Assessment of ethical competence among clinical nurses in health facilities

Abstract

Background:

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

Objectives:

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

Methodology:

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

Ethical consideration:

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

Results:

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

Conclusion:

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

Keywords

Clinical nurses clinical practice ethical competence ethical competence prevalence ethics education moral competence

Introduction

Ethical competence among clinical nurses is important for both present and future nursing practice because it promotes quality of care to patients. It forms the basis for ethical performance,¹ professional nursing competence,² patient safety, improved patient outcomes and health. Poikkeus et al.³ and Aitamaa et al.⁴ contend that ethical competence is as important as clinical competence. It is further attested that nursing practice is an ethical profession and calls for clinical nurses to be well equipped with ethical knowledge, attitudes and skills to enable them handle complex ethical demands they meet during their daily work in health facilities.^1,4

The Regulatory Authority for nurses in Malawi mandates Malawian nurses to provide ethically acceptable nursing and midwifery care to the public.⁵ The code of ethics for nurses and midwives in Malawi is derived from the International Council of Nurses (ICN) code of ethics for nurses. It mandates Malawian nurses to observe and advocate for patients’ rights in the process of promoting health, preventing illness and alleviating suffering.⁶ Thus, clinical nurses are always expected to make decisions on a daily basis that demonstrate ethical competence in practice.⁶ However, contrary results are reported by the Nurses and Midwives Council of Malawi’s (NMCM)⁷ monitoring and evaluation reports of nursing practice in health facilities. There is evidence of unethical practice among clinical nurses in Malawi, such as shouting at patients, not respecting patient rights, lack of confidentiality, leaving patients unattended to, negligence and health workers shouting at each other in the presence of patients.^8–12 In addition, there are negative media reports coming from the general public complaining about nurses’ malpractice and unprofessional conduct towards patients in health facilities.⁷ For example, there are reports regarding nurses making rude remarks to patients, nurses sleeping when on night duty instead of providing care and cases of bulling patients. The negative public perception of nursing practice in Malawi implies that some clinical nurses are not compliant to their codes of ethics as required. Consequently, the public is not satisfied with the nurses’ performance in the hospitals. There is a gap between actual nursing practice and public expectations. This gap could be due to lack of ethical competence among nurses. There is therefore a need for nurses to embrace ethical competence, which contributes to high-quality patient care. Studies related to ethical competence have been conducted in various countries in the world.^4,13–17 However, studies regarding ethical competence among clinical nurses in Malawi are limited, hence this study.

Background

Poikkeus et al.¹⁸ defined ethical competence as ethical behaviour and actions that require ethical knowledge and ethical reflection for meeting and solving ethical problems in nursing practice. Similarly, Jormsri et al.² identified three dimensions of ethical competence, which are ethical perception, ethical reflection and ethical behaviour. Compassion, caring, accountability, responsibility, kindness, honesty and respect for patients’ values, dignity and rights are some attributes of ethical competence.²

Ethical competence in nursing practice helps nurses to think critically, analyse issues, make ethical decisions and solve ethical problems and behave ethically during their daily deliberations.¹⁹ It involves ethical reasoning, ethical sensitivity, ethical knowledge, skills, attitudes, motivation, behaviour and ability to make ethical judgements and being responsible for one’s actions.^1,2,20–22 In addition, nurse ethicists suggest that ethical competence includes the nurses’ capacity to recognize and address ethical dilemmas.²³ Knowledge of ethical principles, theories and professionalism and codes of ethics serves as a guide to nurses in solving ethical dilemmas in the clinical area.²²

Ethical competence is developed mainly through ethics education among health workers including nurses.^19–22 In addition, ethical competence among health workers including nurses is promoted by the existence of professional practice environment or ethical climate which include, but not limited to, inter-professional collaboration and respectful communication, inter-professional relationships, supportive supervision, organizational support, availability of resources, clear job descriptions and conducive infrastructure.^{1,3,4,15,19,22}

Research studies have demonstrated that ethical competence among nurses enables them to promote patients’ advocacy and treat patients with respect and dignity, thereby increasing patients’ satisfaction and improving patients’ outcome.^13,15 Furthermore, nurses are equipped with necessary knowledge, skill and attitudes to solve ethical problems, including dilemmas which tend to reduce tension in provision of patient care, reduce moral distress among nurses and increase nurses’ retention rate.^15,16

Although there is evidence of unethical practice among nurses in Malawi, studies to assess ethical competence level among nurses in Malawi are scanty. In addition, available information on nursing ethics in Malawi from studies by Solum et al.⁸ and Msiska et al.¹⁰ solicited information from student nurses and nurse educators but not on the nurses themselves. There is therefore a need to establish the level of ethical competence among nurses in nursing practice in Malawi. The results would establish evidence-based strategies that could enhance ethical competence among nurses in Malawi. Hence, the aim of this study was to explore ethical competence among clinical nurses in selected hospitals in Malawi.

Objectives

The objectives of this study were the following:

Investigate the ethical competence level among clinical nurses working in selected hospitals in Malawi;

Identify the determinants of high-level ethical competence;

Describe the indicators/characteristics of ethical competence.

Methodology

Research design and setting

This study design was descriptive cross-sectional that utilized a quantitative research method of data collection and analysis. The study was conducted on 271 clinical nurses (registered nurses/midwives and nurse midwifery technicians and ward-in-charges) who were drawn from four selected hospitals in Malawi: one government central hospital, the Queen Elizabeth Central Hospital (n = 172); one government district hospital, the Kasungu District Hospital (n = 28); a private hospital, that is, Mwaiwathu Private Hospital (n = 46); and a mission hospital, Ekwendeni Mission Hospital (n = 25), which is administered by the Christian Health Association of Malawi (CHAM). Due to the differences in the management of the health facilities, a stratified random sampling was used to sample participants from the government, CHAM and private health facilities. The data were stratified to compare the determinants of high ethical competence level among the nurses in different types of health facilities.

Inclusion criteria

The study targeted Malawian clinical nurses who trained in Malawi at registered nurse/midwife (RNM), nurse midwife technician (NMT) or enrolled nurse/midwife (ENM). The study targeted male or female nurses who had at least 6 months’ working experience and were willing to participate in this study. The consenting clinical nurses worked in various wards and departments of the selected health facilities.

Exclusion criteria

Clinical nurses from other countries who were not trained in Malawi but were working in the selected hospitals and other cadres of health workers were excluded. Nurses with less than 6 months of work experience and those who met the criteria but were not willing to participate in the study were also excluded from the study.

Data collection

Data were collected in April and May 2019. Data collection was done through self-administered structured questionnaire.²⁴ The structured questionnaire had three sections. Section 1 collected subjects’ demographic data such as age, work experience, gender, qualification, cadre, marital status, religion, home district and tribe. Section 2 collected data on nurses’ level of ethical competence. The Moral Competence Scale for Home Care Nurses (MCSHCN) by Asahara et al.²³ was used. Permission was sought from the authors to use the scale. It was validated and has a reliable scale, which was developed to assess nurses’ moral or ethical competence in practice in Japan.²⁵ The Cronbach’s alpha ranged from 0.78 to 0.93. Hence, the scale showed satisfactory validity and reliability. Consequently, the authors of the scale recommended that it should be tested in other settings. There is no scale that was developed specifically to assess ethical competence among the clinical nurses in the clinical setting; therefore, this scale was adopted to find out whether it can be applied in the clinical settings and in countries other than Japan. Although ethical competence and moral competence are not exactly the same, the terms are used interchangeably in this scale; hence, this study has also adopted the use of the two terms interchangeably.^1,25 The scale has 45 items based on five theoretical components of moral competence, which are moral/ethical sensitivity, moral/ethical judgement, moral/ethical motivation, moral /ethical character and implementing moral/ethical decision.

Section 3 of the data collection tool collected data on indicators or characteristics of ethical competence among the clinical nurses in the hospitals of Malawi. The question in this section was open-ended to enable clinical nurses explain the characteristics in their own words.^24,26 The clinical nurses were asked the following question: ‘What are the indicators/characteristics of a nurse who is ethically competent in other words how do you know that this nurse is ethically competent?’

Data analysis

Preliminary data analysis was done using SPSS 23.0. The data were then imported into STATA version 12.0 for logistic analyses. Data checks were done to ensure good data quality.²⁷ Descriptive statistics were computed for the demographic variables and ethical competence indicators. Other descriptive statistics were computed for the demographic variables, and the results are presented as means (for scale variables) and frequencies (for ordinal, nominal and categorical variables). Using the SPSS software at 5% test level of significance, the demographic variables were cross-tabulated with the ethical competence level. This procedure was done to identify significant demographic variables for the ethical competence level. Comparison of proportions between low and high ethical competence level groups was done using the chi-square test in the legacy dialogue of the nonparametric tests in the SPSS software. The test level of significance was 5%. The MCSHCN has five subscales. The first subscale has 16 items and is called arranging the caring situation to bring optimal benefit to patient/client/family, and the Cronbach’s alpha is 0.93. The second subscale has 11 items and is known as strong will to face difficult situations, and the Cronbach’s alpha is 0.93. The third sub-scale has also 11 items and it is named judgement based on the values of a nurse, and the Cronbach’s alpha is 0.86. The fourth subscale has four items and is called judgement based on the standards of the organization/hospital or outsider, and it has a Cronbach’s alpha of 0.82. The last subscale has three items, which are known as recognition of discrepancy of intention, and the Cronbach’s alpha is 0.82. The 45 items were measured using a 5-point Likert-type scale: 1 = strongly disagree, 2 = somewhat disagree, 3 = uncertain, 4 = somewhat agree and 5 = strongly agree. The scores less than 3 meant lack of ethical competence and above 3–5 meant the presence of ethical competence.²⁵ In this study, no one scored less than 3. So ethical competence was further classified into low (3.1–4.4) and high (4.5–5) ethical competence based on the scores on the scale to determine the level of ethical competence of the clinical nurses in Malawi.

A correlation matrix was computed to investigate the correlation (for scale variables) or associations (for categorical variables) among all variables and ethical competence. Variables that were significantly correlated or associated with ethical competence (p < 0.05) were selected to build a logistic regression model. Logistical regression is used to describe data and explain the relationship between one dependent binary variable and independent variables. Thus, the binary logistic regression model was used for multiple logistic regression analysis on the binary response variable (high and low ethical competence). Using stepwise regression analysis in the STATA 12.0 software, the best subset of the regressor/predictor variables for high competence level was determined. The final model was significant at the 5% level of significance. All demographic variables were not significantly correlated or associated with ethical competence level (p > 0.05) and were thus dropped from the logistic regression model. Therefore, in the final fitted model, a logistic transformation was used to link the binary response variable (high and low) ethical competence levels to the significantly correlated or associated MCSHCN variables as predictors. The stepwise logistic regression analysis gave the appropriate number of most significant predictors for ethical competence level among the clinical nurses. These predictors were used to build the final high regression model. Odds ratios were computed for predicting individuals with high ethical competence level relative to the low competence level group using a 95% confidence interval.

Validity and reliability

In this study, the validity and reliability of the study results were ensured by pre-testing the study questionnaires and the relevant corrections that were made to ensure that the data collection tools collected the intended data.²⁷ The questionnaire was also reviewed by colleagues, supervisors and expert nurse leaders on the moral competence. The questionnaire content was evaluated to ascertain whether the data collection instrument was relevant to elicit what the study intended to investigate.²⁸ In addition, an appropriate sample size which allows generalizability of the study results was used. The sample size was adequate to minimize biases due to sampling errors. In addition, the sample size was representative of the population, hence ensures generalizability of the study results. Furthermore, the research assistants were trained before data collection begun to ensure data quality. During the data collection period, the researchers checked the answered questionnaires for completion. Still more, during preliminary analysis, the data were tested for the underlying assumptions in using parametric statistical tests; hence, the data showed compliance with the assumptions of sampling from a normal population and constant variances. Constant variances were tested for homogeneity, and the normality test was undertaken using a P-P Plot in the SPSS software.²⁹

Ethical considerations

The study complied with the outlined basic research ethics principles such as respect for persons, beneficence, confidentiality and justice according to the 1979 Belmont Report upon which all research guidelines involving human subjects are based.³⁰ Thus, the clinical nurses were given thorough information about the study for the purpose of informed consent and all the prospective subjects were informed that participation was voluntary. Written consent was sought from both the study sites and the clinical nurses. The subjects’ personal information was strictly confidential and only the researchers had access to the information. The study was approved by the College of Medicine Research Ethics Committee (COMREC) under the University of Malawi certificate number P.02/19/2611.

Results

A total of 235 clinical nurses responded to the questionnaire (87% response rate). The majority of the respondents (77%; n = 180) were female. Less than half of the respondents (42%; n = 100) were registered nurses. The majority (49%) had diploma, while 33% had bachelor’s degree and 18% had certificates. Their ages ranged from 21 to above 40 years, and work experience ranged from 6 months to above 20 years, and most respondents (71%; n = 166) worked in government hospitals.

The MCSHCN was found to be reliable with good internal consistency (Cronbach’s alpha = 0.9). The five subscales of MCSHCN were also found to be reliable with internal consistency (the first subscale, arranging the caring situation to bring optimal benefit to patient/client/family – Cronbach’s alpha = 0.8; the second subscale, strong will to face difficult situations – Cronbach’s alpha = 0.8; the third subscale, judgement based on the values of a nurse – Cronbach’s alpha = 0.7; the fourth subscale, judgement based on the standards of the organization/hospital or outsider – Cronbach’s alpha = 0.7; and the fifth subscale, recognition of discrepancy of intention – Cronbach’s alpha = 0.9. This study has confirmed that the MCSHCN is a reliable instrument for measuring ethical competence among nurses and midwives in low-resource countries such as Malawi.

Association of the level of ethical competence in relation to the demographic variables

The results showed that there was no significant association (p > 0.05) between demographic characteristics and the level of ethical competence. Results show that with any of the demographic characteristics, a clinical nurse could have high or low ethical competence. However, all the MCSHCN variables were significantly correlated with level of ethical competence (p < 0.05). The level of ethical competence in relation to the participants’ demographic characteristics is summarized in Table 1.

Table 1.

Respondents’ demographic characteristics as related to level of ethical competence.

Nurses’ and midwives’ characteristics	Level of ethical competence		χ	P Value
	Low	High
	3.1–4.4	4.5–5.0
Age (years)			4.8	0.44
21–25	23 (56%)	18 (44%)
26–30	38 (62%)	23 (38%)
31–35	19 (46%)	22 (54%)
36–40	18 (51%)	17 (49%)
Above 41	37 (65%)	20 (35%)
Other	11 (61%)	7 (39%)
Sex			3.0	0.8
Female	109 (60.56)	71 (39.44)
Male	26 (47.27)	29 (52.73)
Cadre			0.1	0.9
RN/RNM	57 (57%)	43 (43%)
ENM/NMT	78 (57%)	57 (42%)
Academic qualification			1.6	0.7
Certificate	27 (64%)	15 (36%)
Diploma	62 (54%)	53 (46%)
Bachelor’s degree and above	46 (59%)	32 (41%)
Type of health facility			7.4	0.2
Government	94 (61%)	60 (39%)
CHAM	12 (39%)	19 (61%)
Private	29 (58%)	21 (42%)

CHAM: Christian Health Association of Malawi; ENM: Enrolled nurse/midwife; NMT: nurse midwife technician; RN: registered nurse; RNM: registered nurse/midwife.

The scores of the clinical nurses in this study ranged from 3.16 to 5, meaning that all the clinical nurses were ethically competent. However, 57% (n = 135) had low ethical competence as their scores were within the ranges of 3.16–4.4. The rest of the clinical nurses (43%; n = 100) scored from higher than 4.4 to 5.0 and were hence classified as having high ethical competence. The differences in the proportions of clinical nurses with low and high ethical competence were significantly different, χ² = 5.213, df = 1, p = 0.022, meaning that a significantly high number of nurses had low ethical competence in this study.

To identify determinants of high level of ethical competence, logistic regression was computed, and the results of the stepwise logistic regression analysis showed that only 6 out of 45 variables in the MCSHCN were significant, meaning that the 6 variables were predictors of high-level ethical competence. The variables are as follows:

Giving care with consultation of more experienced nurses and colleagues;

Strong will to face difficult situations;

Judgement based on nursing values;

Judgement based on nursing standards;

Judgement based on institutional values and standard;

Recognition of discrepancy of intention.

However, the best-fit reduced model for prediction of high ethical competence level involved only three variables: strong will to face difficult situations, judgements based on values and standards, and recognition of discrepancy of intention. The other three variables, though significantly correlated with the level of ethical competence, were not important in the model when the effect of these three variables was already accounted for in the logistic regression model. These results were due to the fact that the MCSHCN judgement variables were also highly correlated among themselves (p < 0.05); hence, the model with six variables had a multicollinearity effect among the predictors. The final reduced model with the three predictors was significant (p < 0.05) in predicting high competence level relative to the low ethical competence level. Details of the variables in the reduced model are shown in Table 2.

Table 2.

Determinants/predictors of high ethical competence level.

Variable description	Odds ratio	P value	95% confidence interval
Strong will to face difficult situations	13	0.0001	3.60–43.11
Judgement based on values and standards	7	0.005	1.79–27.53
Recognition of discrepancy of intention	5	0.009	1.51–17.94

Results show that clinical nurses with high ethical competence are 13 times more likely to have a strong will to face difficult situations or to face problems or opposition directly than the clinical nurses with low ethical competence level. Clinical nurses with high ethical competence were seven times more likely to make judgements based on values and standards within and outside the institutions than clinical nurses with low ethical competence. Regarding the recognition of discrepancy of intention between the patient/guardian and nurse, the results show that clinical nurses with high ethical competence were five times more likely to recognize discrepancy of intention between a patient or guardian and a nurse, than clinical nurses with a low level of ethical competence (Table 2).

Indicators of ethical competence

The clinical nurses in this study reported a number of indicators/characteristics of ethical competence, with the highest indicator being caring (57%; n = 134) and the lowest being fidelity (2.1%; n = 5). The other indicators included confidentiality, privacy, dressing code, accountability, responsibility and punctuality. The perceived indicators of ethical competence according to the clinical nurses in Malawi are presented in Table 3.

Table 3.

The nurses perceived indicators of ethical competence.

Indicator	Number of Respondents (n)	Percentage (%)
Caring	134	57.0
Privacy and confidentiality	90	38.3
Accountability and responsibility	51	21.7
Dressing code	45	19.1
Discipline	30	12.8
Respect	29	12.3
Punctuality	24	10.2
Beneficence	22	9.4
Autonomy	14	6
Knowledge	14	6
Justice	12	5.1
CPD	11	4.7
Fidelity	5	2.1

CPD: Continuous Professional Development.

Discussion

The results of this study show that the majority of the clinical nurses have low ethical competence level despite that all the clinical nurses were ethically competent since no clinical nurse in this study scored less than 3. The explanation for the finding that all the clinical nurses are ethically competent is attributed to the history of nursing education in Malawi, which followed the British system. The nursing education system in Britain included nursing ethics. The British system was used because Malawi, then Nyasaland, was under the British Protectorate. Nursing ethics courses were available in nursing curriculum ever since the nursing education started in Malawi though not in detail and not adequately taught.^12,31,32 Hence, the low ethical competence level of the majority of the clinical nurses in this study implies that there are many nurses who have not done ethics course in detail and adequately. These clinical nurses with low-level ethical competence could benefit from continuing professional development in ethical courses. However, the finding that all clinical nurses in this study are ethically competent is in line with recent findings of Poikkeus et al.³³ study, whose results showed that all the nurses and nurse leaders were ethically competent. However, in agreement with the findings of this study, the nurses estimated their ethical competence to be at an average level, while the nurse leaders estimated theirs to be at a high level.³³

However, the finding that a significantly high number of clinical nurses in Malawi have a low ethical competence level is worrisome for the nursing profession in Malawi. The low ethical competence level among the nurses implies that the majority of clinical nurses in Malawi cannot ably handle complex ethical demands they meet in the course of delivering care to patients and interacting with colleagues and other health workers. Studies have shown that the nurses who cannot successfully handle ethical challenges in their day-to-day work are not resilient and are vulnerable to suffer from moral distress and its complications.^{12,15,18,19,34-38} The complexity of the modern nursing practice requires clinical nurses with high ethical competence level because they are ethically responsible. This is so because clinical nurses with high ethical competence level demonstrate ability to be sensitive to ethical issues, ethical judgement skills and strong will to implement ethical decisions. Furthermore, ethically responsible nurses are those nurses who have the ability to handle ethical demands in a critically reflective and unwavering manner.³³ Still more, studies have revealed that ethical competence should enable nurses in clinical practice to promote professional growth, facilitate reflective practice, think critically, make ethical judgements and decisions, solve ethical problems, prevent moral distress and promote conducive work environment.^1,4,16,25,39 The study by Poikkeus et al.³³ showed that nurses with high ethical competence level in practice are vital to competently and successfully manage complex ethical demands in health facilities because they have abilities to recognize and identify ethical problems, strong will to face ethical challenges and abilities to make sound ethical judgements and decisions to act ethically. Similarly, the same qualities were found to be determinants or predictors of high ethical competence level in this study. Furthermore, these qualities are absent in clinical nurses with low-level ethical competence who are in majority in Malawi. Therefore, clinical nurses in Malawi need to be supported to attain a high ethical competence level to ably handle complex ethical demands in the health facilities. The study by Poikkeus et al.³³ and Avortri et al.³⁸ revealed that ethics education among clinical nurses contributes significantly to ethical engagement and positive influence on ethical actions in nursing practice. Continuing clinical nurses’ education in ethics should be ongoing activity in the health facilities in Malawi. Supportive supervision,^{1,12,33,40,41} performance appraisal,³³ establishment of ethics committees^{14,36,38,39,41-45} in health facilities were among the evidence-based strategies that have been put forward to promote ethical competence among the clinical nurses.

The findings on the three main determinants of high ethical competence level in this study are similar to the attributes in Kulju et al.¹ Ethical competence concept analysis demonstrates professional’s personal characteristics. Thus, a strong will to face difficult situations is equated to character strength and willingness to do ‘good’ in the concept analysis. Judgement based on standards is related to moral judgement skill in the ethical competence analysis, and recognition of discrepancy of intention is likened to ethical awareness or sensitivity to identify ethical problems in the ethical competence analysis.¹ It is worth noting that these important characteristics should be present in clinical nursed to ensure provision of quality care in the health facilities.

Indicators of ethical competence

The indicators of ethical competence in this study included caring, compassion, confidentiality, responsibility, accountability, respect and justice among others. These findings are consistent with the findings in the study by Jormsri et al.,² where respondents reported the same as attributes of moral competence. Furthermore, Nunnari⁴⁶ ranked these indicators among the top 10 characteristics and good qualities of a good nurse. Still more, the same indicators are among the professional values of nursing according to the code of ethics for nurses in Malawi.⁶ This finding entails that ethically competent clinical nurses ought to portray these characteristics in their work places. If there were present in nurses there would be no complaints about the nurses’ attitudes by the consumers of nursing services. Therefore, the fact that the public is not happy with nurses’ services⁷ confirms that there is inadequate ethical competence among the clinical nurses in the country. Hence, a great need to support the nurses to boost their ethical competence.

Among the indicators of ethical competence in this study, caring was the highest (57%; n = 135). This is because nursing is about caring, and fundamentally it is agreed that nursing profession is a caring profession.⁴⁷ Whatever nurses do to patients is done in the name of caring. Caring involves a lot of components which nurses should strive to embrace, such as competence, compassion, confidence, conscience, commitment, comportment and creativity.⁴⁷ The concept of caring is characterized by noticing, participating, sharing, active listening, companioning, complementing, comforting, hoping, forgiving, sacrificing and accepting.^16,48 It is through the way caring is done to patients that they are either satisfied or dissatisfied. Therefore, this study has shown that some elements of caring among the nurses in this study are not adequately handled, evidenced by the majority of clinical nurses being scored low on the level of ethical competence. Nurses with high-level ethical competence are required to satisfy the needs of patients. Nurses associate themselves with caring consequently they feel defeated when they fail to meet the demands of patients when caring for them, hence prone to suffer moral distress.^5,12,48,49

The finding that nurses’ dressing code is one of the characteristics of ethical competence is a unique finding in this study. It is worth noting that the professional conduct of a nurse in Malawi demands nurses to be in complete uniform when on duty.⁵ It is believed that nurses’ general appearance, especially in full uniform, makes them look professionally smart, which in turn imparts a sense of confidence and reassures patients since some people associate the uniform with knowledge. Nurses’ dressing code is part of comportment and presents the presence of caring.⁴⁸ Although the nurses indicated that observing the prescribed nurses’ dressing code by NMCM is part of ethical competence, not many nurses abide to the prescribed dressing code in many health facilities across the country.⁷ This therefore entails that some nurses are not committed and responsible enough to obey the rules by their own regulatory authority. Ethically competent nurses abide to their code of conduct, rules and regulations.^33,39

Recommendation

In nursing practice, it is recommended that ethics should be among the compulsory modules prescribed by the NMCM and that the nurses in Malawi should attend regular CPD sessions in ethics each year to enhance their ethical competence level. It is also recommended that nurse managers should conduct proper supportive supervision to ensure that the clinical nurses receive the support that they need from the nurse leaders in the health facilities. External supportive supervision from the Ministry of Health and NMCM is highly recommended in the health facilities to ensure that ethical codes and nursing standards are adhered to by the clinical nurses. It is also recommended that the management teams in the health facilities should seriously consider establishing ethics committees in health facilities to allow nurses opportunities to refer and discuss some hard ethical issues with others to promote ethical growth among health workers.

Limitations and strengths

Self-administered questionnaires are associated with a low response rate, making it impossible to generalize results; however, in this study, the response rate was good because the researchers validated the questionnaires for completeness at the time the respondent submitted the questionnaires.

Second, the self-administered questionnaire may have influenced the clinical nurses to give expected answers about ethical competence, hence the finding that all the nurses were ethically competent. However, the results were both positive and negative in regard to the ethical competence level.

Third, the consumers of nursing services were excluded in assessing the clinical nurses’ ethical competence. The results from patients and guardians could have validated clinical nurses’ ethical competence. However, this could be an area of further study to get the perspectives of patients and guardians in regard to clinical nurses’ ethical competence.

Conclusion

This study suggests that although the clinical nurses in Malawi are ethically competent, there is a significantly high number of clinical nurses with low ethical competence level. The three important factors to determine high ethical competence level are a strong will to face difficult situations, judgement skills based on standards and ethical sensitivity or awareness. Adherence to nurses’ dressing code is one of the ethical competence indicators in Malawi. This study has also confirmed that MCSHCN is a reliable tool to assess ethical competence among clinical nurses in low-resource settings. Continuing nursing ethics education, supportive supervision and availability of ethics committees in the health facilities were recommended among others as evidence-based strategies to enhance ethical competence among clinical nurses.

Footnotes

Acknowledgements

The authors’ sincere gratitude is extended to all the clinical nurses who participated in this study.

Conflict of interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship and/or publication of this article.

Ethical approval

This study was approved by the College of Medicine Research Ethics Committee (COMREC), certificate number P.02/19/2611.

ORCID iDs

Veronica Mary Maluwa

Gladys Msiska

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