Moral courage can be defined as the voluntary willingness to stand up for and act on one’s ethical beliefs despite barriers that may inhibit the ability to proceed toward right action. Such courage is critical to physicians’ commitment to act in the best interest of patients.1–4 Physicians commonly face situations that call for moral courage, including delivering care to an infectious patient, meeting an angry patient or family member, addressing an incompetent or impaired colleague, disclosing a medical error, and raising concerns about unethical or unsafe practices.4–8 In all of these circumstances and others, physicians may be confronted with a challenging trade-off between doing what is right for patients and families and acting in their own self-interest, and in some instances, physicians’ behavior may fall short of expectations or ideals.1–4,9,10 The concept of moral courage may be particularly relevant to physicians in training who, because of organizational constraints, medical hierarchy, and concerns about evaluations and career opportunities, may feel especially hesitant to act in accordance with their ethical convictions.11,12
Sekerka et al1 studied moral courage among military personnel who, like medical personnel, work in morally complex, hierarchical, high-stakes settings where exemplary behavior is critical. Their qualitative study revealed five themes relevant to measurement of moral courage:
- Moral agency—the predisposition to behave ethically and work toward what is right
- Multiple values—the ability to draw on and weigh multiple sets of values in ethical decision making
- Endurance of threats—the conviction to do what is right or just, despite perceived or real threats to one’s self
- Measures beyond compliance—the tendency to consider more than compliance-based measures and reflect on what is right or just
- Moral goals—a virtuous motivation to do what is right, as opposed to being motivated by self-interest (e.g., for praise or reward)
These five themes recur throughout the existing literature on moral courage.1,12 While these themes constitute the core features of moral courage, the authors1 point out that in contexts such as medical practice, where norms or expectations may be less explicit, it may be challenging and impractical to differentiate and measure each feature separately.
Scholars have debated whether moral courage is an innate characteristic or a trait that can be developed and taught.13,14 Most notably, Aristotle argued that moral virtues could be taught and strengthened through application.13 Many modern-day bioethicists and medical educators agree with this Aristotelian view, and the increase in formal medical ethics education in medical schools stems from a desire to produce physicians capable of facing the ethical challenges of medical practice.14 Numerous strategies for developing physicians’ moral courage have been employed, including discussion of ethical principles, case studies, and role-plays. However, evidence of the efficacy of these strategies is limited,15 in part because of the inability to effectively measure moral courage for physicians.2,16
Despite the importance of moral courage in medical practice and a strong interest in cultivating moral courage among medical trainees, empirical investigation of the concept and its implications for patient care and medical education has been lacking. Research in this area has been limited by the absence of an instrument capable of efficiently measuring moral courage for physicians. Thus, we undertook this study to develop a practical and psychometrically sound set of survey items that measures moral courage for physicians in the context of patient care.
Method
Scale development
In 2012, two of us (W.M., L.S.L), who are physicians with expertise in medical ethics and scale development, created 17 survey items, each of which focused on one of the five features (moral agency, multiple values, endurance to threats, measures beyond compliance, and moral goals) of moral courage.1 Fourteen of the 17 items were adapted from the Professional Moral Courage Scale developed by Sekerka et al.1 Because moral courage may take different forms in different roles and contexts,3,17 we edited the adapted items to make them applicable to the work of physicians and specific to moral courage in the context of patient care.
We revised all 17 items through pilot testing for clarity and face validity with 11 practicing physicians from a variety of medical and surgical specialties. During pilot testing, respondents were asked to identify any item they considered irrelevant to measuring moral courage for physicians. In addition, they were asked to evaluate the clarity of the items and simplify and edit items that were unclear. Finally, they were asked to include any new items they felt would help assess moral courage for physicians; this led to the creation of 3 additional items. On the basis of this piloting, 12 items (9 adapted items and 3 new items) of the 17 items were ultimately selected for inclusion in the study questionnaire; these 12 items constituted our preliminary Moral Courage Scale for Physicians (MCSP).
Because it can be difficult and impractical to distinctly measure each feature of moral courage separately in settings such as medical practice, where norms or expectations may be implicit,1,11,12 our goal was to create an overall measure of moral courage for physicians that incorporated all five features and would be useful in practice.
Participants
Study participants were from two large academic medical centers located in the northeastern United States. All 731 postgraduate trainees (interns, and residents in their second years and above) in surgical specialties (i.e., general surgery, plastic surgery, orthopedic surgery, neurosurgery, obstetrics–gynecology, and urology) and internal medicine were eligible to participate (see Table 1 for more information about these trainees). Participation in the study was voluntary. To help motivate participation, all eligible interns and residents received a $5 gift card. Consent was implied by survey completion. The study was approved by the institutional review board (IRB) overseeing the two study sites. The two study sites are part of a health network with a single IRB that oversees the hospitals in the network.
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Table 1: Characteristics of Eligible and Responding Interns and Residents Surveyed About Moral Courage for Physicians, Two U.S. Academic Medical Centers, 2013a
Data collection
Surveys were collected between March and June 2013 and were administered via e-mail link to an electronic, anonymous questionnaire using REDCap (Research Electronic Data Capture) version 5.0.8 (Vanderbilt University, Nashville, Tennessee).18 Nonresponders received up to three reminder e-mails.
Measures
At the two study sites, the moral courage questionnaire (see Supplemental Digital Appendix 1 at https://links.lww.com/ACADMED/A374) was embedded in a larger survey, administered in 2013, of patient safety culture and speaking up. This larger survey included the (1) Safety Attitudes Questionnaire–Teamwork Climate Short Form,19 (2) Safety Attitudes Questionnaire–Safety Climate Short Form,19 (3) Speaking Up Climate for Professionalism Scale, and (4) Speaking Up Climate for Safety Scale (whose results are reported elsewhere20), as well as the (5) Medical Error Disclosure Climate Scale21 and (6) items about attitudes toward speaking up and professionalism. The moral courage questionnaire con tained the 12 preliminary MCSP items along with 6 items from the Jefferson Scale of Physician Empathy (JSPE) that reflect perspective taking (e.g., the degree to which the physician takes on the patient’s perspective), the main component of the JSPE and the core cognitive ingredient of empathy.22,23 The questionnaire also asked respondents about their experiences speaking up about patient safety breaches, an action that involves moral courage.24–26 Specifically, respondents were asked how many times during their most recent inpatient month they observed a patient safety breach. Respondents who reported observing a patient safety breach at least once were then asked how many times during their last inpatient month they had discussed the patient safety breach they had observed with the person(s) involved (i.e., self-reported speaking-up behavior). A patient safety breach was defined as an act or omission that unnecessarily increases the risk of accidental or prevent able injuries produced by medical care, and examples from the literature were provided (e.g., improper sterile technique, poor hand hygiene, inadequate handoff).27–29
Statistical analysis
To examine the underlying constructs and screen for the best conceptually relevant items for inclusion in the final version of the MCSP, we conducted a principal components analysis (PCA) with orthogonal varimax rotation on our 12 preliminary MCSP items. PCA is a statistical technique applied to a single set of items, used to discover which items in the set form coherent subsets that are relatively independent of one another.30 Items that are correlated with one another but largely independent of other subsets of items are combined into factors.30 We computed Cronbach alpha to assess the internal consistency of the scale items (i.e., how well the items within a scale measure the same construct). The MCSP and the 6 JSPE items were both measured on a seven-point Likert scale from strongly disagree = 1 to strongly agree = 7. Negatively worded items were reverse coded. A summary score was computed using the following formula: scale score = (average score across all scale items – 1) × (100/6). Thus, summary scores for the scale ranged from 0 (worst) to 100 (best). Item–total score correlations were calculated to evaluate the contribution of each item to the total score.
We estimated two types of validity—construct and concurrent—for the MCSP.
Construct validity.
Construct validity is established when measures that are theoretically related are observed to be related (i.e., convergent validity) and measures that are theoretically unrelated are observed to be unrelated (i.e., discrim inant validity). Discriminant validity was assessed using the known-groups validation method (i.e., extent to which a measurement is sensitive to expected differences and similarities in various groups).31,32 On the basis of theory and prior research, we expected that in the context of patient care, moral courage would be positively associated with being a resident rather than an intern.16,33 Convergent validity was assessed by testing the association of the MCSP and a theoretically similar concept. On the basis of theory and prior research, we expected that moral courage would be positively associated with empathy.12,34–36 Empathy has been described as a promoting factor for moral courage that drives an individual to act courageous on behalf of another.12 Therefore, we tested the relationship between these variables (postgraduate year and the JSPE perspective-taking score) and MCSP scores using a multivariate linear regression model with the following additional covariates: gender, age group, and specialty. To account for multiple comparisons, we applied the Bonferroni correction when interpreting the significance of the results of the multivariate analysis.
Concurrent validity.
Concurrent validity occurs when a measure is significantly associated with a related outcome. Because “speaking up” about patient safety breaches is considered an action that involves moral courage,24–26 and patient safety events have been shown to occur in 3% of hospitalizations37—meaning that nearly all residents can be expected to encounter them11—we estimated concurrent validity by computing the correlation between the MCSP and self-reported speaking-up behavior.
Analyses were performed using SAS versions 9.4 (SAS Institute, Inc., Cary, North Carolina).
Results
Table 1 describes the characteristics of the 731 interns and residents surveyed and the 352 (48%) who completed the questionnaire. Respondents’ genders and specialties did not differ significantly from those of the total population surveyed. As the table indicates, respondents included a significantly greater proportion of residents and a lower proportion of interns than the corresponding proportions of those groups in the total population surveyed.
The PCA on the preliminary MCSP items produced two factors with eigenvalues greater than 1. Eigenvalues are a measure of the variance consolidated by a group of items and used in deciding how many factors to extract in the overall PCA.38 Generally, only variables with eigenvalues of 1 or higher are considered worth analyzing.38 The first factor accounted for 43% and the second factor for 14% of the total variance. The magnitudes of the eigenvalues and factor coefficients (i.e., correlation between items and factors) are reported in Table 2. The nine positively worded items had factor coefficients greater than 0.50 for factor 1 (shown in bold).
Table 2: Rotated Factor Loadings for 12 Preliminary Items in the MCSP, Based on the Responses of 352 Interns and Residents, Two U.S. Academic Medical Centers, 2013a
On the basis of the content of these items and the magnitude of the eigenvalue, the first factor can be considered the grand factor of physician moral courage. The three negatively worded items had factor coefficients greater than 0.50 for factor 2. However, because the content of the three items did not reveal a distinct and meaningful underlying concept and all three items were negatively worded, we could not be sure whether this factor actually denoted content that would be representative of a different construct entirely or whether factor 2 emerged because of measurement artifacts related to the negative wording of these items.39 In addition, factor 2 demonstrated poor internal consistency40 (Cronbach alpha = 0.59). It was weakly associated with factor 1 (r = 0.19, P < .001), and in tests of construct and concurrent validity, factor 2 was not significantly associated with empathy, intern versus resident status, or self-reported speaking-up behavior (P > .05 for all associations). Therefore, factor 2 was ultimately discarded. The nine remaining items in factor 1 included representation of all five features of moral courage and were retained as the final nine-item MCSP.
Table 3 contains the mean Likert scale scores and item–total score correlations for the moral courage items. The item with the highest mean score (M = 6.75) was “I am determined to do the right thing for my patients” (item 9). The 3 lowest mean scores among the initial 12 moral courage items belonged to the 3 discarded, negatively worded items (items 10, 11, and 12) despite the items’ being reverse coded. For each of the 9 retained items, item–total score correlations were positive and significant (P < .001), which affirmed the direction of scoring and the significant contribution of each item to the total score of the MCSP.
Table 3: Mean Likert Scale Scores and Item–Total Score Correlations of the 12 Preliminary Items in the MCSP, Based on the Responses of 352 Interns and Residents, Two U.S. Academic Medical Centers, 2013a
Descriptive statistics were calculated for the final nine-item MCSP. Results are reported in Table 4. These findings indicate that responses tend to be skewed toward the more positive reports of moral courage. Cronbach coefficient alpha for the MCSP was 0.90, indicating excellent internal consistency.40
Table 4: Distributions, Percentiles, and Descriptive Statistics for Scores on the MCSP Among the 352 Responding Interns and Residents, Two U.S. Academic Medical Centers, 2013a,b
Table 5 shows the results of a multivariate regression analysis for respondent characteristics independently associated with MCSP scores. Consistent with our hypothesis, mean (SD) MCSP scores were significantly lower for interns (80.97 [12.25]) than for residents (84.64 [12.35]); P = .01. Similarly, in the multivariate model, MCSP scores were negatively associated with being an intern compared with being a resident, and were positively associated with respondents’ JSPE perspective-taking score (B = −4.17, P < .001, and B = 0.53, P < .001, respectively). These findings support the construct validity (both the discriminant and convergent validity) of the MCSP.
Table 5: Multivariate Regression Model of Respondent Characteristics Associated With Summary Scoresa on the MCSP for 352 Responding Interns and Residents, Two U.S. Academic Medical Centers, 2013b,c
The factor loading, internal consistency, mean Likert scale scores, and item–total score correlations of the six JSPE perspective-taking items are reported in Supplemental Digital Appendix 2 at https://links.lww.com/ACADMED/A374. In addition, we found that self-reported religiousness was not associated with MCSP scores (B = 1.60, P = .20), and women physicians were associated with lower MCSP scores than were men (B = −3.52, P = .001).
Among respondents who reported observing a patient safety breach during their most recent inpatient month, the MCSP was weakly and positively correlated with self-reported speaking-up behavior about patient safety (r = 0.19, P = .008).
Discussion
An important first step
Our study is the first, to our knowledge, to attempt to measure moral courage for physicians. In this study, we developed a moral courage scale for physicians and provide initial evidence for its reliability and validity. Specifically, the PCA demonstrated a single, meaningful factor described as “physician moral courage” that contained items from all five features of moral courage. Item–total score correlations showed that all items included in the MCSP were relevant to the operational measurement of moral courage for physicians, and reliability estimates (i.e., Cronbach alpha) sug gested excellent internal consistency. Convergent validity was suggested by the positive, independent association between physician moral courage and physician empathy, the latter being a construct conceptually related to moral courage.12,34–46 Similarly, discriminant validity was suggested by the negative, independent association between moral courage and being an intern (versus being a resident), consistent with interns’ greater susceptibility to the conforming pressures in the clinical environment that may conflict with their own moral values.16,33 Finally, concurrent validity was suggested by the positive correlation between MCSP scores and self-reported speaking up about patient safety breaches, an action that involves moral courage.24–26
Because speaking up has been shown to be influenced by a number of the factors, independent of moral courage—including perceived potential harm to the patient, hierarchy, and characteristics of the work environment41,42—the influence of any one individual factor is likely to be relatively modest. Therefore, we were satisfied to see a significant positive correlation, albeit weak, between physician moral courage and self-reported speaking up.
Religiousness was not associated with moral courage, while gender was. Religiousness may motivate morally courageous behavior in some settings43,44 but not others. In the context of the doctor–patient relationship, other motivators, such as a sense of fiduciary duty to patients, may motivate morally courageous behavior regardless of the religiousness of the physician. In our multivariate analysis, women physicians were associated with lower MCSP scores than were men. These findings are consistent with prior research demonstrating gender-based differences of empowerment and confidence for physicians in training.11,45 More research to confirm and better understand these differences is needed.
The positively skewed distributions of scores at the item and summative level, as well as the inconsistency associated with the negatively worded items, offer two opportunities for future modifications to the MCSP. Positively skewed scores have been seen with other measures of positive physician attributes such as empathy.23 Despite the positively skewed scores, the differences in scale scores were associated with morally courageous behavior (e.g., self-reported speaking up). Negatively worded items are usually used to guard against an “acquiescence response style”—a tendency for respondents to agree or disagree constantly with statements—and to increase respondents’ attention to survey items. However, several studies have found that negatively worded items caused problems with internal consistency and factor structures.39,46,47 Future studies may attempt to reintroduce new or revised negatively worded items and assess their impact on the scale’s psychometric properties, as well as test shorter versions of the scale to enhance efficiency.
There are few validated scales to measure courage. Schmidt and Koselka48 constructed a seven-item Courage Scale, with the first three items assessing general courage, and the last four items assessing panic-specific courage. Woodard49 developed a courage scale of situation-based questions that examined social courage (e.g., asking for a raise at work), physical courage (e.g., giving one’s life for one’s country in a time of war), and emotional courage (e.g., helping a grieving family). Pury et al17 constructed a measure of personal courage, or actions that may be courageous only for the particular actor (e.g., swimming in the ocean if you are not a good swimmer), and general courage, or actions that would be courageous for anyone (e.g., knowingly swimming in shark-infested waters). Pury et al point out that while greater confidence may diminish the personal courage needed to act, greater confidence enhances general courage. When developing the MCSP, we were interested in physician actions that could be considered morally courageous for any physician; we conceived of moral courage in line with the general courage model.17,49 Therefore, consistent with the literature on moral courage,17,49,50 we would expect empowerment and self-confidence to enhance moral courage.
Measures of moral courage are even more limited than more general measures of courage. The only validated measure we identified, the Professional Moral Courage Scale, was constructed by Sekerka et al1 among U.S. Navy personnel to measure managers’ “willingness [to act] as they traverse their management decisions with virtues in action.” To the best of our knowledge, there is no psychometrically sound tool available for measuring moral courage for physicians.
Moral courage is central to the practice of medicine. The MCSP builds on the existing literature and the scale developed by Sekerka et al by providing a psychometrically sound measure specific to moral courage in the context of patient care. The ability to assess moral courage for physicians could help determine the efficacy of medical ethics curricula and improve our understanding of the underpinnings of physician behavior. At the same time, creating and using such a measure may help signal that moral courage is an institutional and educational priority.
Study limitations
Our study has several important limitations. First, the external generalizability of our findings may be limited. Our data were collected from two academic medical centers in the United States from the same geographic region, and the sample may not represent interns and residents in other areas and settings. Further validation of the MCSP should include practicing physicians in a variety of settings. Moreover, the measurement of moral courage is relevant not only to physicians but also to other health professionals, particularly nurses, and future studies should aim to modify and validate the MCSP among other health professionals.2,51,52 In addition, despite a response rate consistent with other surveys of physicians,53 nonresponse bias could have affected the results. While the gender and specialty distributions of respondents were not significantly different from those of the total population surveyed and were similar to those of the entire population of U.S. interns and residents,54,55 among the respondents, interns were somewhat underrepresented and residents overrepresented relative to the total population surveyed. While interns had a lower mean MSCP score than residents, the effect size was small; thus, the effects of oversampling residents on our findings is likely limited. Regardless, our study was focused on assessing the internal validity of the MCSP as opposed to the generalizability of results, and the data were sufficient for this purpose.
Second, respondents were asked to recall past events (i.e., self-reported speaking-up behavior), making the study subject to recall bias. By limiting the recall period to the most recent inpatient month and asking respondents to recall a relatively salient event (e.g., speaking up about a patient safety breach), the number of residents who recalled incorrectly is likely small. Finally, although the survey was anonymous, it relied on self-assessment and self-reported behaviors and thus is subject to social desirability bias. Future studies may wish to administer a measure of social desirability56 alongside the MCSP. Alternatively, some researchers have attempted to assess moral courage by asking others to evaluate the moral courage of another individual.57,58 However, such external reports would be susceptible to observer bias and may be more challenging and costly to conduct, which may limit their utility in comparison with a self-reported measure like the MCSP.
Physicians routinely face situations that call for moral courage, yet valid methods of assessment are lacking. The MCSP is a tool that advances the assessment of moral courage among learners and physicians and may help researchers and educators identify deficits, track progress on a set of desired behaviors in response to curricular interventions, and better understand the foundations of physician behavior. Future research should examine the relationship between MCSP scores and other conceptually related measures (e.g., bravery and burnout), as well as situation-based assessments of moral courage (e.g., addressing an incompetent or impaired colleague) and observed, rather than self-reported, morally courageous behavior (e.g., delivering care to a highly infectious patient). Researchers may also want to examine the effects of time, experience, and targeted interventions on MCSP scores. Continued research in this area will deepen our understanding of this important virtue in medical practice.
Acknowledgments: The authors wish to thank the interns and residents who participated in the study, and their residency program directors, who supported this project.
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