The relationship between professional moral courage and individual characteristics among emergency medical services providers

Abstract

Purpose

Emergency Medical Services (EMS) providers are often faced with a range of ethical dilemmas in their line of work that require moral courage to make a quick and ethical decision. The purpose of this study is to investigate the level of professional moral courage (PMC) in EMS providers and its relationship with their demographic characteristics.

Design/methodology/approach

In 2022, a cross-sectional descriptive study was conducted on 175 EMS providers at the Hamadan Emergency Medical Center. The study utilized an available sampling method. Data was collected using a demographic information form and Sekerka's moral courage questionnaire, which was distributed electronically. The collected data was analyzed using SPSS 26 software with descriptive and analytic tests.

Findings

According to the findings, the average age of the participants was 34.57 ± 3.46 years. The majority of participants were married (50.3%), had work experience ranging from 8 to 14 years (49.7%), and held a degree in emergency medicine (52.6%). The participants displayed a high level of PMC, with an average score of 62.5 ± 8.14. Notably, age, work experience, educational level, and employment status were all found to have a significant relationship with moral courage (p < 0.05) among the demographic characteristics.

Research limitations/implications

The study has a limitation in terms of the sampling method employed, which may impact the generalizability of the results. Another limitation, by a narrow margin, is that the sample size is smaller than what was estimated. Furthermore, using various measurement tools to assess PMC might lead to varying outcomes. Consequently, it is recommended that future research incorporates random sampling and devises a dedicated psychometric instrument to assess the PMC of EMS providers.

Originality/value

The results revealed a positive correlation between work experience and PMC among providers. This can be attributed to the challenges and outcomes they have encountered throughout their careers. Moreover, EMS providers with higher educational qualifications and job stability demonstrated higher levels of moral courage.

Citation

Shokouhi, M.R., Torabi, M., Salimi, R. and Hajiloo, P. (2024), "The relationship between professional moral courage and individual characteristics among emergency medical services providers", International Journal of Emergency Services, Vol. 13 No. 2, pp. 153-162. https://doi.org/10.1108/IJES-08-2023-0039

Introduction

Emergency Medical Services (EMS) is an essential part of the health care delivery system that provides pre-hospital care at the appropriate place and time, using available resources, starts from the patient's bedside and may end in the hospital emergency room (Bahadori et al., 2016). Pre-hospital care plays a crucial role in the treatment of emergency patients, significantly reducing mortality rates and improving patient outcomes (Jamali et al., 2019). In Iran, pre-hospital emergency services are provided by two male technicians in 12- or 24-h shifts. They have studied at post-diploma, bachelor's or higher levels in various fields of study, including nursing, emergency medicine, operating room and anesthesia (Torabi et al., 2020). EMS providers frequently encounter unexpected and unique situations requiring rapid decision-making to prevent death and permanent disabilities. These high-pressure situations typically entail psychological pressures and challenges, placing numerous moral responsibilities on these professionals (Jalili, 2020). In this situation, having Professional Moral Courage (PMC) in EMS providers helps them to take the right action by following ethical principles (Hoseini et al., 2019). Moral courage is a virtue that provides the ability to perform moral behavior despite obstacles (Khajevandi et al., 2020) and is one of the inherent characteristics of a human being that is manifested in facing moral difficulties (Sadooghiasl et al., 2018). Moral courage is the inner strength that causes a person to behave according to his moral principles, values, and beliefs in the face of moral conflicts, despite the risk of negative consequences for individual performance (Pajakoski et al., 2021). In other words, moral courage means acting based on moral values, despite moral challenges and dilemmas (Namadi et al., 2019). Moral courage proves invaluable in situations where individuals struggle to adhere to proper moral conduct. It enables them to prioritize the ultimate objective over potential consequences, empowering them to make difficult choices aligned with moral principles (Comer and Vega, 2015). Despite being competent and skilled professionals with vast knowledge in medicine and nursing, individuals in the medical emergency department occasionally struggle to make ethical decisions and perform effectively when confronted with challenging and high-pressure circumstances (Torabi et al., 2018). This inability is not due to the lack of awareness of moral issues, but rather they are not able to recognize and choose the correct solution or are afraid of doing it. Consequently, to conquer this fear, moral courage becomes essential in addition to possessing high skill levels (Khoshmehr et al., 2020). EMS providers who possess strong moral courage strive to adhere to professional ethics when faced with situations such as protecting patient privacy, delivering unfortunate news, and providing care. Conversely, the absence of moral courage poses challenges for healthcare providers, including apprehension about negative responses from colleagues, the risk of job loss, and experiencing intense emotional reactions such as moral distress, depression, guilt, anger, feelings of inadequacy, and a sense of powerlessness (Ebadi et al., 2020). Since EMS providers may hesitate to address these issues, it is important to ask why there is no courage for disclosing such problems (Aliakbari et al., 2021). Corley identified external barriers to moral courage, such as job structures, social hierarchies, resource scarcity, competition, and growing demand for health care (Corley, 2002). The results of some studies have reported job insecurity as the cause of reducing moral courage in healthcare providers (Day, 2007). Conversely, studies conducted in Iran on the moral courage of nurses and its associated factors revealed that the majority of nurses have high moral courage (Namadi et al., 2019; Thorup et al., 2012). Given the intricate nature of providing pre-hospital care in critical situations and the importance of moral courage for EMS providers in decision-making, this study aimed to examine the level of moral courage among EMS providers and its correlation with demographic characteristics, considering the limited existing research in this area.

Purpose of the study

Materials and methods

Study design

The current study is a descriptive cross-sectional study conducted in 2022 to investigate the level of PMC among EMS providers and associated demographic characteristics. The study included all providers employed in emergency medical services systems in Hamadan city. They were selected using an available sampling method. Based on similar studies (Karami Rajabpoor et al., 2022; Aliakbari et al., 2021) and using these parameters (α = 0.05, Z = 1.96, power = 80, and β = 0.2), a sample size of 205 people was calculated, with a potential dropout rate of 10%. To be eligible for inclusion in the study, participants had to meet the following criteria: have a minimum of one year of work experience in EMS, hold at least a bachelor's degree in nursing or emergency medicine, and provide informed consent.

Ethical Approval: The present study was approved by the Ethics Committee of Hamadan University of Medical Sciences (IR.UMSHA.REC.1400.637). The researcher collaborated with the emergency medical center staff to invite EMS providers to participate in the research project. Qualified employees were requested to provide their consent by clicking on a provided link. Consent was obtained electronically at the start of the questionnaire. Both in the research group and in the electronic questionnaire, they were assured about the confidentiality of the information.

Data gathering

In the data collection stage, an electronic questionnaire consisting of two parts of demographic information (age, work experience, marital status, employment status, history of participating in ethical principles courses) and the PMC questionnaire developed by Sekerka et al. (2009) were used (Sekerka et al., 2009). The questionnaire consists of 5 dimensions, each with three items. These dimensions include Moral agency, which measures a person's readiness and desire to perform moral behavior; Multiple values, which assesses a person's ability to simultaneously apply personal and professional values in decision-making; Endurance of threats, which gauges a person's capacity to understand and accept moral issues despite external pressures; Going beyond compliance, which evaluates a person's tendency to perform moral behaviors beyond mere adherence to rules; and Moral target, which measures a person's ability to set goals that surpass moral virtues. Each item was scored on a 5-point Likert scale ranging from 1 to 5, indicating the extent to which the statement is true (from never true to always true). There are three items in every dimension, with a score range of 3–15 and a total range of 15–75. The total moral courage score was categorized as low (15–35), medium (36–55), or high (56–75). The validity and reliability of this questionnaire in Iran were assessed positively (Khoshouei, 2014). The researcher provided the EMS providers with a link to an electronic questionnaire and sent them reminder messages to complete it. Eventually, 175 questionnaires were completed by eligible individuals. To assess the questionnaire's validity, the content validity was used in a qualitative method. This involved giving the questionnaire to 6 medical ethics professors and 4 experienced EMS center managers. After collecting and summarizing their opinions, necessary corrections were made. Additionally, to assess the questionnaire's face validity, it was given to 5 EMS providers who were similar to the research units but not part of the research sample. The tool's reliability was determined using Cronbach's alpha, which yielded a score of 0.87.

Data analysis

The collected data was analyzed using SPSS version 26 software. Additionally, descriptive statistics tests such as relative frequency, mean, and standard deviation were conducted. Furthermore, inferential parametric statistics tests including t-test, ANOVA, and multiple regression were also performed.

Results

Out of the eligible participants, 175 EMS providers completed the questionnaires. The average age of these participants was 34.57 ± 3.46 years. As mentioned in Table 1, the majority of the participants were married, accounting for 88 (50.3%). They had work experience ranging from 8 to 14 years, constituting 87 (49.7%) of the sample. Nearly half of the participants had a contractual employment status, which was 72 (41.1%), and held a degree in emergency medicine, which was 92 (52.6%). The normality of the data was confirmed through the Kolmogorov-Smirnov test. The average score of moral courage was 62.5 ± 8.14, indicating a high level of moral courage. The moral target dimension had the highest score of 14.12 ± 1.72, while the lowest score was observed in the endurance of threats dimension with 11.58 ± 1.32 (Table 2). The results of examining the relationship between personal characteristics and moral courage of emergency medical employees showed that the average score of moral courage is significantly related to increasing age, work experience, type of employment, and educational level (p < 0.05). Using post hoc tests (Tukey), it has been shown that there is a significant difference between the status of permanent and contractual employment and the status of temporary and mandatory employment (p < 0.05). EMS providers who were older and had more work experience, likewise, employees with higher education levels and stable employment status demonstrated greater levels of moral courage (p < 0.05) (Table 3).

The variables of age, work experience, education level, and employment status, with p-values less than 0.25, were included in multiple linear regressions using the backward elimination technique. These variables were retained in the final model, which accounted for approximately 31.27% of the variance in PMC among EMS providers (Table 4).

Discussion

EMS providers as same as other hospital-based nurses encounter numerous ethical challenges in their daily work. Although several studies have explored ethical issues and moral courage among nurses, there is a limited research that specifically focused on EMS providers. Consequently, there is a need for further studies to investigate the ethical challenges encountered by EMS providers and their display of moral courage in such situations.

Results from the current study revealed a high PMC score among participants. This finding aligns with previous studies conducted by Karami Rajabpoor et al. (2022) and Aliakbari et al. (2021), which also found high average scores among EMS providers. Similarly, studies on nurses have consistently shown that the majority of participants scored high in moral courage (Namadi et al., 2019; Ebadi et al., 2020; Pakizekho and Barkhordari-Sharifabad, 2022). However, Aminizadeh et al. (2017) reported moderate levels of moral courage among nurses (Aminizadeh et al., 2017). It has been noted that individual characteristics such as fear and lack of courage can sometimes lead to the cancellation of disclosure actions (Pajakoski et al., 2021).

The study found a positive and significant relationship between increasing age and work experience with the average PMC score (p < 0.05). However, there was no significant relationship between marriage and PMC (p < 0.05). Furthermore, the results of the analysis utilizing multiple linear regression revealed that predictive variables, including age, work experience, education level, and employment status, could account for 31.27% of the variance in PMC among EMS providers. These findings are consistent with the results of a study by Karami Rajabpoor et al. (2022), which investigated the moral courage of 194 emergency medical technicians (EMTs) with an average age of 33.46 years and an average work experience of less than 10 years. Most of the participants in that study were married (72.2%), and the Pearson correlation test showed a significant relationship between increasing age and work experience with the average PMC score. While using the logistic regression test, none of the demographic variables had a significant relationship with PMC (Karami Rajabpoor et al., 2022). However, the results (Ebadi et al., 2020) showed a high PMC score in nurses and found a significant relationship between age, work experience, and participation in ethics courses with PMC score (p < 0.05). The study showed that nurses aged 30–40 years, with 10–15 years of work experience, had the highest PMC score. The results imply that age and work experience, along with education and ethics training, might contribute to the development of moral courage in healthcare professionals (Ebadi et al., 2020).

In our study, we found no significant correlation between participation in professional ethics training courses and moral courage, unlike the findings of Ebadi et al. One possible explanation for this discrepancy is the method of instruction in specialized subjects and its practical application, the utilization of non-specialist and non-professional instructors in the field of medical ethics, and the organization of training sessions with extended intervals at the emergency medical center.

Various studies have explored the relationship between demographic factors and scores on the PMC scale among healthcare professionals, producing inconsistent outcomes. The results from Namadi et al. (2019) indicated a significant correlation between age and work experience. However, Aliakbari et al. (2021) found no significant relationship between these variables and PMC scores among EMS providers who had similar age and work experience. Conversely, Namadi et al. (2019) reported a significantly higher PMC score in married individuals, while Khajevandi et al. (2020) concluded that age, marital status, and work experience were not predictive factors for nurses' moral courage. Additionally, the results from Alinaghian et al. (2018) found that individual characteristics did not influence disclosure (Alinaghian et al., 2018). Despite the presence of guidelines and ethical codes, whistle-blowing, which necessitates moral courage to address violations and moral dilemmas, may be impeded by the fear of negative consequences or discrimination from colleagues and managers (Numminen et al., 2017; Pohjanoksa et al., 2019). The positive correlation between age and work experience with PMC score among EMS providers may be attributed to the exposure of senior providers to ethical challenges and their associated consequences. The findings indicate that providers with more experience were more inclined to consider moral values, organizational rules, and the moral outcomes of their actions. However, some studies did not find a significant association between individual characteristics and PMC score, possibly due to variations in the tools used to assess PMC, sampling techniques, educational background, or the moral climate within organizations.

The results of this study showed a significant relationship between educational level and employment status with PMC. EMS providers with higher educational levels and more stable employment status (permanent and contractual) had higher average PMC scores. The positive impact of postgraduate education on ethical courage in the present study can be attributed to the increased training of employees in professional ethics and their participation in medical ethics conferences during their studies. Additionally, the expectations that others have of employees with higher levels of postgraduate education may influence their attitudes and behavior. These findings are consistent with previous studies indicating that providers with stable employment status tend to have higher moral courage (Ebadi et al., 2020) and that providers with higher education levels have higher moral competence (Aliakbari et al., 2021). Although, Karami Rajabpoor et al. (2022) did not find any significant correlation between the average total PMC score and employment status or field of study among EMS providers in their study, they did find significant correlations between specific dimensions of PMC and these variables. Similarly, the results from Khoshmehr et al. (2020) also did not find any correlation between employment status, marriage, and education level with PMC (p > 0.05). They only found that age and work experience had a significant correlation with PMC score (p < 0.05). These inconsistencies could be attributed to variations in personality traits, organizational ethical climate, or evaluation systems.

The significant relationship between PMC and employment status in this study may be related to the age and high work experience of providers with more stable employment status. The moral climate and evaluation systems in different organizations also affect PMC. The results from Sadooghiasl et al. (2018) noted that the working environment of providers affects their performance and adherence to ethical principles. In Iran, EMS providers with more stable employment situations may have less fear of being reprimanded, which can affect their behavior.

The study found that EMS providers had higher scores in moral agency and moral target dimensions and lower scores in dimension of multiple values, indicating their greater desire to perform ethical behavior with goals beyond moral virtues. Consistent with the present study, their results showed that the highest and lowest score of moral courage dimensions were related to moral agency and multiple values, respectively (Mahdaviseresht et al., 2015). According to Moosavi et al. (2017), moral agency had the highest average score among the PMC dimensions, while endurance of threats had the lowest average score (Moosavi et al., 2017). These differences may be due to personality traits, organizational ethical climate, or evaluation systems.

The literature shows that several factors such as moral climate (Taraz et al., 2019), ethical leadership style (Ali Awad and Al-Anwer Ashour, 2022), interpersonal relationships, organizational factors, and individual characteristics (Hu et al., 2022) affect moral courage, requiring further investigation and planning to improve the moral courage of medical staff.

Limitations

The study has a limitation in terms of the sampling method employed, which may impact the generalizability of the results. Another limitation, by a narrow margin, is that the sample size is smaller than what was estimated. Furthermore, using various measurement tools to assess PMC might lead to varying outcomes. Consequently, it is recommended that future research incorporates random sampling and devises a dedicated psychometric instrument to assess the PMC of EMS providers.

Conclusion

This study demonstrate that EMS providers exhibit high levels of PMC, particularly in the moral agency and moral target aspects. These findings indicate that EMS providers possess a strong sense of responsibility and prioritize moral values in decision-making. Given the sensitive nature of their job and the ethical challenges they face in various settings, it is essential to prioritize the moral virtues of EMS providers in order to enhance the quality of care based on ethical principles. The study found that demographic variables, such as age, work experience, and employment status, significantly impact the moral courage of EMS providers. The results of this study can play a significant role in the development and influence of organizations and managers in increasing the PMC of EMS providers, utilizing methods such as stabilizing job positions, incorporating experienced employees alongside novices, and emphasizing continuity in specialized professional ethics training.

Table 1

Demographic characteristics of the participants

Variables		Number	Percentage (%)
Age (year)	<30	52	29.7
	30–45	89	50.8
	>45	34	19.5
Marital status	Single	76	42.4
	Married	88	50.3
	Other	11	6.3
Educational level	Bachelor	163	93.2
	Master's degree, or higher	12	6.7
Discipline	EM	92	52.6
	Nursing	83	47.4
Work experience (year)	<7	39	22.2
	8–14	87	49.7
	15–21	33	18.9
	>21	16	9.2
Type of employment	Permanent	49	28
	Contractual	72	41.1
	Temporary	31	17.7
	Mandatory	23	13.2
Participating in professional moral courses	Yes	135	77
	No	40	23

Note(s): EM: Emergency Medical

Source(s): Created by authors

Table 2

Mean and standard deviation of PMC and its dimensions in EMS providers

Variables	Mean ± SD	Max score	Min score
Moral agency	14.32 ± 1.65	15	11
Multiple values	12.87 ± 1.56	13	9
Threats endurance	13.75 ± 1.81	14	11
Going beyond compliance	11.58 ± 1.32	14	8
Moral target	14.23 ± 1.72	15	12
Moral courage	62.5 ± 8.14	73	51

Note(s): SD: Standard Deviation

Source(s): Created by authors

Table 3

Mean and standard deviation of PMC total score and its dimensions based on demographic characteristics

Variables		Moral agency	Multiple values	Endurance of threats	Going beyond compliance	Moral target	Total score PMC
Age (Year)	<30	13.32 ± 1.43	11.34 ± 1.45	12.78 ± 1.43	12.21 ± 1.34	13.27 ± 1.42	56.17 ± 6.21
	30–45	13.87 ± 1.87	12.21 ± 1.12	13.54 ± 1.51	12.23 ± 1.26	14.11 ± 1.67	59.45 ± 7.12
	>45	14.21 ± 1.21	13.31 ± 1.79	13.57 ± 1.81	11.89 ± 1.32	14.67 ± 1.78	62.52 ± 8.44
	ANOVA	p = 0.121	*p = 0.041	p = 0.061	p = 0.234	*p = 0.034	*p = 0.042
Marital status	Single	13.45 ± 1.87	12.43 ± 1.32	13.43 ± 1.12	12.43 ± 1.65	13.98 ± 1.33	60.26 ± 6.34
	Married	13.98 ± 1.76	13.21 ± 1.34	12.87 ± 1.32	12.32 ± 1.65	14.87 ± 1.33	61.74 ± 7.14
	Other	13.12 ± 1.45	12.22 ± 1.24	13.13 ± 1.21	11.98 ± 1.81	13.88 ± 1.76	58.58 ± 5.35
	ANOVA	p = 0.351	p = 0.052	p = 0.253	p = 0.212	p = 0.431	p = 0.342
Education	Bachelor	13.42 ± 1.34	13.33 ± 1.20	13.11 ± 1.68	12.98 ± 1.87	13.76 ± 1.45	61.84 ± 8.54
	Master, or higher	14.87 ± 1.76	13.45 ± 1.54	14.44 ± 1.56	13.12 ± 1.21	14.78 ± 1.71	65.12 ± 12
	T-test	p = 0.254	p = 0.621	*p = 0.037	p = 0.314	*p = 0.025	*p = 0.046
Discipline	EM	13.45 ± 1.36	12.79 ± 1.32	12.69 ± 1.13	12.69 ± 1.25	13.32 ± 1.25	57.26 ± 6.12
	Nursing	13.67 ± 1.45	13.20 ± 1.58	13.43 ± 1.46	12.11 ± 1.24	14.76 ± 1.23	59.55 ± 7.11
	T-test	p = 0.641	p = 0.513	p = 0.161	p = 0.725	*p = 0.016	p = 0.251
Work experience (Year)	<7	13.47 ± 1.61	13.36 ± 1.36	11.83 ± 1.31	13.35 ± 1.67	3/37 ± 1.51	56.37 ± 6.31
	8–14	13.47 ± 1.35	12.87 ± 1.41	12.36 ± 1.42	12.89 ± 1.42	13.48 ± 1.72	60.46 ± 8.21
	15–21	14.27 ± 1.48	12.89 ± 1.84	13.75 ± 1.46	12.69 ± 1.37	14.75 ± 1.88	62.28 ± 8.87
	>21	14.58 ± 1.62	14.13 ± 1.69	14.35 ± 1.57	13.31 ± 1.61	14.34 ± 1.73	63.13 ± 1.73
	ANOVA	*p = 0.012	*p = 0.022	*p = 0.018	p = 0.081	*p = 0.041	*p = 0.038
Type of employment	Permanent	14.72 ± 1.59	13.86 ± 1.63	13.33 ± 1.47	12.88 ± 1.31	14.32 ± 1.65	62.24 ± 9.65
	Contractual	13.87 ± 1.53	13.30 ± 1.60	13.49 ± 1.37	13.12 ± 1.41	14.11 ± 1.57	62.39 ± 8.25
	Temporary	12.20 ± 1.31	12.80 ± 1.51	12.19 ± 1.86	12.57 ± 1.46	11.74 ± 1.47	59.62 ± 7.23
	Mandatory	12.88 ± 1.55	12.39 ± 1.34	12.92 ± 1.32	12.33 ± 1.41	12.24 ± 161	60.44 ± 7.46
	ANOVA	*p = 0.021	p = 0.053	p = 0.091	p = 0.631	*p = 0.001	*p = 0.012
Participation in professional moral courses	Yes	14.72 ± 1.53	13.24 ± 1.42	13.32 ± 1.65	12.33 ± 1.14	14.42 ± 1.24	61.42 ± 9.21
	No	14.12 ± 1.41	12.87 ± 1.23	13.73 ± 1.23	11.78 ± 1.31	14.11 ± 1.36	59.85 ± 8.43
	T-Test	p = 0.521	*p = 0.048	p = 0.325	p = 0.061	p = 0.831	p = 0.537

Note(s): ANOVA: Analysis of variance; EM: Emergency medicine; * Significance indicator: p < 0.05

Source(s): Created by authors

Table 4

The predictor variables of PMC in EMS providers

Variable	Unstandardized coefficients		Standardized coefficients	t	p
	B	Std. Error	β
Age	0.295	0.14	0.283	2.36	0.042*
work experience	0.306	0.16	0.292	3.56	<0.026*
education level	0.276	1.12	0.247	2.02	0.046*
employment status	0.341	1.18	0.332	2.86	0.036*
F = 16.637 Adj. R2 = 31.27%

Note(s): B: the coefficient estimate; Adj. R²: adjusted regression coefficient; F: F-test (ANOVA); *Statistically significant at p ≤ 0.05

Source(s): Created by authors