Review
Nursing Ethics
2024, Vol. 0(0) 1–22
© The Author(s) 2024
Article reuse guidelines:
sagepub.com/journals-permissions
DOI: 10.1177/09697330241235305
journals.sagepub.com/home/nej
Factors contributing to the
promotion of moral competence in
nursing
Johanna Wiisak
University of Turku
Minna Stolt
University of Turku; Wellbeing Services County of Satakunta
Michael Igoumenidis
University of Patras
Stefania Chiappinotto
University of Udine
Chris Gastmans
KU Leuven
Brian Keogh
Trinity College Dublin
Evelyne Mertens
KU Leuven
Alvisa Palese
University of Udine
Evridiki Papastavrou
Cyprus University of Technology; Cyprus Nurses and Midwifes Association
Catherine Mc Cabe
Trinity College Dublin
Riitta Suhonen
University of Turku; Turku University Hospital; Wellbeing Services County of Southwest Finland
On behalf of the PROMOCON consortium
Corresponding author:
Johanna Wiisak, Department of Nursing Science, University of Turku, Medisiina B, Kiinamyllynkatu 10, Turku 20520, Finland.
Email: jmtpoh@utu.fi
Abstract
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, im-
plementation and multiple methods designs to ensure ethically sustainable healthcare.
Keywords
Moral competence, nursing, nursing students, qualified nurses, integrative review, ethical competence
Introduction
Ethics is a foundational competency in healthcare1 and is inherent in all nursing practices.2 Healthcare
professionals demonstrate their ethical competence in providing high-quality care to patients.3 Constantly
changing society and healthcare environments with ever-growing demands for ethically sustainable care
require nurses’ and nursing students’ moral competence to evolve continuously. This became more evident
during the COVID-19 pandemic which required nurses to make difficult ethical decisions,4,5 and with the
phenomenon of missed care that requires nurses to prioritise scarce resources.6 Therefore, it is important to
develop a support system to promote and sustain nurses’ and nursing students’ moral competence.
Background
The terms moral competence and ethical competence have been used interchangeably in the literature.7 Moral
competence has been defined as ‘the ability or capacity of persons to recognise their feelings as they influence
what is good or bad in particular situations, and then to reflect on these feelings, to make their decision, and to
act in ways that bring about the highest level of benefit for patients’.8 (p. 586). Ethical competence in
healthcare, in turn, is defined as ‘a personal capacity including ethical awareness, courage, willingness and
skills in decision-making and ethical action’.9 (p. 410). As moral competence and ethical competence have
been used synonymously, in this review, the concept of moral competence is used and defined in terms of
perceptions (seeing), knowledge (knowing), reflection, deliberation and acting as a professional caregiver.10
2 Nursing Ethics 0(0)
There is a wealth of literature on what constitutes nurses’moral competence,3,7,9 as well as the level of their
moral competence11 and the variables associated with it, such as ethics education,12,13 and nurses’ ethical
reasoning and behaviour.14 However, the literature on factors that contribute to the promotion of qualified
nurses’ and nursing students’moral competence is limited. Factors have been considered by the research team
in this study context as those elements facilitating, contributing or leading to a specific outcome, as the
promotion of moral competence among nurses and nursing students. The pedagogical approaches in teaching
or learning ethics in undergraduate nursing education have been found to be limited in terms of what should be
taught about ethics, and how and by whom it should be taught.15 There is also great variation and diversity
globally, with some countries offering ethics as stand-alone courses while in others, it is integrated into other
subject areas. Similarly, the delivery of ethics education in nursing education varies with practices like clinical
and didactic courses including discussions, simulation, case-based learning, problem-based techniques, role
play and analysing ethical issues.16 In view of the increasing complexity of care and the accompanying
emergence of new ethical challenges, there is a need to re-examine the content of nursing curricula to enhance
the promotion of morally competent nurses as well as teaching practices that are more adaptive to the
changing learning needs.
Factors that support and contribute to the promotion of moral competence have been identified not only in
education but also in clinical settings. The main aims of support are to improve ethical decision-making and
action in the clinical environment, to prevent, mitigate or reduce the ethical burden, supervise policymaking
and provide guidelines, education and consultation.17 The ethical competence of healthcare professionals in
undergraduate, continuing and clinical education can be promoted through various interventions, especially
educational ones.18 However, an integrative summary of the factors that may contribute to the promotion of
moral competence was not identified from the literature.
The importance of ethics in healthcare and the requirement of moral competence from nursing profes-
sionals in providing high-quality care with respect to human and patients’ rights have been acknowledged in
the literature.3,4,9 In addition, ethics education in nursing curricula and the best practices varies globally.16
Therefore, this review was conducted to identify the factors that can contribute to the promotion of moral
competence of qualified nurses and nursing students not only in educational institutions but also in healthcare
organisations.
Aim
The aim of this review was to identify the factors contributing to the promotion of qualified nurses’ and
nursing students’ moral competence.
Methods
An integrative review method was used and its five steps followed according to the methodological model of
Whittemore and Knafl,19 namely, (a) problem-identification, which ensures that both the research question
and purpose are appropriately formulated; (b) research strategy and literature search; (c) methodological
quality assessment, (d) data analysis; and (e) presentation and synthesis of findings. The review protocol has
been registered in the International Prospective Register of Systematic Reviews (CRD42023386947). The
Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA)20 was followed.
Search strategy
A literature search regarding factors contributing to qualified nurses’ and nursing students’moral competence
was carried out to identify relevant scientific research articles. The searches were undertaken on 2nd–4th
Wiisak et al. 3
January 2023 from the earliest content in six scientific databases: CINAHL, Cochrane Library, PsycINFO,
PubMed Medline, Scopus and Web of Science. The search terms and strategies were developed in col-
laboration with a health and medical science library informatics expert. The following terms were used with
the Boolean operators AND or OR: (nurse OR nursing OR nursing student OR student nurse) AND (moral
competence OR ethical competence OR ethical sensitivity OR ethical decision-making OR ethical knowledge
OR ethical behaviour OR ethical behaviour OR ethical reflection OR ethical reasoning ORmoral courage OR
moral care). The keywords were applied in all databases andMeSH terms were also used when appropriate. In
addition, the reference lists of the included articles and relevant reviews were screened; however, this did not
produce any new articles to the review. The Zotero software was used to manage references.21
Inclusion and exclusion criteria
The studies were included if they focused on (1) the moral competence of (2) qualified nurses (registered
nurses, practical nurses, Advanced Practice Nurses) or nursing students, including articles that also covered
other healthcare professionals in addition to them, (3) identify the factors contributing to the promotion of
moral competence, (4) peer-reviewed empirical articles (including all research methods), written in (5)
English language and with (6) abstract available. The studies were excluded if they dealt with (1) the moral
competence of manager-level nurses, nurse aids, nurse assistants, or solely of other healthcare professionals,
and if the articles were (2) theoretical articles, literature reviews, books, dissertations, reports, editorials,
opinions, discussion papers or grey literature.
Quality appraisal
Quality appraisal was employed using the Joanna Briggs Institute Critical Appraisal Checklists for Qualitative
Research in twelve studies, for Analytical Cross-Sectional Studies in eleven studies, and for Quasi-
Experimental Studies in five studies.22 However, for one mixed-method study the Mixed Method Ap-
praisal Tool (MMAT)23 was used instead, as no Joanna Briggs Institute (JBI) checklist existed for this
purpose. The ranking of the JBI checklist items included Yes, No, Unclear and Not applicable. The quality of
the included articles was rated as moderate (n = 10) or high quality (n = 18). The mixed-method article was
rated as low quality. However, as suggested in the literature, none of them were excluded based on quality
appraisal.23 The quality appraisal of each article was carried out by two researchers. A total of eight re-
searchers (JW, MS, SC, CG, BK, EM, EP, RS) participated and discrepancies were resolved among three
researchers (JW, MS, RS).
Data analysis
A data extraction template was constructed for the review and data from the included articles were extracted
and inserted into the template to describe the existing literature. The information included the author(s), year,
country of origin, aim(s), study design/methods, setting/sample, factors contributing to moral competence and
reported outcomes. Data were analysed by four researchers (JW, MS, MI, RS) using inductive content
analysis.24 First, the articles were scrutinized by reading them thoroughly several times. During familiar-
isation, notes were made on the manifest content. Second, the unit of analysis was selected as the original
expressions of the authors of the articles that were considered relevant to respond to the aim of the review.
These were drawn into table worksheet as meaning units. Third, meaning units were further reduced into
condensed meaning units. Fourth, condensed meaning units were abstracted and interpreted by comparing
them and notes for differences and similarities and sorted into sixteen sub-categories and further into eight
categories. Finally, two main categories that unified the content in the categories were formulated (Table 1).
4 Nursing Ethics 0(0)
Findings
Studies retrieved
The studies were retrieved according to the four stages of the PRISMA20 flowchart (Figure 1). At the first
stage, 5233 records were identified from six databases; 2949 duplicates were removed. The remaining
2284 records were then screened by their titles and abstracts. Following this, 50 full text reports remained,
which were screened for eligibility. Twenty-one reports were excluded. In the last stage, 29 studies were
included in the review.
Table 1. Example of data analysis.
Meaning unit
Condensed meaning
unit Sub-category Category
Main
category
‘The learning experience of being situated
within the scenario and being able to
explore their own feelings in
connection with what was happening’
(Oddvang et al. 2021).
Explore one’s own
feelings
Self-reflection Individual factors Human
factors
‘Strong will to face difficult situations’
(Asahara et al. 2014, Go¨l & Arkan
2022).
Strong will Character
strength
‘Moral transition: At this stage, students
are motivated to accomplish these
skills, which they see modelled by both
their educators and their peers’
(Ranjbar et al. 2018).
Seeing modelled by both
their educators and
their peers
A professional
role model
Social factors
‘Discussing the ethical problems of each
patient’ (Borhani et al. 2010)
Discussing the ethical
problems
Mutual
interaction
‘An interactive situational e-learning
system, integrating traditional face to
face teaching with an interactive
multimedia online system’. (Chao et al.
2017)
An interactive
situational e-learning
system
Teaching
methods
Educational
factors
Structural
factors
‘The practice scenario… facing the
problem, assuming responsibility for
solving it and taking actions grounded in
values and knowledge’ (Schaefer &
Junges 2014).
Face to face teaching
Hypothetical scenarios Content of
teaching
‘Multidisciplinary discussion of ethical
issues’ (Maluwa et al. 2021).
Lack of ethical
guidelines, protocols
or frameworks
Ethics
management
strategies
Organisational
factors
‘Availability of resources including
guidelines, rules and protocols as part of
material resources’ (Maluwa et al.
2021).
Availability of resources Resources of the
organization
Wiisak et al. 5
Characteristics of the studies
The studies (n = 29) were published between 2007 and 2022, the majority (n = 17) between 2010 and 2019,
only one study before 2010,25 and the rest of the studies (n = 11) in 2020 or later (Table 2). Four studies were
carried out in Finland26–29 and three in Iran.30–32 Two studies were conducted in each of the following
countries Brazil,33,34 Norway,35,36 Japan,37,38 Portugal,39,40 Sweden25,41 and Turkey.42,43 One study was
conducted in each of the following countries: Belgium,44 Canada,45 Czech Republic,46 Israel,47 Malawi,48
Slovenia,49 South Korea,50 Spain,51 Taiwan52 and the Netherlands.53
The designs of the studies were mainly qualitative26,30–36,41,45,48,51 or quantitative.27–29,37,38,42–44,46,47,53
One study had a mixed-method design,50 and a quasi-experimental design was used in five studies25,39,40,49,52
Figure 1. The PRISMA flow diagram, 2020 statement: An updated guideline for reporting systematic reviews.20
6 Nursing Ethics 0(0)
T
ab
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op
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20
18
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pa
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T
o
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e
st
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’
pe
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e
pr
oc
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s
of
le
ar
ni
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et
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th
ro
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h
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to
de
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si
on
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de
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lm
ed
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ur
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r
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rs
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=
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on
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ni
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m
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)
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to
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la
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PR
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(5
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tic
re
le
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ne
ss
,(
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to
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de
rl
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20
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ra
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tif
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te
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d
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ac
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by
pr
of
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so
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to
pr
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ot
e
th
e
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ve
lo
pm
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of
th
e
m
or
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co
m
pe
te
nc
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of
nu
rs
in
g
un
de
rg
ra
du
at
e
st
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ts
.
A
qu
al
ita
tiv
e
st
ud
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w
ith
se
m
i-s
tr
uc
tu
re
d
in
te
rv
ie
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s
N
ur
si
ng
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of
es
so
rs
(n
=
20
)
T
ea
ch
in
g
st
ra
te
gi
es
an
d
sp
ac
es
th
at
pr
om
ot
e
th
e
de
ve
lo
pm
en
t
of
m
or
al
co
m
pe
te
nc
e.
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hr
ee
ca
te
go
ri
es
:(
1)
A
ct
iv
e
m
et
ho
do
lo
gi
es
as
st
ra
te
gi
es
fo
r
th
e
de
ve
lo
pm
en
t
of
m
or
al
co
m
pe
te
nc
e,
(2
)
K
no
w
le
dg
e
an
d
de
ve
lo
pm
en
t
of
cl
in
ic
al
re
as
on
in
g
as
m
ot
iv
at
in
g
sp
ac
es
of
m
or
al
co
m
pe
te
nc
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(3
)
A
tt
itu
de
of
pr
of
es
so
rs
as
a
st
ra
te
gy
fo
r
di
al
og
ue
,e
m
pa
th
y,
re
co
ve
ry
of
m
or
al
va
lu
es
an
d
de
ve
lo
pm
en
t
of
ca
ri
ng
sk
ill
s
7/
10
In
te
rm
ed
ia
te
ca
te
go
ri
es
:(
a)
te
ac
hi
ng
st
ra
te
gi
es
,(
b)
ac
tiv
e
m
et
ho
do
lo
gi
es
,(
c)
st
ud
y
dy
na
m
ic
s,
(d
)
kn
ow
le
dg
e,
(e
)
cl
in
ic
al
re
as
on
in
g,
(f)
m
or
al
co
m
pe
te
nc
e,
(g
)
at
tit
ud
e
of
pr
of
es
so
rs
,(
h)
di
al
og
ue
,a
nd
(i)
m
or
al
va
lu
es
H
em
be
rg
&
H
em
be
rg
,2
02
0,
Fi
nl
an
d
T
o
in
ve
st
ig
at
e
he
al
th
ca
re
pr
of
es
si
on
al
s’
vi
ew
s
on
et
hi
ca
lc
om
pe
te
nc
e
in
a
st
ud
en
t
he
al
th
ca
re
co
nt
ex
t.
A
qu
al
ita
tiv
e
de
si
gn
an
d
a
he
rm
en
eu
tic
al
ap
pr
oa
ch
w
ith
in
te
rv
ie
w
s
N
ur
se
s
(n
=
9)
V
ie
w
s
on
et
hi
ca
l
co
m
pe
te
nc
e.
T
he
m
ai
n
th
em
e:
sa
fe
gu
ar
di
ng
th
e
vu
ln
er
ab
ili
ty
of
th
e
ot
he
r.
Fo
ur
su
b-
th
em
es
:(
a)
us
in
g
se
ns
iti
vi
ty
to
es
ta
bl
is
h
a
tr
us
tfu
lr
el
at
io
ns
hi
p,
(b
)
ac
tin
g
in
an
ob
je
ct
iv
e
an
d
fl
ex
ib
le
m
an
ne
r,
(c
)
us
in
g
a
re
fl
ec
tiv
e
pr
oc
es
s
in
de
ci
si
on
-m
ak
in
g,
(d
)
m
ai
nt
ai
ni
ng
co
nfi
de
nt
ia
lit
y
an
d
ho
ne
st
y.
8/
10
O
th
er
(n
=
1)
(c
on
tin
ue
d)
Wiisak et al. 7
T
ab
le
2.
(c
on
tin
ue
d)
A
ut
ho
rs
,y
ea
r,
co
un
tr
y
A
im
St
ud
y
de
si
gn
/m
et
ho
ds
Se
tt
in
g/
sa
m
pl
e
M
or
al
co
m
pe
te
nc
e
co
nt
ri
bu
tin
g
fa
ct
or
s
R
ep
or
te
d
ou
tc
om
es
Q
ua
lit
y
ap
pr
ai
sa
l
po
in
ts
a
H
o¨g
lu
nd
et
al
.,
20
10
,S
w
ed
en
T
o
de
sc
ri
be
an
d
ex
pl
or
e
et
hi
ca
ld
ile
m
m
as
th
at
Sw
ed
is
h
re
se
ar
ch
nu
rs
es
ex
pe
ri
en
ce
in
th
ei
r
da
y-
to
da
y
w
or
k.
A
qu
al
ita
tiv
e
st
ud
y
w
ith
in
-
de
pt
h
in
te
rv
ie
w
s
R
es
ea
rc
h
nu
rs
es
(n
=
6)
Ex
pe
ri
en
ce
s
on
et
hi
ca
l
di
le
m
m
as
.
T
hr
ee
th
em
es
:(
1)
et
hi
ca
ld
ile
m
m
as
,(
2)
et
hi
ca
l
re
as
on
in
g,
(3
)
at
tit
ud
es
to
w
ar
ds
re
se
ar
ch
nu
rs
es
an
d
th
ei
r
w
or
k.
8/
10
Su
b-
ca
te
go
ri
es
:(
a)
re
se
ar
ch
in
te
re
st
s
ve
rs
us
th
e
pa
tie
nt
’s
in
te
re
st
s,
(b
)
fe
el
in
g
re
sp
on
si
bl
e,
(c
)
et
hi
ca
ld
is
ag
re
em
en
ts
w
ith
th
e
PI
,(
d)
co
nfl
ic
tin
g
ro
le
s,
(e
)
w
or
ki
ng
pa
tie
nt
-c
en
tr
ed
,(
f)
an
‘in
vi
si
bl
e’
pr
of
es
si
on
an
d
(g
)
no
t
en
co
ur
ag
ed
to
de
ve
lo
p
et
hi
ca
l
co
m
pe
te
nc
e.
M
al
uw
a
et
al
.
20
21
,M
al
aw
i
T
o
ex
pl
or
e
th
e
fa
ct
or
s
th
at
af
fe
ct
et
hi
ca
l
co
m
pe
te
nc
e.
A
qu
al
ita
tiv
e
ex
pl
or
at
or
y
de
si
gn
w
ith
in
-d
ep
th
in
te
rv
ie
w
s
an
d
fo
cu
s
gr
ou
ps
R
eg
is
te
re
d
N
ur
se
sa
nd
R
eg
is
te
re
d
N
ur
se
M
id
w
iv
es
(n
=
44
)
Pe
rc
ep
tio
ns
on
th
e
fa
ct
or
s
af
fe
ct
in
g
et
hi
ca
l
co
m
pe
te
nc
e.
M
ai
n
th
em
e:
Sy
st
em
s
in
fl
ue
nc
in
g
et
hi
ca
l
co
m
pe
te
nc
e
am
on
g
cl
in
ic
al
nu
rs
es
in
M
al
aw
i.
7/
10
O
th
er
(n
=
29
)
Su
b-
th
em
es
:(
1)
Pe
rc
ep
tio
ns
of
cl
in
ic
al
nu
rs
es
on
nu
rs
e
m
an
ag
er
s’
ro
le
s
in
in
fl
ue
nc
in
g
et
hi
ca
lc
om
pe
te
nc
e,
(2
)
N
ur
se
s’
pe
rc
ep
tio
ns
on
th
e
nu
rs
e
le
ad
er
s’
at
tr
ib
ut
es
th
at
in
fl
ue
nc
e
et
hi
ca
lc
om
pe
te
nc
e.
O
dd
va
ng
et
al
.,
20
21
,N
or
w
ay
T
o
co
ns
id
er
th
e
po
te
nt
ia
lr
ol
e
of
si
m
ul
at
io
n
in
he
lp
in
g
nu
rs
in
g
st
ud
en
ts
bu
ild
th
e
et
hi
ca
la
w
ar
en
es
s
an
d
co
m
pe
te
nc
e
th
at
ar
e
su
ch
im
po
rt
an
t
as
pe
ct
s
of
pe
rs
on
-
ce
nt
re
d
ca
re
.
A
qu
al
ita
tiv
e,
ex
pl
or
at
iv
e
de
si
gn
,u
si
ng
fo
cu
s
gr
ou
p
in
te
rv
ie
w
s.
2-
ye
ar
nu
rs
in
g
st
ud
en
ts
(n
=
9)
Ed
uc
at
io
na
li
nt
er
ve
nt
io
n
of
a
2-
w
ee
k
si
m
ul
at
io
n
pr
og
ra
m
m
e
w
ith
sc
en
ar
io
s.
Ex
pe
ri
en
ce
ga
in
ed
th
ro
ug
h
pa
rt
ic
ip
at
io
n
an
d
ac
tin
g
in
si
m
ul
at
io
ns
.T
he
sh
ar
ed
ex
pe
ri
en
ce
w
as
a
go
od
st
ar
tin
g
po
in
t
fo
r
gu
id
ed
re
fl
ec
tio
n
on
et
hi
ca
la
nd
ta
ci
t
kn
ow
le
dg
e.
T
he
ac
qu
ir
ed
ex
pe
ri
en
ce
le
d
to
kn
ow
le
dg
e
tr
an
sf
er
ab
le
to
si
m
ila
r
si
tu
at
io
ns
in
cl
in
ic
al
pr
ac
tic
e.
8/
10
2-
w
ee
k
si
m
ul
at
io
n
pr
og
ra
m
m
e
w
ith
sc
en
ar
io
s
an
d
ph
as
es
:b
ri
efi
ng
,a
ct
io
n
an
d
de
br
ie
fi
ng
.
Et
hi
ca
lf
oc
us
:(
1)
Et
hi
cs
of
du
ty
,
co
ns
eq
ue
nc
e,
au
to
no
m
ou
s
ch
oi
ce
s,
(2
)
Et
hi
cs
of
pr
ox
im
ity
,t
he
fo
ur
pr
in
ci
pl
es
,(
3)
A
ut
on
om
y,
pa
te
rn
al
is
m
Pe
te
r
et
al
.,
20
15
,
C
an
ad
a
T
o
ex
pl
or
e
nu
rs
es
’
m
or
al
co
m
pe
te
nc
e
re
la
te
d
to
fo
st
er
in
g
ho
pe
in
pa
tie
nt
s
an
d
th
ei
r
fa
m
ili
es
w
ith
in
th
e
co
nt
ex
t
of
ag
gr
es
si
ve
te
ch
no
lo
gi
ca
lc
ar
e.
A
cr
iti
ca
lq
ua
lit
at
iv
e
ap
pr
oa
ch
w
ith
in
te
rv
ie
w
s
G
ra
du
at
e
nu
rs
in
g
st
ud
en
ts
(n
=
15
)
Ex
pe
ri
en
ce
so
fm
or
al
di
st
re
ss
w
hi
le
pr
ov
id
in
g
ca
re
.
M
ed
ia
tin
g
th
e
te
ns
io
n
be
tw
ee
n
pr
ov
id
in
g
fa
ls
e
ho
pe
an
d
de
st
ro
yi
ng
ho
pe
w
ith
in
bi
om
ed
ic
in
e.
T
hr
ee
su
b-
th
em
es
:
R
ei
m
ag
in
in
g
ho
pe
fu
lp
os
si
bi
lit
ie
s;
Ex
er
ci
si
ng
ca
ut
io
n
w
ith
in
th
e
so
ci
al
–
m
or
al
sp
ac
e
of
nu
rs
in
g;
M
ai
nt
ai
ni
ng
nu
rs
es
’
ow
n
ho
pe
.
9/
10
R
an
jb
ar
et
al
.,
20
18
,I
ra
n
T
o
ex
pl
or
e
th
e
m
or
al
de
ve
lo
pm
en
tp
ro
ce
ss
in
nu
rs
in
g
st
ud
en
ts
.
A
co
ns
tr
uc
tiv
is
t
gr
ou
nd
ed
th
eo
ry
,i
nt
er
vi
ew
s
N
ur
si
ng
st
ud
en
ts
(n
=
19
)
Ex
pe
ri
en
ce
so
ft
he
ch
an
ge
s
in
pr
ac
tic
al
sk
ill
s,
m
or
al
ca
pa
bi
lit
ie
s
an
d
co
m
pe
te
nc
ie
s.
St
ud
en
ts
ex
pe
ri
en
ce
ch
an
ge
s
to
bo
th
th
ei
r
pr
ac
tic
al
sk
ill
s
an
d
th
ei
r
m
or
al
ca
pa
bi
lit
ie
s
an
d
co
m
pe
te
nc
ie
s.
T
hr
ee
m
ai
n
st
ep
s:
m
or
al
tr
an
si
tio
n,
m
or
al
re
co
ns
tr
uc
tio
n,
an
d
m
or
al
in
te
rn
al
iz
at
io
n.
T
ec
hn
o-
sc
ie
nt
ifi
c
co
m
pe
te
nc
e,
bi
om
ed
ic
al
co
m
pe
te
nc
e,
an
d
nu
rs
in
g
co
m
pe
te
nc
e
ar
e
de
ve
lo
pe
d
in
ea
ch
st
ep
,r
es
pe
ct
iv
el
y.
9/
10
N
ur
si
ng
in
st
ru
ct
or
s
(n
=
3)
(c
on
tin
ue
d)
8 Nursing Ethics 0(0)
T
ab
le
2.
(c
on
tin
ue
d)
A
ut
ho
rs
,y
ea
r,
co
un
tr
y
A
im
St
ud
y
de
si
gn
/m
et
ho
ds
Se
tt
in
g/
sa
m
pl
e
M
or
al
co
m
pe
te
nc
e
co
nt
ri
bu
tin
g
fa
ct
or
s
R
ep
or
te
d
ou
tc
om
es
Q
ua
lit
y
ap
pr
ai
sa
l
po
in
ts
a
Sc
ha
ef
er
&
Ju
ng
es
,
20
13
,B
ra
zi
l
T
o
un
de
rs
ta
nd
th
e
pe
rc
ep
tio
ns
of
pr
im
ar
y
he
al
th
ca
re
se
rv
ic
es
nu
rs
es
on
th
e
co
ns
tr
uc
tio
n
pr
oc
es
s
of
et
hi
ca
l
co
m
pe
te
nc
e.
A
qu
al
ita
tiv
e
st
ud
y,
w
ith
an
in
te
rp
re
ta
tiv
e
ph
en
om
en
ol
og
ic
al
ap
pr
oa
ch
w
ith
in
te
rv
ie
w
s
C
om
m
un
ity
H
ea
lth
ca
re
N
ur
se
s
(n
=
10
)
Pe
rc
ep
tio
ns
on
th
e
co
ns
tr
uc
tio
n
of
et
hi
ca
l
co
m
pe
te
nc
e.
Is
su
es
in
th
e
co
ns
tr
uc
tio
n
of
th
e
et
hi
ca
l
co
m
pe
te
nc
e:
Pe
rs
on
al
va
lu
es
;E
du
ca
tio
n;
an
d
Pr
ac
tic
e
6/
10
So
lu
m
et
al
.,
20
16
,
N
or
w
ay
T
o
ex
pl
or
e
th
e
ch
al
le
ng
es
ex
pe
ri
en
ce
d
by
nu
rs
e
te
ac
he
rs
in
M
al
aw
ii
n
th
ei
r
ef
fo
rt
s
to
en
ha
nc
e
st
ud
en
ts
’
m
or
al
co
m
pe
te
nc
e
in
cl
in
ic
al
pr
ac
tic
e.
A
qu
al
ita
tiv
e
he
rm
en
eu
tic
ap
pr
oa
ch
w
ith
in
te
rv
ie
w
s
N
ur
se
te
ac
he
rs
:
in
di
vi
du
al
in
te
rv
ie
w
s
(n
=
8)
fo
cu
s
gr
ou
p
in
te
rv
ie
w
s
(n
=
9)
Ex
pe
ri
en
ce
s
of
th
e
ch
al
le
ng
es
in
en
ha
nc
in
g
st
ud
en
t’s
m
or
al
co
m
pe
te
nc
e.
O
ve
ra
ll
th
em
es
:(
1)
au
th
or
ita
ri
an
le
ar
ni
ng
cl
im
at
e,
w
ith
su
b-
th
em
es
(a
)
fe
ar
of
m
ak
in
g
cr
iti
ca
lc
om
m
en
ts
ab
ou
tc
lin
ic
al
pr
ac
tic
e,
(b
)
fe
ar
of
di
sc
lo
si
ng
m
is
ta
ke
s
an
d
la
ck
of
kn
ow
le
dg
e,
(c
)
la
ck
of
a
cu
ltu
re
of
cr
iti
ca
l
di
sc
us
si
on
an
d
re
fl
ec
tio
n
th
at
pr
om
ot
es
m
or
al
co
m
pe
te
nc
e;
(2
)
di
sc
re
pa
nc
y
be
tw
ee
n
ex
pe
ct
at
io
ns
on
le
ar
ni
ng
ou
tc
om
e
fr
om
nu
rs
in
g
co
lle
ge
an
d
th
e
le
ar
ni
ng
op
po
rt
un
iti
es
in
pr
ac
tic
e
co
m
pr
is
in
g
th
re
e
su
b-
th
em
es
(a
)
ga
p
be
tw
ee
n
th
e
th
eo
ry
ta
ug
ht
in
cl
as
s
an
d
le
ar
ni
ng
op
po
rt
un
iti
es
in
cl
in
ic
al
pr
ac
tic
e,
(b
)
la
ck
of
go
od
ro
le
m
od
el
s,
(c
)
la
ck
of
re
so
ur
ce
s.
10
/1
0
Z
af
ar
ni
a
et
al
.,
20
17
,I
ra
n
T
o
de
fi
ne
an
d
ex
pl
ai
n
di
m
en
si
on
s
of
m
or
al
co
m
pe
te
nc
y
am
on
g
th
e
cl
in
ic
al
nu
rs
es
of
Ir
an
.
A
qu
al
ita
tiv
e
co
nt
en
t
an
al
ys
is
w
ith
in
-d
ep
th
se
m
i-s
tr
uc
tu
re
d
in
te
rv
ie
w
s
an
d
fi
el
d
no
te
s
C
lin
ic
al
N
ur
se
s
(n
=
12
)
Ex
pe
ri
en
ce
s
of
m
or
al
co
m
pe
te
nc
e.
M
ai
n
ca
te
go
ri
es
:(
1)
‘m
or
al
ch
ar
ac
te
r’
,w
ith
su
b-
ca
te
go
ri
es
of
al
tr
ui
sm
,s
ea
rc
h
fo
r
m
ea
ni
ng
,b
e
pi
on
ee
ri
ng
,p
er
fe
ct
io
ni
sm
,s
el
f-
co
nt
ro
l,
ho
ne
st
y,
an
d
fo
rg
iv
en
es
s;
(2
)‘
m
or
al
ca
re
’
w
ith
su
b-
ca
te
go
ri
es
of
di
gn
ifi
ed
ca
re
,
sa
fe
ca
re
,f
ai
r
ca
re
,a
nd
ho
lis
tic
ca
re
;(
3)
‘m
or
al
de
ci
si
on
-m
ak
in
g’
w
ith
su
b-
ca
te
go
ri
es
of
m
or
al
se
ns
iti
vi
ty
,m
or
al
th
in
ki
ng
,m
or
al
re
as
on
in
g
an
d
m
or
al
co
ur
ag
e.
8/
10
C
ro
ss
-s
ec
ti
o
na
l
st
ud
ie
s
C
ro
ss
-s
ec
tio
na
l
(e
ig
ht
ite
m
s)
A
sa
ha
ra
et
al
.,
20
14
,J
ap
an
T
he
pu
rp
os
e
of
th
is
st
ud
y
w
as
to
de
ve
lo
p
a
va
lid
an
d
re
lia
bl
e
m
or
al
co
m
pe
te
nc
e
se
lf-
as
se
ss
m
en
t
qu
es
tio
nn
ai
re
fo
r
pu
bl
ic
he
al
th
nu
rs
es
th
at
is
ea
sy
to
us
e
in
pr
ac
tic
e.
A
qu
an
tit
at
iv
e
de
sc
ri
pt
iv
e,
cr
os
s-
se
ct
io
na
ls
ur
ve
y
Pu
bl
ic
H
ea
lth
N
ur
se
s
(n
=
34
93
)
M
ea
su
re
m
en
t
of
m
or
al
co
m
pe
te
nc
e.
M
or
al
C
om
pe
te
nc
e
Q
ue
st
io
nn
ai
re
th
re
e
fa
ct
or
s
w
ith
15
ite
m
s:
Ju
dg
em
en
t
ba
se
d
on
th
e
va
lu
es
of
co
m
m
un
ity
m
em
be
rs
;S
tr
on
g
w
ill
to
fa
ce
di
ffi
cu
lt
si
tu
at
io
ns
;C
o-
op
er
at
in
g
w
ith
re
le
va
nt
pe
op
le
/o
rg
an
is
at
io
ns
.
5/
8
Bu
zˇg
ov
a´
&
Si
ko
ro
va´
,2
01
3,
C
ze
ch
R
ep
ub
lic
T
o
de
te
rm
in
e
th
e
le
ve
lo
fm
or
al
ju
dg
em
en
t
co
m
pe
te
nc
e
in
st
ud
en
ts
of
nu
rs
in
g,
an
d
w
he
th
er
it
is
in
fl
ue
nc
ed
by
th
e
fi
el
d
of
st
ud
y,
ty
pe
of
st
ud
y,
cu
rr
en
ty
ea
r
of
st
ud
y
an
d
ag
e.
A
cr
os
s-
se
ct
io
na
ls
ur
ve
y
N
ur
si
ng
st
ud
en
ts
(n
=
66
2)
M
ea
su
re
m
en
t
of
m
or
al
ju
dg
em
en
t
co
m
pe
te
nc
e.
M
or
al
ju
dg
em
en
t
co
m
pe
te
nc
e
in
nu
rs
in
g
st
ud
en
ts
sh
ow
ed
m
os
tly
lo
w
an
d
m
ed
iu
m
sc
or
es
.O
n
av
er
ag
e,
th
e
st
ud
en
ts
pr
ef
er
re
d
st
ag
es
5
an
d
6
of
m
or
al
ju
dg
em
en
t,
th
at
is
th
e
po
st
-c
on
ve
nt
io
na
ll
ev
el
.
6/
8
G
o¨l
&
A
rk
an
,
20
22
,T
ur
ke
y
T
o
de
te
rm
in
e
th
e
m
or
al
co
m
pe
te
nc
e
an
d
in
te
rc
ul
tu
ra
ls
en
si
tiv
ity
le
ve
ls
of
nu
rs
es
w
or
ki
ng
in
pr
im
ar
y
he
al
th
ca
re
in
st
itu
tio
ns
an
d
th
e
re
la
tio
ns
hi
p
be
tw
ee
n
th
e
tw
o.
A
cr
os
s-
se
ct
io
na
ls
ur
ve
y
N
ur
se
s
(n
=
83
)
M
ea
su
re
m
en
t
of
m
or
al
co
m
pe
te
nc
e.
T
he
In
te
rc
ul
tu
ra
lS
en
si
tiv
ity
Sc
al
e
an
d
C
om
pe
te
nc
e
Q
ue
st
io
nn
ai
re
fo
r
Pu
bl
ic
H
ea
lth
N
ur
se
s-
T
ur
ki
sh
V
er
si
on
.J
ud
ge
m
en
t
ba
se
d
on
th
e
va
lu
es
of
co
m
m
un
ity
m
em
be
rs
,
st
ro
ng
w
ill
to
fa
ce
di
ffi
cu
lt
si
tu
at
io
ns
,c
o-
op
er
at
in
g
w
ith
th
e
re
le
va
nt
pe
op
le
/
or
ga
ni
sa
tio
ns
.
7/
8
(c
on
tin
ue
d)
Wiisak et al. 9
T
ab
le
2.
(c
on
tin
ue
d)
A
ut
ho
rs
,y
ea
r,
co
un
tr
y
A
im
St
ud
y
de
si
gn
/m
et
ho
ds
Se
tt
in
g/
sa
m
pl
e
M
or
al
co
m
pe
te
nc
e
co
nt
ri
bu
tin
g
fa
ct
or
s
R
ep
or
te
d
ou
tc
om
es
Q
ua
lit
y
ap
pr
ai
sa
l
po
in
ts
a
K
at
ay
am
a
et
al
.,
20
22
,J
ap
an
T
o
ve
ri
fy
th
e
re
lia
bi
lit
y
an
d
va
lid
ity
of
th
e
Et
hi
ca
lC
ar
in
g
C
om
pe
te
nc
y
Sc
al
e
(E
C
C
S)
an
d
to
ob
ta
in
su
gg
es
tio
ns
fo
r
its
us
e
as
an
ev
al
ua
tio
n
fo
rm
in
ru
br
ic
fo
rm
at
.
A
de
sc
ri
pt
iv
e
an
d
cr
os
s-
se
ct
io
na
ls
ur
ve
y
N
ur
se
s
(n
=
96
2)
M
ea
su
re
m
en
t
of
et
hi
ca
l
ca
ri
ng
co
m
pe
te
nc
e.
C
or
e
co
m
pe
te
nc
ie
s:
(1
)
Ex
pr
es
si
ng
th
e
se
ns
iti
vi
ty
an
d
va
lu
e
of
go
od
ca
re
;(
2)
A
ct
in
g
w
hi
le
th
in
ki
ng
ab
ou
t
ho
w
to
pr
ov
id
e
be
tt
er
ca
re
;(
3)
C
re
at
in
g
in
di
re
ct
ef
fe
ct
s
to
pr
ov
id
e
be
tt
er
ca
re
;(
4)
A
ct
in
g
to
le
ar
n
w
ha
t
be
tt
er
ca
re
is
.
6/
8
O
be
id
&
M
an
,
20
20
,I
sr
ae
l
T
o
ev
al
ua
te
an
ad
va
nc
ed
ed
uc
at
io
n
w
or
ks
ho
p
ai
m
ed
at
st
re
ng
th
en
in
g
th
e
se
lf-
pe
rc
ep
tio
ns
of
et
hi
ca
lc
om
pe
te
nc
e
by
ra
is
in
g
st
ud
en
ts
’s
el
f-e
ffi
ca
cy
w
he
n
co
pi
ng
w
ith
et
hi
ca
ld
ile
m
m
as
.
A
cr
os
s-
se
ct
io
na
ls
tu
dy
N
ur
si
ng
st
ud
en
ts
(n
=
12
7)
Ed
uc
at
io
na
li
nt
er
ve
nt
io
n
Pe
da
go
gi
ca
la
xe
s:
(1
)T
he
et
hi
ca
la
xi
s
–
de
al
in
g
w
ith
th
e
pr
in
ci
pl
es
of
et
hi
ca
lt
hi
nk
in
g,
va
lu
es
,
an
d
th
e
gu
id
in
g
pr
in
ci
pl
es
of
et
hi
ca
lt
hi
nk
in
g;
(2
)
T
he
th
eo
re
tic
al
ax
is
–
th
eo
ri
es
th
at
ex
pl
or
e
et
hi
ca
ld
ile
m
m
as
,a
m
od
el
fo
r
th
e
re
so
lu
tio
n
of
et
hi
ca
ld
ile
m
m
as
;(
3)
T
he
pe
rs
on
al
ax
is
–
em
ot
io
na
lp
os
iti
on
s
an
d
a
se
ns
e
of
th
e
ab
ili
ty
to
co
pe
w
ith
et
hi
ca
l
di
le
m
m
as
;(
4)
Pr
of
es
si
on
al
ex
pe
ri
en
ce
–
th
e
en
co
un
te
r
w
ith
an
et
hi
ca
li
ss
ue
th
at
ra
is
es
a
di
le
m
m
a.
5/
8
Po
ik
ke
us
et
al
.,
20
14
,F
in
la
nd
T
o
an
al
ys
e
ho
w
nu
rs
e
le
ad
er
s
su
pp
or
t
th
e
et
hi
ca
lc
om
pe
te
nc
e
of
nu
rs
es
du
ri
ng
re
cr
ui
tm
en
t
an
d
pe
rf
or
m
an
ce
re
vi
ew
s.
A
de
sc
ri
pt
iv
e,
cr
os
s-
se
ct
io
na
ls
ur
ve
y
N
ur
se
le
ad
er
s
(n
=
19
8)
Su
pp
or
t
N
ur
se
le
ad
er
s
su
pp
or
te
d
nu
rs
es
’
et
hi
ca
l
co
m
pe
te
nc
e
du
ri
ng
pe
rf
or
m
an
ce
re
vi
ew
s
an
d
re
cr
ui
tm
en
t.
D
ur
in
g
re
cr
ui
tm
en
t,
et
hi
ca
lb
eh
av
io
ur
an
d
kn
ow
le
dg
e
of
nu
rs
es
w
er
e
en
su
re
d
to
va
ry
in
g
de
gr
ee
s.
D
ur
in
g
pe
rf
or
m
an
ce
re
vi
ew
s,
nu
rs
e
le
ad
er
s
en
su
re
th
at
nu
rs
es
m
ee
t
th
e
re
qu
ir
em
en
ts
fo
r
co
lle
gi
al
ity
an
d
co
m
pl
y
w
ith
et
hi
ca
l
gu
id
el
in
es
ac
co
rd
in
g
to
nu
rs
in
g
va
lu
es
an
d
pr
in
ci
pl
es
.
5/
8
Po
ik
ke
us
et
al
.,
20
18
,F
in
la
nd
T
o
id
en
tif
y
th
e
le
ve
lo
f
nu
rs
es
’
an
d
nu
rs
e
le
ad
er
s’
et
hi
ca
lc
om
pe
te
nc
e
an
d
an
al
ys
e
nu
rs
es
’
an
d
nu
rs
e
le
ad
er
s’
pe
rc
ep
tio
ns
of
su
pp
or
tf
or
nu
rs
es
’e
th
ic
al
co
m
pe
te
nc
e
at
th
e
or
ga
ni
sa
tio
na
la
nd
in
di
vi
du
al
le
ve
ls
an
d
to
ex
am
in
e
as
so
ci
at
io
ns
be
tw
ee
n
ba
ck
gr
ou
nd
fa
ct
or
s
an
d
su
pp
or
t.
A
de
sc
ri
pt
iv
e,
cr
os
s-
se
ct
io
na
ls
ur
ve
y
N
ur
se
s
(n
=
29
8)
M
ea
su
re
m
en
t
Et
hi
ca
lc
om
pe
te
nc
e
w
as
es
tim
at
ed
at
an
av
er
ag
e
le
ve
la
m
on
g
nu
rs
es
an
d
at
hi
gh
le
ve
l
am
on
g
nu
rs
e
le
ad
er
s
an
d
hi
gh
es
t
in
et
hi
ca
l
ac
tio
n
an
d
et
hi
ca
lr
efl
ec
tio
n.
H
ig
h
pe
rf
or
m
an
ce
in
ac
tin
g
ac
co
rd
in
g
to
la
w
s
an
d
re
gu
la
tio
ns
,t
he
ir
or
ga
ni
sa
tio
n’
s
ow
n
va
lu
es
an
d
pr
in
ci
pl
es
,p
ro
fe
ss
io
na
lv
al
ue
s
as
w
el
la
s
pa
tie
nt
s’
va
lu
es
.T
he
et
hi
ca
ld
ec
is
io
n-
m
ak
in
g
w
as
es
tim
at
ed
to
be
av
er
ag
e
am
on
g
nu
rs
es
,
ho
w
ev
er
,9
0%
es
tim
at
ed
th
ei
r
ab
ili
ty
to
re
co
gn
is
e
et
hi
ca
lp
ro
bl
em
s
an
d
et
hi
ca
l
co
nfl
ic
ts
be
tw
ee
n
di
ffe
re
nt
va
lu
es
on
a
hi
gh
le
ve
l.
8/
8
N
ur
se
le
ad
er
s
(n
=
19
3)
Po
ik
ke
us
et
al
.,
20
20
,F
in
la
nd
T
o
ex
am
in
e
re
la
tio
ns
hi
ps
be
tw
ee
n
nu
rs
es
’
pe
rc
ei
ve
d
or
ga
ni
za
tio
na
la
nd
in
di
vi
du
al
su
pp
or
t,
et
hi
ca
lc
om
pe
te
nc
e,
et
hi
ca
l
sa
fe
ty
,a
nd
w
or
k
sa
tis
fa
ct
io
n.
A
cr
os
s-
se
ct
io
na
l
qu
es
tio
nn
ai
re
su
rv
ey
N
ur
se
s
(n
=
29
8)
Su
pp
or
t
Su
pp
or
t
ge
ne
ra
lly
lo
w
(4
4.
5%
an
d
38
.3
%
,
re
sp
ec
tiv
el
y)
.M
od
er
at
e
su
pp
or
t:
en
co
ur
ag
em
en
t
of
et
hi
ca
la
ct
iv
ity
an
d
su
pp
or
t
fo
r
co
m
pl
ia
nc
e
w
ith
la
w
s
an
d
re
gu
la
tio
ns
(6
2%
an
d
57
%
,r
es
pe
ct
iv
el
y)
.
N
ur
se
s’
ov
er
al
lp
er
ce
pt
io
n
of
th
ei
r
et
hi
ca
l
co
m
pe
te
nc
e
w
as
m
od
er
at
e
(6
8.
8%
).
8/
8
(c
on
tin
ue
d)
10 Nursing Ethics 0(0)
T
ab
le
2.
(c
on
tin
ue
d)
A
ut
ho
rs
,y
ea
r,
co
un
tr
y
A
im
St
ud
y
de
si
gn
/m
et
ho
ds
Se
tt
in
g/
sa
m
pl
e
M
or
al
co
m
pe
te
nc
e
co
nt
ri
bu
tin
g
fa
ct
or
s
R
ep
or
te
d
ou
tc
om
es
Q
ua
lit
y
ap
pr
ai
sa
l
po
in
ts
a
va
n
Sc
ha
ik
et
al
.,
20
21
,T
he
N
et
he
rl
an
ds
T
o
ev
al
ua
te
th
e
fe
as
ib
ili
ty
an
d
fi
rs
tp
er
ce
iv
ed
ou
tc
om
es
of
a
ne
w
ly
de
ve
lo
pe
d
cl
in
ic
al
et
hi
cs
su
pp
or
t
in
st
ru
m
en
t
ca
lle
d
C
U
R
A
.
A
de
sc
ri
pt
iv
e
cr
os
s-
se
ct
io
na
le
va
lu
at
io
n
st
ud
y
N
ur
se
s
an
d
ce
rt
ifi
ed
nu
rs
e
as
si
st
an
ts
(n
=
97
)
Su
pp
or
t
T
he
fo
ur
st
ep
so
fC
U
R
A
in
ts
ru
m
en
ta
re
cl
ea
rl
y
de
sc
ri
be
d
an
d
ea
sy
to
ap
pl
y.
T
he
pe
rc
ei
ve
d
ou
tc
om
es
sh
ow
ed
th
at
C
U
R
A
he
lp
ed
re
sp
on
de
nt
s
to
re
fl
ec
t
on
m
or
al
ch
al
le
ng
es
(7
1%
st
ro
ng
ly
ag
re
ed
),
in
pe
rs
pe
ct
iv
e
ta
ki
ng
(6
7%
),
w
ith
be
in
g
aw
ar
e
of
m
or
al
ch
al
le
ng
es
(6
3%
)
an
d
in
de
al
in
g
w
ith
m
or
al
di
st
re
ss
(5
4%
).
O
rg
an
is
at
io
na
lb
ar
ri
er
s:
re
sp
on
de
nt
s
co
ul
d
ea
si
ly
fi
nd
tim
e
fo
r
us
in
g
C
U
R
A
(5
0%
st
ro
ng
ly
ag
re
ed
).
6/
8
C
ol
le
ag
ue
s
of
co
ur
se
pa
rt
ic
ip
an
ts
(n
=
12
4)
V
yn
ck
ie
r
et
al
.,
20
15
,B
el
gi
um
T
o
de
ve
lo
p
a
va
lid
an
d
re
lia
bl
e
in
st
ru
m
en
t,
na
m
ed
th
e
‘S
tu
de
nt
s’
Pe
rc
ei
ve
d
Ef
fe
ct
iv
en
es
s
of
Et
hi
cs
Ed
uc
at
io
n
Sc
al
e’
(S
PE
EE
S)
.
A
qu
an
tit
at
iv
e
de
sc
ri
pt
iv
e
no
n-
ex
pe
ri
m
en
ta
lp
ilo
t
st
ud
y
3-
ye
ar
nu
rs
in
g
st
ud
en
ts
(n
=
86
)
Ed
uc
at
io
na
li
nt
er
ve
nt
io
n
T
he
co
nt
en
t
va
lid
ity
in
de
x/
A
ve
sc
or
es
fo
r
th
e
su
bs
ca
le
s
w
er
e
1.
00
,1
.0
0
an
d
0.
86
.T
he
co
m
pr
eh
en
si
bi
lit
y
an
d
us
er
fr
ie
nd
lin
es
s
w
er
e
fa
vo
ur
ab
le
.C
ro
nb
ac
h’
s
α
w
as
0.
94
fo
r
ge
ne
ra
le
ffe
ct
iv
en
es
s,
0.
89
fo
r
te
ac
hi
ng
m
et
ho
ds
an
d
0.
85
fo
r
et
hi
ca
lc
on
te
nt
.
St
ud
en
ts
pe
rc
ei
ve
d
ca
se
st
ud
y,
le
ct
ur
e
an
d
in
st
ru
ct
io
na
ld
ia
lo
gu
e
to
be
ef
fe
ct
iv
e
te
ac
hi
ng
m
et
ho
ds
an
d
ge
ne
ra
le
th
ic
al
co
nc
ep
ts
to
co
nt
ai
n
ef
fe
ct
iv
e
co
nt
en
t.
R
efl
ec
tin
g
cr
iti
ca
lly
on
th
ei
r
ow
n
va
lu
es
w
as
m
en
tio
ne
d
as
th
e
on
ly
et
hi
ca
lc
om
pe
te
nc
e
th
at
w
as
pr
om
ot
ed
by
th
e
et
hi
cs
co
ur
se
s.
6/
8
Y
ild
iz
&
G
üd
üc
ü
T
üf
ek
ci
,2
01
7,
T
ur
ke
y
T
o
ad
ap
t
an
d
ev
al
ua
te
th
e
ps
yc
ho
m
et
ri
c
pr
op
er
tie
s
of
th
e
m
or
al
co
m
pe
te
nc
e
qu
es
tio
nn
ai
re
fo
r
pu
bl
ic
he
al
th
nu
rs
es
in
T
ur
ke
y.
A
m
et
ho
do
lo
gi
ca
ls
tu
dy
Pu
bl
ic
H
ea
lth
N
ur
se
s
(n
=
13
8)
M
ea
su
re
m
en
t
T
hr
ee
fa
ct
or
s
w
er
e
ex
tr
ac
te
d,
w
hi
ch
to
ge
th
er
ex
pl
ai
ne
d
a
to
ta
lo
f6
7.
50
%
of
th
e
va
ri
an
ce
.
T
he
C
ro
nb
ac
h’
s
α
va
lu
es
w
er
e
.8
3,
.9
1,
.8
7,
an
d
.8
8
fo
r
fa
ct
or
s
1,
2,
an
d
3
an
d
fo
r
th
e
w
ho
le
sc
al
e,
re
sp
ec
tiv
el
y.
Fa
ct
or
s:
(1
)
St
ro
ng
w
ill
to
fa
ce
di
ffi
cu
lt
si
tu
at
io
ns
,(
2)
C
o-
op
er
at
in
g
w
ith
re
le
va
nt
pe
op
le
/
or
ga
ni
za
tio
ns
,(
3)
Im
pl
em
en
tin
g
th
e
m
or
al
de
ci
si
on
.
4/
8
(c
on
tin
ue
d)
Wiisak et al. 11
T
ab
le
2.
(c
on
tin
ue
d)
A
ut
ho
rs
,y
ea
r,
co
un
tr
y
A
im
St
ud
y
de
si
gn
/m
et
ho
ds
Se
tt
in
g/
sa
m
pl
e
M
or
al
co
m
pe
te
nc
e
co
nt
ri
bu
tin
g
fa
ct
or
s
R
ep
or
te
d
ou
tc
om
es
Q
ua
lit
y
ap
pr
ai
sa
l
po
in
ts
a
M
ix
ed
-m
et
ho
d
st
ud
ie
s
M
ix
ed
-m
et
ho
d
(s
ev
en
ite
m
s)
C
om
m
en
ts
K
im
et
al
.,
20
20
,
So
ut
h
K
or
ea
T
o
de
ve
lo
p
an
d
ev
al
ua
te
a
cl
in
ic
al
et
hi
cs
ed
uc
at
io
n
pr
og
ra
m
fo
r
nu
rs
es
to
im
pr
ov
e
th
ei
r
et
hi
ca
lc
on
fi
de
nc
e,
et
hi
ca
l
co
m
pe
te
nc
e,
an
d
m
or
al
se
ns
iti
vi
ty
.
A
m
ix
ed
-m
et
ho
ds
st
ud
y
R
eg
is
te
re
d
nu
rs
es
(n
=
14
)
Ed
uc
at
io
na
li
nt
er
ve
nt
io
n
of
an
et
hi
cs
pr
og
ra
m
.
T
he
se
ve
n-
se
ss
io
n
et
hi
cs
pr
og
ra
m
im
pr
ov
ed
et
hi
ca
lc
on
fi
de
nc
e,
et
hi
ca
lc
om
pe
te
nc
e,
an
d
m
or
al
se
ns
iti
vi
ty
in
nu
rs
es
.T
he
C
lin
ic
al
Et
hi
cs
Ed
uc
at
io
n
Pr
og
ra
m
in
cl
ud
ed
(1
)
sh
ar
in
g
in
di
vi
du
al
et
hi
ca
li
ss
ue
s
in
cl
in
ic
al
se
tt
in
gs
;(
2)
un
de
rs
ta
nd
in
g
a
pr
oc
es
s
in
vo
lv
ed
in
et
hi
ca
ld
ec
is
io
n-
m
ak
in
g;
(3
)
id
en
tif
yi
ng
et
hi
ca
li
ss
ue
s
in
en
d
of
-li
fe
ca
re
;
(4
)
id
en
tif
yi
ng
et
hi
ca
li
ss
ue
s
in
fa
m
ily
ca
re
gi
vi
ng
;(
5)
le
ar
ni
ng
co
m
m
un
ic
at
io
n
sk
ill
s;
(6
)d
ev
el
op
in
g
et
hi
ca
ll
ea
de
rs
hi
p
sk
ill
s;
(7
)
re
fl
ec
tin
g
to
bu
ild
se
lf-
aw
ar
en
es
s
of
th
e
si
gn
ifi
ca
nc
e
of
pr
ac
tic
in
g
cl
in
ic
al
et
hi
cs
.
2/
7
Fo
cu
s
gr
ou
p
an
d
qu
es
tio
nn
ai
re
O
nl
y
pu
rp
os
e
of
th
e
st
ud
y
w
as
de
sc
ri
be
d,
no
t
th
e
re
se
ar
ch
qu
es
tio
ns
M
et
ho
ds
in
cl
ud
ed
(a
)
se
lf-
re
fl
ec
tio
n;
(b
)
le
ct
ur
e;
(c
)d
is
cu
ss
io
n;
(d
)fi
lm
;e
)v
id
eo
cl
ip
;
(f)
ro
le
pl
ay
;(
g)
pr
es
en
ta
tio
n
Q
ua
si
-e
xp
er
im
en
ta
l
st
ud
ie
s
Q
ua
si
-e
xp
er
im
en
ta
l
(n
in
e
ite
m
s)
C
ha
o
et
al
.,
20
17
,
T
ai
w
an
T
o
de
ve
lo
p
an
d
im
pl
em
en
t
an
in
te
ra
ct
iv
e
si
tu
at
io
na
le
-le
ar
ni
ng
sy
st
em
,i
nt
eg
ra
tin
g
nu
rs
in
g
et
hi
ca
ld
ec
is
io
ns
in
to
a
nu
rs
in
g
et
hi
cs
co
ur
se
,a
nd
to
ev
al
ua
te
th
e
ef
fe
ct
s
of
th
is
co
ur
se
on
st
ud
en
t
nu
rs
es
’
et
hi
ca
l
de
ci
si
on
-m
ak
in
g
co
m
pe
te
nc
e.
A
qu
as
i-e
xp
er
im
en
ta
ls
tu
dy
,
qu
es
tio
nn
ai
re
2-
ye
ar
nu
rs
in
g
st
ud
en
ts
(n
=
10
0)
Ed
uc
at
io
na
li
nt
er
ve
nt
io
n
of
a
co
m
bi
na
tio
n
of
tr
ad
iti
on
al
fa
ce
to
fa
ce
te
ac
hi
ng
w
ith
an
in
te
ra
ct
iv
e
m
ul
tim
ed
ia
on
lin
e
sy
st
em
.
Ex
pe
ri
m
en
ta
lg
ro
up
:s
ig
ni
fi
ca
nt
im
pr
ov
em
en
t
in
nu
rs
in
g
et
hi
ca
ld
ec
is
io
n-
m
ak
in
g
co
m
pe
te
nc
e,
in
cl
ud
in
g
sk
ill
s
in
ra
is
in
g
qu
es
tio
ns
,r
ec
og
ni
zi
ng
di
ffe
re
nc
es
,
co
m
pa
ri
ng
di
ffe
re
nc
es
,s
el
f-d
ia
lo
gu
e,
ta
ki
ng
ac
tio
n,
an
d
id
en
tif
yi
ng
th
e
im
pl
ic
at
io
ns
of
de
ci
si
on
s
m
ad
e,
co
m
pa
re
d
to
th
ei
r
pe
rf
or
m
an
ce
pr
io
r
to
th
e
cl
as
s.
St
ud
en
ts
in
th
e
ex
pe
ri
m
en
ta
lg
ro
up
sh
ow
ed
su
pe
ri
or
ity
to
th
os
e
in
th
e
co
nt
ro
lg
ro
up
in
th
e
co
m
pe
te
nc
y
of
re
co
gn
iz
in
g
di
ffe
re
nc
es
.T
he
ex
pe
ri
m
en
ta
lc
ou
rs
e
pu
sh
ed
st
ud
en
ts
to
se
ar
ch
fo
ra
nd
co
lle
ct
in
fo
rm
at
io
n
ne
ed
ed
to
re
so
lv
e
th
e
et
hi
ca
ld
ile
m
m
a.
7/
9
Ex
pe
ri
m
en
ta
lg
ro
up
(n
=
51
)
C
on
tr
ol
gr
ou
p
(n
=
49
)
(c
on
tin
ue
d)
12 Nursing Ethics 0(0)
T
ab
le
2.
(c
on
tin
ue
d)
A
ut
ho
rs
,y
ea
r,
co
un
tr
y
A
im
St
ud
y
de
si
gn
/m
et
ho
ds
Se
tt
in
g/
sa
m
pl
e
M
or
al
co
m
pe
te
nc
e
co
nt
ri
bu
tin
g
fa
ct
or
s
R
ep
or
te
d
ou
tc
om
es
Q
ua
lit
y
ap
pr
ai
sa
l
po
in
ts
a
K
a¨l
ve
m
ar
k
Sp
or
ro
ng
et
al
.,
20
07
,S
w
ed
en
T
o
ev
al
ua
te
th
e
im
pa
ct
on
pe
rc
ei
ve
d
m
or
al
di
st
re
ss
of
an
ed
uc
at
io
n
an
d
tr
ai
ni
ng
pr
og
ra
m
in
et
hi
cs
.
A
co
nt
ro
lle
d
pr
os
pe
ct
iv
e
st
ud
y,
qu
es
tio
nn
ai
re
In
te
rv
en
tio
n
de
pa
rt
m
en
t:
Ed
uc
at
io
na
li
nt
er
ve
nt
io
n
of
th
re
e
th
re
e-
ho
ur
et
hi
cs
le
ct
ur
es
an
d
th
re
e
on
e-
ho
ur
et
hi
cs
ro
un
ds
.
T
he
Q
ua
lit
y
W
or
k
C
om
pe
te
nc
e
(Q
W
C
)
8/
9
N
ur
se
s
(n
=
47
)
Pa
rt
ic
ip
an
ts
w
er
e
po
si
tiv
e
ab
ou
t
th
e
tr
ai
ni
ng
pr
og
ra
m
.M
or
al
di
st
re
ss
di
d
no
t
ch
an
ge
si
gn
ifi
ca
nt
ly
.L
ec
tu
re
s
co
ve
re
d
th
eo
ri
es
of
et
hi
cs
as
a
to
ol
in
et
hi
ca
ld
ec
is
io
n-
m
ak
in
g,
th
eo
ri
es
of
hu
m
an
di
gn
ity
,a
nd
as
pe
ct
s
of
m
ed
ic
al
et
hi
cs
su
ch
as
pr
io
ri
tiz
at
io
n
in
he
al
th
ca
re
pr
ac
tic
e.
T
he
et
hi
cs
ro
un
ds
ba
se
d
on
et
hi
ca
ls
itu
at
io
ns
in
re
al
-li
fe
w
or
kp
la
ce
.S
om
e
of
th
e
pa
rt
ic
ip
an
ts
pr
ep
ar
ed
an
au
th
en
tic
ca
se
be
fo
re
ea
ch
ro
un
d
to
be
di
sc
us
se
d
an
d
w
er
e
m
od
er
at
ed
by
th
e
ed
uc
at
or
s
O
th
er
(n
=
10
)
C
on
tr
ol
de
pa
rt
m
en
t:
N
ur
se
s
(n
=
10
1)
O
th
er
(n
=
41
)
M
ar
tin
s
et
al
.,
20
21
,P
or
tu
ga
l
T
o
de
te
rm
in
e
th
e
in
fl
ue
nc
e
of
th
e
bi
oe
th
ic
s
te
ac
hi
ng
on
th
e
m
or
al
co
m
pe
te
nc
e
of
m
ed
ic
al
an
d
nu
rs
in
g
st
ud
en
ts
.
A
lo
ng
itu
di
na
l,
de
sc
ri
pt
iv
e
st
ud
y
N
ur
si
ng
st
ud
en
ts
(n
=
26
3)
Ed
uc
at
io
na
li
nt
er
ve
nt
io
n
as
bi
oe
th
ic
s
co
ur
se
C
-s
co
re
w
as
lo
w
er
af
te
r
th
e
at
te
nd
an
ce
of
th
e
et
hi
cs
cu
rr
ic
ul
ar
un
its
,w
ith
a
st
at
is
tic
al
ly
si
gn
ifi
ca
nt
de
cr
ea
se
fo
r
nu
rs
in
g
st
ud
en
ts
an
d
no
t
st
at
is
tic
al
ly
si
gn
ifi
ca
nt
fo
r
m
ed
ic
al
st
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Wiisak et al. 13
three of which had control groups.25,49,52 Data were mainly collected with interviews26,30,31,33–36,41,45,48 or
questionnaires,25,27–29,37–40,42–44,46,47,49,52,53 one study used video filming,51 one used both questionnaire and
focus group interview,50 and one used individual interviews and field notes.32
The participants were mainly nurses29,32,34,37,38,41–43,50 or nursing students.30,35,40,44–47,49,51,52 In addition,
seven studies included a mix of healthcare professionals or students25,26,28,31,39,48,53 such as physicians or
medical students; however, the majority of the participants in those studies were nurses or nursing students.
Even though, in some studies the participants were nurse teachers36 or professors33 or nurse leaders,27 the
articles focused on qualified nurses’ or nursing students’ moral competence and how to support it. The
number of participants in qualitative studies ranged between 6 and 30, in quantitative studies between 83 and
3,493, and in quasi-experimental studies between 100 and 333 (Table 2). One mixed-method study included
14 participants.50
Third of the studies proposed that exploring stakeholder’s experiences,30–32,36,41,45 perceptions34,48,51 or
views26 on competence was meaningful in order to describe and make visible the meaning and existence of
competence. One study raised the promotion of moral competence on strategies and spaces as pedagogical
teaching solutions.33 In several studies,25,35,39,40,44,47,49,50,52 the contributing factors were different educa-
tional interventions including basic education and continuing education. In addition, the interventions in-
cluded ethics training programmes including ethics rounds, educational workshops, interactive e-learning
interventions, pedagogical experiments and simulations. Six studies focused on the evaluation of the moral
competence level of qualified nurses and nursing students.28,37,38,42,43,46 By operationalising moral com-
petence, awareness of the required level becomes apparent, contributing to the promotion of moral com-
petence. Finally, support from a third party, including superiors or organisational support structures such as
clinical ethics support, was identified in three studies.27,29,53
Factors contributing to the promotion of moral competence
Factors contributing to the promotion of qualified nurses’ and nursing students’ moral competence were
identified as comprising two main categories, human factors and structural factors, consisting of eight
categories and eighteen sub-categories. Human factors consist of four categories: individual, social, man-
agerial and professional factors, and ten sub-categories. Structural factors consist of four categories: edu-
cational, environmental, organisational and societal factors, and eight sub-categories. Human factors relate to
the individual oneself, others such as patients, colleagues, managers and teachers and the nursing profession,
whereas structural factors relate to the workplace (micro), organisation (meso) and society (macro) level
structures (Figure 2, Table 3).
Human factors. Individual factors contribute to the promotion of qualified nurses’moral competence through
the individuals themselves. This category comprises four sub-categories: personal profound experience,
character strength, self-reflection and learning strategies. Personal profound experience means individuals
having personal ethical experiences that they relate to practising as morally competent nurses.25,33,35
Character strength is about having a moral character with a desire and strong will to do good when
managing difficult situations while providing nursing care.26,30–32,37,42,43,45 Self-reflection is an individual’s
ability to reflect on the moral decision-making process and moral challenges and thinking while providing
nursing care. Furthermore, it includes individuals recognising and reflecting on their own performance,
ethical knowledge and personal values and exploring their own feelings.32–35,38,45,47,51,53 Learning strategies
are comprised of an active role and engagement of the individual nurse in active learning.38,46,49,51
Social factors contribute to the promotion of qualified nurses’ moral competence through interaction and
collaboration in workplace relationships. Two sub-categories were identified as mutual interaction and a
professional role model. Mutual interaction takes different forms including discussions, argumentation and
14 Nursing Ethics 0(0)
sharing experiences and knowledge. Furthermore, receiving support and feedback from educators and leaders
as well as peer support are forms of mutual interaction.25,29,31,33,37,42,43,47,51,52 An individual’s moral
competence develops by having a professional role model, such as manager, educator, peer or some other
colleague who acts as an ethical example and whose practice, behaviour and moral characteristics are being
observed and regarded as ethical.30,31,36,48
Two sub-categories of managerial factors were identified: role-related attributes and role-related ac-
tivities. For contribution of moral competence, the manager should be humble, exemplary, approachable and
flexible.31,48 In addition, they should possess knowledge on ethics and effective communication skills.
Furthermore, managers with moral competence should demonstrate certain role-related activities such as
Figure 2. Moral competence contributing factors: Main categories, categories and sub-categories.
Wiisak et al. 15
Table 3. Factors contributing to the promotion of moral competence.
Contributing factors References
Human factors
Individual factors
Personal profound
experience
Enderle et al. 2018,1 Ka¨lvemark Sporrong 2007,4 Oddvang et al. 20211
Character strength Asahara et al. 2014,2 Borhani et al. 2010,1 Go¨l & Arkan 2022, Hemberg & Hemberg 2020,1 Peter
et al. 2015,1 Ranjbar et al. 2018,1 Yildiz & Güdücü Tüfekci 2017,2 Zafarnia et al. 20171
Self-reflection Dı´az Agea et al. 2018,1 Enderle et al. 2018,1 Katayama et al. 2022,2 Obeid & Man 2020,2 Oddvang
et al. 2021,1 Peter et al. 2015,1 Schaefer & Junges 2014,1 van Schaik et al. 2021,2 Zafarnia et al.
20171
Learning strategies Buzˇgova´ & Sikorova´, 2013,2 Dı´az Agea et al. 2018,1 Katayama et al., 2022,2 Tropec & Starcic
20154
Social factors
A professional role
model
Borhani et al. 2010,1 Maluwa et al. 2021,1 Ranjbar et al. 2018,1 Solum et al. 20161
Mutual interaction Asahara et al. 2014,2 Chao et al. 2017,4 Dı´az Agea et al. 2018,1 Enderle et al. 2018,1 Go¨l & Arkan
2022,2 Ka¨lvemark Sporrong 2007,4 Obeid & Man 2020,2 Poikkeus et al. 2020,2 Ranjbar et al.
2018,1 Yildiz & Güdücü Tüfekci 20172
Managerial factors
Role-related activities Maluwa et al. 2021,1 Poikkeus et al. 2014,2 Poikkeus et al. 2018,2 Poikkeus et al. 20202
Role-related attributes Maluwa et al. 2021,1 Ranjbar et al. 20181
Professional factors
Being a nurse Borhani et al. 2010,1 Hemberg & Hemberg 2020,1 Katayama et al. 2022,2 Kim et al. 2013,3 .
Poikkeus et al. 2014,2 Ranjbar et al. 2018,1 Tropec & Starcic 2015,4 van Schaik et al. 20212
Professional ethics Poikkeus et al. 2020,2 Ranjbar et al. 20181
Structural factors
Educational factors
Teaching methods Borhani et al. 2010,1 Chao et al. 2017,4 Dı´az Agea et al. 2018,1 Enderle et al. 2018,1 Kim et al.
2013,3 Ka¨lvemark Sporrong 2007,4 Martins et al. 2021,4 Martins et al. 2020,4 Obeid & Man
2020,2 Oddvang et al. 2021,1 Schaefer & Junges 2014,1 Solum et al. 20161 Tropec & Starcic
2015,4 van Schaik et al. 2021,2 Vynckier et al. 2015,2 Zafarnia et al. 20171
Content of teaching Chao et al. 2017,4 Dı´az Agea et al. 2018,1 Enderle et al. 2018,1 Kim et al. 2013,3 Ka¨lvemark
Sporrong 2007,4 Martins et al. 2021,4 Martins et al. 2020,4 Obeid & Man 2020,2 Oddvang et al.
2021,1 Tropec & Starcic 2015,4 van Schaik et al. 2021,2 Vynckier et al. 20152
Environmental factors
Safe environment Borhani et al. 2010,1 Dı´az Agea et al. 2018,1 Solum et al. 20161
Supportive environment Borhani et al. 2010,1 Ho¨glund et al. 2010,1 Poikkeus et al. 2018,2 Poikkeus et al. 20202
Organisational factors
Resources of the
organisation
Maluwa et al. 2021,1 Poikkeus et al. 2018,2 Solum et al. 20161
Ethics management
strategies
Poikkeus et al. 2018,2 Poikkeus et al. 20202
Societal factors
Values in society Asahara et al. 2014,2 Go¨l & Arkan 2022,2 Yildiz & Güdücü Tüfekci 20172
Norms of society Poikkeus et al. 2018,2 Poikkeus et al. 20202
Study design.
Qualitative study.1
Quantitative study.2
Mixed-method study.3
Quasi-experimental study.4
16 Nursing Ethics 0(0)
providing feedback, rewarding ethical behaviour, supporting and encouraging ethical practice as well as
arranging regular meetings to discuss ethical issues and performance and recruitment appraisals.27–29,31
Two sub-categories of professional factors were also identified as human factors: professional ethics and
being a nurse. Professional ethics refers to the values and principles of the profession and nurses’ capacity to
acknowledge, reason, commit and comply with them. Professional ethics pave the way for what it is to be a
nurse.29,31 Being a nurse is understanding and using the ethical decision-making process from identifying and
solving ethical problems to making decisions autonomously. It is about knowing one’s own responsibilities
and collegiality as a nurse and aiming at better care for patients. In addition, being a nurse means expressing
sensitivity and ability to deal with moral distress.26,27,30,31,38,49,50,53
Structural factors. Educational factors conducted by educational specialists contribute to the promotion of
qualified nurses’ and nursing students’moral competence through teaching methods and content of teaching,
which were identified as two sub-categories. Traditional face-to-face teaching in a classroom as well as an
interactive teaching using e-platforms as well as creative, problem-based and simulation-based teaching were
methods of moral competence promotion.25,30,32–36,39,40,44,47,49–53 The foundation of teaching content are ethics
theories, general ethical concepts as well as ethical principles and values. In addition, understanding the ethical
decision-making process, from the identification of ethical issues and problems –whether hypothetical scenarios
or realistic events – through ethical reasoning and reflection to ethical judgement and ethical practice, contributes
to the promotion of qualified nurses’ and nursing students’ moral competence.25,33,35,39,40,44,47,49–53
Two sub-categories of environmental factors were identified: safe environment and supportive envi-
ronment. A safe environment enables open reflection on ethical issues and values without the threat of
negative responses.30,36,51 Furthermore, a supportive environment facilitating learning conditions and
providing organisational structures encourages students and nurses to participate in ethical discussions and
engage in ethical activity.28–30,41
Two sub-categories of organisational factors were also identified: resources of the organisation and
ethics management strategies. Resources of the organisation comprise the availability of resources such as
rules, guidelines and protocols. In addition, nurses from larger organisations reported having more ethical
concerns/issues than those in smaller organisations where nurses felt more supported when addressing ethical
issues.28,36,48 Ethics management strategies in the organisation are identified as the provision of information
on ethical issues and enabling and arranging multidisciplinary discussions of ethical issues.28,29
Societal factors contribute to the promotion of qualified nurses’ moral competence by values in society
and norms of society, which were the two sub-categories identified. Morally competent nurses should base
their ethical judgement on the values of the community and comply with laws and regulations in their ethical
decision-making. In addition, nurses considered that when the law and regulations were clarified, they had
high competence in ethical decision-making.28,29,37,42,43
Discussion
This review provides knowledge about the factors contributing to the promotion of qualified nurses’ and
nursing students’ moral competence. This knowledge is useful for the development of ethics education
interventions and everyday clinical practice. The results indicate that the moral competence can be promoted
by various factors at all levels, from the level of an individual nurse or nursing student (micro) to society
(macro) level. Given the importance of ethics in healthcare and the required moral competence of pro-
fessionals,4 only a limited number of studies about factors contributing to the promotion of moral competence
was discovered. However, the number of studies has been increasing during the past decade. Consistent with
previous considerations,3 this indicates a growing interest in exploring nurses’ and nursing students’ moral
competence. This can be explained by the increased requirement to prioritise scarce resources6 and address
Wiisak et al. 17
ethical issues4 and the need to alleviate the increased moral distress54 to which moral competence is a
potential response.
The nature of the integrative method and the international character of the review allowed combining evidence
producedwith different study designs, identifying a broad perspective of the factors contributing to the promotion of
moral competence. The studies, both qualitative and quantitative were mainly descriptive and based on nurses’ or
nursing students’ experiences or their self-assessed level of moral competence, thus providing an insight into the
contributing factors. In addition, some educational interventions were identified. However, in order to gain a deeper
understanding and to see whether these factors are effective in contributing to the promotion of moral competence,
more research is needed using intervention studies,18 implementation research and multiple methods designs.
Human and structural factors contributing to the promotion of moral competence were identified (Figure 2).
Human factors were identified in relation to the individual oneself, others such as patients, colleagues, managers
and teachers and the nursing profession, whereas structural factors were related to the workplace (micro), or-
ganisation (meso) and society (macro) level structures. Human factors that contribute to the promotion of moral
competence relate mainly to informal practices and processes. This is supported by the literature stating that
informal practices refer to socialisation processes, human encounters, interaction and professional autonomy.55 In
addition, the findings indicate that structural factors create formal and structured practices, policies, strategies and
programmes and enable informal opportunities for the systematic promotion of moral competence.56
The findings of human factors indicate that it is possible for individuals to promote their moral competence
if they are empowered to practice as nurses and use their experiences in a positive way. In addition, it is
expected that those who have chosen nursing as a career possess certain characteristics and are usually willing
to help and do good to other people.57 In relation to other people, moral competence does not exist in a
vacuum. Hence, the findings suggest that it is important for both nurses and nursing students to have ethical
role models, colleagues and managers with whom to reflect critically on ethical issues14,58 in order to provide
ethically high-quality care. In addition, it is stated that managers have a key role in promoting nurses’ moral
competence by providing support and encouragement,59 which was also identified in this review.
The findings on structural factors indicate that attention must be paid to the content of teaching and the
diversity of teaching methods when designing education and curricula.12 In addition, according to the
findings, it is suggested that healthcare services need to build resilient organisations to support ethics
management and enhance ethically sustainable nursing practices. Moral competence should also be given
thorough consideration when making health policy decisions on a societal level. These may remove the
impediments to nurses’ integrity and build psychological safety and a moral community where moral
competence is effectively promoted.4 In addition, considering moral competence and the multiple levels of
contributing factors,10 a complex intervention engaging stakeholders from the micro (patients, nurses, nursing
students, managers and teachers) to the macro (policymakers) level is needed to effectively promote the moral
competence of nurses and nursing students. Therefore, it is necessary to discuss whether the moral com-
petence of individuals will broaden into ethical competence of the profession and the organisation. It is not
enough to have morally competent individuals; highlighting professional ethics and supporting collective
ethical competence as well as advancing value-based healthcare and care provision for patients is also needed.
Limitations and strengths of the review
There are some limitations and strengths in this review. As a limitation, the literature search was performed by
one researcher; however, the review protocol was registered in PROSPERO and followed throughout the
process. The search strategy was developed among the research team and the search terms in collaboration
with library informatics expert. In addition, preliminary searches were conducted by another person within the
research team. Furthermore, reference lists of the included articles and relevant reviews were screened to
identify all the relevant literature; however, it did not produce any new results.
18 Nursing Ethics 0(0)
A further limitation is that only studies written in English were included, introducing a potential selection
bias. It should be noted that these studies originated from various countries, ensuring a multicultural per-
spective. Moreover, in order to ensure inclusiveness, no studies were excluded due to poor quality; as
strengths any discrepancies were resolved among three researchers and according to the literature, excluding
studies on the basis of poor quality is not recommended.23
As the final limitations, studies regarding the moral competence of mixed professionals were not excluded
given that the majority of the participants were qualified nurses or nursing students. Furthermore, the data
analysis process was performed by researchers frommultiple countries, which may have introduced bias since
only EU countries were included; however, no pre-defined frameworks were used, and the international
perspective, as well as the inductive approach, may have prevented interpretation bias.
Conclusion
Moral competence is a phenomenon that is essential to ensure ethically high-quality and sustainable healthcare.
Research about the factors contributing to the promotion of qualified nurses’ and nursing students’ moral
competence is limited but seems to be increasing. Human and structural factors were identified as the two main
categories contributing to the promotion of moral competence from micro to macro levels. This review provides
knowledge for researchers to develop interventions such as ethics education programs and to conduct im-
plementation research. For nurse educators, this review provides knowledge to plan and develop ethics ed-
ucation, nursing education and nursing curricula. Moreover, this review provides knowledge for managers and
organisations to create ethics structures that support and promote individuals’ moral competence, and for
policymakers to enable the creation of such structures. It is important for both practice and education to pay
attention to individuals’ ethical conduct by supporting and encouraging their moral competence and moral
development from the beginning of basic nursing education throughout nursing careers and life-long learning.
To gain a deeper understanding and to see whether the identified factors are effective in contributing to the
promotion of moral competence, more research is needed using complex intervention, implementation and
multiple methods designs, which would ensure ethically high-quality and sustainable healthcare.
Author’s note
On behalf of the PROMOCON consortium: Stefania Chiappinotto, University of Udine, Department of Medicine; Maria
Dimitriadou, (1) Cyprus University of Technology, School of Health Sciences, Department of Nursing, (2) Cyprus Nurses and
Midwifes Association; Georgios Efstathiou, Melina Evripidou & Paraskevi Charitou, Cyprus Nurses and Midwives Asso-
ciation; Alessandro Galazzi, University of Udine, Department of Medicine; Chris Gastmans, Department of Public Health and
Primary Care, Centre for Biomedical Ethics and Law;Michael Igoumenidis, University of Patras, Department of Nursing; Brian
Keogh, Trinity College Dublin, School of Nursing & Midwifery; Jessica Longhini, 1 University of Verona, Department of
Diagnostics and Public Health, 2 University of Udine, Department of Medicine; Catherine Mc Cabe, Trinity College Dublin,
School of Nursing & Midwifery; Evelyne Mertens, KU Leuven, Department of Public Health and Primary Care, Centre for
Biomedical Ethics and Law; Alvisa Palese, University of Udine, Department of Medicine; Evridiki Papastavrou, (1) Cyprus
University of Technology, School of Health Sciences, Department of Nursing, (2) Cyprus Nurses and Midwifes Association;
Nikos Stefanopoulos University of Patras, Department of Nursing; Minna Stolt, (1) Department of Nursing Science, University
of Turku, and (2) Wellbeing Services County of Satakunta; Riitta Suhonen, (1) Department of Nursing Science, University of
Turku, 2) TurkuUniversity Hospital,Wellbeing Services County of Southwest Finland; JohannaWiisak, Department ofNursing
Science, University of Turku; Maria Zafiropoulou, Non-Governmental Organization ‘Co2gether’.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Wiisak et al. 19
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this
article: This work was Co-funded by the Erasmus + programme of the European Union (agreement nr. 2022-1-IT02-
KA220-HED-000087544). The European Commission’s support for the production of this publication does not constitute
an endorsement of the contents, which reflect the views only of the authors, and the Commission cannot be held re-
sponsible for any use which may be made of the information contained therein.
ORCID iDs
Johanna Wiisak  https://orcid.org/0000-0002-4348-2412
Minna Stolt  https://orcid.org/0000-0002-1845-9800
Michael Igoumenidis  https://orcid.org/0000-0002-9458-3424
Stefania Chiappinotto  https://orcid.org/0000-0003-4829-1831
Brian Keogh  https://orcid.org/0000-0001-6349-486X
Evelyne Mertens  https://orcid.org/0000-0001-8154-3346
Alvisa Palese  https://orcid.org/0000-0002-3508-844X
Riitta Suhonen  https://orcid.org/0000-0002-4315-5550
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