice, but it will also be advantageous to the patients or clients. As a result, the patients will have the opportunity to obtain good health and well-being as well as for nurse to have decent work and economic growth, which is highly congruent with the third and eight sustainable development goals.

Research Objectives

The main purpose of the study was to assess whether the dimensions of moral courage predicts organizational commitment among nurses in a Level I hospital in Wao, Lanao del Sur for the second quarter of 2025.

Specifically, the study answered the following queries:

1. What were the personal characteristics of the respondents in terms of age, sex, marital status, religion, educational attainment, years of experience, and position?
2. What is the moral courage of the nurses in terms of compassion and true presence, moral responsibility, moral integrity, and commitment to good care?
3. What was the level of organizational commitment among nurses in terms of affective commitment, normative commitment, and continuance commitment?
4. Which personal characteristics predicted moral courage of the nurses?
5. Which personal characteristics predicted organizational commitment of nurses?
6. Which dimension of moral courage predicted organizational commitment of the nurses?
7. What organizational commitment enhancement plan was proposed based on the findings of the study?

Statement of Null Hypotheses

Ho1: The personal characteristics did not predict moral courage of the nurses.

Ho2: The personal characteristics did not predict organizational commitment of nurses.

Ho3: The dimensions of moral courage did not predict organizational commitment of nurses.

REVIEW OF RELATED LITERATURE AND STUDIES

Moral Courage. To provide care of high quality, nurses face several moral issues requiring them to have moral abilities in professional performance (Amiri et al., 2019). Moral courage means the courage or inner strength a person has when acting in ethical conflicts according to ethical principles and one’s own values and beliefs, even at the risk of negative outcomes for the acting individual (Pajakoski et al., 2021). Morally courageous acting manifested itself as speaking up and acting as the patients’ advocate when patients’ rights, safety, or good care were threatened. As a part of nurses’ moral competence, moral courage has gained increasing interest in strengthening nurses acting on their moral decisions and offering alleviation to their moral distress (Numminen et al., 2021). Moral courage has been described as a personal virtue that could become a natural part of an individual’s behavior and moral deliberation, and need to be learned and developed through training or research (Papouli, 2019).

Moral courage as part of the moral competence of nurses has received increasing attention. Determination of the factors affecting moral courage is important in improving the quality of care. The level of moral courage among nurses is above average. Structural empowerment and psychological empowerment were the key factors affecting the promotion of moral courage. All the dimensions and the total scores of the conditions for work effectiveness and psychological empowerment were significantly correlated with the moral courage. According to the multivariate stepwise regression analysis, conditions for work effectiveness and psychological empowerment were determined to be factors affecting moral courage. These variables explained 35.9 percent of the total variance in the moral courage scores of nurses (Hu et al., 2022).

Moral courage is one of the fundamental values of nursing profession and a powerful method of coping with ethical problems. The results indicated that the mean score of moral courage was 21.11 ± 69.90 and the greatest amount of moral courage was in the dimension of “going beyond compliance”. The mean score of “psychological empowerment” was 30.9 ± 73.58 and the greatest mean belonged to “competence”. There was a positive significant correlation between “psychological empowerment” and “moral courage and its dimensions” (Khoshmehr et al., 2020).

Moral courage and understanding of its meaning are essential when nurses face ethical conflicts in their practice. 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 indicated 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 (Pajakoski et al., 2021).

The results of the meta-analysis showed that nurses’ moral courage levels were in the medium to high range, among the nurses who seemed to be male, non-nursing managers, high school education, had not experienced ethical issues, and considering resignation had lower levels of moral courage. The results of the meta-analysis may provide some reference for nursing managers and even hospital administrators to develop strategies to optimize nursing quality (Li et al., 2024).

The study findings demonstrated that the moral courage inhibitors in the nursing practice could be split into two general themes, that is, the individual and organizational ones. Accordingly, organizations could motivate nurses to make ethical decisions courageously, using supporting strategies, such as giving importance to nurses and empowering them, applying appropriate evaluation criteria, and appreciating ethical performance in these frontline healthcare workers (Namadi et al., 2023).

The results showed that three categories of factors most related to moral courage are individual, moral, and factors related to the organization. Underlying factors of each category are also provided within this paper. Moral courage is an integral part of nursing, which as a profession, is becoming even more challenging with the advancement of science and technology. Therefore, there is a need for nurses and especially nursing managers to be considerate of factors affecting moral courage of nurses, with a view to strengthening the positive factors and reducing the negative impacts (Abdollahi et al., 2024).

Nurses’ mean score of the 21-item Nurses’ Moral Courage Scale was 3.77. The total Nurses’ Moral Courage Scale score was associated with age, experience, professional function, level of education and personal interest (Konings et al., 2021).

The Chinese nurses perceived themselves, on average, as morally courageous. The mean NMCS score was 3.64 ± 0.692. The six factors showed statistically significant correlations with moral courage. Regression analysis showed that the main factors influencing nurses’ moral courage were active learning of ethics knowledge and nursing was a career goal. This study provides the self-evaluation level and related influencing factors of Chinese nurses’ moral courage. There is no doubt that nurses still need strong moral courage to face unknown ethical problems and challenges in the future (Huang et al., 2023).

One of the ethical challenges in the nursing profession is implementing beneficial decisions in practice to ensure the safety and efficiency of the healthcare system for patients and healthcare providers. This underscores the critical role of education, policies, and societal actions in shaping and supporting moral courage in nursing. Studies suggest that creating supportive environments and providing adequate resources are essential strategies to enhance moral courage, equipping nurses better to address moral challenges effectively, especially in developing countries (Kakhki et al., 2024).

Most nurses showed a moderate level of moral distress and a high level of moral courage. The dimension of multiple values had the highest mean and endurance of threats had the lowest mean. There was a statistically significant correlation between moral distress and moral courage, and moral distress and the dimensions of endurance of threat, going beyond compliance, and moral goals. A statistically significant relationship was also found between moral distress and work shift, position and gender, and between moral courage and position. It was concluded that nurses need more organizational support in terms of protective facilities, job security and organizational incentives to be able to show ethical behaviors (Hthelee et al., 2023).

Findings of the study showed that the moral courage of nurses was moderate. Four factors related to moral courage include factors related to the individual, factors related to ethics, factors related to the negligence of medical staff, factors related to the organization. Considering that the moral courage of nurses has been at a moderate level, so it is suggested that managers in medical centers be diligent in ways to increase the moral courage of nurses. Also, retraining courses should be provided to increase the moral courage of nurses (Arablarimi et al., 2021).

According to the Institute of Medicine, the demographic characteristics of the nursing workforce should more closely match the population at large to enhance interactions and communication (National Academies of Sciences, Engineering, and Medicine [NASEM], 2016). Therefore, an increase in the diverse nursing workforce is an essential component to achieving concordance in patient–nurse relationships (Hoyert, 2022).

Organizational Commitment. Organizational commitment refers to the relative strength of an individual’s identification and involvement with the overall employing organization and not with a department or specific workgroup (Mowday, 1998 as cited in Fantahun et al., 2023). Organizational commitment also means complying with the aims and objectives of the organization, organizational principles, rules and norms, and volunteering for their survival (Dominic & Salim, 2018 as cited in Fantahun et al., 2023).

Meyer and Allen theorized three types of organizational commitment in 1984: affective, continuance, and normative commitment (Meyer & Allen, 1989 as cited in Fantahun et al., 2023). Affective commitment is related to an employee’s emotional connection, identification, and participation in the organization. Normative commitment is about employees’ feelings of responsibility to the organization, while continuance commitment is associated with perceived costs related to exiting the organization (Meyer & Allen, 1989 as cited in Fantahun et al., 2023; Meyer & Allen, 1991 as cited in Fantahun et al., 2023).

Organizations comprise individuals united by common goals. The success of organizations hinges on individuals aligning their actions with these goals, facilitated by their commitment. In healthcare settings, organizational commitment is vital for consistently delivering quality care (Kasimoglu, 2021). It refers to the psychological bond individuals have with their organization and is a scare research topic within healthcare. Relationship of an individual with an organization. This type of research is rare within healthcare area, making it additionally valuable for human resource management which aims to provide the clients with continuous quality healthcare, making it valuable for human resource management aiming to ensure continuous quality healthcare (Dugalić et al. 2022).

Organization commitment influences whether employees stay with an organization long-term and work passionately toward its goals (Kasalak, 2019). Initially rooted in sociological theories analyzing punitive systems’ impact on socially accepted values, organizational commitment evolved into a complex concept studied from sociological and psychological perspective (Walter et al., 2021).

Most nurses showed a moderate level of job commitment. Greater organizational commitment was positively related to sociodemographic variables, such as age and nationality, and the only positive predictor of overall organizational commitment was age. Nursing policy makers should enhance the organizational commitment of nurses by developing strategies to recruit, attract, and retain committed nurses (Al-Haroon HI & Al-Qahtani, 2020).

Health professionals’ organizational commitment percentage mean score was low. A higher level of organizational commitment was associated to satisfaction with recognition, work climate, supervisor support, and workload. Besides, good practice of transformational and transactional leadership styles and employee empowerment are significantly associated with high organizational commitment. To improve the organizational commitment of health professionals, hospital managers, and healthcare policy-makers need to develop and institutionalize evidence-based satisfaction strategies, practice good leadership styles and empower healthcare providers on the job (Fantahun et al., 2023).

Among the participants, majority of the participants were nurses and few were nurse managers. Significant difference of opinions is observed among nurse managers in relation to transformational and transactional leadership styles and engagement. Transformational and transactional leaderships are positively correlated with organizational commitment and nurses’ engagement (AL-Dossary, 2022).

The study results revealed that the job satisfaction score was significantly higher in permanent nurses than in temporary nurses. However, temporary nurses were more committed toward organization than permanent nurses. There was a significant association between nurses’ job satisfaction and their gross salary and their organizational commitment with the selected profession by own will (Panchal et al., 2022).

A statistically significant positive correlation was found between the continuance commitment scale and the normative commitment scale. A statistically significant negative correlation was also found between the continuance commitment scale and the satisfaction scale, as well as between the normative commitment scale and the satisfaction scale. Finally, a statistically significant relationship emerged between the scale of satisfaction by educational level (Digonis, 2023).

The results show a high affective and continuance commitment of nurses with the hospital, and a reduced tendency of the intention to leave. A significant positive association was also found between the intent to leave and individual/structural factors. Organizational commitment and intention to leave levels are satisfactory, despite the influence of several factors, such as nurse staffing, work environment, or other opportunities for professional development. The results identify particularly sensitive areas that, through adequate health and management policies, can reduce nurses’ intentions to leave and promote the sustainability of the health system (Neves et al., 2022).

Study findings show that over one third of respondents reported great pride in their affiliation with the company, demonstrating high loyalty and job satisfaction. In addition, almost half of respondents strongly agreed with the importance of the organization’s values. Moreover, the findings also showed that very few demonstrated low commitment, and majority fell into the moderate commitment category. Meanwhile, over one third exhibited high commitment. The study revealed a diverse spectrum of commitment levels, with a substantial majority demonstrating moderate commitment. Addressing this issue should be a priority for the organization, focusing on recognizing and appreciating employees’ efforts to enhance overall satisfaction and foster a more supportive work environment (Ishaq et al., 2023).

Pearson’s correlation analysis showed that that workplace bullying was significantly negatively correlated with organizational commitment and significantly positively correlated with turnover intention, organizational commitment was significantly negatively correlated with turnover intention. Mediation analysis indicated organizational commitment partially mediated the association between workplace bullying and turnover intention. The total effect of workplace bullying on turnover intention consisted of its direct effect and the indirect effect mediated through organizational commitment, with the mediating effect accounting for 40.58% of the total effect (Xia et al., 2023).

Personal Characteristics and Moral Courage. In the study of Hauhio et al. (2021) revealed that respondents’ gender, present work role, ethical knowledge base, additional ethics education, self-study as a means to acquire ethical knowledge, and frequency of work situations needing moral courage were statistically significantly associated with nurses’ moral courage. In the study of Shokouhi (2024) it revealed that age, work experience, educational level, and employment status were all found to have a significant relationship with moral courage among the demographic characteristics.

Personal Characteristics and Organizational Commitment. In the study of Castillo (2024), it revealed that age, sex, educational attainment, years of service, and type of hospital did not have a significant relationship with affective commitment. There was a significant relationship between years of experience and normative commitment while age, sex, educational attainment, and the type of hospital showed no significant relationship with normative commitment. Significant relationships were seen between years of experience and overall organizational commitment as well as type of hospital and overall organizational commitment. Meanwhile age, sex, and educational attainment did not have a significant relationship with overall organizational commitment. In conclusion, years of experience and the type of hospital influence organizational commitment. Longer years of experience translate to higher organizational commitment. Private hospitals have been seen to have increased organizational commitment.

In the study of Sepahvand et al. (2017), revealed that there was a significant correlation between the continuance commitment and work experience, the staff posts and shifts. Also the results of the study of Nabizadeh et al. (2014) showed that there is a positive and significant relationship between age, level of education, the record of clinical work and organizational commitment whereas there is not such a relationship between marital status and organizational commitment as well as between age, marital status, level of education, the record of clinical work and job satisfaction. In the study of Al-Haroon and Al-Qahtani (2020) revealed that there was a significant difference in the levels of commitment among nurses in the various age groups. The continuous commitment subscale received the largest number of positive responses.

Moral Courage and Organizational Commitment. The mean scores of moral courage of operating room nurses was high and in high in organizational commitment. Moreover, moral courage did not have a statistically significant relationship with organizational commitment. The moral courage and organizational commitment of the participants differed significantly in terms of their type of employment and age. Given the high mean score of moral courage and organizational commitment in operating room nurses, it can be said that nurses tend to show moral behaviors. On the other hand, the low score of the endurance of threat indicates that operating room nurses do not receive the necessary support from the organization for their courageous behavior (Mohadeseh et al., 2021).

In the study of Azeez Thajeel and AbdulKadhim Johnni (2022), it revealed that there is a direct correlation and statistical significance between moral courage and organizational commitment among the employees. Considering the position of nurses and their role in caring for patients, it is necessary to support moral courage by increasing organizational commitment and responsibility, and providing relevant training opportunities about ethical principles (Khoshmehr et al., 2020, Pirdelkhosh et al., 2022).

RESEARCH METHODOLOGY

Design. The quantitative research made use of the descriptive, correlational (predictive) research design. In application to the study, the descriptive design was used in determining the personal characteristics, moral courage, and organizational commitment. The correlational (predictive) design was used to assess whether the personal characteristics predicted moral courage and organizational commitment as well as whether the dimensions of moral courage predicted organizational commitment of the nurses.

Environment. The research locale was the nursing department of X Hospital. It is located in Wao Lanao del Sur, a remote area of autonomous region in Muslim Mindanao, a second municipality in the province of Lanao del sur, Philippines. The institution offered services like minor surgeries, normal/uncomplicated deliveries, Newborn Screening, Family Planning dispensing/counselling, basic laboratory examinations, X-rays, consultations and admissions. It is a 100-bed capacity hospital and is applying to become a level II hospital. It is the vision of X Hospital to be first and foremost for customer satisfaction with fully implement health programs, committed health personnel in functional health facilities under participatory management and supportive stakeholder, where healthcare services are available, accessible and sustainable at all times. Each of the forty staff nurses who have been providing care to patients around the clock are housed within the nursing department. With such number it is important to assess their oral courage and commitment. It is about time that an evaluation of the nurses’ organizational commitment and moral courage be carried out in order to guarantee that they are committed to the responsibility of serving patients and to the hospital.

Respondents. Respondents of the study were the 40 staff nurses of the hospital.

Sampling Design. No sampling was done. All those nurses who qualified based on the inclusion and exclusion criteria will be invited to participate. With this, a complete enumeration was utilized.

Inclusion and Exclusion Criteria. In order to evaluate the moral courage and organizational commitment, the study included staff nurses who had been engaged at the hospital for a minimum of three months. They possessed a current and genuine license to practice nursing and were directly engaged in actual patient care. They were of legal age, irrespective of their sex, marital status, educational qualification, religion, and socio-economic status.  They were willing to provide voluntary consent and participate. The study did not include nurses who were currently employed in holding administrative positions, including the chief nurse and nurse supervisors.  Additionally, individuals who had submitted their resignations and expressed their intention to retire were excluded, as they may provide biased responses.

Instruments. The study made use of a two-part questionnaire. Part one of the questionnaire was an adopted questionnaire, the Nurses’ Moral Courage Scale (NMCS) by Numminen et al. (2019) is an instrument designed to measure nurses’ self-assessed moral courage. Moral courage, required at all levels of nursing, helps nurses solve ethical problems, and also fulfills the moral quest of the nursing profession (i.e., the optimal well-being of the patient). Development of the NMCS was based on the theoretical model developed in the concept analysis of moral courage in nursing (Numminen et al., 2017), and on a review of related nursing literature.

The NMCS consists of 21 items and 4 subscales scored on a 5-point Likert-type scale (1=“Does not describe me at all,” 2=“Describes me a little,” 3=“Somewhat describes me,” 4=“Describes me well,” and 5=“Describes me greatly”). The NMCS is divided into four subscales:  Compassion and true presence (five items), Moral responsibility (four items), Moral integrity (seven items) and Commitment to good care (five items). The total scale score ranges from 21 to 105. Higher scale scores indicate higher adherence to professional ethics and moral principles and higher tendency to do what is right for the patient. Parametric scores and interpretation are as follows: 21 – 38 is very low adherence and tendency, 39 – 55 is low adherence and tendency, 56 – 72 is moderate adherence and tendency, 73 – 89 is high adherence and tendency, 90 – 105 very high adherence and tendency.

Reliability. Psychometric evaluation showed that the 4-sub-scale, 21-item Nurses’ Moral Courage Scale demonstrates good reliability and validity at its current state of development showing a good level of internal consistency for a new scale, the internal consistency values ranging from 0.73 to 0.82 for sub-scales and 0.93 for the total scale, thus well exceeding the recommended Cronbach’s alpha value of >0.7. Principal component analysis and confirmatory factor analysis supported the theoretical construct of Nurses’ Moral Courage Scale. Face validity and expert panel assessments markedly contributed to the relevance of items in establishing content validity (Numminen et al., 2018).

Part two of the instrument was an adopted questionnaire, Organizational Commitment Inventory as developed by Raji et al. (2021). It is a standard questionnaire that measures organizational in three dimensions, namely: affective commitment (6 items), continuance commitment (6 items), and normative commitment (6 items). These were rated in a scale of 1 being strongly disagree to 5 being strongly agree. Parametric scores and interpretations are as follows: A score of 1.00-1.80 is very low (strongly disagree), 1.81 – 2.60 is low (disagree), 2.61 – 3.40 is moderate (neither disagree nor agree), 3.41 – 4.20 is high (agree), and 4.21 – 5.00 is very high (strongly agree).

Reliability. All the three Cronbach alphas (0.910, 0.850,  0.745)  exceeded  the  benchmark  of  0.7 (Tavakol  &  Dennick,  2011)  meaning  that  the items for the respective constructs were reliable.

Data Gathering Procedures. The initial stage involved the creation and submission of transmittal letters to the Dean of the College of Allied Health Sciences and the Medical Center Chief in order to obtain permission to conduct the study.  The study was submitted for a design hearing.  Subsequently, the work was submitted to the ethics committees of the university and the hospital for ethical approval. Immediately once the notice to proceed had been issued, the recruitment process started.  Due to the fact that the researcher was also employed at the hospital, the recruitment process was conducted through face-to-face intercept.  The distribution of survey questionnaires took place either before the nurses’ shifts, during their break times, or after their shifts, depending on the situation. The inclusion and exclusion criteria served as the guiding principles for the recruitment process.  After the respondent had been provided with the questionnaire, the respondent was requested to complete it in a private place where the respondent was able to maintain privacy and concentrate on completing the questionnaire.  The researcher waited for the questionnaire to be returned, and then it was examined to ensure that it was complete before allowing the respondent to depart.  In the event that the questionnaire was not entirely filled-out, it was sent back to the respondent so that they can finish filling it out.  In order to ensure that all nurses were recruited, this entire process was repeated multiple times. The Excel format was employed to compile and summarize all questionnaires that had been completed. This was forwarded to a statistician for the computation of suitable statistical treatments. The data was presented in tables, along with the interpretations, analysis, implications, and supporting literature and studies. The paper was presented for the final defense. After the final defense, all questionnaires that had been answered were shredded, and all raw soft copies of data were deleted.

Statistical Treatment of Data. The following descriptive and inferential statistics were used to treat the data: (a) Frequency Distribution and Simple Percentage. These were used to determine the personal characteristics of the nurses; (b) Mean score and Standard Deviation. These were used to determine the moral courage and organizational commitment among nurses; and (c) Linear Regression. This was used to assess whether the personal characteristics predicted moral courage and organizational commitment as well as whether the dimensions of moral courage predicted organizational commitment of nurses.

Ethical Considerations. The requirement of obtaining ethical approval was met by the study.  This work was evaluated for ethical soundness by the ethics committees of both the university and the hospital.  The study did not proceed with data collection until the aforementioned committees issued a notice to proceed.

Presentation, Analysis, and Interpretation of Data

Table 1 Personal Characteristics of the Nurses

Personal Characteristics	f	%
Age
18 to 35 years old	25	62.50
36 to 55 years old	15	37.50
Sex
Male	9	22.50
Female	31	77.50
Marital status
Single	21	52.50
Married	19	47.50
Religion
Roman Catholic	24	60.00
Islam	16	40.00
Educational Attainment
Bachelor’s Degree	32	80.00
Post-Graduate	8	20.00
Years of Experience
Three years below	20	50.00
Four to six years	6	15.00
Seven to Nine years	7	17.50
Ten and above	7	17.50
Position
Nurse I	22	55.00
Nurse II	16	40.00
Nurse IV	1	2.50
Nurse V	1	2.50

Note: n=40.

Majority of the respondents were aged 18 to 35 years old while over one third were aged 36 to 55 years old. Majority of the respondents were females while the remaining almost a quarter were males. Just over half of the nurses were single and almost fifty percent were married. Majority of the respondents were Roman Catholics and the remaining over one third were Muslims. Majority of the nurses had bachelor’s degree and almost a quarter are in their post-graduate program. Half of the respondents had served the organization for three years below while few had served for seven to nine years. Also, few had served for ten years and above as well as four to six years. Just over half o the nurses are ranked as Nurse I while almost half were Nurse II. Moreover, very few were ranked as Nurse IV and V.

This data implies that from the personal characteristics of the nurses, the nurses are so diverse that the come from different walks of life with varying profile. This is indeed the characteristics of the workforce nowadays. It is true that the nursing workforce is growing more diverse, which is a reflection of the shifting demographics of the population.  There are a lot of variables that contribute to this diversity, including the growing number of persons who identify with different racial and ethnic backgrounds, as well as the increased participation of minority students in nursing schools. According to the Institute of Medicine, the demographic characteristics of the nursing workforce should more closely match the population at large to enhance interactions and communication (National Academies of Sciences, Engineering, and Medicine [NASEM], 2016). Therefore, an increase in the diverse nursing workforce is an essential component to achieving concordance in patient–nurse relationships (Hoyert, 2022).

Moral Courage of the Nurses

Table 2 is the presentation of the data on the moral courage of the nurses in terms of compassion and true presence, moral responsibility, moral integrity, and commitment to good care.

Table 2 Moral Courage of the Nurses

Level of Moral Courage	Average Score	f	%
Compassion and True Presence
Very Low Adherence and Tendency	0.00	0	0.00
Low Adherence and Tendency	0.00	0	0.00
Moderate Adherence and Tendency	16.00	2	5.00
High Adherence and Tendency	19.45	22	55.00
Very High Adherence and Tendency	22.81	16	40.00
Average Score	20.63	High Adherence and Tendency
Moral Responsibility
Very Low Adherence and Tendency	0.00	0	0.00
Low Adherence and Tendency	0.00	0	0.00
Moderate Adherence and Tendency	12.50	4	10.00
High Adherence and Tendency	15.78	27	67.50
Very High Adherence and Tendency	18.56	9	22.50
Average Score	16.08	High Adherence and Tendency
Moral Integrity
Very Low Adherence and Tendency	0.00	0	0.00
Low Adherence and Tendency	0.00	0	0.00
Moderate Adherence and Tendency	0.00	0	0.00
High Adherence and Tendency	19.00	4	10.00
Very High Adherence and Tendency	28.39	36	90.00
Average Score	27.45	Very High Adherence and Tendency
Commitment to Good Care
Very Low Adherence and Tendency	0	0	0.00
Low Adherence and Tendency	16.14	7	17.50
Moderate Adherence and Tendency	20.67	21	52.50
High Adherence and Tendency	24.25	12	30.00
Very High Adherence and Tendency	0.00	0	0.00
Average Score	20.95	Moderate Adherence and Tendency
Overall Moral Courage
Very Low Adherence and Tendency	0.00	0	0.00
Low Adherence and Tendency	0.00	0	0.00
Moderate Adherence and Tendency	62.50	2	5.00
High Adherence and Tendency	83.42	26	65.00
Very High Adherence and Tendency	92.50	12	30.00
Average Score	85.10	High adherence and tendency

Note: n=40.

Legend: For four items, a score of 4 to 7 is very low adherence and tendency, 8 to 10 is low adherence and tendency, 11 to 13 is moderate adherence and tendency, 14 to 17 is high adherence and tendency, 18 to 20 is very high adherence and tendency. For the specific dimensions, for five items: A score of 5 to 9 is very low adherence and tendency, 10 to 13 is low adherence and tendency, 14 to 17 is moderate adherence and tendency, 18 to 21 is high adherence and tendency, 22 to 25 is very high adherence  and tendency. For seven items, a score of 7 to 12.6 is very low adherence and tendency, 12.7 to 18.2 is L, 18.3 to 23.8 is moderate adherence and tendency, 23.9 to 29.4 is high adherence and tendency, 29.5 to 35 is very high adherence and tendency. For the overall moral courage, a score of 21 – 38 is very low adherence and tendency, 39 – 55 is low adherence and tendency, 56 – 72 is moderate adherence and tendency, 73 – 89 is high adherence and tendency, 90 – 105 very high adherence and tendency.

There was a high adherence and tendency in terms of the overall moral courage of the nurses.  Majority had high adherence and tendency while one third had a very high adherence and tendency and very few had moderate adherence and tendency. A high level of moral courage is characterized by the possession of a robust internal fortitude that allows one to prioritize ethical and moral ideals, even when confronted with enormous dangers or repercussions.  The act of standing up for what is right, acting in accordance with one’s principles, and being prepared to take action despite the possibility of adverse outcomes such as losing one’s job, being isolated, or suffering personal hurt are all components of this concept.

Moral courage and understanding of its meaning are essential when nurses face ethical conflicts in their practice. 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 (Pajakoski et al., 2021).

In terms of compassion and true presence, there was a high adherence and tendency. Just over half of the nurses had high adherence and tendency while almost half of them had a very high adherence and tendency and very few had a moderate adherence and tendency. This implies that nurses has a high adherence and tendency to support a suffering patient by being truly present for him or her, discuss the fears caused by the illness with their patients, regardless of the care situation, they sought to create a genuine human encounter with the patient and tried to encounter each patient as a dignified human being, and ensure good care for their patients. This further implies that nurses are experiencing and behaving with compassion, kindness, and understanding toward other people, particularly those who are going through a difficult time. In contrast, presence is defined as the state of being fully engaged and attention in the present moment, without any interruptions or distractions.Moral courage is one of the fundamental values of nursing profession and a powerful method of coping with ethical problems. The results indicated that the mean score of moral courage was 21.11 ± 69.90 and the greatest amount of moral courage was in the dimension of “going beyond compliance”. The mean score of “psychological empowerment” was 30.9 ± 73.58 and the greatest mean belonged to “competence” (Khoshmehr et al., 2020).

In terms of moral responsibility, there was a high adherence and tendency. Majority of the nurses had high adherence and tendency while almost a quarter had a very high adherence and tendency and few of them had a moderate adherence and tendency. This implies that when nurses brought up for discussion the patient’s right to good care, they participated in care team’s ethical decision-making, they participated in care team’s ethical decision-making, and brought up their honest opinion. All these describes the nurses well.

This further means that nurses possess the responsibility that each person has to behave morally and to make decisions that are in the best interest of society and other people. Learning to distinguish between right and wrong and putting that information to use in directing your behavior is the key.The results of the meta-analysis showed that nurses’ moral courage levels were in the medium to high range, among the nurses who seemed to be male, non-nursing managers, high school education, had not experienced ethical issues, and considering resignation had lower levels of moral courage. The results of the meta-analysis may provide some reference for nursing managers and even hospital administrators to develop strategies to optimize nursing quality (Li et al., 2024).

In terms of moral integrity, there was a very high adherence and tendency. Almost all of the respondents had a very high adherence and tendency and very few had high adherence and tendency. This implies that even if someone else acts professionally dishonestly, if someone else tries to cover up an evident care mistake, if someone else acts unethically, admitted their own mistakes, nurses maintain moral integrity, describes the nurses greatly. Moreover, they acted in accordance with professional ethical principles, adhered to professional ethical principles and brought up for discussion an ethical problem situation describes the nurses greatly. This further implies that nurses have a strong commitment to being honest, fair, and adhering to ethical values, especially when doing so is challenging or makes one uncomfortable. What matters is that you remain true to your ideals and that you always act in a manner that is morally sound, regardless of the consequences. Contrary to the findings, the Chinese nurses perceived themselves, on average, as morally courageous. The six factors showed statistically significant correlations with moral courage (Huang et al., 2023).

Lastly, in terms of commitment to good care, this was rated as moderate adherence and tendency. Just over half of the nurses had a moderate adherence and tendency on commitment to good care while one third of them had high adherence and tendency and few of them had low adherence and tendency. This implies that nurses are somewhat described as having commitment to good care despite observing evident shortcomings and despite resources required for ensuring good care are inadequate. Moreover, they are somewhat described as not compromising on their patient’s right to good care. Lastly, they are somewhat described to be committed to good care despite break prevalent care practices and brought up for discussion the patient’s right to good care.

This further implies that nurses need to improve commitment to good care. This could have been brought about by the fact that nurses are handling more patients that they can handle that their commitment has diminished. This finding may result to a poor commitment to good care and therefore should be addressed by the hospital administration to lift it higher. Moral courage as part of the moral competence of nurses has received increasing attention. Determination of the factors affecting moral courage is important in improving the quality of care. The level of moral courage among nurses is above average. Structural empowerment and psychological empowerment were the key factors affecting the promotion of moral courage. All the dimensions and the total scores of the conditions for work effectiveness and psychological empowerment were significantly correlated with the moral courage. According to the multivariate stepwise regression analysis, conditions for work effectiveness and psychological empowerment were determined to be factors affecting moral courage. These variables explained 35.9 percent of the total variance in the moral courage scores of nurses (Hu et al., 2022).

For nurses to be able to provide quality, safe care and advocate for patient rights, they need to have the moral courage to do so, even if doing so puts them in danger or causes them to come into confrontation with others. Maintaining professional standards, prioritizing the well-being of patients, and acting ethically in difficult circumstances are all made possible for nurses by this provision. In the nursing profession, those who possess moral courage are more likely to voice their concerns, question practices that could be potentially harmful, and continually work toward achieving the greatest possible outcomes for their patients.

Table 3 Level of Organizational Commitment of the Nurses

Dimensions	Mean score	SD	Interpretation
Affective Commitment	3.80	.345	High
Continuance Commitment	3.58	.403	High
Normative Commitment	3.93	.264	High
Grand mean	3.77	.262	High

Note: n=40.

Legend: A score of 1.00-1.80 is very low (strongly disagree), 1.81 – 2.60 is low (disagree), 2.61 – 3.40 is moderate (neither disagree nor agree), 3.41 – 4.20 is high (agree), and 4.21 – 5.00 is very high (strongly agree).

Overall, the organizational commitment of nurses was high. When nurses have a high organizational commitment, it indicates that they have a strong emotional connection to the healthcare organization in which they work, and that they experience a sense of belonging and pride over their membership in the company.  This results in a greater desire to accomplish the objectives of the business, an increase in motivation, and a decreased intention to terminate employment or look for another position.  They are more likely to be satisfied and engaged, which contributes to increased organizational performance and efficiency. In essence, they are more likely to be satisfied.

Contrary to the findings, most nurses showed a moderate level of job commitment. Greater organizational commitment was positively related to sociodemographic variables, such as age and nationality, and the only positive predictor of overall organizational commitment was age. Nursing policy makers should enhance the organizational commitment of nurses by developing strategies to recruit, attract, and retain committed nurses (Al-Haroon HI & Al-Qahtani, 2020).

In terms of affective commitment, this was rated as high. The respondents agreed that being a member of the hospital makes them feel happy, felt good whenever they discuss their job with others outside it, and really felt as if the hospital’s problems were my own. Additionally, they agreed that they hardly felt like “a member of the family” at the hospital, hardly felt “emotionally attached” to the hospital, and thought about the hospital every day.

When it comes to nurses, having a high affective commitment indicates that they have a strong emotional attachment to their organization, as well as a sense of belonging and devotion to the organization.  They have a strong commitment to their work, a positive attitude, and are more likely to remain as employees of the firm even when they are confronted with difficulties.  The strong emotional connection that exists between employees and the organization results in enhanced job satisfaction, increased motivation, and a greater willingness to contribute to the success of the organization.

Contrary to the findings, health professionals’ organizational commitment percentage mean score was low. A higher level of organizational commitment was associated to satisfaction with recognition, work climate, supervisor support, and workload. Besides, good practice of transformational and transactional leadership styles and employee empowerment are significantly associated with high organizational commitment (Fantahun et al., 2023).

In terms of continuance commitment, this was rated as high. Respondents agreed that they were concerned about the loss of investment of their time and skills in the hospital and that their loyalty to the hospital is a result of emotional, social, and economic investment made in it. Moreover, they agree that they always felt concerned about what they may likely lose with the hospital, that sometimes, it gives them concern what might happen if they ceases to be a member of the hospital, and they were not worried about leaving the hospital for something else. However, they neither disagree nor agreed that if they were not working in the hospital, they would not feel good.

When it comes to nurses, having a high continuance commitment indicates that they believe they have little choice but to remain with their current organization because they believe that leaving would result in either significant costs or a limited number of options.  The motivation for this commitment is either a sense of obligation or a fear of loss that is related with being unable to quit. Supporting the findings, the results showed a high affective and continuance commitment of nurses with the hospital, and a reduced tendency of the intention to leave (Neves et al., 2022).

In terms of normative commitment, this was rated as high. They strongly agree that the hospital had contributed favorably to their well-being. Moreover, they only agreed to feeling indebted to the hospital because of what they had benefited from it and that their loyalty to the hospital cannot be compromised due to the fair treatment they had received from it. Their loyalty to the hospital is as a result of similarity in their personal values and the hospital’s values, and they had better belief in the mission of the hospital and they were committed to it. However, the neither disagree nor agreed that if there was no longer a member of the hospital, their co-workers would be disappointed in them.

When nurses have a high normative commitment, it indicates that they have a strong sense of moral obligation and responsibility to remain with their organization and the nursing profession as a whole. As a result of this sense of obligation, they are less likely to leave their current position or look for other chances because they believe they owe the business and their patients anything. Supporting the findings, study findings showed that over one third of respondents reported great pride in their affiliation with the company, demonstrating high loyalty and job satisfaction. In addition, almost half of respondents strongly agreed with the importance of the organization’s values. Moreover, the findings also showed that very few demonstrated low commitment, and majority fell into the moderate commitment category. Meanwhile, over one third exhibited high commitment (Ishaq et al., 2023).

A significant amount of organizational commitment on the part of nurses is essential for a number of reasons, including the enhancement of patient care, the enhancement of job satisfaction, the reduction of turnover, and the improvement of organizational performance.  It is more probable that nurses who are devoted to their organization will be motivated, dedicated, and interested in their work. This will result in excellent outcomes not only for the nurses but also for the patients that they serve.

Table 4 Personal Characteristics Predicting Moral Courage

Variables	B	Std error	Beta	t	p value	Decision	Interpretation
(Constant)	78.215	10.531		7.427	.000	—	—
Age	1.393	4.207	.088	.331	.743	Failed to reject Ho	Not significant
Sex	-2.568	3.238	-.139	-.793	.434	Failed to reject Ho	Not significant
Marital Status	5.760	3.034	.374	1.898	.067	Failed to reject Ho	Not significant
Religion	5.220	3.226	.333	1.618	.115	Failed to reject Ho	Not significant
Educational attainment	-4.326	3.753	-.225	-1.153	.257	Failed to reject Ho	Not significant
Years of experience	.257	1.827	.039	.140	.889	Failed to reject Ho	Not significant
Position	-1.019	2.029	-.111	-.503	.619	Failed to reject Ho	Not significant

Legend: Significant if p value is < .05. If R-squared value < 0.3 is None or Very weak effect size, if R-squared value 0.3 < r < 0.5 is Weak or low effect size, if R-squared value 0.5 < r < 0.7 is Moderate effect size, and if R-squared value r > 0.7 is Strong effect size.

The table shows that the p values for all the correlation with personal characteristics and moral courage were below the significant value of .05. These values were interpreted as not significant leading to the decision of failing to reject the null hypothesis. Thus, the personal characteristics of age, sex, marital status, religion, educational attainment, years of experience, and position did not predict moral courage. Therefore, there was no regression model that was created.

It is not always the case that demographic factors such as age, gender, or race have an effect on moral courage. Moral courage is defined as the capacity to act on one’s values despite the possibility of adverse consequences.  Although a number of research have been conducted to investigate the connection between these elements and moral bravery, the findings of these investigations are sometimes unclear.  A person’s age, degree of job experience, and educational attainment are all factors that can occasionally be connected with moral courage; however, this association is not always constant or predictable.

There could be another factors that may influence moral courage. The particular circumstances under which an individual demonstrates moral courage, such as the culture of the organization, the nature of the ethical conundrum, and the individual’s own personal principles, frequently have an effect on the moral courage that is displayed. Individual characteristics such as empathy, a feeling of social duty, high ethical standards, and a willingness to take risks can also play a key influence in the development of moral courage. Contrary to the findings, in the study of Hauhio et al. (2021) revealed that respondents’ gender, present work role, ethical knowledge base, additional ethics education, self-study as a means to acquire ethical knowledge, and frequency of work situations needing moral courage were statistically significantly associated with nurses’ moral courage. Also, in the study of Shokouhi (2024) it revealed that age, work experience, educational level, and employment status were all found to have a significant relationship with moral courage among the demographic characteristics.

It is essential for nurses to possess moral courage because it enables them to prioritize the well-being of their patients and adhere to ethical values, even when they are confronted with personal dangers or problems. It is an essential trait that helps ensure that patients receive care that is not just safe but also compassionate and of high quality. Nurses who possess moral courage are more likely to speak out against behaviors that violate ethical standards, advocate for the rights of patients, and ensure that they fulfill their professional commitments.

Table 5 Personal Characteristics Predicting Organizational Commitment

Variables	B	Std error	Beta	t	p value	Decision	Interpretation
(Constant)	3.614	.322		11.217	.000	—	—
Age	.042	.129	.078	.325	.747	Failed to reject Ho	Not significant
Sex	-.081	.099	-.131	-.816	.421	Failed to reject Ho	Not significant
Marital Status	.254	.093	.492	2.740	.010	Reject Ho	Significant
Religion	.075	.099	.143	.765	.450	Failed to reject Ho	Not significant
Educational attainment	-.053	.115	-.082	-.461	.648	Failed to reject Ho	Not significant
Years of experience	.048	.056	.216	.853	.400	Failed to reject Ho	Not significant
Position	-.174	.062	-.561	-2.802	.009	Reject Ho	Significant

Legend: Significant if p value is < .05. If R-squared value < 0.3 is None or Very weak effect size, if R-squared value 0.3 < r < 0.5 is Weak or low effect size, if R-squared value 0.5 < r < 0.7 is Moderate effect size, and if R-squared value r > 0.7 is Strong effect size.

The table shows that the p values for marital status and position were below the significant value of .05. These values were interpreted as significant leading to the decision of rejecting the null hypothesis. Thus, marital status and position predicted organizational commitment. Looking at the table, the t value for marital status was positive while for position was negative. These indicate that the influence of marital status is positive while the influence of position was negative. A positive prediction means that as the marital status becomes married, the organizational commitment increases while a negative prediction means that as the position becomes Nurse I, organizational commitment increases. For every one unit increase in marital status and decreases in position, the organizational commitment increases 2.740 and 2.802 units, respectively. Marital status predicted organizational commitment considering when a person is married he or she receives spousal support and support from the partner. This support received would further increase their commitment to their organization as this is where the person draws strength to do good in his work because of the presence of a partner.

Also, nurses in the position of Nurse I are the ones directing engaged in the care of patients, on top of the fact that they are majority of the respondents, this could be the reason why Nurse I position predicted the organizational commitment. However, contrary to the findings, in the study of Castillo (2024), it revealed that age, sex, and educational attainment did not have a significant relationship with overall organizational commitment. Years of experience and the type of hospital influence organizational commitment. Longer years of experience translate to higher organizational commitment. Also, in the study of Al-Haroon and Al-Qahtani (2020) revealed that there was a significant difference in the levels of commitment among nurses in the various age groups. The continuous commitment subscale received the largest number of positive responses.

The model summary revealed the following values: R = .550, R Square = .303, Adjusted R Square = .150, Std. Error of Estimate = .24124, F = 1.984, Sig. = .088. Therefore, the regression model created is as follows:

Organizational Commitment = 3.614 + 2.740 (marital status) – 2.802 (position)

The equation reads that organizational commitment is the result of the constant value of 3.614 plus 2.740 of marital status minus 2.802 of position. Based on the model summary, the r squared value was .303 which indicates that the total variation in the organizational commitment can be explained by the independent variables of marital status and position. In this case, 30.30 percent can be explained which is weak. This means that the variable of marital status and position predicting organizational commitment had weak effect. Thus, the regression model was also weak. Based on the significant value of .088, the regression model predicts the dependent variable insignificantly. The value was equal to .088, and indicates that, overall, the regression model statistically insignificantly predicts the outcome variable (i.e., it is a good fit for the data).

However, the p values for the profile of age, sex, religion, educational attainment, and years of experience were greater than the significant value of .05 which were interpreted as not significant which further means that they did not predict organizational commitment. Therefore, organizational commitment is not influenced by age, sex, religion, educational attainment, and years of experience. There can still be a high level of organizational commitment no matter what age, sex, religion, educational attainment, and years of experience.

Table 6 Dimensions of Moral Courage Predicting Organizational Commitment

Variables	B	Std error	Beta	t	p value	Decision	Interpretation
(Constant)	2.436	.450		5.412	.000	—	—
Compassion and true presence	.011	.029	.092	.389	.699	Failed to reject Ho	Not significant
Moral responsibility	.021	.028	.155	.747	.460	Failed to reject Ho	Not significant
Moral integrity	-.001	.015	-.019	-.094	.926	Failed to reject Ho	Not significant
Commitment to good care	.038	.019	.431	2.045	.048	Reject ho	Significant

Legend: Significant if p value is < .05. If R-squared value < 0.3 is None or Very weak effect size, if R-squared value 0.3 < r < 0.5 is Weak or low effect size, if R-squared value 0.5 < r < 0.7 is Moderate effect size, and if R-squared value r > 0.7 is Strong effect size.

The table shows that the p value for commitment to good care was below the significant value of .05. This value was interpreted as significant leading to the decision of rejecting the null hypothesis. Thus, commitment to good care predicted organizational commitment. Looking at the table, the t value was positive which indicates that the influence of commitment to good care towards organizational commitment was positive. A positive prediction means that as the commitment to good care increases, the organizational commitment increases. For every one unit increase in the commitment to good care, the organizational commitment increases 2.045 units.

Commit to good care as nurses also means that they are committed to their work. They know for a fact that caring for patients is the very nature of the work ofa nurse and that they are in the caring profession. Being there would mean that they really have to be committed to providing care as patient advocates. After all, they have a four-fold responsibility of promoting health, preventing illness, alleviation of suffering and restoration of health. Therefore, it is not surprising that being committed to care also means that they are committed to their organization. Contrary to the findings, moral courage did not have a statistically significant relationship with organizational commitment. The moral courage and organizational commitment of the participants differed significantly in terms of their type of employment and age. Given the high mean score of moral courage and organizational commitment in operating room nurses, it can be said that nurses tend to show moral behaviors. On the other hand, the low score of the endurance of threat indicates that operating room nurses do not receive the necessary support from the organization for their courageous behavior (Mohadeseh et al., 2021). However, in the study of Azeez Thajeel and AbdulKadhim Johnni (2022), it revealed that there is a direct correlation and statistical significance between moral courage and organizational commitment among the employees. Considering the position of nurses and their role in caring for patients, it is necessary to support moral courage by increasing organizational commitment and responsibility, and providing relevant training opportunities about ethical principles (Khoshmehr et al., 2020, Pirdelkhosh et al., 2022).

The model summary revealed the following values: R = .532, R Square = .283, Adjusted R Square = .201, Std. Error of Estimate = .23387, F = 3.456, Sig. = .018. Therefore, the regression model created is as follows:

Organizational Commitment = 2.436 + 2.045 (commitment to good care)

The equation reads that organizational commitment is the sum of the constant value of 2.436 plus 2.045 of commitment to good care. Based on the model summary, the r squared value was .283 which indicates that the total variation in the organizational commitment can be explained by the independent variable of commitment to good care. In this case, 28.30 percent can be explained which is very weak. This means that the variable of commitment to good care predicting organizational commitment had very weak effect. Thus, the regression model was also very weak. Based on the significant value of .018, the regression model predicts the dependent variable significantly. The value was equal to .018, and indicates that, overall, the regression model statistically significantly predicts the outcome variable (i.e., it is a good fit for the data).

However, the p values for compassion and true presence, moral responsibility, and moral integrity were greater than the significant value of .05 which were interpreted as not significant which further means that they did not predict organizational commitment. Therefore, organizational commitment is not influenced by compassion and true presence, moral responsibility, and moral integrity. There can still be a high level of organizational commitment despite the low levels of compassion and true presence, moral responsibility, and moral integrity.

CONCLUSION AND RECOMMENDATIONS

Conclusion. In conclusion, organizational commitment is influenced by commitment to good care. The higher the commitment to good care, the better the organizational commitment. Further, organizational commitment is influenced by marital status and position. As the marital status becomes married and the position becomes Nurse I, the higher the organizational commitment. Furthermore, age, sex, marital status, religion, educational attainment, years of experience, and position do not influence moral courage. No matter what the personal characteristics, there can still be high moral courage.

The findings of moral courage are reflective of the nurses’ appeal to his/her moral intuitions, values, principles, etc. reflective of compassion and true presence, moral responsibility, moral integrity, commitment to good care as explained by the Moral Courage Model. Alsi, the findings on the organizational commitment were reflective of the Organizational Commitment Theory where nurses had a high sense of obligation to continue working for the hospital for moral or ethical purposes, a high commitment to their positions remain at the hospital because they believe it is the ethical course of action and high emotional attachment, affiliation, and involvement that nurses have with the institution through their involvement. To address these findings of the study, an organizational commitment enhancement plan is proposed.

Recommendations. To address the specific findings of the study, the following recommendations are given, to wit:

Nursing Practice. Tom provide information and guide their practice, the study will be presented to the nursing department and the hospital administrators for them to allow to review, revisit, and revise their already established strategic, operational, and staff developments plans. With this, the organizational commitment enhancement plan is also recommended for implementation in the hospital. Other hospitals may also adopt the plan as they see it appropriate in their respective organizations.

Nursing Education. This study adds to the knowledge regarding moral courage of nurses as well as nurses’ organizational commitment along with the influence of moral courage on organizational commitment. This study can be used as a supporting reference when discussing topics in relations to moral courage and organizational commitment of nurses. This can further aid as a teaching material in discussing research methodology along with statistical treatment of data and ethics in research.

Nursing Policy. Internal policies in relation to moral courage and organizational commitment may be crafted to strengthen the moral courage of nurses as well as heightened their organizational commitment as a means of promoting welfare of the nurses and mental well-being of the nurses.

Nursing Research. To comply with research dissemination, the abstract of the study will be posted in social media. It will also be submitted for publication in any local or international refereed journal. It will also be submitted for a possible oral or poster presentation in a local or international research congress. Also, the following research titles are suggested for future studies:

1. Exploring the lived experience on moral courage influencing organizational commitment among nurses in Cebu City;
2. A validation of regression model on the commitment to good care predicting organizational commitment and other dimensions not predicting it; and
3. A mixed method on the moral courage influencing organizational commitment among nurses in Cebu City.

Organizational Commitment Enhancement Plan

Rationale

Moral courage, which is the capacity to act morally despite the risk to one’s own life, is an essential quality for nurses, since it positively influences their dedication to their place of employment. It is more probable that nurses who exhibit moral courage will be dedicated to their organizations. This is because they will feel respected and empowered to uphold ethical standards, which will ultimately result in enhanced patient care and outcomes for the organization. Findings of the study revealed that there was a high adherence and tendency in terms of the overall moral courage. Specifically, in terms of compassion and true presence and moral responsibility, there were high adherence and tendency and in terms of moral integrity, there was a very high adherence and tendency while in terms of commitment to good care, this was rated as moderate adherence and tendency. Overall, the organizational commitment of the nurses was high. Affective, continuance, and normative commitment were high. Marital status and position predicted organizational commitment. Commitment to good care predicted organizational commitment. Thus, the creation of this enhancement plan.

General Objectives

The main purpose of this organizational commitment enhancement plan is to further improve the moral courage and organizational commitment of nurses.

Specific Objectives

Specifically, this enhancement plan aims to achieve the following specific objectives:

1. To further improve the high level to very high level of adherence and tendency in providing compassion and true presence and moral responsibility among nurses;
2. To further improve the moderate level to very high level of adherence and tendency on commitment to good care among nurses;
3. To sustain the very high level of adherence and tendency on moral integrity among nurses;
4. To further improve the high levels of organizational commitment to very high in terms of the affective, continuance, and affective commitment among nurses;
5. To achieve a very high commitment across all marital status; and
6. To improve further the moral courage from high to very and organizational commitment from high to very high among nurses.

Areas of Concerns	Specific Objectives	Activities	Persons responsible	Resources	Time Frame	Success Indicators
The need to further improve the high adherence and tendency of moral courage	·        To further improve the high level to very high level of adherence and tendency in providing compassion and true presence and moral responsibility among nurses. ·        To further improve the moderate level to very high level of adherence and tendency on commitment to good care among nurses. ·        To sustain the very high level of adherence and tendency on moral integrity among nurses.	Personally-initiated activities: ·        Read articles and view videos about moral courage. ·        Attend webinars or seminars about the role of moral courage in nursing. Hospital-initiated activities: ·        Conduct a seminar on the following: ·        Acronym of CODE: Courage to be moral requires Obligations to honor (What is the right thing to do?), Danger management (What do I need to handle my fear?), Expression and action (What action do I need to take to maintain my integrity?) ·        Developing Cognitive Strategies to Promote Ethical Competence. ·        Overcoming Risk Aversion. ·        Expression Management Strategy: Assertiveness and Negotiation. ·        Conduct periodic meetings with the nursing department to discuss issues concerning moral courage. ·        Re-assess moral courage six months following the implementation of this plan utilizing the same instrument.	·        Staff Nurses. ·        Nurse Managers and the Chief Nurse. ·        HR Director. ·        Hospital Administrators.	·        Desktop, laptops, tablets or android phones. ·        Internet connectivity. ·        Budget for the seminar , etc. (Php 10,000.00). ·        Instrument to measure moral courage.	3rd quarter of 2025 onwards	·        Saved articles and videos. ·        Certificates of participation or attendance to the webinars or seminars. ·        Minutes of meetings. ·        Re-assessment result – very high levels of moral courage and all its dimensions.
The need to further improve the high levels of organizational commitment.	·        To further improve the high levels of organizational commitment to very high in terms of the affective, continuance, and affective commitment among nurses.	Personally-initiated activities: ·        Read articles and view videos about organizational commitment. ·        Attend webinars or seminars about organizational commitment. Hospital-initiated activities: ·        Conduct Orientation and re-orientation of the VMGO and Values. ·        Leadership Training ·        Implement Staff Development Plan ·        Create a retention plan. ·        Revisit the retirement plan. ·        Foster transparency and clear communication by issuing memoranda all the time for any instructions or policies, etc. ·        Conduct a survey about job satisfaction and the baseline data will serve as basis for activities ·        Promote an inclusive environment at work. ·        Conduct an employee survey and act on the findings ·        Review recruiting and compensation practices ·        Reassess employee policies. ·        Make inclusion part of the onboarding process. ·        Demonstrate your commitment to employee wellbeing by promoting or introducing activities such as seminars on Work-life Balance and Taking Care of Mental Health and Well-being, ·        Strive for pay equity and fairness, making sure to do benchmarking to offer competitive salaries. ·        Implement strictly the staff development plan ·        Conduct periodic meetings with the nursing department to discuss issues concerning organizational commitment. ·        Re-assess organizational commitment six months following the implementation of this plan utilizing the same instrument.	·        Staff Nurses. ·        Nurse Managers and the Chief Nurse. ·        HR Director. ·        Hospital Administrators.	·        Desktop, laptops, tablets or android phones. ·        Internet connectivity ·        Budget for the seminar, etc. (Php 10,000.00). ·        Retention plan ·        Retirement plan ·        Survey tools. ·        Staff development plan. ·        Recruitment and compensation policies. ·        Salary schemes. ·        Instrument to measure organizational commitment.	3rd quarter of 2025 onwards	·        Saved articles and videos. ·        Certificates of participation or attendance to the webinars or seminars. ·        Implemented staff development plan. ·        Survey results. ·        Updated policies and salary schemes. ·        Updated Retention plan and Retirement Plans. ·        Minutes of meetings. ·        Re-assessment result – very high levels of organizational commitment and all its dimensions.
Marital status predicting organizational commitment.	·        To achieve a very high commitment across all marital status.	Note: Activities cited in the first two concerns are applicable here.	·        Staff Nurses. ·        Nurse Managers and the Chief Nurse. ·        HR Director. ·        Hospital Administrators.	Note: Resources cited in the first two concerns are applicable here.	3rd quarter of 2025 onwards	Note: Success indicators cited in the first two concerns are applicable here.
Moral courage influencing organizational commitment.	·        To improve further the moral courage from high to very and organizational commitment from high to very high among nurses.	Note: Activities cited in the first two concerns are applicable here.	·        Staff Nurses. ·        Nurse Managers and the Chief Nurse. ·        HR Director. ·        Hospital Administrators.	Note: Resources cited in the first two concerns are applicable here.	3rd quarter of 2025 onwards	Note: Success indicators cited in the first two concerns are applicable here.

REFERENCES

1. Abdollahi, R., Ghasemianrad, M., Hosseinian-Far, A., Rasoulpoor, S., Salari, N., & Mohammadi, M. (2024). Nurses’ moral courage and related factors: A systematic review. Applied Nursing Research, 75, 151768. https://doi.org/10.1016/j.apnr.2024.151768.
2. AL-Dossary, R. N. (2022). Leadership style, work engagement and organizational commitment among nurses in Saudi Arabian Hospitals. Journal of Healthcare Leadership, 14, 71-81. https://doi.org/10.2147/JHL.S365526
3. Al-Haroon, H. I., & Al-Qahtani, M. F. (2020). Assessment of organizational commitment among nurses in a major public hospital in Saudi Arabia. Journal of Multidisciplinary Healthcare, 13, 519-526. https://doi.org/10.2147/JMDH.S256856
4. Allen, N. J., & Meyer, J. P. (1990). The measurement and antecedents of affective, continuance and normative commitment to the organization. Journal of Occupational Psychology, 63(1), 1–18. https://doi.org/10.1111/j.2044-8325.1990.tb00506.x
5. Amiri, E., Ebrahimi, H., Vahidi, M., Asghari, J. M., & Namdar, A. H. (2019). Relationship between nurses’ moral sensitivity and the quality of care. Nursing Ethics, 26(4), 1265–73. https://doi.org/10.1177/0969733017745726.
6. Arablarimi, M., Araghian Mojarad, F., Ghasemi Charati, F., & Jafari, H. (2021). Moral courage of burses and its affecting factors: A systematic review. Tabari Biomedical Studies and Research Journal, 3(2), 58-69. http://tbsrj.mazums.ac.ir/article-1-3730-en.html
7. Azeez Thajeel, M., & AbdulKadhim Johnni, A. (2022). The moral courage and its relationship to the job commitment of employees in the directorate of civil status, passports and residence. Res Militaris, 12(2).
8. Brodowicz, M. (2024). Correlational research: Explanatory and predictive designs. https://aithor.com/essay-examples/correlational-research-explanatory-and-predictive-designs
9. Castillo, M. J. A. (2024). Profile on the Organizational Commitment of Nurses During COVID-19 Pandemic. Psychology and Education, 22(5), 530-542. https://doi.org/10.5281/zenodo.12789889
10. Digonis, S. (2023). The impact of the organizational commitment of nurses in health units in Greece: Cross-sectional study. International Archives of Nursing and Health Care, 9(3). https://doi.org/10.23937/2469-5823/1510188
11. Dugalić, S., Šantrić-Milićević, M., Stanisavljević, D., Vukobrat, B. G.,Gojnić, M., Macura, M., & Dragana Božić, D. (2022). Organizational commitment of healthcare employees in a private sector. Medicinska istaživanja 55(3), 71-78 https://doi.org/10.5937/medi55-38730.
12. Fantahun, B., Dellie, E., Worku, N. et al. (2023). Organizational commitment and associated factors among health professionals working in public hospitals of southwestern Oromia, Ethiopia. BMC Health Services Research, 23, 180. https://doi.org/10.1186/s12913-023-09167-3
13. Fubin, J., & Zhen, W. (2023). A review of research on the formation and effects of moral courage in the workplace. Journal of Management, 20(01), 149–58.
14. Hauhio, N., Leino-Kilpi, H., Katajisto, J., & Numminen, O. (2021). Nurses’ self-assessed moral courage and related socio-demographic factors. Nursing Ethics, 28(7-8), 1402-1415. https://doi.org/10.1177/0969733021999763
15. Hoyert, D. L. (2022). Maternal mortality rates in the United States, 2020. NCHS Health E-Stats.
16. Hthelee, L., Sadooghiasl, A., & Kermanshahi, S. (2023). Moral distress and moral courage among Iraqi nurses during the COVID-19 pandemic: a cross-sectional study. Journal of Medical Ethics and History of Medicine, 16. https://doi.org/10.18502/jmehm.v16i19.14618.
17. Hu, K., Liu, J., Zhu, L. et al. (2022). Clinical nurses’ moral courage and related factors: an empowerment perspective. BMC Nursing, 21, 321. https://doi.org/10.1186/s12912-022-01093-9
18. Huang, M., Dong, W., Zhao, Q., & Mo, N. (2023). Factors associated with the moral courage of nurses in China: A cross-sectional study. Nursing Open, 10(7), 4305-4312. https://doi.org/10.1002/nop2.1672
19. Ishaq, M., Bibi, A., Khaliq, F., Ali, T., Ahmed, H., Mahmood, S., & Gulzada, M. (2023). Assessment of the organizational commitment among nurses: Organizational commitment among nurses. NURSEARCHER (Journal of Nursing & Midwifery Sciences), 3(02), 22–27. https://doi.org/10.54393/nrs.v3i02.55
20. Kakhki, S., Movagharnia, E., Motie, M., Eksir, A., Shirozhan, S., & Javazm, A. (2024). The average of moral courage among nurses and nursing students: A systematic review and meta-analysis protocol. 10, 122-125. https://doi.org/10.30477/cjm.2024.481033.1091.
21. Kasalak, G. (2019). Toxic Behaviors in Workplace: Examining the Effects of the Demographic Factors on Faculty Members’ Perceptions of Organizational Toxicity. International Journal of Research in Education and Science (IJRES), 5(1), 272-282.
22. Kasimoglu, M. (2021). Investigations of organizational commitment of healthcare professionals in terms of personal and business factors. International Journal on Social and Education Sciences (IJonSES), 3(2), 267-286. https://doi.org/10.46328/ijonses.143.
23. Khodaveisi, M., Oshvandi, K., Bashirian, S., Khazaei, S., Gillespie, M., Masoumi, S. Z., & Mohammadi, F. (2021). Moral courage, moral sensitivity and safe nursing care in nurses caring of patients with COVID-19. Nursing Open, 8(6), 3538–46.
24. Khoshmehr, Z., Barkhordari-Sharifabad, M., Nasiriani, K. et al. Moral courage and psychological empowerment among nurses. BMC Nursing, 19, 43. https://doi.org/10.1186/s12912-020-00435-9
25. Konings, K. J.-P., Gastmans, C., Numminen, O. H., et al. (2021). Measuring nurses’ moral courage: an explorative study. Nursing Ethics, 29(1), 114-130. https://doi.org/10.1177/09697330211003211
26. Li, H., Guo, J., Ren, Z. et al. Moral courage level of nurses: a systematic review and meta-analysis. BMC Nursing, 23, 530 (2024). https://doi.org/10.1186/s12912-024-02082-w
27. McCombes, S. (2023). Descriptive research. Definition, types, methods and examples. https://www.scribbr.com/methodology/descriptive-research/
28. Meyer, J. P., & Allen, N. J. (1991). A three-component concept of organizational commitment. Human Resource Management Review, 1, 64-98. https://doi.org/10.1016/1053-4822(91)90011-Z
29. Miller, R. (2005). Moral courage: Definition and development. Ethics Resource Center. http://www.ethics.org/files/u5/Moral_courage_Definition_and_Development.pdf
30. Mohadeseh, R., Mohaddeseh, M., Azam, M., & Mahboobeh, K. (2021). Correlation of moral courage and organizational commitment in Operating Room nurses. Southern Medical Journal, 73(3), 183-190.
31. Nabizadeh, Z., Atashzadeh-Shoorideh, F., Khazaei, N., & Alavi Majd, H. (2014). The study of correlation between organizational commitment and job satisfaction of nurses working in selected hospitals of Isfahan University of Medical Sciences. Scientific Journal of Pure and Applied Sciences, 3. https://doi.org/10.14196/sjpas.v3i8.1561.
32. Namadi, F., Shahbaz, A., & Jasemi, M. (2023). Nurses’ lived experiences of moral courage inhibitors: A qualitative descriptive study. SAGE Open Nursing, 9, 23779608231157326. https://doi.org/10.1177/23779608231157326
33. National Academies of Sciences, Engineering, and Medicine (2016). Assessing progress on the Institute of Medicine report The future of nursing National Academies Press.https://www.ncbi.nlm.nih.gov/books/NBK350171/
34. Neves, T., Parreira, P., Rodrigues, V., & Graveto, J. (2022). Organizational commitment and intention to leave of nurses in Portuguese hospitals. International Journal of Environmental Research and Public Health, 19(4), 2470. https://doi.org/10.3390/ijerph19042470
35. Numminen, O., Repo, H., & Leino-Kilpi, H. (2017). Moral courage in nursing: A concept analysis. Nursing Ethics, 24(8), 878–889.
36. Numminen, O., Katajisto, J., & Leino-Kilpi, H. (2019). Development and validation of Nurses’ Moral Courage Scale. Nursing Ethics, 26(7-8), 2438-2455. https://doi.org/10.1177/0969733018791325
37. Numminen, O., Repo, H., & Leino-Kilpi, H. (2017). Moral courage in nursing: a concept analysis. Nursing Ethics, 24(8), 878–91.
38. Numminen, O., Katajisto, J., & Leino-Kilpi, H. (2019). Nurses’ Moral Courage Scale (NMCS). APA PsycTests. https://doi.org/10.1037/t74384-000
39. Numminen, O., Konings, K., Claerhout, R., Gastmans, C., Katajisto, J., Leino-Kilpi, H., et al. (2021). Validation of the Dutch-language version of Nurses’ Moral Courage Scale. Nursing Ethics, 28(5), 809–22. https://doi.org/10.1177/0969733020981754.
40. Pajakoski, E., Rannikko, S., Leino-Kilpi, H., & Numminen, O. (2021). Moral courage in nursing – An integrative literature review. Nursing Health Science, 23(3), 570–85. https://doi.org/10.1111/nhs.12805.
41. Panchal, N., Sharma, S. K., Sharma, R., & Rani, R. (2022). Job satisfaction and organizational commitment among nurses working on temporary versus permanent jobs at a tertiary care teaching hospital, Uttarakhand, India. Journal of Integrative Nursing, 4(4), 224-230. https://doi.org/10.4103/jin.jin_23_22
42. Papouli, E. (2019). Aristotle’s virtue ethics as a conceptual framework for the study and practice of social work in modern times. European Journal of Social Work, 22(6), 921–34.
43. Pirdelkhosh, M., Mohsenipouya, H., Mousavinasab, N., Sangani, A., Mamun, M. A. (2022). Happiness and moral courage among Iranian nurses during the COVID-19 pandemic: The role of workplace social capital. Frontiers in Psychiatry, 13, 844901.
44. Safarpour, H., Ghazanfarabadi, M., Varasteh, S., Bazyar, J., Fuladvandi, M., Malekyan, L. (2020). The Association between Moral Distress and Moral Courage in nurses: a cross-sectional study in Iran. Iranian Journal of Nursing and Midwifery Research, 25(6), 533–8.
45. Sepahvand F, Atashzadeh-Shoorideh F, Parvizy S, Tafreshi MZ. The relationship between some demographic characteristics and organizational commitment of nurses working in the Social Security Hospital of Khorramabad. Electron Physician. 2017 Jun 25;9(6):4503-4509. doi: 10.19082/4503. PMID: 28848623; PMCID: PMC5557128.
46. Shokouhi, M. R., Torabi, M., Salimi, R., & Hajiloo, P. (2024). The relationship between professional moral courage and individual characteristics among emergency medical services providers. International Journal of Emergency Services, 13(2), 153-162. https://doi.org/10.1108/IJES-08-2023-0039
47. Tavakol, M., & Dennick, R. (2011). Making sense of Cronbach’s alpha. International Journal of Medical Education, 2, 53-55. http://dx.doi.org/10.5116/ijme.4dfb.8dfd
48. Walter, E. M., Beach, A. L., Henderson, C., Williams, C. T., & Ceballos-Madrigal, I. (2021). Understanding Conditions for Teaching Innovation in Postsecondary Education: Development and Validation of the Survey of Climate for Instructional Improvement (SCII). International Journal of Technology in Education (IJTE), 4(2), 166-199. https://doi.org/10.46328/ijte.46.
49. Xia, G., Zhang, Y., Dong, L. et al. (2023). The mediating role of organizational commitment between workplace bullying and turnover intention among clinical nurses in China: a cross-sectional study. BMC Nursing, 22, 360. https://doi.org/10.1186/s12912-023-01547-8