Moral competence among nurses in Malawi: A concept analysis approach

Definitions of moral competence

Moral in this article is defined as a standard of behaviour or beliefs that a person holds in regard to what is and what is not acceptable. ²³ It is a right conduct and the person who has the right conduct has also the ability to differentiate between right and wrong. Morality then is about people trying to define what is right or what is wrong. However, competence is the ability to act with efficiency. It means the person has the ability to combine knowledge, skill and experience gained from training to perform tasks with safety. ²³ Moral competence has to do with behaviour or conduct, knowledge and skills.

Hemmerling ¹¹ defined moral competence as the ability to solve conflicts through deliberation and communication rather than through violence, deceit and power. The title of his study was ‘Morality behind bars: an intervention study on fostering moral competence of prisoners as a new approach to social rehabilitation’. Hemmerling ¹¹ reported that imprisonment is not a best solution to reform convicts. He suggested that through proper training methods, moral competence can be fostered to convicts so that they change behaviour positively. He stated that there are methods that people can learn to solve morally stressful situations with mutual respect, critical thinking and fruitful discussion. Hemmerling ¹¹ perceived moral competence as a key to live peacefully in the society and used moral competence as a main concept and mainly as an approach for reformation of prisoners. He claims that there are appropriate methods to teach and foster moral competence.

Ma, ¹⁶ in his research titled ‘Moral Competence as a positive Youth Development Construct: A Conceptual Review’, defined moral competence as the affective orientation to perform altruistic behaviours towards others and the ability to judge moral issues logically, consistently and at an advanced level of development. Ma ¹⁶ aimed at helping the adolescents to develop the competence for acting altruistically and to judge fairly. Ma ¹⁶ noted that most people abused Internet usage. His point of view was that understanding of the moral competence concept can be useful for implementation of moral education, whole-person education and positive youth development education.

Ma’s ¹⁶ model proposed two parameters for moral development, which are (1) altruism and human relationships which demands an affective orientation towards others and (2) justice. These two parameters were recommended as principles for resolving interpersonal conflicts because they include both affective and cognitive aspects of moral development. Moral development is a prerequisite for moral competence. According to Ma, ¹⁶ parental care, peer interactions and sibling interactions were identified as factors that influence the development of moral competence in children and the youth. Therefore, parents should be taught to understand the concept of moral competence because they influence its development in their children and youth. Furthermore, Ma ¹⁶ recommended a safe environment for children where the children can be treated with love and good care for them to grow with good conduct. Therefore, moral competence can be used as a main concept and an important tool for better youth development.

Lind ¹⁷ discussed a moral competence test (MCT) in a paper that was presented at the 41st Annual Meeting of the Association for Moral Education. A specific definition of moral competence was presented which was the ability to judge arguments by their moral quality rather than other attributes such as opinion agreement. Other terms such as moral orientation and moral judgement in relation to moral competence were introduced. Moral competence was used as one of the concepts in the cognitive-development theory. It was shown that people who are exposed to moral orientation develop moral reasoning and moral judgement. MCT was presented as a theoretically valid measure of moral judgement competence because of the significant correlation between moral orientations and moral judgement competence, which made it possible to predict one when the other is known. It was noted that moral competence cannot be simulated but must be imparted through education. The results mean that moral competence does not just come into a person from elsewhere, but it is developed through other forms of learning such as conscious and non-conscious forms of knowledge acquisition, observation of the behaviour of others and reflection.

Jomsri et al. ² through interviewing nurse practitioners, nurse educators and patients came up with a definition of moral competence concept in nursing. Moral competence was defined as nurses’ ability to recognise their feelings as they influence what is good and/or bad in particular situations, and then to reflect on these feelings in order to make their decisions, and to act in ways that bring about the highest level of benefit for their patients. This definition of moral competence is the one used in the nursing practice model.

Jomsri et al. ² described three dimensions of moral competence, namely, affective, cognitive and behavioural dimensions. The affective dimension is called moral perception and requires that nurses be aware of values and be able to express them clearly in their messages. The cognitive dimension is called moral judgement and it is the ability of nurses to choose one value over the other based on logical reasoning and critical thinking. The behavioural dimension is called moral behaviour and it involves the ability of nurses to apply the values into action willingly and consistently.

The nurses’ values originated from culture including religion, personal experience and the learning of the nursing profession. The following characteristics – love, kindness, compassion, honesty, responsibility, caring, discipline, and respect for human values, dignity and rights – were identified as indicators of moral competence in nursing practice. These characteristics are also known as professional values and they are acquired through learning professionalism, nursing standards and nursing ethics. It is moral competence that helps nurses to solve ethical issues during practice. ^2,5 Therefore, moral competence concept can be used as a conceptual framework for dealing with ethical issues in nursing practice.

Rzymska et al. ³ described moral competence as a complex of moral knowledge, skills, attitudes, motivation and evaluation. The researchers randomised nurses and midwives. Some went through active ethics training while some went through passive ethics training. All the groups had religion classes before they joined the university. The concept of moral competence was measured based on moral competence C-index. The results showed that ethics training and parental guidance had strong influence on the development of moral competence on student nurses.

Other researchers such as Johnstone ²⁴ argued that the concept of moral competence had not been well defined in nursing practice. The argument is that moral competence is a complex concept, hence the perception of moral competence was beyond what was being described. Therefore, it should not be assumed that a nurse could develop moral competencies by learning professionalism and professional ethics alone. Johnstone ²⁴ contended that there should be a clear and proper way of teaching and assessing the concept of moral competence in nursing education and practice. The questions that needed to be addressed were what is the proper way to teach and assess moral competence in nursing education and practice? Which teaching methods are appropriate for teaching and learning moral competence? What is the content for teaching moral competence in nursing?

Haegert ⁹ explained the concept of ‘Ubuntu’ as suitable to be an ethic in nursing in Africa. She points out that Ubuntu is about giving care to others who are vulnerable and also receiving care when you need it from others. A person is a person because of other persons and that a person is not a person in isolation. ⁸ Caring is of paramount importance to nursing profession. Nurses are expected to provide ethical care to their patients and clients. Haegert described this type as the one that comes from deep down one’s heart and it is demonstrated by willingness to provide care with compassion patients, family and community (moral action). She pointed out the following attributes as implications Ubuntu/personhood to nursing profession: showing respect and dignity to patients, solidarity, team work spirit, fairness and tolerance.

It is necessary to note that the Kohlberg moral development theory plays a big role in terms of moral reasoning and judgement. According to this theory, nurses who have developed moral judgement when faced with ethical or moral dilemma make ethical decisions based on justice making use of ethical principles and universal human rights. However, it is worth noting that nurses do not make ethical decisions based on justice only but also based on caring attitude of nurses. ²² Nurses are motivated to care because of the connections and attachments based on the relationships they develop with patients, families and community. ²²

The definitions of the concept of moral competence in this study have presented some important words such as the ‘ability to make decisions’, ‘to communicate effectively’, ‘good conduct’, ‘willingness to provide care’ ‘critical thinking’ and ‘solving problems’.

Operational definition of moral competence

The discussions on the definition of moral competence have given rise to the operational definition of moral competence in nursing in this analysis, which is the

ability of a nurse to utilise nursing professional values, nursing ethics principles and nursing standards in a favourable work environment to think critically, make ethical or moral decisions and solve problems in the provision of quality and ethical care in order to meet patients’ needs and satisfaction in nursing practice.

Determining defining attributes

The deductive analysis of the characteristics and values of the concept gave rise to the following defining attributes for moral competence in nursing:

Kindness;

Model case

According to Walker and Avant, ¹⁵ a model case portrays a real-life example of the use of the concept and contains all the defining attributes of the concept. It must be noted, however, that the utilisation of a model case and other cases to identify or verify essential attributes is limited. Concept analysis lacks empirical methods that could provide triangulation and rigour to the analysis. The following is the description of a model case of moral competence concept.

Nurse J is a registered nurse with 4 years’ experience working in a male medical ward. She reported for duties 15 min late on Monday morning. She greeted her colleagues cheerfully. She confessed to the nurse in charge in charge about her coming late, which was due to her waking up late. The in charge nurse commended her for her honesty. She then joined her colleagues and received handover attentively. She was assigned to work in Room 3 where Mr G was one of her patients. She greeted all the patients respectfully and introduced herself to them, informing them that she would be their nurse for the day. She went further informing the patients that she will care for them accordingly. She encouraged the patients to inform her if they needed anything from her. She assessed her patients and identified their problems and needs and provided holistic, compressive care to each patient.

She followed aseptic technique when she was dressing Mr G’s wound. She screened his bed to ensure privacy and gave pain killer medication before she started dressing the wound. She was compassionate throughout the time she was dressing the wound and she kept on talking to the patient to distract him from concentrating on the pain from the wound. She documented all the care she rendered to her patients. She made sure not to knock off before she handed over to her night duty colleagues. Her colleagues were happy with her because they found everything in order. At the end of her shift she informed the patients of her going away and wished them well. The patients were happy with her because of her good conduct and thanked her for her care, love and kindness.

Analysis

In this case, Nurse J demonstrated good professional conduct. She was honest and not defensive and she provided care with passion. She demonstrated critical thinking, decision making, and problem-solving ability, caring accountability and responsibility. She followed the nursing standards of practice and professional values. It is assumed that nurse J is morally competent.

Borderline case

A borderline case includes some of the defining attributes but not all of them. ¹⁵ A borderline case for moral competence was described as follows: Nurse M is 25 years old working in male medical ward. She was assigned by the in charge nurse to collect sputum sample from Mr D. For 2 days nurse M was not able to get the sample because Mr D could not produce any sputum. The in charge nurse persuaded nurse M to bring the sputum results. Nurse M decided to give her sputum sample to the laboratory so as to have results to give to the in charge nurse. The sputum results become positive. The implication was Mr D had to start TB treatment when he had no TB. Nurse M went to the matron and confessed that she was sorry for what she did. Mr D had no TB and needed no TB treatment. However, she needed TB treatment because her sputum sample tested positive. Nurse M reported that she knew that she would be dismissed from work because of her professional misconduct but she felt that it was right for her to report the truth about the matter.

Analysis

In this case, nurse M portrayed some attributes of moral competence but not all. She was able to speak the truth even though her doing so would land her in problems. She was honest. She reflected on her conduct and decided to reveal what was hidden.

Contrary case

Nurse G is assigned to do burn wound dressing in the burn unit. In this unit, all ambulatory patients go to treatment room to have their wounds dressed. Nurse G is working with other three nurses (Nurse F, Nurse L and Nurse X). Each one of the four nurses had their own dressing trolley. Aseptic technique was not followed when making the trolleys. Four patients enter the treatment room to have their wounds dressed by the four nurses. There were no bed screens to provide privacy. There were two female patients, one had her wounds on both buttocks, and the other female had her wounds on both breasts including the neck. There was one male patient who had his wound on his left lower leg and the last was a 13-year-old girl who had her wound on her abdomen including the pubic area. The girl was not willing to expose herself but Nurse X shouted at her and threatened to leave her if she continued to refuse to expose her wounds. The other three nurses were in support of Nurse X. The nurses dressed the wounds using non-sterile gloves and without dressing forceps.

Analysis

This is a contrary case to the concept of moral competence. There is no demonstration of ethical competency, nursing standards and professional values.

Related case

Nurse A was conducting a research in village E. Her research topic was about the factors that motivated the women of village E to attend family planning services. She gave consent forms to the participants and explained to them in detail what was expected of them. She informed the participants that they were free to stop from participating if they felt so. She assured them that the information that would be collected would be treated with confidentiality and that they would not be punished in any way if they opted out. The participants agreed and data were collected. Nurse A followed the research process including the ethical aspects.

Analysis

This is a related case of moral competence concept. Nurse A demonstrated ethical competence in conducting research. Moral competence is not ethical competence; however, they are related.

Antecedents of moral competence in nursing practice

Antecedents are events or situations or phenomena that precede the concept under study. Antecedents are important in concept analysis because they help the researcher to gain understanding on how to refine the concept. ²⁶

The antecedents that were identified in this analysis were as follows:

Personal, cultural, religious values. ^2,17 These influence nurses in the way they make decisions and solve problems. The values also help in the way the nurses will relate to patients and others.

Consequences

The consequences are events or situations or circumstances that happen because of the use of the concept. ²⁶ In this analysis, the consequences of moral competence are team work spirit, improved performance in providing nursing care and improved nursing attitudes. ²⁰ Nurses demonstrate ethical competence and professional values in nursing practice. Consequently, patients receive quality care and are treated with respect and dignity. ²⁷ The concept may help to reduce moral distress and attrition among nurses in nursing practice. ^18,21,28

Defining empirical referents

According to Walker and Avant, ¹⁵ defining empirical referents is the last step of concept analysis. Empirical referents are actual phenomena that by their existence or presence demonstrate the occurrence of the concept. They are measurable ways to demonstrate occurrence or existence of a concept. They contribute to construct and validate the content. In this case, the concept of moral competence in nursing can be explored further through research to determine its existence and magnitude in Malawi. Furthermore, the factors that influence attributes of moral competence in nursing practice can be researched on.

Implication of moral competence analysis in nursing practice

The concept of moral competence is of great importance to nursing profession in Malawi. As it has been stated in this article, moral competence make nurses think critically, analyse issues, solve problems and make reasonable decisions. Malawi as any other country may benefit from morally competent nurses whose care meets and satisfies the needs and problems of patients and the public at large. Johnstone ²⁴ stated that there must be proper methods of teaching nurses for them to develop moral competence in nursing practice. It would be helpful to uncover appropriate teaching methods and content to be used by nurse educators to enable student nurses develop moral competence so as to improve the quality of nursing care in Malawi. Despite the fact that the nursing curricula contain a component of nursing ethics, it is still questionable whether the content taught and the teaching methods used are sufficient to enable student nurses and nurses develop anything more than a superficial understanding of nursing ethics or indeed the skills, knowledge, attitudes, values and abilities necessary to demonstrate the expected moral competencies. This observation agrees with the observation by Johnstone. ²⁴ Furthermore, the use of this concept in Malawi may also entail who should teach nursing students and may enhance the collaboration between nurse educators, nurse managers and clinical nurses to promote student nurse learning and consequently promote the delivery of nursing care. In other words, the moral competence concept has policy implications for nursing practice, education, management and research.

In other countries such as Japan, there is a tool that is used to measure moral competence among public health nurses. ¹ However, in Malawi and Southern Africa, there is no tool for assessing moral competence in nursing practice. The new knowledge that this analysis of the concept of moral competence has brought to nursing literature can be used to develop a tool or a checklist that can be used to assess moral competence among nurses in Malawi and the region. The existing tools should be modified and adapted to fit Malawian context with regard to effective communication and decision making skills in resource scarce settings.

Implication for nursing practice

Morally competent nurses will provide quality of nursing care as stipulated in the nursing code of ethics and practice. Furthermore, moral competence among the nurses will eliminate moral distress and burn out and increase retention among the practicing nurses. Consequently, patients’ problems and needs will be met and the public will register satisfaction with nursing care from its nurses.