Presenteeism, moral courage, and moral disengagement among nurses: a cross-sectional structural equation modeling study.

BACKGROUND

Presenteeism, the act of attending work while physically or mentally unfit has been recognized as a critical issue in healthcare, particularly among nurses. Although presenteeism is often linked to reduced productivity, its ethical consequences remain underexplored. This study investigated the relationship between presenteeism, moral disengagement, and moral courage among nurses, aiming to illuminate how occupational strain affects ethical functioning in clinical settings.

METHODS

A cross-sectional analytical study was conducted between October 2024 and March 2025 among 320 nurses working in two educational hospitals in Gonabad, Iran. Data were collected using validated instruments: the Nursing Presenteeism Scale, Moral Disengagement Scale, and Professional Moral Courage Scale. Non-parametric tests, Spearman correlations, multiple regression, and Partial Least Squares Structural Equation Modeling (PLS-SEM) were employed for analysis using SPSS and SmartPLS software.

RESULTS

Presenteeism was strongly negatively correlated with moral courage (r = - 0.650, p < 0.001) and moderately positively correlated with moral disengagement (r = 0.445, p < 0.001). Regression and SEM analyses showed that presenteeism significantly predicted lower moral courage (β = -0.687) and higher moral disengagement (β = 0.508). Mediation analysis confirmed that moral courage partially mediated the relationship between presenteeism and moral disengagement (β_indirect = 0.305, p < 0.001), indicating that presenteeism undermines ethical behavior indirectly through its adverse effect on moral resilience.

CONCLUSIONS

Presenteeism poses a serious threat to nurses' moral functioning by eroding their capacity for ethical action and increasing the risk of moral disengagement. Strengthening moral courage through training and reducing workplace stressors may help mitigate these effects. These findings highlight the need for ethical and organizational interventions to support nurses' well-being and safeguard the quality of patient care.