Moral Competence in Nursing Practice

Moral sensitivity, moral courage, and ethical behaviour among clinical nurses

Background: Ethical behaviour in nursing practice is integral to establishing a harmonious nurse-patient relationship and improving the quality of care. A multitude of factors shapes such behaviour. Therefore, it is crucial to understand the interplay between these factors. Research objectives: This study aimed to explore the mechanisms underlying the influence of moral sensitivity on nurses' ethical behaviour and clarify the mediating role of moral courage. Research design: This cross-sectional quantitative study was conducted between July and August 2023. Participants and Research Context: The sample comprised 465 clinical nurses from three tertiary hospitals in Zhengzhou City, Henan Province, China. Data were collected using the Chinese version of the Moral Sensitivity Questionnaire-Revised Version, Nurses' Moral Courage Scale, and Ethical Behaviour Scale for Nurses. Data analysis was performed with SPSS 26.0 and AMOS 24.0, using descriptive statistics, Pearson correlation analysis, structural equation modelling, and bootstrapping methods. Ethical considerations: This study was approved by the Ethical Review Committee of Life Sciences of Zhengzhou University, China. Results: The participants were predominantly female (95.1%), with a mean age of 31.9 years. Moral courage and moral sensitivity were positively correlated with ethical behaviour. Moral sensitivity was positively associated with moral courage. Moral courage partially mediates the relationship between moral sensitivity and ethical behaviour. The indirect effect of nurses' moral sensitivity on ethical behaviour was quantified through moral courage (indirect effect = 0.290). Conclusion: Moral courage intermediates nurses' moral sensitivity and ethical behaviour. This conclusion provides nursing administrators with the insight that improving clinical nurses' moral sensitivity and courage can contribute to ensuring appropriate ethical behaviour.

The relationship between nurses' moral competency and missed nursing care: a descriptive-correlational study

BACKGROUND

When any aspect of patient care is overlooked or delayed, it is known as Missed Nursing Care (MNC), leading to adverse events such as medication errors, infections, increased mortality rates, and poor prognosis. Moral competence is crucial for clinical nurses as it guarantees high-quality patient care in nursing practice. Thus, this study aimed to investigate the correlation between moral competencies and MNC among nurses.

METHODS

This study was conducted with a descriptive-correlational design. The participants in the study were nurses who were currently enrolled at Shahid Beheshti University of Medical Sciences. In order to recruit nurses for the study, a convenience sampling method was implemented. The study tools were completed by a total of two hundred nurses. Research tools included a demographic questionnaire, the Moral Competence of Clinical Nurses Questionnaire, and the Kalisch and Williams Missed Nursing Care (MISSCARE) survey.

ETHICAL CONSIDERATION

This study was approved by the Medical Ethics and Law Research Center of Shahid Beheshti University of Medical Sciences.

RESULTS

The mean scores of moral competencies and MNC were 151.83 ± 12.60 and 42.71 ± 9.38, respectively. In other words, descriptive statistics showed that the moral competence score was more than 75%, and the MNC score was less than 50%. Also, there was a significant negative correlation between the total scores of moral competencies and MNC (r = -0.38, p < 0.001), indicating that more moral competence was correlated with lower levels of MNC.

CONCLUSION

The study revealed a negative correlation between nurses' moral competence and MNC, suggesting that enhancing moral competence could reduce MNC. To reduce MNC occurrences, hospitals, and organizations should prioritize moral competency, according to our research.

Factors contributing to the promotion of moral competence in nursing

Ethics is a foundational competency in healthcare inherent in everyday nursing practice. Therefore, the promotion of qualified nurses' and nursing students' moral competence is essential to ensure ethically high-quality and sustainable healthcare. The aim of this integrative literature review is to identify the factors contributing to the promotion of qualified nurses' and nursing students' moral competence. The review has been registered in PROSPERO (CRD42023386947) and reported according to the PRISMA guideline. Focusing on qualified nurses' and nursing students' moral competence, a literature search was undertaken in January 2023 in six scientific databases: CINAHL, Cochrane Library, PsycINFO, PubMed Medline, Scopus and Web of Science. Empirical studies written in English without time limitation were eligible for inclusion. A total of 29 full texts were retrieved and included out of 5233 citations. Quality appraisal was employed using Joanna Briggs Institute checklists and the Mixed Method Appraisal Tool. Data were analysed using inductive content analysis. Research about the factors contributing to the promotion of qualified nurses' and nursing students' moral competence is limited and mainly explored using descriptive research designs. The contributing factors were identified as comprising two main categories: (1) human factors, consisting of four categories: individual, social, managerial and professional factors, and ten sub-categories; and (2) structural factors, consisting of four categories: educational, environmental, organisational and societal factors, and eight sub-categories. This review provides knowledge about the factors contributing to the promotion of qualified nurses' and nursing students' moral competence for the use of researchers, nurse educators, managers, organisations and policymakers. More research about the contributing factors is needed using complex intervention, implementation and multiple methods designs to ensure ethically sustainable healthcare.

Development and psychometric evaluation of the Ethical Behavior for Thai Nurses Scale

Background

Ethical problems in the nursing profession are mostly found in the undesirable ethical behavior (EBE) of nurses. If there is no concern about these problems, it may negatively affect the quality of nursing care, patients’ safety, and trust in the nursing profession. In assessing nurses’ EBE, it is important to develop an instrument that reflects the actual EBE of nurses.

Objectives

To develop and evaluate the psychometric properties of the Ethical Behavior for Thai Nurses Scale (EBTNS).

Methods

The construct definition, 5 sub-constructs, 43 items, and the hypothesized model were synthesized and generated from a comprehensive literature review and existing research instruments by using document analysis. The EBTNS was verified for content validity by 4 experts. Of the 43 items, 37 items were retained for psychometric testing. The construct validity was tested by using second-order confirmatory factor analysis (CFA). The EBTNS was tested on 1500 professional nurses working at tertiary, secondary, and primary hospitals in 6 regions (the central, northern, northeast, eastern, western, and southern) of Thailand. Proportional quota sampling was applied to recruit participants.

Results

The hypothesized model fitted the empirical data. All 37 first-order indicators and 5 second-order sub-constructs showed significantly standardized factor loadings and effect sizes. The standardized factor loadings of 37 first-order indicators ranged from 0.58 to 0.89, and the construct reliabilities were moderate to substantial (R 2 = 0.34–0.79). The 5 second-order sub-constructs displayed the standardized effect sizes, ranging from 0.81 to 0.96, and accounted for 65%–96% of the total explained variance. In addition, the construct validity was supported by convergent validity and discriminant validity. It also satisfied Cronbach's alpha coefficients of 5 sub-constructs from 0.87 to 0.94, and a full scale was 0.97.

Conclusions

The psychometric properties of the EBTNS are acceptable. This instrument has the potential to be used for evaluating and monitoring to prevent ethical problems of Thai nurses.

Psychometric evaluation of the Ethical Caring Competency Scale in nursing

BACKGROUND

An ethical competence list for nurses could guide educators and managers in the field of health care to both support the development of ethical conduct and improve the assessment of ethical competence in health care.

AIM

This study aimed to verify the reliability and validity of the Ethical Caring Competency Scale (ECCS) and to obtain suggestions for its use as an evaluation form in rubric format among a sample of Japanese nurses.

RESEARCH DESIGN

This research employed a descriptive and cross-sectional design.

PARTICIPANTS AND RESEARCH CONTEXT

A self-administered questionnaire was distributed to 1157 nurses working in two hospitals in Japan. The contents of the survey were demographic data, a draft of the ECCS consisting of 22 competencies from four core competencies, questions regarding experience in learning about medical/nursing ethics, and the Work Motivation Measurement Scale for Nurses. Three levels of difficulty for the 22 items were established using relative comparisons of the mean scores within the four core competencies. Three groups, namely, an expert group, a middle group, and a beginner group, were categorized according to the quartiles of the total ECCS score.

ETHICAL CONSIDERATIONS

This study was approved by the Clinical Research Ethics Committee of Hamamatsu University School of Medicine (Decision no. 18-267). The ethical principles of voluntary participation, anonymity, and confidentiality were considered.

FINDINGS

A total of 962 valid responses were analyzed. The ECCS scores for the three levels of difficulty were significantly different from each other. Stability was confirmed by the test-retest of the total ECCS scores (r = .900, p < .0001). The total ECCS scores for the three groups showed significant differences in all pairs. The Cronbach's α coefficient ranged from .72 to .89 for each core competency, and internal consistency was confirmed.

CONCLUSION

The reliability and validity of the ECCS as a scale were statistically verified, and we were able to obtain suggestions for its application as a form of evaluation in rubric format.

The factors influencing the innovative performance of leaders in nurses' professional: a developing country perspective

PURPOSE

The health-care services in Iraq currently face many challenges. The most noted is the lack of effective nursing leaders to meet the growing needs of the health-care services. Effective nursing leadership is critical to the health-care system, affecting work performance, quality of care and staff satisfaction. The literature suggests that nursing leaders in Iraq are not adequately trained to provide leadership to improve the nursing profession and have limited involvement in decision-making. The purpose of this study is to explore the views of nurses on what they believe constitutes effective leadership in Iraq.

DESIGN/METHODOLOGY/APPROACH

A qualitative methods approach is used involving 20 semi-structured interviews of senior nurses. The sample of nurses came from two large general hospitals in Iraq. The qualitative data was thematically analyzed and interpreted.

FINDINGS

The study results indicated that there were factors that influence the performance of nurse leader, namely, excessive workload, personal relationship with nursing staff, professional recognition of nursing and selection criteria of leaders. Test results show that there were significant differences in views of the nurses toward nurse leaders' performance. This research concludes that the nurse leader performance in developing countries is affected by excessive workload, personal relationship with nursing staff, professional recognition of nursing and selection criteria of leaders.

ORIGINALITY/VALUE

The relevance of the study stems from the scarcity of research on the leader performance in developing countries, while studies on the factors influencing the innovative performance of leaders in nurses' professional are significantly limited. This study is one of the earliest studies that investigate these factors influencing the nurse leader's performance.

Assessment of ethical competence among clinical nurses in health facilities

BACKGROUND

Ethical competence in nursing practice helps clinical nurses to think critically, analyse issues, make ethical decisions, solve ethical problems and behave ethically in their daily work. Thus, ethical competence contributes to the promotion of high-quality care. However, studies on ethical competence in Malawi are scanty.

OBJECTIVES

The aim of this study was to explore ethical competence among clinical nurses in selected hospitals in Malawi.

METHODOLOGY

A cross-sectional survey was conducted in four selected hospitals in Malawi with a sample of 271 clinical nurses. Data were collected using self-administered questionnaires, which included a Moral Competence Scale for Home Care Nurses. Descriptive statistics and logistic regression were computed for the dataset using STATA version 12.0.

ETHICAL CONSIDERATION

The study protocol complied with all ethical requirements and was approved by the College of Medicine Research Ethics Committee under the University of Malawi.

RESULTS

The clinical nurses in Malawi are ethically competent. However, there is a significantly high number (p < 0.05) of nurses 57% (n = 135) with low ethical competence. There was no significant association between respondents' demographic variables and level of ethical competence (p > 0.05). Three determinants of high ethical competence level (strong will, judgement skills and recognition of discrepancy of intention) were identified through a reduced model after stepwise logistic regression analysis. Furthermore, results show that indicators of ethical competence include caring, confidentiality and observance of nurses dressing code. The study has also confirmed that the Moral Competence Scale for Home Care Nurses is a reliable tool to assess ethical competence in low-resource settings.

CONCLUSION

The majority of nurses who completed the survey had low ethical competence. However, clinical nurses with high ethical competence level are required to competently manage complex ethical challenges in health facilities. Strategies for enhancing ethical competence such as continuing ethics education, establishment of ethics committees and provision of supportive supervision are recommended to enable nurses in Malawi attain a high level of ethical competence.

Validation of the Dutch-language version of Nurses' Moral Courage Scale

BACKGROUND

Moral courage as a part of nurses' moral competence has gained increasing interest as a means to strengthen nurses acting on their moral decisions and offering alleviation to their moral distress. To measure and assess nurses' moral courage, the development of culturally and internationally validated instruments is needed.

OBJECTIVE

The objective of this study was to validate the Dutch-language version of the four-component Nurses' Moral Courage Scale originally developed and validated in Finnish data.

RESEARCH DESIGN

This methodological study used non-experimental, cross-sectional exploratory design.

PARTICIPANTS AND RESEARCH CONTEXT

A total of 559 nurses from two hospitals in Flanders, Belgium, completed the Dutch-language version of the Nurses' Moral Courage Scale.

ETHICAL CONSIDERATIONS

Good scientific inquiry guidelines were followed throughout the study. Permission to translate the Nurses' Moral Courage Scale was obtained from the copyright holder, and the ethical approval and permissions to conduct the study were obtained from the participating university and hospitals, respectively.

FINDINGS

The four-component 21-item, Dutch-language version of the Nurses' Moral Courage Scale proved to be valid and reliable as the original Finnish Nurses' Moral Courage Scale. The scale's internal consistency reliability was high (0.91) corresponding with the original Nurses' Moral Courage Scale validation study (0.93). The principal component analysis confirmed the four-component structure of the original Nurses' Moral Courage Scale to be valid also in the Belgian data explaining 58.1% of the variance. Confirmatory factor analysis based on goodness-of-fit indices provided evidence of the scale's construct validity. The use of a comparable sample of Belgian nurses working in speciality care settings as in the Finnish study supported the stability of the structure.

DISCUSSION AND CONCLUSION

The Dutch-language version of the Nurses' Moral Courage Scale is a reliable and valid instrument to measure nurses' self-assessed moral courage in speciality care nursing environments. Further validation studies in other countries, languages and nurse samples representing different healthcare environments would provide additional evidence of the scale's validity and initiatives for its further development.

Reframing Personal and Professional Values: A Substantive Theory of Facilitating Lesbian, Gay, Bisexual, Transgender and Intersex Youth-Inclusive Primary Health Care by Nurses

LGBTI youth are prone to health-care inequalities and experience poorer health outcomes than the general population. Nurses are not always equipped to effectively respond to LGBTI healthcare needs. The aim of the study was to develop substantive theory based on the social processes involved in facilitating LGBTI youth-inclusive primary healthcare. Using a constructivist grounded theory approach, a sample of seven nurses was interviewed. The codes and categories, that emerged during data analysis were conceptualized to develop the theory: "reframing personal and professional values" which is outlined in three phases. Phase 1 illuminates subtle and covert ways that nurses used to identify value-laden tension and conflict as barriers to LGBTI youth-inclusive care. Phase 2 and 3 reflect thoughtful and reflexive strategies that nurses used to facilitate nurse-patient interaction to resolve value-laden tension and conflict. The substantive theory provides a way of improving the healthcare and health-seeking behavior of LGBTI youth.

Clarifying the concept of the four-season symphony (I SEA) in nursing practice: A Wilson's approach to concept analysis

Acquired knowledge provides one with intuitive rationality as a means of achieving a goal. Spiritual, ethical and esthetic competencies are also required for acquiring intuitive rationality. Nurses pay less attention to intuitive rationality, think only with their brain rather than observe with their heart and therefore deprive themselves of proper, immediate and comprehensive cognition of their environment. An initiative to harmonize sensory receptors in charge of thinking, speaking, and acting in nurses is required for establishing a symphonic intellectual, spiritual, ethical, and aesthetic (I SEA) nursing practice. The present research was conducted to clarify the concept of four-season symphony of I SEA in nursing practice. The present study was conducted by employing Wilson's method of concept analysis and searching databases including Google Scholar, ScienceDirect, Scopus, PubMed, SID, and Magiran using symphony, rationality, intellectuality, spirituality, ethics, aesthetic, and nursing practice as keywords. According to the integrated concept of the four-season symphony in nursing care, nursing practice refers to performing the symphonic action of four seasons of I SEA in orderly and smart thinking, speaking and acting in looking, listening, speaking, heartfelt sympathy and using the hands for caregiving and steps for accompanying patients. This symphony provides an opportunity for the emergence of perfect nurses of four seasons and helps with individual and organizational symphonic improvements in nursing care and nurses. According to this perspective, nurses should always ask themselves whether their thought, speech, and action are intellectual, spiritual, ethical and aesthetic.

Moral neutralization: Nurses' evolution in unethical climate workplaces

Introduction

Good quality of care is dependent on nurses’ strong clinical skills and moral competencies, as well. While most nurses work with high moral standards, the moral performance of some nurses in some organizations shows a deterioration in their moral sensitivity and actions. The study reported in this paper aimed to explore the experiences of nurses regarding negative changes in their moral practice.

Materials and methods

This was a qualitative study utilizing an inductive thematic analysis approach, which was conducted from February 2017 to September 2019. Twenty-five nurses participated in semi-structured interviews.

Results

The main theme that emerged from our analysis was one of moral neutralization in the context of an unethical moral climate. We found five sub-themes, including: (1) feeling discouraged; (2) normalization; (3) giving up; (4) becoming a justifier; and (5) moral indifference.

Conclusions

Unethical moral climates in health organizations can result in deterioration of morality in nurses which can harm both patients and health systems. Some unethical behaviors in nurses can be explained by this process.

"There is total silence here" Ethical competence and inter-organizational learning in healthcare governance

PURPOSE

The purpose of this paper is to analyse ethical competence related to healthcare governance and management tasks at the county/regional level in Sweden. The paper also discusses conditions that support or constrain the development and application of such competence.

DESIGN/METHODOLOGY/APPROACH

The study is based on original qualitative data from 13 interviews and 6 meeting observations. Three key groups of actors were included: politicians, civil servants and CEOs in publicly financed health-provider organizations. An abductive analysis was carried out by a stepwise method guided by thematic research questions.

FINDINGS

The informants viewed themselves as having a high degree of ethical responsibility for healthcare practice. However, they did not integrate ethical reflection and dialogue into their work decisions (e.g. regarding budgets, reforms and care agreements). The current organization, control systems and underlying business principles, along with the individuals' understanding of their own and others' roles, tended to constrain the development and use of ethical competence.

PRACTICAL IMPLICATIONS

Qualities of an appropriate ethical competence related to healthcare governance and management, and conditions to develop and use such competence, are suggested.

ORIGINALITY/VALUE

Hardly any empirical research has examined ethical competence related to healthcare governance and management tasks. The paper integrates ethics and theories on learning in organizations and contributes knowledge about ethical competence and the conditions necessary to develop and practise ethical competence in an organizational and inter-organizational context.

Ethical competence in a profession: Healthcare professionals' views

Aim

Ethical competence is a crucial component for enabling good quality care but there is insufficient qualitative research on healthcare professionals' views on ethical competence. The aim of this study was to investigate healthcare professionals' views on ethical competence in a student healthcare context.

Design

A qualitative design and a hermeneutical approach were used.

Methods

The material consists of texts from interviews with healthcare professionals (N = 10) in a student healthcare context. The method was inspired by content analysis.

Results

One main theme and four subthemes emerged. The main theme was as follows: safeguarding the vulnerability of the other. The subthemes were as follows: using sensitivity to establish a trustful relationship, acting in an objective and flexible manner, using a reflective process in decision-making, and maintaining confidentiality and honesty. Future research should focus on investigating ethical competence from various perspectives in student health care, for example the student perspective or observational studies.

Is there a relationship between moral competencies and the formation of professional identity among nursing students?

Background

Moral competencies are essential for nursing work. Professional identity is a set of values and beliefs that a person has about her/his job, which includes moral values as well. The development of moral competencies and formation of professional identity in nursing students occurs mainly during their college years. The aim of this study was to investigate the relationship between moral competencies and the formation of professional identity among nursing students.

Methods

This study was designed as a descriptive-correlational study. The study population was consisted of nursing students who were enrolled in nursing schools at the time of the study. Two hundred and twenty-one nursing students completed the study tools. The research tools were a demographic questionnaire, Moral Development Scale for Professionals (MDSP), and Professional Identity Scale for Nursing Students (PISNS).

Results

The mean (SD) of MDSP and PISNS scores was 45.69 ± 5.90 and 55.61 ± 12.75, respectively. There was a significant statistical relationship between MSDP and PISNS scores (p < 0.05). A significant equation was found (f (2, 218) = 16.68, p < 0.001) with an R2 of 0.113. The MSDP scores increased 0.136 for each score of PISNS, and married students had 2.452 scores higher than single students.

Conclusions

The positive correlation between the formation of professional identity and development of morality in nursing students indicates that by strengthening students’ professional values, their moral competencies may develop positively.

Nurses’ experience of providing ethical care following an earthquake: A phenomenological study

Background

Ethical care provided by nurses to earthquake victims is one of the main subjects in nursing profession.

Objectives

Given the information gap in this field, the present study is an attempt to explore the nurses’ experience of ethical care provided to victims of an earthquake.

Research design and method

A hermeneutic phenomenological study was performed. The participants were 16 nurses involved in providing care to the injured in Kermanshah earthquake, Iran. They were selected using purposeful sampling, and in-depth and semi-structured interviews were carried out. The transcribed interviews were analyzed based on the hermeneutic approach using the analysis method proposed by Diekelmann et al.

Ethical considerations

The study was approved by the Research Council and Ethics Committee of Urmia University of Medical Sciences, Iran.

Findings

Data analyses revealed four themes and 10 sub-themes that illustrated nurses’ experience of ethical care during earthquake. The themes were (1) Respecting humanistic values (sacrifice, stepping beyond task description, and voluntary work), (2) Commitment to ethics (honesty, confidentiality, and trustworthiness), (3) Respecting dignity of victims (respecting cultural values, maintaining privacy, having humanistic perspective, and effective communication), and (4) Spiritual support (helping patients to do religious rituals Psychological support).

Conclusion

The results showed the nurses’ experience with providing care to earthquake victims. The findings underlined ethics and ethical values in providing nursing care during disasters. It is suggested that special courses on the importance of nursing ethics in critical situations be incorporated into nursing curriculums and in-service educations.

Threats to patient dignity in clinical care settings: A qualitative comparison of Indonesian nurses and patients

AIMS AND OBJECTIVES

To explore and compare nurses' and patients' viewpoints of disrespectful behaviours that threaten patient dignity during hospitalised care.

BACKGROUND

Patient's dignity is an important ethical consideration for nursing care practice. In clinical settings, nurse-patient interactions can generate behaviour considered disrespectful and undignified, often due to a disruptive hospital atmosphere and emotional frustrations of nurses and patients. How behaviours and attitudes threaten patient dignity in Indonesian clinical care settings has not been well studied.

DESIGN

Qualitative descriptive study.

METHODS

This multi-site study purposively recruited nurses and inpatients from six public hospitals in four districts in Eastern Java, Indonesia. Individual, face-to-face semi-structured interviews were conducted with 35 inpatients and 40 registered nurses from medical and surgical wards. Data from verbatim transcriptions of digital audio recordings were analysed with inductive content analysis. The COREQ checklist for qualitative research was used for reporting this study.

RESULTS

Five categories emerged which described disrespectful behaviours that threaten patient dignity. Three categories were important for both nurses and patients: negligence, impoliteness and dismissal. Descriptions of the behaviours were comparable for both groups. The forth category, inattentiveness, was highlighted by nurses, while the fifth category, discrimination, was highlighted by patients.

CONCLUSIONS

Examining behaviours considered to be disrespectful in an Indonesian healthcare setting expand on perspectives towards dignity in care. The comparable viewpoints of nurses and patients provide knowledge of how undignified behaviours could be reduced in cross-cultural healthcare settings. Behaviours perceived as undignified primarily by nurses or patients might result from differences in social roles and responsibilities.

RELEVANCE TO CLINICAL PRACTICE

Understanding nurses' and patients' perspectives of undignified care is an important step in reducing behaviours that violate patient dignity in clinical practice. Nurses' commitment to patient-centred care should include being responsive, compassionate, communicative and attentive, which could ameliorate instances of undignified behaviours.

Reciprocal Relationships Between Moral Competence and Externalizing Behavior in Junior Secondary Students: A Longitudinal Study in Hong Kong

Defining moral competence using a virtue approach, this longitudinal study examined the prospective relationships between moral competence and externalizing behavior indexed by delinquency and intention to engage in problem behavior in a large and representative sample of Hong Kong Chinese adolescents. Starting from the 2009-2010 academic year, Grade 7 students in 28 randomly selected secondary schools in Hong Kong were invited to join a longitudinal study, which surveyed participating students annually during the high school years. The current study used data collected in the first 3 years (Wave 1 to Wave 3) across junior secondary school stage (Grades 7-9) with a sample of 3,328 students (Age = 12.59 ± 0.74 years and 52.1% boys at Wave 1). Cross-lagged panel path analyses were conducted to compare four models involving different hypothesized patterns of relationships between moral competence and externalizing behavior. Results revealed that the reciprocal effects model best fit the data, supporting reciprocal causal relationships between moral competence and externalizing behavior measures. Specifically, a higher level of moral competence significantly predicted a lower level of delinquency and problem behavioral intention over time. At the same time, a higher level of externalizing behavior also significantly predicted a lower level of moral competence 1 year later. As the magnitudes of the significant findings were not high, replications in different Chinese communities are needed. Nevertheless, the present findings provide important theoretical insights on how moral competence and externalizing behavior in adolescents are associated with each other. Practically speaking, the findings suggest that it is promising to reduce adolescent externalizing behavior by promoting their virtues through moral education programs, and guiding adolescents to behave in a good manner would help promote the development of their virtues.

Healthcare professionals' ethical competence: A scoping review

AIM

The aim of this study was to examine the extent and nature of the available research literature on healthcare professionals' ethical competence and to summarize the research findings in this field.

DESIGN

A scoping review guided by Arksey and O'Malleys methodological framework was conducted.

METHODS

Six databases including Pubmed/Medline, CINAHL, Web of Science Core Collection, PsycInfo, Philosophers' Index, and Scopus were searched systematically. Of 1,476 nonduplicate citations, 17 matched the inclusion criteria.

RESULTS

Findings revealed that healthcare professionals' ethical competence is a limited but topical research area. The focus areas of the studies were conceptualization, measuring, and realization of the ethical competence. The studies provided varying definitions and constructions for ethical competence and a few instruments to measure ethical competence were identified. Research in this area seems to be in a transition phase from theorization to empirical measurement. Methodologically, the research was rather heterogeneous and mainly focused on nurses.

Analysis of self-evaluated ethical competence of midwifery students at a selected nursing college in the Free State

BACKGROUND

 It is imperative to know whether the students who have undergone a specific training perceive themselves as confident and competent in handling ethical dilemmas, in the face of contemporary ethical challenges. Such evaluation is significant especially for nursing and midwifery students who have undergone training that stipulates adherence to a code of ethics and professional norms. At present, such knowledge is limited, and this has an impact for ethics education.

OBJECTIVES

 The article aims to describe the self-evaluated ethical competence of midwifery students and to contrast the findings to the content of the ethics instruction received. Based on outcomes, the article aims to convey the claim to nursing institutions that current strategies that rely on teaching nursing ethics without appraising the context of a situation are ineffective in fostering ethical competence amongst students.

METHOD

 This study made use of a set of self-reflection reports in which the midwifery nursing students narrated their experiences in handling ethical issues.

RESULTS

 Analysis of the self-reflective reports revealed that one of the three dimensions of ethical competence was limited. There was evidence of moral perception, moral action and substandard moral reasoning. The principles that were mostly referred to within the narratives were autonomy and beneficence.

CONCLUSION

 The findings support the argument that teaching principlism and enforcing a code of ethics without contextualising it coerces the student to conform without questioning their beliefs. Thus, ethical competence amongst the midwifery students may be described in terms of compliance to principles with limited reflection on the situation as a whole.

Moral competence among nurses in Malawi: A concept analysis approach

BACKGROUND

Nurses are expected to provide comprehensive, holistic and ethically accepted care according to their code of ethics and practice. However, in Malawi, this is not always the case. This article analyses moral competence concept using the Walker and Avant's strategy of concept analysis.

OBJECTIVE

The aim of this article is to analyse moral competence concept in relation to nursing practice and determine defining attributes, antecedents and consequences of moral competence in nursing practice.

METHOD

Analysis of moral competence concept was done using Walker and Avant's strategy of concept analysis.

RESULTS

Deductive analysis was used to find the defining attributes of moral competence, which were kindness, compassion, caring, critical thinking, ethical decision making ability, problem solving, responsibility, discipline, accountability, communication, solidarity, honesty, and respect for human values, dignity and rights. The identified antecedents were personal, cultural and religious values; nursing ethics training, environment and guidance. The consequences of moral competence are team work spirit, effective communication, improved performance and positive attitudes in providing nursing care.

CONCLUSION

Moral competence can therefore be used as a tool to improve care in nursing practice to meet patients' problems and needs and consequently increase public's satisfaction in Malawi.

Self-Reported Risk and Delinquent Behavior and Problem Behavioral Intention in Hong Kong Adolescents: The Role of Moral Competence and Spirituality

Based on the six-wave data collected from Grade 7 to Grade 12 students (N = 3,328 at Wave 1), this pioneer study examined the development of problem behaviors (risk and delinquent behavior and problem behavioral intention) and the predictors (moral competence and spirituality) among adolescents in Hong Kong. Individual growth curve models revealed that while risk and delinquent behavior accelerated and then slowed down in the high school years, adolescent problem behavioral intention slightly accelerated over time. After controlling the background socio-demographic factors, moral competence and spirituality were negatively associated with risk and delinquent behavior as well as problem behavioral intention across all waves as predicted. Regarding the rate of change in the outcome measures, while the initial level of spirituality was positively linked to the growth rate of risk and delinquent behavior, the initial level of moral competence was negatively associated with the growth rate of problem behavioral intention. The theoretical and practical implications of the present findings are discussed with reference to the role of moral competence and spirituality in the development of adolescent problem behavior.

Responsibility among bachelor degree nursing students: A concept analysis

BACKGROUND

Responsibility is an important component of the professional values and core competencies for bachelor degree nursing students and has relationships with nursing education and professionalization. It is important for providing safe and high-quality care to the clients for the present and future performance of student. But there is no clear and operational definition of this concept for bachelor degree nursing students; however, there are extensive contents and debates about the definitions, attributes, domains and boundaries of responsibility in nursing and non-nursing literature.

OBJECTIVE

To examine the concept of responsibility among bachelor degree nursing students using the evolutionary approach to concept analysis.

METHODS

A total of 75 articles published between 1990 and 2016 and related to the concept of responsibility were selected from seven databases and considered for concept analysis based on Rogers' evolutionary approach.

ETHICAL CONSIDERATIONS

Throughout all stages of data collection, analysis and reporting, accuracy and bailment were respected.

FINDINGS

Responsibility is a procedural, spectral, dynamic and complex concept. The attributes of the concept are smart thinking, appropriate managerial behaviours, appropriate communicational behaviours, situational self-mandatory and task-orientation behaviours. Personal, educational and professional factors lead to the emergence of the responsible behaviours among bachelor degree nursing students. The emergence of such behaviours facilitates the learning and education process, ensures nursing profession life and promotes clients and community health level. Responsibility has some effects on nursing students.

DISCUSSION

This concept had been changed over time since 1990-2016. There are similarities and differences in the elements of this concept in disciplines of nursing and other educational disciplines.

CONCLUSION

The analysis of this concept can help to develop educational or managerial theories, design instruments for better identification and evaluation of responsible behaviours among bachelor degree nursing students, develop strategies for enhancing the responsibility and improve the safety and quality of nursing care in the community and healthcare system.

Patient perspectives of maintaining dignity in Indonesian clinical care settings: A qualitative descriptive study

AIM

To gain an understanding towards the perspectives of hospitalized inpatients in Indonesia regarding maintaining dignity during clinical care.

BACKGROUND

Dignity is a basic human right that is crucial for an individual's well-being. Respect for a person as a valuable human is a concept that is comparable to treating a person with dignity. Maintaining patient's dignity is an ethical goal of nursing care. Nevertheless, the concept is highly dependent on cultural context. This issue has not been well studied in Indonesia.

DESIGN

This study used a qualitative descriptive design.

METHODS

Thirty-five participants were recruited by purposive sampling from medical to surgical wards of six public hospitals in Eastern Java, Indonesia. Data were collected in 2016 through individual face-to-face semi-structured interviews. Inductive content analysis was applied to the data.

FINDINGS

Four major categories which described qualities of nursing care essential for maintaining a patient's dignity in clinical care settings were revealed: (1) responsiveness; (2) respectful nurse-patient relationships; (3) caring characteristics and (4) personalized service.

CONCLUSIONS

Our findings provide a cultural viewpoint of dignity for care recipients in Indonesia. The findings provide empirical support for linking dignified care and person-centred care principles with regards to cultural sensitivity. Nurses must not only be clinically competent but also culturally competent. The ability to provide culturally competent care is important for nurses as a strategy to maintain patient dignity during hospitalized care.

Reliability and Validity of the Turkish Version of the Moral Competence Scale for Public Health Nurses: A Methodological Study

BACKGROUND

Moral competencies must be improved in nursing area practice. To evaluate the moral competence seems necessary for nurses.

AIM

The aims of this study are to adapt and evaluate the psychometric properties of the moral competence questionnaire for public health nurses in Turkey.

METHOD

The moral competence scale was translated into Turkish by a skilled translator, after which it was back-translated into English by another translator. We then administered the Turkish version of the moral competence scale to 138 public health nurses working in family and public health centers in Erzurum, a city in eastern Turkey. We analyzed the data using factor analysis and Cronbach's α.

RESULTS

Three factors were extracted, which together explained a total of 67.50% of the variance. The Cronbach's α values were .83, .91, .87, and .88 for factors 1, 2, and 3 and for the whole scale, respectively.

CONCLUSION

The Turkish version of the moral competence scale for public health nurses is a valid and reliable assessment tool.

Moral competency: meta-competence of nursing care

Introduction

To follow the progress of technology and increasing domain of nurses’ duties, ethical challenges can be observed more than ever. Therefore, the growing and dynamic system of nursing requires nurses with professional and ethical competence who can provide optimal care. The aim of the present study was to define and explain dimensions of moral competency among the clinical nurses of Iran.

Methods

This qualitative content analysis study was carried out in the years 2014 and 2015 in Iran. Data were collected through in-depth semistructured interviews and field notes. The resulting data were analyzed by Graneheim and Lundman’s method of conventional content analysis. The participants were 12 clinical nurses who were selected using purposive convenient sampling and continued interviews until data saturation.

Results

Themes obtained in the present study were posited in three main categories of “moral character,” with subcategories of altruism, search for meaning, be pioneering, perfectionism, self-control, honesty, and forgiveness; “moral care” with subcategories of dignified care, safe care, fair care, and holistic care; and “moral decision-making” with subcategories of moral sensitivity, moral thinking, moral reasoning, and moral courage.

Conclusions

Findings of the present study suggest that nurses’ moral competency is an adorable character with a wide range that includes moral virtues and character, moral decision-making, and ultimately providing moral care; therefore, moral competency is a meta-competence in the field of nursing. Because there are many competencies in different fields.

Enhancing students’ moral competence in practice

Background:

Nurses and student nurses in Malawi often encounter challenges in taking a moral course of action. Several studies have demonstrated a need for increased awareness of ethical issues in the nursing education.

Objective:

To explore the challenges experienced by nurse teachers in Malawi in their efforts to enhance students’ moral competence in clinical practice.

Research design:

A qualitative hermeneutic approach was employed to interpret the teachers’ experiences.

Participants and research context:

Individual interviews (N = 8) and a focus group interview with teachers (N = 9) from different nursing colleges were conducted.

Ethical considerations:

Ethical approval was granted and all participants signed their informed consent.

Findings:

Two overall themes emerged: (1) authoritarian learning climate, with three subthemes: (a) fear of making critical comments about clinical practice, (b) fear of disclosing mistakes and lack of knowledge and (c) lack of a culture of critical discussion and reflection that promotes moral competence; and (2) discrepancy between expectations on learning outcome from nursing college and the learning opportunities in practice comprising three subthemes: (a) gap between the theory taught in class and learning opportunities in clinical practice, (b) lack of good role models and (c) lack of resources.

Discussion:

Our findings indicated that showing respect was a central objective when the students were assessed in practice. A number of previous studies have enlightened the need for critical reflection in nursing education. Few studies have linked this to challenges experienced by teachers for development of moral competence in practice. This is one of the first such studies done in an African setting.

Conclusion:

There is a clear relationship between the two themes. A less authoritarian learning climate may enhance critical reflection and discussion between students, teachers and nurses. This can narrow the gap between the theory taught in college and what is demonstrated in clinical practice. Moral competence must be enhanced in order to ensure patients’ rights and safety.

Trends in nursing ethics research: Mapping the literature production

BACKGROUND

There have been a number of debates in the field of nursing ethics. Researchers have focused on various aspects of nursing ethics, such as professional ethics, professional, nursing and ethical values. Within this research, a variety of literature reviews have been conducted, but to the best of our knowledge, bibliometric mapping has not yet been used.

OBJECTIVE

This article aims to analyse the production of literature within nursing ethics research.

RESEARCH DESIGN

In order to examine publishing patterns, we focused on publishing dynamics, prolific research entities and the most-cited articles. We additionally visualised the content of the literature using a novel mixed-method approach, combining bibliometric analysis and mapping with thematic analysis. Ethical considerations: In our study, ethical review was not required.

FINDINGS

A total of 1416 information sources were found in the Scopus database. Overall, literature production has increased; however, in recent years, the quantity of published material has begun to decrease. The most prolific countries are the United States, the United Kingdom and Canada, and the most prolific source titles are Nursing Ethics, Journal of Advanced Nursing and Nursing Times. Lately, research in the field of nursing ethics has been focused more on life care (providing for the basic needs of older residents), moral distress and community nursing.

DISCUSSION

The dynamics of research literature production showed an exponential rise in the number of published information sources - a rise which started in the period between 1974 and 1998. Since that period, the trend has stabilised, which might indicate that nursing ethics research is starting a transition to a mature phase.

CONCLUSION

The innovative use of bibliometric analysis and mapping, together with thematic analysis, is a useful tool for analysis of research production in the field of nursing ethics. The results presented can be an excellent starting point for literature reviews and more exhaustive data, information and knowledge seeking.

Factors affecting professional ethics in nursing practice in Iran: a qualitative study

Background

Professional ethics refers to the use of logical and consistent communication, knowledge, clinical skills, emotions and values in nursing practice. This study aimed to explore and describe factors that affect professional ethics in nursing practice in Iran.

Methods

This qualitative study was conducted using conventional content analysis approach. Thirty nurses with at least 5 years of experience participated in the study; they were selected using purposive sampling. Data were collected through semi-structured interviews and analyzed using thematic analysis.

Results

After encoding and classifying the data, five major categories were identified: individual character and responsibility, communication challenges, organizational preconditions, support systems, educational and cultural development.

Conclusions

Awareness of professional ethics and its contributing factors could help nurses and healthcare professionals provide better services for patients. At the same time, such understanding would be valuable for educational administrators for effective planning and management.

Ethical competence

Background:

Exploring the concept of ethical competence in the context of healthcare is essential as it pertains to better quality of care. The concept still lacks a comprehensive definition covering the aspects of ethical expertise, ethical knowledge and action of a health professional.

Objective:

This article aims to report an analysis of the concept of ethical competence.

Method:

A modified strategy suggested by Walker and Avant was used to analyse the concept.

Results:

As a result, the concept of ethical competence can be defined in terms of character strength, ethical awareness, moral judgement skills and willingness to do good. Virtuous professional, experience of a professional, human communication, ethical knowledge and supporting surroundings in the organisation can be seen as prerequisites for ethical competence. Ethical competence results in the best possible solutions for the patient, reduced moral distress at work and development and democratisation of society.

Conclusion:

The results of the analysis establish a basis for an instrument to evaluate health professionals’ ethical competence. It will guide educators, as well as managers in healthcare, to support the development of ethical conduct in healthcare.

Sustaining hope as a moral competency in the context of aggressive care

BACKGROUND

Nurses who provide aggressive care often experience the ethical challenge of needing to preserve the hope of seriously ill patients and their families without providing false hope.

RESEARCH OBJECTIVES

The purpose of this inquiry was to explore nurses' moral competence related to fostering hope in patients and their families within the context of aggressive technological care. A secondary purpose was to understand how this competence is shaped by the social-moral space of nurses' work in order to capture how competencies may reflect an adaptation to a less than ideal work environment.

RESEARCH DESIGN

A critical qualitative approach was used.

PARTICIPANTS

Fifteen graduate nursing students from various practice areas participated.

ETHICAL CONSIDERATIONS

After receiving ethics approval from the university, signed informed consent was obtained from participants before they were interviewed.

FINDINGS

One overarching theme 'Mediating the tension between providing false hope and destroying hope within biomedicine' along with three subthemes, including 'Reimagining hopeful possibilities', 'Exercising caution within the social-moral space of nursing' and 'Maintaining nurses' own hope', was identified, which represents specific aspects of this moral competency.

DISCUSSION

This competency represents a complex, nuanced and multi-layered set of skills in which nurses must be well attuned to the needs and emotions of their patients and families, have the foresight to imagine possible future hopes, be able to acknowledge death, have advanced interpersonal skills, maintain their own hope and ideally have the capacity to challenge those around them when the provision of aggressive care is a form of providing false hope.

CONCLUSION

The articulation of moral competencies may support the development of nursing ethics curricula to prepare future nurses in a way that is sensitive to the characteristics of actual practice settings.

Developing nursing ethical competences online versus in the traditional classroom

Background:

The development of society and science, especially medical science, gives rise to new moral and ethical challenges in healthcare.

Research question/objectives/hypothesis:

In order to respond to the contemporary challenges that require autonomous decision-making in different work contexts, a pedagogical experiment was conducted to identify the readiness and responsiveness of current organisation of nursing higher education in Slovenia. It compared the successfulness of active learning methods online (experimental group) and in the traditional classroom (control group) and their impact on the ethical competences of nursing students. The hypothesis set in the experiment, hypothesis 1 (the experimental group will be successful and will have good achievements in comprehension and application of ethical principles) was confirmed based on pre-tests and post-tests. The hypothesis tested by the questionnaire, hypothesis 2 (according to the students, the active learning methods online in the experimental group have a positive impact on the development of ethical competences) was confirmed.

Research design:

The pedagogical experiment was supported by a multiple-case study that enabled the in-depth analysis of the students’ attitudes towards the active learning methods in both settings.

Participants and research context:

The study included Slovenian first-year nursing students (N = 211) of all the enrolled students (N = 225) at the University of Ljubljana and University of Primorska in the academic year 2010/2011.

Ethical considerations:

Before the study ethical permission was obtained from the managements of both participating faculties. The students were given all the necessary information of the experiment before the tutorials.

Findings:

No significant difference was found between the two learning settings and both had a positive impact upon learning. The results of the content analysis show that the students’ active engagement with the active learning methods in the group enables the development of ethical competences and the related communicative competences, interpersonal skills, collaboration and critical thinking.

Discussion:

Active learning methods in the settings compared, online and the traditional classroom, enabled the development of a higher level of knowledge defined by the ability of critical thinking and reflective response, the core of ethical competences. Students develop ethical competence through active engagement in a group work, role play and discussion, and there is no difference between online or traditional learning settings.

Conclusion:

In the healthcare, it is crucial for providers to be capable of making autonomous decisions and managing various communication situations and contexts in which the moral attitudes and ethical sensibility are essential.

Guidelines for value-sensitive clinical accompaniment in community health nursing

AIM

The goal of the first part of the study was to explore and describe the experiences of students with regard to value-sensitive clinical accompaniment in community nursing. The purpose of phase two of the research and of this article was to develop guidelines for value-sensitive clinical accompaniment of student nurses by professional nurses in community nursing

BACKGROUND

Undergraduate students have reported that owing to different cultures and values, value conflicts are experienced during clinical accompaniment, which affects clinical learning in community nursing negatively.

METHOD

A qualitative, exploratory and descriptive research design was done in a specific context; guidelines were formulated as a result of the findings in phase 1. Once the guidelines were formulated the guidelines were validated and refined by presenting them to a panel of experts for validation. The accessible population was experts in the field of community health nursing and the participants that were conveniently selected were asked to validate the guidelines.

RESULTS

Three main categories were identified, namely, respect during clinical accompaniment, value-sensitive communication and sensitivity to quality of clinical accompaniment. The validated and refined guidelines were described. CONCLUSION AND IMPLICATIONS FOR NURSE MANAGERS: Guidelines for value-sensitive clinical accompaniment of student nurses by professional nurses as experts in community nursing should be implemented by nurse managers as they are important in any relationship to set the climate for both personal and professional wellbeing.

Development and Psychometric Evaluation of the Moral Competence Scale for Home Care Nurses in Japan

Purpose: The purpose of this study was to evaluate the validity and reliability of the Moral Competence Scale for Home Care Nurses (MCSHCN). Methods: A self-administered questionnaire that included the preliminary MCSHCN (90 items) was distributed to home care nurses (HCNs) in Japan. Usable data (from 1,961 questionnaires) were analyzed. Results: Item and exploratory factor analysis for the MCSHCN revealed 45 items that loaded on 5 factors. This 5-factor model showed reasonable fit to the data by confirmatory factor analysis (root mean square error of approximation [RMSEA] = 0.070). Thus, the model closely corresponded to the theoretical components of moral competence. Cronbach’s alpha ranged from .78 to .93. Conclusions: The construct validity and internal consistency reliability were supported. Further research is needed to refine this scale to increase the generalizability.

Work values and job satisfaction

This study aimed to describe the effect of nursing profession work-related values on job satisfaction among a sample of Iranian nurses. We used in-depth interviews with 30 nurses who worked in university-affiliated and public hospitals in Tehran, Iran. The results of thematic analysis of interviews are reported in four themes to present the participants’ articulations in linking their work-related values to job satisfaction. The themes consist of values that “encourage tolerance,” “enhance inner harmony,” “reflect traditional commitment,” “enhance unity,” and are “centered around altruism and spiritual values.” The most satisfied participants considered nursing a divine profession and a tool by which they could gain spiritual pleasure and satisfaction. Our findings highlight the potential role of nursing work-related values in reducing dissatisfaction with one’s job. For the nursing profession, this may have implications in reducing job instability and turnover.

Balancing between closeness and distance: emergency medical services personnel's experiences of caring for families at out-of-hospital cardiac arrest and sudden death

INTRODUCTION

Out-of-hospital cardiac arrest (OHCA) is a lethal health problem that affects between 236,000 and 325,000 people in the United States each year. As resuscitation attempts are unsuccessful in 70-98% of OHCA cases, Emergency Medical Services (EMS) personnel often face the needs of bereaved family members.

PROBLEM

Decisions to continue or terminate resuscitation at OHCA are influenced by factors other than patient clinical characteristics, such as EMS personnel's knowledge, attitudes, and beliefs regarding family emotional preparedness. However, there is little research exploring how EMS personnel care for bereaved family members, or how they are affected by family dynamics and the emotional contexts. The aim of this study is to analyze EMS personnel's experiences of caring for families when patients suffer cardiac arrest and sudden death.

METHODS

The study is based on a hermeneutic lifeworld approach. Qualitative interviews were conducted with 10 EMS personnel from an EMS agency in southern Sweden.

RESULTS

The EMS personnel interviewed felt responsible for both patient care and family care, and sometimes failed to prioritize these responsibilities as a result of their own perceptions, feelings and reactions. Moving from patient care to family care implied a movement from well-structured guidance to a situational response, where the personnel were forced to balance between interpretive reasoning and a more direct emotional response, at their own discretion. With such affective responses in decision-making, the personnel risked erroneous conclusions and care relationships with elements of dishonesty, misguided benevolence and false hopes. The ability to recognize and respond to people's existential questions and needs was essential. It was dependent on the EMS personnel's balance between closeness and distance, and on their courage in facing the emotional expressions of the families, as well as the personnel's own vulnerability. The presence of family members placed great demands on mobility (moving from patient care to family care) in the decision-making process, invoking a need for ethical competence.

CONCLUSION

Ethical caring competence is needed in the care of bereaved family members to avoid additional suffering. Opportunities to reflect on these situations within a framework of care ethics, continuous moral education, and clinical ethics training are needed. Support in dealing with personal discomfort and clear guidelines on family support could benefit EMS personnel.

A study of an ethics education topic for undergraduate nursing students

The study aims to explore nursing students' perceptions of the relative value of various aspects of the ethical component of the undergraduate topic, 'Ethics and Law applied to Nursing' (topic NURS2104). To enable time for reflection on ethics in nursing, sampling occurred 1 year after successful completion of the above-mentioned topic and after successful completion of all but the final clinical experience components of the Bachelor of Nursing (BN) degree. A significant proportion of respondents perceived ethics education as relevant to professional practices. It is also noteworthy that the ethical decision-making strategies that had been incorporated into the topic (NURS2104) became transformed by the clinical experience of each particular student. While results of this study are not conclusive, they nevertheless provide important information for future nursing students on the evolutionary development of ethics education.