Iran Journal of Nursing

Introduction
Nursing is one of the important foundations of the healthcare system in every country and the effective provision of nursing services is associated with health outcomes. Providing health care is complicated and challenging due to the invention of new technologies, multiple treatment recommendations, regulatory restrictions, and the severity of ‘ illnesses in patient. The clinical competence of nurses is one of the main concerns in medical centers due to the importance and necessity of providing quality care. Competency is a complex and ambiguous concept, and is one of the controversial issues in health care. Clinical competence refers to the ability to perform tasks with desirable results under various circumstances in real world.  Nurses must have professional qualifications. Regular assessment of nurses’ competence and qualifications is essential. The nurse’s clinical competence depends on individual and environmental factors. One of the individual factors is professional ethics. One of the aspect of professional ethics is moral courage which depends on time and place, and it is different based on value, role, and culture and society context. One of the components of professional ethics in nursing is moral courage. Moral courage is the ability to use moral principles to do what one believes is right. Moral courage is a means to strengthen and empower nurses in ethical decision-making and its implementation in a multi-professional care team. Nurses who are morally courageous can confidently and fearlessly act for the benefit of the patient. Considering the multi tasks of nurses, they should have moral courage and clinical competency, since appropriate clinical competence requires moral courage. Since few studies have been conducted in assessing the relationship between clinical competence and moral courage in nurses, this study aims to determine the relationship between clinical competence and moral courage in Iranian nurses.

Methods
This is a cross-sectional study that was conducted on 213 nurses working in hospitals in Hamadan, Iran, who were selected using a stratified sampling method. The criteria for entering the study were willingness to participate in the research and having at least 3 months of work experience. The exit criterion was the return of incomplete questionnaires. Data collection tools were Sekarka’s moral courage questionnaire, Liu et al.’s competency inventory for registered nurses (CIRN), and a demographic form (Surveying age, gender, marital status, education level, and employment status). 
The CIRN has 7 subscales and 55 items rated on a 5-point Likert scale. The total score is a range of 0 and 220 with higher scores indicating higher competency [18]. 
The moral courage questionnaire has 15 items with a 7-point Likert scale. The total score ranged from 15 to 105 [19]. For its Persian version, Montazeri et al. reported a reliability of 0.80 [12]. 
Data analysis was done using descriptive statistics, independent t-test, one-way analysis of variance and Pearson’s correlation test in SPSS software, version 16. The significance level was set at 0.05.

Results
Most of the participants were female (54.71%), married (63.41%), with bachelor’s degree (82.93%), permanent employment (54.47%), rotating shift (66.04%), and no history of participation in ethics workshop (58.54%). The mean age of participants was 34.39‌±‌6.69 years. The mean scores of clinical competence and moral courage scores were 151.18‌±‌22.32 and 59.56‌±‌7.47, respectively, which indicates a moderate clinical competence and a high moral courage. There was a significant and positive relationship between moral courage and clinical competence (r=0.272, P=0.001). There was no significant in moral courage or clinical competence based on demographic factors (P≥0.05).

Conclusion
There is a positive and significant relationship between clinical competency and moral courage in Iranian nurses. Therefore, by strengthening moral courage of nurses, their clinical competence can be increased, which can increase the quality of patient care and reduce moral tensions. It is recommended to use seminars and educational courses to strengthen the moral courage and clinical competence of nurses. It is also recommended to conduct more research on the relationship of the factors other than clinical competence with the clinical competence of nurses.

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Ethics Committee of Hamadan University of Medical Sciences (Code IR.UMSHA.REC.1401.114). Written informed consent was obtained from all participants.

Funding
This article was extracted from the research project, funded by Vice-Chancellor for Research and Technology of Hamadan University of Medical Sciences (Grant No. 140103171739). 

Authors' contributions
All authors equally contributed to preparing this article.

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
The authors would like to thank the Vice-Chancellor for Research and Technology of Hamadan University of Medical Sciences for their financial support.

References

1. Sanjari M, Zahedi F, Aalaa M, Peimani M, Parsapoor A, Cheraghi MA, et al. [Code of ethics for Iranian nurses (Persian)]. Iran J Med Ethics Hist Med. 2011; 5(1):17-28. [Link]
2. Ghorbani S, Heshmati Nabavi F, Heidarian Miri H, Mazlom SR, Akbari Rad SA, Mohebbi T. [Evaluation of clinical competence of novice nurses from the perspective of head nurses, a cross-sectional descriptive study in Mashhad University of Medical Sciences in 2019 (Persian)]. J Nurs Manage. 2021; 10(1):60-7. [Link]
3. Najafi B, Nakhaee M, Vagharseyyedin SA. [Clinical competence of nurses: A systematic review study (Persian)]. J Nurs Manage. 2022; 11(1):1-9. [Link]
4. Nascimento JDSG, Siqueira TV, Oliveira JLG, Alves MG, Regino DDSG, Dalri MCB. [Development of clinical competence in nursing in simulation: The perspective of Bloom's taxonomy (English, Portuguese)]. Rev Bras Enferm. 2021; 74(1):e20200135. [DOI:10.1590/0034-7167-2020-0135] [PMID]
5. Koskenvuori J, Stolt M, Suhonen R, Leino-Kilpi H. Healthcare professionals' ethical competence: A scoping review. Nurs Open. 2018; 6(1):5-17. [DOI:10.1002/nop2.173] [PMID] [PMCID]
6. Grol R. Successes and failures in the implementation of evidence-based guidelines for clinical practice. Med Care. 2001; 39(8 Suppl 2):II46-54. [DOI:10.1097/00005650-200108002-00003] [PMID]
7. Khoshmehr Z, Barkhordari-Sharifabad M, Nasiriani K, Fallahzadeh H. Moral courage and psychological empowerment among nurses. BMC Nurs. 2020; 19:43. [DOI:10.1186/s12912-020-00435-9] [PMID] [PMCID]
8. Jodaki K, Esmaeili M, Cheraghi MA, Pashaeypoor S, Sadat Hoseini AS. Clarifying the concept of conscience in nurses' ethical performance in Iran: A concept analysis study. J Med Ethics Hist Med. 2021; 14:14. [DOI:10.18502/jmehm.v14i14.7669] [PMID] [PMCID]
9. Kleemola E, Leino-Kilpi H, Numminen O. Care situations demanding moral courage: Content analysis of nurses' experiences. Nurs Ethics. 2020; 27(3):714-25. [DOI:10.1177/0969733019897780] [PMID]
10. Numminen O, Konings K, Claerhout R, Gastmans C, Katajisto J, Leino-Kilpi H, et al. Validation of the Dutch-language version of Nurses' Moral Courage Scale. Nurs Ethics. 2021; 28(5):809-22. [DOI:10.1177/0969733020981754] [PMID] [PMCID]
11. Hu K, Liu J, Zhu L, Zhou Y. Clinical nurses' moral courage and related factors: An empowerment perspective. BMC Nurs. 2022; 21(1):321. [DOI:10.1186/s12912-022-01093-9] [PMID] [PMCID]
12. Montazeri M, Rahgoi A, Fallahi M, Vahedi M. The relationship between clinical competence and moral courage of nurses in intensive care units of hospitals affiliated to Tehran University of Medical Sciences: A multicenter cross-sectional study. Crit Care Nurs. 2022; 15(4):2. [DOI:10.30491/JCC.15.4.11]
13. Takase M. The relationship between the levels of nurses' competence and the length of their clinical experience: A tentative model for nursing competence development. J Clin Nurs. 2013; 22(9-10):1400-10. [DOI:10.1111/j.1365-2702.2012.04239.x] [PMID]
14. Mohamadirizi S, Kohan S, Shafei F, Mohamadirizi S. The relationship between clinical competence and clinical self-efficacy among nursing and midwifery students. Int J Pediatr. 2015; 3(6.2):1117-23. [DOI:10.22038/ijp.2015.5222]
15. Zahed Babelan A, Gharibzadeh R, Gharibzadeh S, Mortezazadeh Giri AA. [The role of mediator psychological empowerment, the relationship between professional ethics and work engagement of nurses (Persian)]. Educ Ethics Nurs. 2022; 5(2):55-62. [DOI:10.52547/ethicnurs.5.2.8]
16. Ramezanzade Tabriz E, Orooji A, Bikverdi MA. Investigation clinical competence and its relationship with professional ethics and spiritual health in nurses. Health Spirit Med Ethics. 2017; 4(1):2-9. [Link]
17. Sharafieh S, Khaleghparast S, Ghani Dehkordi F, Mazloomzadeh S. [Relationship between moral courage of nurses and their participation in clinical decision-making (Persian)]. J Hayat. 2021; 27(3):233-44. [Link]
18. Saadati SM, Emami Sigaroudi A, Mitra Chehrzad M, Kazemnezhad Lili E. [Pediatric nursing clinical competency from the viewpoints of nurses and headnurses (Persian)]. J Sabzevar Univ Med Sci. 2019; 25(6):875-83. [Link]
19. Habibzade H, Ahmadi F, Vanaki Z. [Ethics in professional nursing in Iran (Persian)]. Iran J Med Ethics Hist Med. 2010; 3(5):26-36. [Link]
20. Ha NS, Choi J. An analysis of nursing competency affecting on job satisfaction and nursing performance among clinical nurses. J Korean Acad Nurs Adm. 2010; 16(3):286-94. [DOI:10.11111/jkana.2010.16.3.286]
21. McCaughan E, Parahoo K. Medical and surgical nurses' perceptions of their level of competence and educational needs in caring for patients with cancer. J Clin Nurs. 2000; 9(3):420-8. [DOI:10.1046/j.1365-2702.2000.00403.x] [PMID]
22. Cruz JP. Quality of life and its influence on clinical competence among nurses: A self-reported study. J Clin Nurs. 2017; 26(3-4):388-99.[DOI:10.1111/jocn.13402] [PMID]
23. Imani B, Vanaki Z, Mohamdkhan Kermanshahi S, Karampourian A. [The correlation between nurses' clinical competency and emotional intelligence in nurses of health care units in hamadan university of medical sciences hospitals (Persian)]. Nurs Manage. 2018; 7(3):27-34. [Link]
24. Khodadadei N, Rezaei B, Salehi S. Investigating the relationship of organizational commitment and clinical competence (Case study: Nurses working in Montazeri Hospital, City of Najafabad, Iran, 2015). Int J Med Res Health Sci. 2016; 5(S):308-16. [Link]
25. Jaffari- Golestan N, Vanak Z, Memarian R. [Organizing” nursing mentors committee”: An effective strategy for improving novice nurses’ clinical competency (Persian)]. Iran J Med Educ. 2008; 7(2):237-47. [Link]
26. Mirlashari J, Qommi R, Nariman S, Bahrani N, Begjani J. Clinical competence and its related factors of nurses in neonatal intensive care units. J Caring Sci. 2016; 5(4):317-24. [DOI:10.15171/jcs.2016.033] [PMID] [PMCID]
27. Abdollahzadeh H. Effectiveness of spiritual self-care training on nurses’ self-compassion and moral courage. J Res Behav Sci. 2020; 18(3):393-402. [DOI:10.52547/rbs.18.3.393]
28. Safarpour H, Ghazanfarabadi M, Varasteh S, Bazyar J, Fuladvandi M, Malekyan L. The association between moral distress and moral courage in nurses: A cross-sectional study in Iran. Iran J Nurs Midwifery Res. 2020; 25(6):533-8. [DOI:10.4103/ijnmr.IJNMR_156_19] [PMID] [PMCID]
29. Fazljoo SE, Nasiriani K, Zamani N, Azimpor S. Nurses' perceptions of ethical climate, ethical reasoning, and moral courage in the hospital. Iran J Nurs. 2021; 34(133):28-39. [DOI:10.32598/ijn.34.5.3]