Conceptualization, measurement, and factors associated with moral courage in nursing: A scoping review

BackgroundFrequent exposure to ethically challenging situations can lead to moral distress and, over time, moral injury among nurses. Moral courage, acting in accordance with ethical convictions despite personal or professional risk, has been proposed as a protective factor, though the concept remains fragmented.ObjectivesTo identify, map, and summarize existing research on moral courage among nurses, focusing on its conceptualization, measurement, associated factors, and implications for practice, education, and research.Research designThis scoping review followed Joanna Briggs Institute methodology and PRISMA-ScR reporting guidelines, using a Population-Concept-Context framework: registered nurses in clinical settings; the concept of moral courage (definition, measurement, factors); any clinical context.Search strategyWeb of Science, PubMed/MEDLINE, Scopus, and the University of Toronto Library datasets were searched on 14 April 2026, for articles published from January 2000, limited to English and French. Two independent reviewers screened titles, abstracts, and full texts in Rayyan and extracted data using a piloted tool.Findings/resultsSixty-five studies (2019-2026) across eleven countries were included; 52% from Iran and 22% from China, with only three from Europe. Most (87%) used a cross-sectional design. Six instruments were identified, most commonly the Professional Moral Courage Scale (49%) and Nurses' Moral Courage Scale (33%), with clear geographic variation in instrument selection. Moral courage was conceptualized either as a stable Aristotelian virtue or a learnable ethical competence. Age, experience, ethical climate, and ethical leadership were consistently positively associated with moral courage, whereas its associations with some constructs, including moral distress and burnout, varied across studies. Structured ethics education consistently improved moral courage.ConclusionsMoral courage research in nursing has grown rapidly since the COVID-19 pandemic, yet the evidence base remains geographically concentrated, instrument-divided, and conceptually unsettled. Longitudinal and mediation-based research across diverse geographic settings is needed to clarify how moral courage develops and can be strengthened.