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Document Type

Dissertation - University Access Only

Award Date


Degree Name

Doctor of Philosophy (PhD)

First Advisor

Margaret Hegge


ethical, experience, fear, Magnet®, moral courage, patient safety


Problem: Threats to patient safety exist in perioperative nursing. Nurse appraisal of these threats and the likelihood to act with moral courage have not been documented. Design: This descriptive correlational study examined moral courage in response to threat to patient safety. The moral courage model is based on Lazarus and Folkman’s theory of stress and coping. The Dillman, Smythe, and Christenson (2009) tailored design method was used to construct the Moral Courage Questionnaire for Nurses (MCQN) instrument. Moral courage frequency and intensity were explored relative to personal experience and institutional operating room environment.
Methods: A mail questionnaire was randomly distributed to Midwest perioperative registered nurses yielding a 50% response rate (N = 154).
Results: Multiple regression analysis results indicate moral courage in perioperative nurses is significantly influenced by Magnet® status, certification, peer support, institutional culture, fear, and previous operating room experience. Perioperative nurses from Magnet® hospitals were significantly more likely than nurses from non-Magnet® hospitals to stop a surgical procedure performed by a physician with alcohol breath (F = 7.99, p = .005). Urban perioperative nurses were significantly more likely to stop the procedure than nurses from smaller rural hospitals (F = 4.95, p = .028). Significant positive correlations were shown between previous OR experience and the level of moral courage addressing physician substandard practice (p = .004). Significant negative correlations occurred between fear of reprisal and retaliation and (a) reporting ethical issues to administration (p = .001), (b) questioning provider when not in best interest of patient (p = .001), (c) frequency of speaking up when risks to the patient are known (p = .006), and (d) moral courage overcoming being silent about an ethical issue (p = .005). Fear of reprisal and retaliation were positively correlated with moral distress (p = .000). Sufficient performance of the MCQN Likert-type scale showed contrast of scale scores to reflect variance; Cronbach’s alpha measured 0.81.
Conclusions: Findings indicate the moral courage model performance was robust with the exception of the motivational value systems variable. Perioperative nurses reported high moral courage in situational threats to patient safety. Significant findings clustered influencing factors of fear, previous experience, peer support, and institutional culture. Furthermore, Magnet® status, peer support, previous operating room experience, institution’s urban location, supportive nursing management and administration promote perioperative nurses’ exhibition of moral courage. Future research is indicated for supportive nursing management and policy creation promoting moral courage in situations that are threats to patient safety within the perioperative area.

Library of Congress Subject Headings

Operating room nurses -- Attitudes
Operating room nursing
Patients -- Safety measures
Patients -- Care


Includes bibliographical references (pages 312-330)



Number of Pages



South Dakota State University


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