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. 2025 Apr 8;24(1):392.
doi: 10.1186/s12912-025-03043-7.

The mediating role of moral courage in the relationship between ethical leadership and error reporting behavior among nurses in Saudi Arabia: a structural equation modeling approach

Ebtisam A Elhihi  1 , Khadija Lafi Aljarary  2 , Maha Alahmadi  3 , Jawaher Bakor Adam  4 , Ohud Atiah Almwualllad  5 , Marwan S Hawsawei  6 , Abdulmajid Ahmad Hamza  7 , Ibrahim Abdullatif Ibrahim  8
Affiliations

The mediating role of moral courage in the relationship between ethical leadership and error reporting behavior among nurses in Saudi Arabia: a structural equation modeling approach

Ebtisam A Elhihi et al. BMC Nurs. .

Abstract

Background: Ethical leadership in nursing is pivotal for fostering a transparent workplace culture and encouraging error reporting, a critical behavior for enhancing patient safety. In Saudi Arabia, cultural and organizational factors may influence nurses' willingness to report errors, making this an essential area of study. This study investigates the correlation between ethical leadership and error reporting behavior, emphasizing the mediating influence of moral courage among nurses in Saudi Arabia.

Methods: This cross-sectional research used a simple random sampling technique to recruit 269 clinical nurses from four specialized medical centers affiliated with King Abdullah Medical City in Makkah, Saudi Arabia. Data was collected between October and December 2024 using online self-reported questionnaires that included validated scales for ethical leadership, moral courage, error reporting, and demographic information form. This study was conducted in accordance with the STROBE guidelines. Structural equation modeling was used to investigate hypothesized relationships.

Results: Ethical leadership significantly impacted error reporting behavior (β = 0.58, p < 0.001) and ethical courage (β = 0.35, p < 0.001). Moral courage was a significant predictor of error reporting behavior (β = 0.30, p = 0.01) and partially mediates the link between ethical leadership and error reporting (β = 0.11, p = 0.01). The total effect of ethical leadership on error reporting behavior was substantial (β = 0.69), with a BC 95% CI of (0.51, 0.89).

Conclusions: The findings highlight the critical role of ethical leadership in fostering moral courage and promoting error reporting behavior among nurses. The mediation effect of moral courage underscores the importance of cultivating an ethical work environment that empowers nurses to act with integrity and report errors without fear of retaliation. These insights emphasize the need for nursing managers to prioritize ethical leadership practices and create transparent workplace cultures that enhance patient safety. By addressing cultural and organizational barriers, healthcare institutions in Saudi Arabia can further encourage error reporting, ultimately improving the quality of care and patient outcomes.

Keywords: Courage; Leadership; Organizational culture; Patient safety; Saudi Arabia.

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Conflict of interest statement

Declarations. Ethics approval and consent to participate: This study was conducted in accordance with the principles of the Declaration of Helsinki [60]. The study design was approved by the King Abdullah Medical City Institutional Review Board (IRB) (approval no. 23-1090) in Saudi Arabia. All participants were thoroughly informed about the study’s purpose and provided online informed consent before participating. Responses were kept strictly confidential for research purposes only, and the results did not personally identify respondents. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests.

Figures

Fig. 1
Fig. 1
The conceptual framework of the study
Fig. 2
Fig. 2
Measurement model / Confirmatory factor analysis
Fig. 3
Fig. 3
The mediation model. Abbreviations: EL: Ethical leadership, MC: Moral Courage, ERB: Error Reporting Behavior
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