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Abstract

Background

Ethical competence in nursing is essential. However, a theoretical definition of ethical competence in nursing and the critical components of ethical competence appear to be absent, resulting in a lack of convergence on the core content to be taught on ethical competence in nursing education.

Aim and research questions

This study aimed to answer the following questions: What are the essential components of ethical competence in nursing? What is their definition in terms of nursing? What is the theoretical definition of ethical competence in nursing?

Method

Walker and Avant’s concept synthesis.

Results

Ethical competence in nursing consists of 12 essential components, defined and grouped into three main themes: (1) Ethical knowledge and understanding; having knowledge and understanding of the main theories of theoretical and practical ethics and the principal codes of ethics in nursing; (2) Personal ethical qualities; having ethical awareness and ethical self-awareness, ethical sensitivity, ethical perception, and ethical judgement. (3) Ethical ability and courage to perform; capable of moral reasoning, ethical reflection, and ethical decision-making, having moral courage and demonstrating ethical action and behaviour. The theoretical definition is thus: Nurses considered ethically competent have knowledge and understanding of the main ethical principles in nursing and possess personal ethical qualities, that is, ethical self-awareness, ethical awareness, ethical sensitivity, ethical perception, and ethical judgment as well as having the ethical ability and the courage to perform ethically, that is, capable of moral reasoning, ethical reflection, ethical decision-making, having moral courage, they demonstrate ethical action, and ethically responsible conduct.

Conclusions

This study is essential to nursing as a discipline and profession. The findings provide a theoretical definition of ethical competence in nursing and the qualities characterising ethically competent nurses, which can be of great value in clinical practice, nursing education, leadership, and nursing research and theory development.

Keywords

ethics of care philosophical perspectives codes of ethics dignity in care ethical climate ethics education

Introduction

Ethical competence consists of several components. The three key components are knowing how to be (fr. savoir être), knowing (fr. savoir), and being able (fr. savoir faire).^1,2 Ethical competence is critical to providing good nursing care,³ but a theoretical definition of ethical competence has yet to be found within general healthcare or nursing.

Theoretical definitions deepen our understanding of fundamental concepts. These definitions are called ‘theoretical’ because they aim to develop a ‘theory’ about the nature of the concept in question. Using our current knowledge about a specific concept, we define it based on the best insights available.⁴ Professional fields develop frameworks of commonly accepted theoretical definitions to understand these fundamental concepts better.⁵

This study aims to develop a theoretical definition of ethical competence within nursing, which could be of value in helping nurses reflect on and improve their practice,⁶ for research and theory development and when teaching ethics to nursing students. To present an introduction to the theoretical definition of ethical competence in nursing, we will begin by discussing what ethical competence means within the health sector and then, more importantly, what it means within nursing. We will end the introduction with research on various aspects of ethical competence in nursing, the study’s purpose, and the research questions.

Ethical competence in the health sector

In every discipline, knowledge is required, and the ability to apply that knowledge is assumed.⁷ Academic disciplines must set standards for the minimum professional skills required of professionals in the relevant profession so that students have the knowledge, skills, and abilities they need to possess when graduating.⁸ Professional skills include, among other things, cognitive skills, such as knowledge and understanding and the ability to use them in practice; functional skills and technical expertise to be able to carry out specific tasks; and ethical skills, which refer to certain personal and professional values of professionals.⁸ Professional competence thus involves not only knowing (fr. savoir) or knowing how to do something (fr. savoir faire) but also knowing how to be (fr. savoir être), which refers to the values, attitudes, and intrinsic motivation of the individual.

Ethical competence has long been considered a central aspect of all healthcare services¹; however, it has yet to be sufficiently studied in healthcare.³ The increased activity and financial pressure in the healthcare sector, as well as the development of telemedicine,² the evolution of the use of AI in healthcare systems,⁹ and other circumstances like the ones caused by the COVID-19 pandemic,^10,11 have led to increased demands on staff regarding ethical practices.¹² Unfortunately, a scoping review of healthcare professionals’ ethical competence found that healthcare professionals’ ethical competence was limited.¹³

Value sensitivity, or recognising value-related issues when they arise in practice, is a vital competence for health professionals. Interestingly, when value sensitivity was measured, nursing professionals recognized and ascribed importance to principle-related issues more than, for example, professionals from hospital management.¹⁴ A concept analysis of ethical competence in healthcare involved personal character strength, ethical awareness, the ability to evaluate morality or moral judgment skills, and willingness to do what is good and right.¹⁵ The authors consider ethical competence to consist of having ethical knowledge and possessing ethical qualities as a professional, including being skilled in interpersonal relations and that ethical skills will likely result in the best possible solutions for the client and better moral well-being of healthcare professionals at work.¹⁵

There are some definitions of ethical competence within the health sector. In a scoping review of healthcare professionals’ ethical competence,¹³ the authors found varying definitions and constructions for ethical competence. They decided, however, not to refer to any sole definition. They point out that one author defined ethical competence in terms of moral competence as ‘the ability or capacity of persons to recognize their feelings when they encounter what is morally right or wrong in particular situations and then to reflect on those feelings to direct their decisions and act in ways which bring about the highest level of benefaction for patient’s best interest’.¹⁶ In another definition, ethical competence was defined in terms of character strength, ethical awareness, moral judgement skills, and willingness to do good.¹⁵ However, this definition is generally about healthcare professionals and not specifically about nursing.

Ethical competence within nursing

Nursing is rooted in a holistic approach that emphasizes nurses’ ethical obligations to protect clients’ rights, respect their autonomy, and maintain the client’s dignity, which requires an understanding of what is morally right and the ability to implement it.^17,18 Due to changes in healthcare, nurses are increasingly faced with ethical issues in their clinical practice and, therefore, need specific ethical skills.¹⁸ They are responsible for many people’s well-being and quality of life and must meet high technical and ethical competence standards.¹⁹ If nurses fail to do what they believe is right, they will likely experience moral distress, which can negatively impact the quality of care they provide.^18,20 Ethical competence has been seen as ethical knowledge and the ability to read situations ethically and reflect critically on what nurses know, stand for, and do.²¹ However, ethical competence in nursing does not appear to have been clearly defined, and a theoretical definition of the concept does not exist.²² In an integrative review in 2016 on ethical competence, Lechasseur et al.²² contributed considerably to understanding ethical competence in nursing. They cited the following definition of ethical competence from Gallagher in 2006 which was used at that time, ‘the possession of ethical knowledge next to the ability to “see” what a situation presents (ethical perception); to reflect critically about what nurses know, are, and do (ethical reflection); to bring out the ethical practice (ethical behavior); and to “be” ethical’.²¹ They note that this definition emphasizes that ethical competence comprises different dynamically interconnected components. They assert that it is akin to an iterative process, complex and in perpetual development, which can be organized in different steps. Lechasseur et al. also note that ethical competence consists of several essential components, such as ethical reasoning, ethical action, or ethical behaviour. However, they found that these essential components are usually not formally defined. Although they initially sought to define ethical competence, these clues changed the aim of their analysis, in the sense that a specific definition of ethical competence was no longer sought. Instead, they catalogued recurring nursing ethics concepts and noted their connections as a second step. They conclude that ethical sensitivity, ethical knowledge, ethical reflection, ethical decision-making, ethical behaviour, and ethical action are all components of ethical competence and resources to be mobilized.²² Their identification and linkage allow for an understanding of how ethical competence is developed by nurses and are an essential step towards a theoretical definition of ethical competence in nursing.

Growing interest in ethical competence among nurses

There is a growing interest in ethical competence among nurses because their responsibility for the safety and well-being of vulnerable individuals requires a solid knowledge of, among other things, ethical competence.^18,19 Ethical climate is a type of organizational work climate. It is the shared perception of ethically correct behaviour, and how ethical issues are handled in the organization. It is an essential component of the nursing environment and has been the focus of several studies.²³ Research shows that increased job satisfaction among nurses positively correlates with a good ethical climate and ethical leadership in the workplace.²⁴ Nurse leaders are responsible for creating an ethically sustainable culture with their staff. Through their management, they are responsible for maintaining the core art of caring and the ethical and professional competence of the care staff.²⁵ However, working conditions in modern nursing are increasingly complex and ethically demanding and tend to challenge nurses’ ability to respond to situations on ethically correct grounds, such as due to rapid developments in knowledge and technology, as well as increasing demands for performance. Such conditions can create a variety of ethical dilemmas and cause anxiety and distress, which can lead to burnout in the long run.¹⁷ Interestingly, a study on ethical climate and nurse competence among newly graduated nurses found strong associations between perceived ethical climate and self-assessed competence, turnover intentions, and job satisfaction.²⁶ Another study emphasised the value of ethical climate in the moral resilience of head nurses, ultimately enhancing their ethical competence.²⁷

Knowledge and understanding of the main theories of theoretical and practical ethics, the nurses’ code of ethics and the main ethical principles in nursing can be seen as part of the core components of ethical competence in nursing.^8,21,22 An integrative review found that professional ethics in nursing consists of values, duties, rights, and responsibilities regulated by national legislation and international agreements and detailed in professional codes.²⁸ Nurses must adopt ethical and professional values to develop and maintain a professional identity in the ever-increasing ethical challenges. These values concern human dignity, integrity, and justice and can serve as a benchmark for standards, practices, and evaluation of professional nursing services.²⁹ Nurses also need moral courage to ensure ethically sound nursing care,³⁰ because ethical competence is crucial in providing good nursing care.³

Ethics and ethical competence must be fundamental components of nursing education and be integrated into the nursing student curriculum.²² Research has shown that ethical decision-making training is likely to positively impact the moral development of nursing students,³¹ and health science students have long desired a practical course in ethics that would be useful for them in ethical decision-making in clinical situations.³² Interestingly, a Finnish study found that nurse educators’ teaching of the codes of ethics was rather extensive, and the teaching focus was mainly on the nurse–patient relationship.³³

Research on various aspects of nurses’ ethical competence

Research on various aspects of ethical competence in nursing has increased, for example, on ethical perception, ethical judgment, and ethical behaviour, as well as on ethical sensitivity, ethical awareness, ethical reasoning, ethical self-awareness, and, finally, on moral courage. Some of these studies will now be introduced.

Ethical perception, ethical judgment, and ethical behaviour

In a study on ethical competence in nursing practice, the definition of ethical competence in nursing consisted of the following three dimensions: ethical perception, ethical judgment, and ethical behaviour.¹⁶ However, ethical perception, judgment, and behaviour are essential not only for nurses but also for nursing students. In a systematic literature review of 15 studies regarding nursing students’ and nursing educators’ experiences of the contribution of ethics education to nursing students’ ethical competence, the authors found that ethics education increases nursing students’ ethical perception and develops their reflective and analytical skills as future nurses. Therefore, every effort should be made to ensure nurses’ ethical competence and encourage nursing educators to continue to create the best ways to teach ethics to nursing students to develop their ethical competence right from the start of their nursing education.³⁴

Ethical sensitivity, ethical awareness, ethical reasoning, and ethical self-awareness

One of the concepts related to ethical competence is ethical sensitivity. A scoping review of nursing students’ moral sensitivity development found three distinct but related dimensions of ethical sensitivity, including (a) increased ethical awareness, (b) the ability to identify and name ethical issues, and (c) improved ethical reasoning. It was found that ethical self-awareness appears to be more loosely related to the other two dimensions, which raises the question of whether ethical self-awareness can be seen as a prerequisite for the other two.³⁵

Moral courage

A key concept that has emerged within ethical competence is moral courage, which has garnered attention from Finnish nurses and others, emphasizing that it requires significant bravery to stand up for what is right and to live by one’s moral values. A conceptual analysis of moral courage identifies its primary characteristics as actual presence, moral integrity, responsibility, honesty, commitment, perseverance, personal risk, and advocacy for the patient. The precursors to moral courage are recognized as moral sensitivity, conscience, and experience, while the outcomes include personal and professional growth and empowerment.³⁶ In a descriptive cross-sectional study involving 482 registered nurses, nurses’ self-assessed moral courage was relatively high, and the participants valued honesty and humanity in their communication with patients. This research focused on nurses’ self-assessed moral courage, utilising the Nurses’ Moral Courage Scale.³⁰ The authors suggest that the results indicate that the participants had internalised the fundamental values of nursing. In a study on the moral courage of 966 Chinese nurses, three levels of moral courage were analysed: low-level, medium-level, and high-level. Most participants belonged to groups with low or medium levels of moral courage.³⁷ Interestingly, the results revealed that nurses with high moral courage possessed greater abilities to make ethical decisions than those in the other groups. The authors emphasize the need for guidance and training programs to complement nurses’ moral courage and decision-making. They conclude that raising the moral courage of nurses is likely to result in safer nursing care.³⁷

Research aims and research questions

In summary, ethical competence in nursing is essential. However, according to an integrated literature review, a consensus on the theoretical definition of ethical competence in nursing appears absent.²² Moreover, a lack of convergence on core content to be taught on nursing ethics in nursing education to ensure ethical competence has been identified.³⁸ A theoretical definition of ethical competence could be of value in helping nurses reflect on and improve their practice,⁶ for research and theory development, and when teaching ethics to nursing students. Even if different parties are promoting ethics and nursing scholars have already worked on this concept, it is still challenging to identify the essential components of ethical competence.²² This study aimed to determine the essential components of ethical competence in nursing, define them in terms of nursing, and develop a theoretical definition of ethical competence in nursing. The research questions, therefore, were as follows:

• What are the essential components of ethical competence in nursing?

• What is their definition in terms of nursing?

• What is the theoretical definition of ethical competence in nursing?

Research design

The method used to answer the research questions was concept synthesis, described by Walker and Avant.³⁹ Concept synthesis provides a mechanism for creating something new from available data. It is one of the knowledge synthesis methods, which means combining separate components to form a coherent whole, focussing on identifying the defining attributes of the concepts.⁴⁰ Walker and Avant point out that concept synthesis may be helpful when theorists have clusters of related data but need a way to summarize them. It combines disparate data into something new and gives it a name that makes it possible to communicate clearly about it.³⁹ The use of concept synthesis, therefore, requires the use of data, and the choice of a synthesis method, qualitative, quantitative, literary, or mixed method, is influenced by the needs of the theorists, the type of literature available on the topic, the state of knowledge in the relevant field, and the quality and completeness of the existing literature.³⁹ A literary concept synthesis was used since much data on ethical competence is already available, the type of literature is relatively high, for example, many review studies, the state of knowledge is considerable, and the quality and completeness of the existing literature is relatively high. Thorough literature examination is required in literary synthesis to acquire new insights about the phenomena of interest. This examination may yield previously unrecognized concepts for study. Particular to literary synthesis is the idea that literature itself becomes the database.³⁹ The research work continues until a certain theoretical saturation is reached. The thoroughness of the process in determining which features are most important to the concepts and which are less critical is essential. Concept synthesis culminates in a theoretical definition that includes its defining attributes.³⁹

Procedure

An integrated literature review was performed on CINAHL, PubMed, MEDLINE, PsychINFO, Scopus, and Web of Science. Nursing Ethics was searched separately since it is the most productive source title in nursing ethics research, publishing 232 information sources, followed by the Journal of Advanced Nursing (n = 55).⁴¹ The keywords at the beginning were ‘nursing ethics’ and ‘ethical competence’, and the search strings were (‘ethical competence’ OR ‘ethical skills’ OR ‘moral competence’ OR ‘ethical judgment’ OR ‘ethical decision making’ OR ‘ethical reasoning’ OR ‘ethical sensitivity’ OR ‘ethical awareness’) AND (‘nursing’ OR ‘nurse’ OR ‘nurses’ OR ‘healthcare’ OR nurs* OR ‘nursing practice’ OR ‘registered nurses’ OR ‘nurse practitioners’). Only published peer-reviewed scientific papers were used, emphasising literature reviews such as integrative reviews, systematic reviews, and scoping reviews. However, concept analysis, empirical studies, and discussion papers were also used. No limit was placed on the search time, ensuring the inclusivity of the review. Later, the authors looked for new dimensions of ethical competence in nursing by studying related concepts and determining what they have in common with ethical competence and what they do not. Initial screening identified 72 published papers, and after removing duplicates, 38 articles remained. Finally, 11 published papers met the inclusion criteria to help answer the research questions and were used in the concept synthesis (Table 1). The excluded papers did not contribute to answering the research questions from the point of view of the first author. As the data were collected, they were examined for similarities and differences much as one would in using a grounded theory approach.³⁹ Most of the strategies in concept synthesis are iterative; the theorists do not always progress from step to step but may cycle through steps several times or go back and forth between steps to reach theoretical saturation.³⁹ To do this, the theorists became thoroughly familiar with the area of interest, ethical competence, and were open to all published, peer-reviewed, usable data. Determining which features are most important to the concept and which are less critical is essential, but it is always a question of the judgement of the theorists. Evaluating evidence is significant in concept synthesis, to look at data, determine its value, and extract new ideas. Openness to new ideas is also critical, which takes plenty of time because the synthesis creates something new that cannot be accomplished quickly. Ideas take time to develop or incubate.³⁹

Table 1.

Overview of the 11 studies used in the first stage of the concept synthesis.

References	Methodology	Data sources	Further information	Findings
Contribution of ethics education to the ethical competence of nursing students: Educators’ and students’ perceptions.	Literature review	15 scientific papers from 1992 to 2012	MEDLINE, EMBASE, CINAHL, PsycINFO, and Web of Science were searched	Students and teachers argued that ethics teaching strengthened nursing students’ moral perceptions and developed their reflective and analytical skills. However, the contribution of ethics education to the development of ethical behaviour was hardly noticed. Student and teacher narratives revealed important characteristics of effective ethics teaching, particularly active student participation in the discussion of case studies and the use of ethical frameworks. Using such teaching methods requires a safe learning environment where students can openly reflect on the values at stake in their care work.
Cannaerts et al./2014³⁴	Literature review	15 scientific papers from 1992 to 2012
Nurses’ experiences of ethical dilemmas: a review.	Literature review	Published research between 2011 and 2016, 110 records.	PubMed, CINAHL, Scopus, and SveMed+ were searched	The relationship between nurse and patient, work organization and cooperation with colleagues are essential aspects of nursing work. The results were summarized in the following three themes: (1) balance between harm and care, (2) work overload affecting quality, and (3) dealing with conflict. Ethically difficult situations were evident in the work environment, which was very diverse, from neonatal intensive care to the care of older people. The organization of the workplace, the experience of tension between one’s values and the values of the workplace, prevailing standards and busyness revealed the complexity of the nursing profession and the variety of ethical problems, concerns and distress experienced by clinical nurses.
Haahr et al./2020¹⁷	Literature review	15 scientific papers from 2011 to 2016 were included in the review	PubMed, CINAHL, Scopus, and SveMed+ were searched
Nurses’ self-assessed moral courage and related socio-demographic factors.	A quantitative descriptive cross-sectional study	482 nurses from a major university hospital in Southern Finland	The Finnish language version of Nurses’ Moral Courage Scale was used	Nurses’ self-rated moral courage was relatively high. On the Visual Analogy Scale (0–10), the mean value was 8.20, and the mean score on the four-dimensional, 21-item Nurses’ Moral Courage scale was 4.09 on a 5-point Likert scale. Respondents’ gender, current work role, ethical knowledge base, additional education in ethics, self-study to acquire ethical knowledge, and how often nurses encountered situations that required moral courage were statistically significantly related to nurses’ moral courage.
Hauhio et al./2021³⁰	A quantitative descriptive cross-sectional study
Ethical competence: a concept analysis.	Concept analysis	18 articles, 12 theoretical papers and six empirical papers were used	CINAHL, MEDLINE, and ERIC were searched	Moral skills are strength of character, moral awareness, moral judgment, and the will to do good. Ethical competence is a prerequisite for being an accomplished professional, having interpersonal skills and ethical knowledge, and being in a supportive workplace. Ethical competence can translate positively into nursing and reduce the risk of moral distress at work.
Kulju et al./2016¹⁵	Concept analysis		CINAHL, MEDLINE, and ERIC were searched
Ethical competence: An integrative review.	Integrative review	89 scientific papers were used from the years 2009-2014	CINAHL, MEDLINE, and EMBASE were searched. The journal Nursing Ethics was also specifically searched	Ethical sensitivity, ethical knowledge, ethical reflection, ethical decision-making, ethical action, and ethically responsible behaviour are most often used to describe competence in nursing. These concepts were then defined to find the essential elements of ethical competence in nursing.
Lechasseur et al./2018²²	Integrative review	89 scientific papers were used from the years 2009-2014
Moral courage in nursing: a concept analysis.	Concept analysis	31 articles were used in the analysis	PubMed, CINAHL, Scopus, Web of Science, PsycINFO, and The Philosopher’s Index were searched.	Seven critical qualities of moral courage were identified: True presence, moral integrity, responsibility, honesty, advocacy, commitment and persistence, and personal risk. The effects of having ethical competence were moral sensitivity, conscience, and experience. Consequences of ethical competence included personal and professional development and empowerment.
Numminen et al./2017³⁶	Concept analysis	31 articles were used in the analysis
Nursing students’ ethical decision making: a Review of the literature.	Literature study	29 studies were used in the analysis	MEDLINE and CINAHL were searched from 1980 to 2006	Nursing education and education in ethics influence the development of ethical reasoning and ethical behaviour in nursing students. The choice of teaching method affects students’ moral decision-making skills. Students’ perceptions and reactions to ethical issues depend on how they approach ethical decision-making, their ideas about the nurse’s role in decision-making, the work environment and their attitudes towards the issues they consider ethically important. Students’ ethical reasoning is related to the type of curriculum, their level of education and their experience with ethical issues in clinical practice. Students’ moral reasoning is mainly at a conventional level. Students’ cultural environment, their clinical experience, their perception of their role as nurses, and their recent education are factors that influence their ethical decision-making.
Numminen & Leino-Kilpi/ 2007³¹	Literature study	29 studies were used in the analysis	MEDLINE and CINAHL were searched from 1980 to 2006
Professional nursing values: a concept analysis.	Concept analysis of professional nursing values	Method of Walker and Avant	Sources from 1973 to 2016	Professional nursing values are defined as the important principles of professional nursing regarding human dignity, honesty, altruism, and justice that serve as a framework for standards, practices, and assessments.
Schmidt & McArthur/ 2018²⁹	Concept analysis of professional nursing values	Method of Walker and Avant	Sources from 1973 to 2016
Ethical perception and resulting action in perioperative nurses.	Survey	The survey was conducted among 40 surgical nurses		The nurses described ethical conflicts and identified factors that influenced their ethical decision-making. The results showed that nurses perceive and define certain ethical problems in the operating room environment. Analysis of their responses revealed that the most common methods used to resolve ethical conflicts were to report to a superior or meet personally with those involved.
Schroeter/1999⁴²	Survey	The survey was conducted among 40 surgical nurses
The development of moral sensitivity of nursing students: a scoping review.	Scoping review	10 articles (out of 964 original articles)	CINAHL, PubMed, MEDLINE and SpringerLink were searched.	Three different but related dimensions of moral sensitivity were identified: (1) developing moral awareness, (2) developing the ability to spot moral issues, and (3) developing moral reasoning. Moral self-awareness appeared loosely related to the other two dimensions, raising whether it can be considered a prerequisite for them.
Spekkink & Jacobs/2021³⁵	Scoping review	10 articles (out of 964 original articles)	CINAHL, PubMed, MEDLINE and SpringerLink were searched.
Competence and competence frameworks in career guidance: complex and contested concepts.	Discussion paper			Discussion of the concept of skills and its importance for the development of competence frameworks. Such frameworks are increasingly seen as important in supporting the development of skills training programmes, identifying skills gaps, promoting self-development and ensuring common standards. It is stated that ideas about skills have a special meaning in a certain context, that there are very different opinions about skills and that ideas about skills are constantly changing.
Sultana/2009⁸	Discussion paper

Verification

The concepts developed through concept synthesis need to be verified or validated, which can be likened to establishing content validity or transferability in research.³⁹ Verifying concepts takes time, and the theorists must remain objective and scientific. If the concepts are truly data-based, they should come through the verification with only minor revisions,³⁹ and a good theoretical definition containing the defining attributes should be written once the concepts are adequately supported.³⁹ So, in this verification stage of the concept synthesis, the 12 essential components in our preliminary results were searched to deepen their definition and discussion. This way, 24 published papers were added (Table 2). Some of these were also used as sources in the literature review (introduction), to polish the results further (results), as well as to deepen the understanding of the findings (discussion), ensuring a comprehensive and well-informed study. The authors provide tables that provide an overview of the studies selected for the synthesis, thus allowing the reader to follow the process (Tables 1 and 2) and, in that way, make the decision trail more visible and traceable, which is part of establishing rigour in concept synthesis. An overview of the procedure for the concept synthesis itself is found in Table 3.

Table 2.

An overview of the 24 studies and peer-reviewed articles that were used in the verification stage of the concept synthesis.

References	Methodology	Findings and the insight they give into ethical competence
Academic ethical awareness and moral sensitivity of undergraduate nursing students: Assessment and influencing factors.	A descriptive correlational study. A convenient sample of 246 nursing students. Data were collected using the Academic Ethical Awareness Questionnaire and Moral Sensitivity Questionnaire.	Nursing students exhibited moderate academic ethical awareness and moral sensitivity. Constant efforts to foster nursing ethics courses with inspiring learning content and innovative instructional material are vital in improving nursing students’ academic integrity and ethical care.
Alnajjar & Abou Hashish (2021)⁴³		The study gives an insight into ethical awareness and moral sensitivity.
Moral competence questionnaire for public health nurses in Japan: scale development and psychometric validation.	Scale development and psychometric validation of the moral competence questionnaire for public health nurses in Japan.	This questionnaire reflects Japan’s characteristics in public health nursing practice.
Asahara et al. (2015)⁶		The study gives an insight into assessing moral practices and the need for continuing education.
Ethical dilemmas experienced by nurses while caring for patients during the COVID‐19 pandemic: An integrative review of qualitative studies.	An integrative review of qualitative studies.	Nurses often risked their and their families’ health while caring for patients during the COVID-19 pandemic.
Aydogdu (2022)⁴⁴	An integrative review of qualitative studies.	This review gives insight into the ethical dilemmas experienced by nurses and how nurse managers can support and empower them to act ethically.
Practising virtue: a challenge to the view that a virtue centred approach to ethics lacks practical content.	A discussion paper	A virtue-centred approach to ethics is criticized for its vagueness, especially regarding the ideal person, which some argue limits its practical guidance compared to traditional ethical frameworks.
Begley (2005)⁴⁵	A discussion paper	This discussion paper explains how virtue ethics can provide actionable guidance through virtue rules and moral exemplars.
Moral judgment competence of nursing students in the Czech Republic.	Cross-sectional study: 662 full-time and part-time students of General Nursing and Midwifery. Lind’s Moral Judgment Test (MJT, 1995) measured ethical competence, that is, nursing students’ skills in demonstrating ethical judgment.	The assessment of moral judgment competence in nursing students showed primarily low and medium scores of the C-index as measured by the MJT. The C-index was significantly influenced only by the type of study and age. Part-time students and those over 30 had lower C-index scores.
Bužgová & Sikorová (2013)⁴⁶		This cross-sectional study provides insight into assessing moral judgment competence in nursing students.
Development, implementation, and effects of an integrated web-based teaching model in a nursing ethics course.	One hundred two-year technical college nursing students in their second year of the program participated in the study, 51 in the experimental group and 49 in the control group.	After completing the course, students in the experimental group showed significant improvement in their nursing ethical decision-making skills, including ‘raising questions’, ‘recognizing differences’, and ‘self-dialogue’. When controlling for influencing factors, they outperformed the control group in “recognizing differences.”
Chao et al. (2017)⁴⁷		This study examines how an integrated web-based nursing ethics course can motivate nursing students to develop ethical decision-making skills and seek information to address ethical dilemmas.
Nursing ethics, caring and culture.	A discussion paper focused on the findings of a qualitative study on the expectations and perceived experiences of nursing care among members of the Pakistani community in Bradford, UK.	Numerous articles have been published in recent years that critically align ethics and caring. This theme suggests that caring is a moral pursuit centred on one person’s kind attention to another.
Cortis & Kendrick (2003)⁴⁸		This discussion paper suggests that nurses should develop a more informed narrative that readily reflects the needs of specific communities and how ethics and caring can be culture-based.
Exploring the heart of ethical nursing practice: Implications for ethics education.	Interpretive/constructivist paradigm. Involving 19 focus groups with 87 nurses and student nurses.	Ethical nursing practice was found to be a personal and socially mediated process.
Doane et al. (2004)⁴⁹		This focus group study gives nurses insight into becoming aware of how central their person is to their professional role and, ultimately, their ability to practice ethically.
Undergraduate nursing students’ ability to apply ethics in simulated cases.	Evaluation of the use of four simulation-based scenarios – Teenage Pregnancy, The Impaired Nurse, Withholding Treatment, and Neonatal Intensive Care Unit – on the American Nurses Association Code of Ethics among 93 undergraduate students.	Ethical practices are a core competency for delivering quality patient care. However, nursing faculty struggle to foster ethical growth in large classrooms, as traditional methods are often ineffective. Feedback from a five-item Likert scale indicated students could discern the ethical values of advocacy, autonomy, beneficence, and nonmaleficence.
Greenawalt et al. (2017)⁵⁰		The results give insight into how high-fidelity simulations can enhance the understanding of ethics among undergraduate nursing students.
Nurses experiences of ethical dilemmas: a review.	Literature review/the matrix method. Published research between 2011 and 2016, 110 records. 15 published papers were included in the review	The study identified three themes that reflect ethical dilemmas currently experienced by nurses in hospital settings: balancing harm and care, work overload influencing quality, and navigating disagreement.
Haahr et al. (2020)¹⁷		Interestingly, although the clinical settings of the published studies were very different, the findings revealed that the three identified themes were evident in all the settings.
Latent profile analysis of nurses’ moral courage: a professional values perspective.	A cross-sectional design. Data were collected through convenient sampling. The sample size was 966 nurses.	The moral courage of nurses can be classified into three subgroups. Nurses’ professional values positively correlate with moral courage, with head nurses showing significantly higher levels of moral courage.
Hu et al. (2024)³⁷		This cross-sectional study shows how strengthening professional values through training can enhance ethical behaviour in nursing, potentially improving patient care and safety.
Professional ethics in nursing: An integrative review.	Systematic literature searches from 1948–February 2013, using the CINAHL, PubMed and Scopus electronic databases to look at previously published peer-reviewed studies. Fourteen papers were included in this integrative review.	According to the synthesis, professional ethics is described as an intra-professional approach to care ethics, and professionals commit to it voluntarily. Professional ethics consist of values, duties, rights, and responsibilities regulated by national legislation and international agreements and detailed in professional codes.
Kangasniemi et al. (2015)²⁸		This systematic literature study shows that professional ethics are well established in nursing but constantly change due to internal and external factors affecting the profession.
Moral distress in critical care nursing: the state of the science.	This state-of-the-science review focused on moral distress research in critical care nursing from 2009 to 2015 and included 12 qualitative, 24 quantitative, and 6 mixed-methods studies.	A synthesis of the scientific literature uncovered inconsistencies in measurement, conflicting findings regarding moral distress and nurse demographics, challenges within the professional practice environment, difficulties in communication during end-of-life decision-making, compromised nursing care resulting from moral distress, and a scarcity of effective interventions.
McAndrew et al. (2018)²⁰		The provision of compassionate care is a core professional nursing value. This study explains how an inability to achieve this due to moral distress can significantly affect the quality of care delivered.
The development and validation of the Ethical Sensitivity Questionnaire for Nursing Students.	The ESQ-NS was developed in three phases, 528 nursing students responded to the final draft questionnaire.	The EAQ-NS, developed to evaluate the ethical sensitivity of nursing students, showed good validity, internal consistency, and reliability.
Muramatsu et al. (2019)⁵¹		This questionnaire can be used to evaluate nursing students’ ethics education through self-evaluation of ethical sensitivity. It gives an insight into such self-evaluation of ethics education.
An internal morality of nursing: What it can and cannot do.	Philosophical analysis	Nurses must never perform certain acts due to the ethical obligations inherent in their profession, regardless of their actions outside of nursing. While the literature doesn’t explicitly mention an internal morality of nursing, the underlying ideas about proper nursing practice can be connected to this concept.
Newham (2013)⁵²	Philosophical analysis	This study explains how understanding internal morality can clarify positions on contentious issues like euthanasia within the nursing profession. Ultimately, the relationship between nursing and moral actions remains complex, particularly when challenging bioethical dilemmas.
Ethical awareness among first year medical, dental and nursing students.	A 29-item, open and closed questionnaire was designed, piloted and distributed to all medical, nursing and dental students at one university. Of 306 questionnaires distributed, 174 were returned, a response rate of 57%.	Most students considered the teaching of ethics necessary. They wanted a practical course to help them cope with situations they will likely encounter in their professional practice rather than a course centring on the intellectual debate about definitions and concepts of morality.
Nolan & Smith (1995)³²		As a follow-on from this study, research could be helpful in how students learn to apply ethical knowledge in practice. Such research would facilitate the designing of the type of ‘practical’ course in ethics that the students who responded to this study clearly wanted.
Nurse educators’ teaching of codes of ethics.	183 nurse educators from polytechnics providing basic nursing education in Finland answered a structured questionnaire developed for the study.	The nurse educators found that teaching ethics primarily focused on the nurse-patient relationship, with less emphasis on the broader social context. While integrated teaching was common, methods were narrow and aimed at student-centred learning. Most educators relied on informal means to assess their knowledge, which they found sufficient, but those seeking to expand their expertise taught more effectively.
Numminen, Leino-Kilpi, van der Arend et al. (2010)³³		The nurse educators in this study considered nursing students’ understanding of ethical codes mediocre, indicating a need for further exploration of teaching organization, educator competence assessment, and evaluation of student outcomes.
Ethical climate and nurse competence - newly graduated nurses’ perceptions.	A descriptive, cross-sectional, correlational research design was applied. The participants were 318 newly graduated nurses. Data were collected electronically and analysed statistically.	Nurses generally had a positive perception of the ethical climate, particularly regarding peers, patients, and physicians, while views on hospitals and managers were less favourable. There were strong links between perceived ethical climate and self-assessed competence, turnover intentions, and job satisfaction related to quality of care.
Numminen, Leino-Kilpi, Isoaho et al. (2015)²⁶		This study shows the importance of the ethical climate in the workplace and how nurses with higher competence, job satisfaction, and low turnover intentions perceived the climate more positively.
Professional nursing values: a concept analysis.	Walker and Avant’s (2011) method guided an analysis of this concept. Resources published from 1973 to 2016 were identified via electronic databases and hand-searching of reference lists.	Professional nursing values were defined as crucial professional nursing principles of human dignity, integrity, altruism, and justice.
Schmidt & McArthur (2018)²⁹		This study provides important insight into professional nursing values, which can serve as a framework for standards, professional practice, and evaluation.
Nursing students’ experiences of ethical issues in clinical practice: a New Zealand study.	A study surveying 373 undergraduate nursing students	Nursing students encounter ethical issues in clinical practice differently than registered nurses. The study revealed that over two-thirds faced breaches of patient confidentiality, privacy, dignity, or respect, while 87% reported unsafe working conditions. The most distressing issues involved patient safety and included unsafe practices and suspected abuse. Common themes from open responses included lack of support, bullying, and end-of-life challenges. Notably, third-year students reported the highest frequency of ethical issues, but those in later years experienced lower overall distress levels.
Sinclair et al. (2016)⁵³	A study surveying 373 undergraduate nursing students	This study gives an insight into nursing students’ experiences of ethical issues in clinical practice.
Developing ethical competence in health care organizations.	Controlled prospective study evaluating a structured education and training program in ethics concerning its effects on moral distress	Findings show that moral distress did not change significantly. This could be interpreted as competence development without affecting moral distress. Alternatively, the result could be attributed to shortcomings of the training program, or that it was too short, or it could be due to the evaluation instrument used.
Sporrong et al. (2007)¹²		This study adds to the knowledge of the development of ethical competence and the evaluation of its impact on moral distress.
The development of moral self-awareness.	A discussion paper	Moral self-awareness involves individuals’ perceptions of themselves as moral actors. Its roots begin early with the development of empathy and emotional understanding, as children become aware of how their actions affect others’ feelings and intentions. This awareness continues to grow through the development of conscience and moral emotions like shame and guilt, culminating in the emergence of the “moral self” in preschool years. This paper examines these milestones, their origins in parent-child relationships, and their links to later moral identity development in adolescence.
Thompson (2020)⁵⁴	A discussion paper	This discussion paper gives insight into the development of ethical self-awareness.
Nurturing the moral imagination: a Reflection on bioethics education for nurses.	This reviews some key issues relevant to teaching ethics and explores what nurturing the moral imagination could do for nurses as they learn to apply abstract ethics concepts to their clinical practice.	The Carnegie Report on Nursing Education, ‘Educating Nurses: A Call for Radical Transformation’, called for the nursing profession to adopt an educational model that unifies knowledge, practical skills, and ethics. Central to this new model is the development of moral imagination, the ability to reflect on the rightness or wrongness of decisions and actions.
Wocial (2010)⁵⁸		This interesting paper emphasizes the need for intentional teaching that fosters the growth of individual nurses and the profession.
Effects of ethics education on moral sensitivity of nursing students.	A one-group pre-and post-test design was used to measure moral sensitivity and critical thinking disposition in 70 undergraduate nursing students. Nursing ethics education was conducted weekly for 90 minutes over 7 sessions.	After the education, patient-oriented care and inquisitiveness improved significantly. However, overall scores for moral sensitivity and critical thinking did not change. Positive correlations between moral sensitivity and critical thinking were observed before and after the intervention.
Yeom et al. (2017)⁵⁵		This paper gives insight into the effects of ethics education on moral sensitivity.

Table 3.

The procedures for the concept synthesis in the present study.

Steps	The steps descriptions by walker and AVANT³⁹	What the theorists did in the present study
Step 1: Getting to know the area of interest	Theorists familiarize themselves with the area of interest using many resources, including literature reviews and case studies, that is, all data providing potential sources of usable data.	The theorists read everything they could find on ethical competence, emphasizing reviews, to become thoroughly familiar with it and theoretically saturated. Only published, peer-reviewed scientific papers were used in the synthesis.
Step 2: Classification	When they become theoretically saturated, theorists begin classifying the data they have found. The classification system need not be rigorous. Indeed, it is better if it is loose at this stage.	Theorists began classifying the data to determine the essential components of ethical competence and their theoretical definition.
Step 3: Looking for clusters of phenomena	While classifying the data, the theorists look for clusters of phenomena that seem to relate closely to each other or even overlap.	The theorists looked for clusters of concepts that helped them identify the essential components of ethical competence and define them theoretically. Some concepts overlapped.
Step 4. Re-examining the clusters	Once the theorists are satisfied that all the clusters have been discovered and combined where possible, they re-examine and reduce them as much as possible.	After finding clusters of concepts identified as essential components of ethical competence, the theorists re-examined them and reduced redundancy and overlapping.
Step 5. Naming the concepts	When the new concepts have been reduced as much as possible, a name that accurately describes them and facilitates communication about them is chosen.	The theorists found 12 essential components of ethical competence and defined each one. These were then the building blocks of the theoretical definition of ethical competence.
Step 6. Verification	Once the concepts are named, they are verified and modified as necessary. Verification involves returning to the literature to determine if the concepts are empirically supported. The verification process continues until the theorists are satisfied that no new information is being received.	The theorists returned to the literature and now only searched for published data on the 12 essential components of ethical competence identified to see if the concepts were empirically supported. The verification process continued until the theorists were satisfied that no new information was being received.
Step 7. Definition and description of the new concepts	The new concepts are defined and described in a theoretical definition that includes their defining attributes.	The 12 essential components were then defined and described in a theoretical definition that included their defining attributes.
Step 8. Consideration of the usefulness or implications of the new concepts	Theorists consider the distinctive insights and potential approaches to research, practice, education, and further theory development that the new concepts make possible.	The theorists considered the distinctive insights and potential approaches to research and practice, as well as education and further theory development that the findings made possible (see Table 5).

Moral reflection

The theorists considered and respected academic writers’ ethics when reviewing the analysis and contributions of other authors and respected their copyright in all research work for this concept synthesis.

Results

The results of the concept synthesis of ethical competence in nursing are presented in three layers to answer the research questions point by point:

(1) Twelve essential components of ethical competence in nursing were identified and defined based on published, peer-reviewed sources.

(2) Three core components of ethical competence in nursing were identified based on the twelve sub-components.

(3) The theoretical definition of ethical competence in nursing was developed.

Twelve essential components of ethical competence in nursing

Ethical competence in nursing includes nurses’ 1. ethical knowledge and understanding; 2. ethical awareness, 3. ethical self-awareness, 4. ethical sensitivity, 5. ethical perception, 6. ethical judgment, 7. moral reasoning, 8. ethical reflection, 9. ethical decision-making, 10. moral courage, manifested in their work as 11. ethical action, and 12. ethically responsible conduct.

Table 4 analyses and defines the twelve components of ethical competence in nursing and the three core components identified, that is, ethical knowledge and understanding, personal ethical qualities, and ethical ability and courage to perform. The last column of Table 4 shows the sources, that is, the academic scholarly writings on which the concept synthesis is based.

Table 4.

Essential components of ethical competence, defined in terms of nursing.

Core elements	Element of ethical competence	Definition in terms of nursing	Sources
Ethical knowledge and understanding	Ethical knowledge and understanding	Ethical knowledge and understanding in nursing include a nurse’s knowledge and understanding of the main theories of theoretical ethics and practical ethics, the nurses’ code of ethics, and the main ethical principles in nursing, such as the importance of responsibility, justice, autonomy, kindness, fidelity, truth, and harmlessness.	Gallagher²¹ Kulju et al.¹⁵ Lechasseur et al.²² Sultana⁸
Personal ethical qualities	Ethical self-awareness	Ethical self-awareness in nursing includes nurses’ view of the moral implications of their actions, their role, and the ethical implications of their behaviour. Such self-awareness develops through increased empathy, emotional understanding, and sensitivity to the impact of people’s actions on the feelings, goals, and intentions of others.	Spekkink & Jacobs³⁵ Thompson⁵⁴
	Ethical awareness	Ethical awareness in nursing is the ability of nurses to make ethical assessments of situations and problems, reflect on and change their own moral opinions when necessary, and be aware of the ethical implications of their behaviour in their work. The nurses’ minds are alert to ensure ethical practice.	Kulju et al.¹⁵ Nolan & Smith³² Spekkink & Jacobs³⁵
	Ethical sensitivity	Ethical sensitivity in nursing consists of sensitivity to moral values that appear in various situations in nursing and self-awareness of one’s role and responsibility in such situations; sensitivity in care, sensitivity in communication, sensitivity in decision-making, and sensitivity in the entire nursing practice.	Lechasseur et al.²² Muramatsu et al.⁵¹ Spekkink & Jacobs³⁵
	Ethical perception	Ethical perception in nursing involves nurses spotting specific ethical problems and issues in their work and seeing the ethical side of problems and issues in the health service.	Cannaerts et al.³⁴ Jormsri et al.¹⁶ Schroeter⁴²
	Ethical judgment	Ethical judgment in nursing consists of nurses having the acumen to make decisions and judge real ethical issues and problems in nursing. Such judgment often reflects the beliefs, attitudes, and basic moral principles the nurses have and use to distinguish between right and wrong and make ethical decisions about the problems that arise in their work.	Jormsri et al.¹⁶
Ethical ability and courage to perform	Moral reasoning	Ethical reasoning in nursing is the nurses’ ability to think ethically and reason ethically, which is a prerequisite for ethical decision-making in nursing.	Spekkink & Jacobs³⁵
	Ethical reflection	Ethical reflection is the ability of nurses to consider and evaluate ethical issues in their work and change one’s own moral opinion when there is a reason to do so. The nurse develops a critical awareness of the values that underlie the decisions made in such situations. It is a powerful method for developing respect for others.	Lechasseur et al.²²
	Ethical decision-making	Ethical decision-making in nursing refers to the process nurses use when making decisions about ethical problems: studying the issue, using nursing ethics to conclude the nature of the problem, developing possible courses of action, considering the potential consequences of all options, deciding on a course of action, and finally evaluating the decisions made.	Lechasseur et al.²² Numminen & Leino-Kilpi³¹
	Moral courage	Moral courage in nursing occurs when nurses stand by their moral values and dare to stand by those values in morally challenging situations. It also includes ethical integrity, honesty, and the ability to advocate for patients.	Hauhio et al.³⁰ Numminen et al.³⁶
	Ethical action	Ethical action in nursing involves nurses constantly considering protecting and respecting the moral rights of patients and other recipients of nursing services. This approach is based on nurses’ beliefs that all human beings possess dignity and have the right to life, liberty, and dignity, which should be protected.	Lechasseur et al.²²
	Ethically responsible conduct	Ethically responsible conduct in nursing is characterized by honesty, fairness, responsibility, and professionalism. Nurses respect the diversity and rights of individuals and groups of people, show responsibility toward them, and promote mutual respect in all interactions.	Jormsri et al.¹⁶ Lechasseur et al.²²

A theoretical definition of ethical competence in nursing

Nurses considered ethically competent have knowledge and understanding of the main ethical principles in nursing and possess personal ethical qualities, that is, ethical self-awareness, ethical awareness, ethical sensitivity, ethical perception, and ethical judgment as well as having the ethical ability and the courage to perform ethically, that is, capable of moral reasoning, ethical reflection, ethical decision-making, having moral courage, they demonstrate ethical action, and ethically responsible conduct.

Description of ethically competent nurses

Ethically competent nurses have ethical knowledge and understanding; a variety of personal ethical qualities; and the ability and courage to perform ethically. These three main components are described in more detail below.

Have ethical knowledge and understanding

Ethically competent nurses know and understand the leading theories on ethics, practical ethics, the code of ethics for nurses, and the main ethical principles in nursing and realize their importance in their work

Have personal ethical qualities

Ethically competent nurses are aware of their role and the impact of their actions and conduct (ethical self-awareness), can assess situations and problems that arise and ensure that nursing is carried out ethically (ethical awareness), are sensitive to ethical values, show responsibility in complex situations in nursing and nursing practice (ethical sensitivity), and notice ethical problems or issues in their work and healthcare in general (ethical perception). They can make decisions regarding real ethical issues and concerns in nursing that confront them in their work (ethical judgment).

Have the ability and courage to perform ethically

Ethically competent nurses make decisions at work after ethical reflection and justify their choices in an ethical way (moral reasoning), reflect on ethical issues at work, are aware of the ethical values that underlie their own decisions and can change their own ethical opinion when there is reason to (ethical reflection). The nurses are guided by ethics when making decisions about ethical problems at work (ethical decision-making) and have the courage to stand by their ethical values (moral courage). They respect and protect the moral rights of their patients and clients (ethical activity), promote mutual respect and act with honesty, fairness, responsibility, and professionalism as a guide (ethically responsible conduct).

Discussion

One of the aspects of professional competence in each profession is ethical competence, which refers to specific personal and professional values of professionals in the relevant field,⁶ and such competencies have long been considered the backbone of health services and in providing good nursing care.^1,3,15 The subject of this study was to analyse the essential components of ethical competence in nursing and to present a theoretical definition of the concept. The results describe the essential components of ethical competence in nursing and what characterises ethically competent nurses. Ethically competent nurses possess and understand specific ethical knowledge and ethical principles in nursing and have personal ethical qualities (ethical self-awareness, ethical awareness, ethical sensitivity, ethical perception, and ethical judgement). In addition, ethically competent nurses must have the aptitude and courage to perform ethically (moral reasoning, capable of ethical reflection, ethical decision-making, moral courage, ethical behaviour, and ethically responsible conduct).

Nurses work in an ever-changing and often highly technical environment where they are responsible for the well-being and even the lives of their clients. Ethical issues regularly arise in the work of nurses, where their ethical knowledge and skills are tested as they protect patients' rights and autonomy.^16,18 In addition to working in a demanding work environment, nurses and other health professionals must comply with many laws, rules, and guidelines in their work, which often test the moral endurance of nurses.¹ Various things also indicate that nurses' moral distress at work can have an adverse effect on nursing and healthcare^18,20 and cause them personal distress.^15,17 This information reflects the need for a clear theoretical definition of ethical competence, especially defined in terms of nursing, which was the task of this research. It must not happen that the nursing work is so challenged by the organization and development of the health system that it hinders the professional decision-making of nurses and forces them to compromise the fundamental values of nursing.¹⁷

A code of ethics is the most common form of ethical guidance.¹⁹ A study among nurses from six European countries found that most participants did not understand their code of ethics or did not know its content.¹⁹ A newer study involving a scoping review found that additional research is needed to increase evidence-based knowledge of the impact of codes of ethics.^55,56 However, codes of ethics alone are insufficient for ethical competence. Defining ethical competence and developing ways to teach, train, and maintain it is essential,⁵⁷ which supports the need for a theoretical definition built on the analysis of the essential components of the concept and the definition of each of the components in terms of nursing.

There have been calls for a better understanding of how nurses and nursing students develop ethical competence and what needs to be considered when designing an ethics course for the profession.³⁴ Ethical education is not only information or training but also ethical knowledge and competence that require constant reflection and discussion, and must be viewed broadly.⁵⁸ It can be concluded that ethical knowledge and competence among nurses could be promoted through intensive, continuous and continuing education in ethics. In such education, the theoretical definition of ethical competence, as defined in terms of nursing in this research, could be helpful.

Considering the importance of ethical competence in nurses’ work, it is remarkable that no theoretical definition of ethical competence in nursing has been found. It is concluded that the theoretical definition of nurses’ ethical competence can benefit nurses and nursing students in their work and contribute to their good moral well-being. Therefore, this study is an essential contribution to nursing as a discipline and a profession.

Future research

Future research could, among other things, focus on investigating ethical competence from various perspectives, such as the perspective of nursing students at different levels of education and the perspective of nursing teachers and nurses in various practice areas. It would also be interesting to investigate whether and how the nurses’ code of ethics in multiple countries is helpful to nurses in their work within the healthcare system, and the relationship between moral courage and the moral well-being of nurses and nursing students in various countries. The Greek term ‘phronesis’, translated as moral sense, moral understanding, or practical wisdom, is also worth studying, as some hope it can help bridge the gap between ethical knowledge and actions.^59,60

Strengths and limitations

The research has several strengths, as this is the first theoretical definition of ethical competence in nursing and is vital for nursing. This concept synthesis provides an overview of 12 sub-components that define the concept of ethical competence in nursing, which are grouped into three main components. The 12 sub-components are defined, which can prevent the same term from being used to refer to different phenomena. The first author evaluated all the scientific papers used in the study, which is a theoretical weakness of the study. Other limitations include the quantity and quality of the articles used. Only 11 articles were usable in the first stage of the concept synthesis, so the perspective may be limited. Despite the limitations, the current findings help clarify the essential components of ethical competence in nursing and offers a much-needed theoretical definition of ethical competence in nursing.

Implications of research results

The results of this study are the first theoretical definition of ethical competence in nursing, along with the main components that characterize an ethically competent nurse. Such a theoretical definition can prove helpful to nurses in defining their own ethical and professional values and thus maintaining their professional identity. The definition can also support nurses in upholding their ethical values at work, which can sometimes prove complicated in the fast-paced and ever-changing healthcare environment. A theoretical definition of ethical competence can also help teach nursing students as they develop ethical competence in nursing and establish their professional values. Such skills are likely to contribute to their well-being at work when they start working as nurses, as well as to better services in the future healthcare system. Table 5 further expands on the implications of the findings on the four main pillars of nursing.

Table 5.

The implications of the findings on the four main pillars of nursing.

Pillars of nursing	Description of each pillar of nursing⁶¹	Utility of the theoretical definition in the pillars of nursing
Clinical practice	The clinical pillar includes the knowledge, skills, behaviours, and nursing proficiencies to ensure high-quality, safe, effective, and person-centred care.	The theoretical definition can help nurses define their ethical and professional values and thus maintain their professional identity. It can also support nurses in upholding their ethical values at work, which can sometimes prove complicated in the fast-paced and ever-changing healthcare environment of nursing.
Nursing education	The education pillar includes the knowledge, skills, behaviours, and nursing proficiencies needed to enable reflective practice, ongoing self-development, and effective learning in the nursing workplace.	A theoretical definition of ethical competence can be helpful to nurse educators in teaching nursing students to acquire ethical competence and establish their professional values. Such competence will likely contribute to their well-being when they start working as nurses, resulting in better services in the future healthcare system.
Nursing leadership	The leadership pillar concerns individual skills and how these skills contribute to team effectiveness. It includes the knowledge, skills, behaviours, and nursing proficiencies needed to work effectively in a team, lead in a manner appropriate to their level within the career framework, and fulfil management responsibilities (if applicable).	Nurses’ job satisfaction positively correlates with the ethical climate and ethical leadership. Therefore, nurse leaders are responsible for creating an ethically sustainable culture for their staff and maintaining their staff’s ethical and professional competence. Leaders in nursing can use the theoretical definition, along with the description of the ethically advanced nurse, to encourage and reward ethical competence in nursing.
Nursing research and theory development	The research pillar includes the knowledge, skills, behaviours, and nursing proficiencies needed to lead, deliver research, source, and use high-quality evidence to inform practice and education activities and improve nursing services.	The theoretical definition is instrumental in all research and theory development. It is essential to have a solid theoretical definition as a basis for all research on ethical competence and when using research to inform practice and to improve services.

Footnotes

Acknowledgements

The authors thankfully acknowledge the invaluable support of the University of Akureyri.

Declaration of Conflicting Interests

The authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclose receipt of the following financial support for the research, authorship, and/or publication of this article: Financially supported by the Háskólinn á Akureyri (University of Akureyri).

Ethical statement

ORCID iD

Sigridur Halldorsdottir

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Ethical competence in nursing: A theoretical definition

Abstract

Background

Aim and research questions

Method

Results

Conclusions

Keywords

Introduction

Ethical competence in the health sector

Ethical competence within nursing

Growing interest in ethical competence among nurses

Research on various aspects of nurses’ ethical competence

Ethical perception, ethical judgment, and ethical behaviour

Ethical sensitivity, ethical awareness, ethical reasoning, and ethical self-awareness

Moral courage

Research aims and research questions

Research design

Procedure

Verification

Moral reflection

Results

Twelve essential components of ethical competence in nursing

A theoretical definition of ethical competence in nursing

Description of ethically competent nurses

Have ethical knowledge and understanding

Have personal ethical qualities

Have the ability and courage to perform ethically

Discussion

Future research

Strengths and limitations

Implications of research results

Footnotes

Acknowledgements

Declaration of Conflicting Interests

Funding

Ethical statement

ORCID iD

References