The relationship between professional moral courage and patient safety silence among nurses.

backgroundPatient safety silence-the deliberate withholding of concerns or observations related to patient safety-has emerged as a critical barrier to ensuring safe healthcare delivery. Among nurses, patient safety silence in the face of safety errors may result in adverse outcomes for patients. Given the ethical nature of speaking up, identifying psychological and moral determinants, such as professional moral courage, is essential. Therefore, this study aimed to examine the relationship between professional moral courage and patient safety silence among nurses.

methodsA cross-sectional descriptive-correlational study was conducted from 2024 to 2025 in hospitals affiliated with Hamadan University of Medical Sciences. Using stratified sampling, 214 eligible nurses were selected for the study. Inclusion criteria were: at least one year of clinical experience, a bachelor's degree or higher in nursing, and provision of written informed consent. Incomplete questionnaires were excluded. Data were collected using a demographic information form, as described by Sekerka et al. Professional Moral Courage Scale, and the Tangirala and Ramanujam Patient Safety Silence Questionnaire. Ethical approval was obtained, and all procedures were conducted in accordance with the Declaration of Helsinki.

resultsA significant negative correlation was found between professional moral courage and patient safety silence (r = -0.451, p < 0.001). In the initial regression model, professional moral courage significantly predicted lower levels of patient safety silence (β = -0.451, p < 0.001; Adjusted R² = 0.20). After incorporating demographic and occupational variables, the explained variance increased to 61.6% (Adjusted R² = 0.616), and professional moral courage remained a significant predictor (β = -0.270, p < 0.001). Factors associated with reduced patient safety silence included male gender, over 10 years of experience, and moderate to high job satisfaction. In contrast, insufficient ethics education, night shifts, high nurse-to-patient ratios, and burnout were associated with increased patient safety silence.

conclusionProfessional moral courage was found to have an inverse association with patient safety silence and remained a significant predictor even after adjusting for other factors. Male gender, longer experience, and job satisfaction reduced patient safety silence, while insufficient ethics education, night shifts, high workload, and burnout increased it. Therefore, strengthening professional moral courage through education and support may help reduce patient safety silence and improve safety culture in healthcare. CLINICAL TRIAL NUMBER: Not applicable.