Is nurses’ clinical competence associated with their moral identity and injury?

Abstract

Background

The enhancement of nursing care quality is closely related to the clinical competence of nurses, making it a crucial component within health systems.

Objective

The present study investigated the relationship between nurses’ clinical competence, moral identity, and moral injury during the COVID-19 outbreak.

Research design

This cross-sectional study was carried out among frontline nurses, using the Moral Identity Questionnaire (MIQ), the Moral Injury Symptom Scale-Healthcare Professionals version (MISS-HP), and the Competency Inventory for Registered Nurse (CIRN) as data collection tools.

Participants

and research context: The research population for this study consisted of all frontline nurses (n = 251) employed in a hospital in southern Iran. Sampling was conducted between May 1, 2021 and September 30, 2021, during the COVID-19 outbreak.

Ethical considerations

The present study received approval from the research ethics committee of Rafsanjan University of Medical Sciences, with project No. 99267 and code of ethics ID No. IR. RUMS.REC.1399.262, dated 15.02.2021.

Results

According to the study findings, 42.2% of the nurses demonstrated high clinical competence, while 51.4% exhibited moderate clinical competence. The results indicated a positive correlation between moral identity and clinical competence but a negative correlation between moral injury and clinical competence. Furthermore, the variables of moral identity and moral injury were found to predict 10% of the variance in clinical competence.

Conclusion

According to the results, moral identity and moral injury had an impact on the clinical competence of nurses. Therefore, implementing a program aimed at enhancing moral identity and providing training strategies to address moral injury during crises like the COVID-19 pandemic can lead to improvements in nurses’ clinical competence and the overall quality of care they provide.

Keywords

Nurse clinical competence moral identity moral injury COVID-19

Introduction

Since its emergence in December 2019, the COVID-19 pandemic has posed a significant global health threat,¹ presenting numerous challenges for healthcare workers, particularly nurses.² As the first responders in emergency and critical healthcare situations,³ nurses have played a crucial role in the control and treatment of COVID-19 patients worldwide.⁴ However, the crisis has also brought forth a range of issues for nurses, including social phobia, anxiety, and a shortage of protective equipment, mirroring the challenges faced by the general population.⁵

During the COVID-19 outbreak, nurses faced significant risks to both their physical and mental health.^6,7 Given the pivotal role of nurses in providing care and their constant interaction with patients, they are consistently exposed to physical and mental health risks, which ultimately affect both the nurse and the patient.⁸

Ethics plays a vital role in nursing care and is an integral part of a nurse’s professional life. As nurses have extensive interactions with patients, colleagues, and their work environment, they must prioritize ethical considerations in their practice. Failure to do so can result in irreparable harm to themselves, patients, and others. Nurses must adhere to ethical principles to ensure that they do not cause harm to themselves or others.⁹

Moral identity refers to the extent to which an individual considers being moral as an important aspect of their self-concept.¹⁰ In the nursing profession, moral identity is crucial for fostering an ethical community within healthcare organizations.¹¹ It significantly influences an individual’s ability to exercise moral agency and develop ethical practices.^12,13 The sustainability of nurses’ moral identities may rely on recognizing their own needs for professional satisfaction and self-care.¹⁴

Professional ethics is closely linked to maintaining a conscientious approach toward ensuring patient safety, promoting their recovery, and upholding the values of healthcare organizations.¹⁵ However, the anxiety, stress, and challenges associated with the COVID-19 pandemic can disrupt nurses’ ability to cope and adapt effectively.¹⁶ This can potentially lead to moral injury among nurses, as they grapple with the dilemma of balancing their own physical and mental health needs with the needs of their patients. Additionally, the task of caring for severely ill patients with limited resources can further contribute to moral injury among nurses.¹⁷

The risk of virus spread during pandemics can have significant consequences and give rise to concerns regarding emotional and spiritual exhaustion, commonly known as moral distress. In extreme cases, this distress can lead to moral injury.¹⁸ When moral distress persists, it can result in moral harm, which is characterized by moral suffering and encompasses high-risk situations that violate our integrity and erode our moral core.^19,20

Background

Moral injury is characterized by a prolonged emotional, psychological, social, and spiritual impact that contradicts an individual’s moral values. Hossain et al. (2020) conducted a study on self-care strategies in response to moral injury during the COVID-19 pandemic. They found that factors such as a high mortality rate, fear of transmitting the disease to loved ones, and a lack of protective equipment could contribute to moral injury in nurses.²¹ Other studies have also demonstrated a relationship among moral injury, low religiosity, depression, anxiety, and job burnout, which can result in moderate-to-severe social, occupational, and familial problems (Mantri et al., 2020).²²

Accurate diagnosis of nurses’ moral injury is crucial in order to mitigate the long-term effects on their behavioral health.²³ Stovall et al. (2020) identified key symptoms of moral injury in nurses, including guilt, shame, spiritual-existential crisis, and loss of trust. Secondary symptoms included depression, anxiety, anger, self-harm, and social problems.²⁴ It is important to note that moral injury can have detrimental effects on the quality of patient care and the clinical competence of nursing staff.²⁵

Clinical competence is crucial for providing safe care to patients. The ability to deliver quality care services and ensure patient satisfaction is directly linked to clinical competence, which ultimately contributes to the survival of hospitals. Clinical competence encompasses a range of skills, including technical and communication skills, knowledge, clinical reasoning, as well as emotions and values that healthcare providers employ effectively in the clinical setting.²⁶

In order to optimize the allocation of clinically competent nurses and provide opportunities for their professional growth, nurse managers must be able to identify them accurately (Aued et al., 2016).²⁷ It is important to note that nurses’ clinical competence can be influenced by various factors, such as moral distress experienced during the COVID-19 outbreak. However, nursing professionalism has been found to have a positive correlation with self-control, empathy, and interpersonal competence, although it is not directly associated with ethical behavior (Je et al., 2020).²⁸

To identify moral injury in frontline nurses caring for patients with COVID-19, it is important to understand the mechanisms that expose some of these nurses to such injury.¹⁷ The problems arising from the spread of COVID-19 can have an impact on the moral identity of nurses, potentially leading to moral injury, which in turn can affect their nursing care and clinical competence. Given the lack of previous research in Iran on the factors influencing moral injury among nurses, the present study aimed to investigate the relationship among moral identity, moral injury, and the clinical competence of nurses.

Method

Study design and setting

This cross-sectional study aimed to examine the relationship among nurses’ clinical competence, moral identity, and moral injury in two public hospitals located in southern Iran, during the COVID-19 outbreak.

Sample size and sampling

The study included a total of 352 nurses who were responsible for the care of COVID-19 patients. These nurses were selected using census sampling, meaning that the entire population of eligible nurses was included in the study. The nurses had experience working in various units, including intensive care units, general wards, and other wards dedicated to COVID-19 patients. It is important to note that hospital served as the sole referral center for COVID-19 patients in southern Iran.

The inclusion criterion for the study was nurses with a minimum of 1 year of work experience in the 3 months leading up to the COVID-19 outbreak. Nurses with a history of mental disorders who were unable to complete the questionnaires were excluded from the study. A total of 352 questionnaires were distributed among the nurses, out of which 308 questionnaires were returned, resulting in a response rate of 87.5%. After removing 57 incomplete questionnaires, a total of 251 questionnaires were included in the final analysis.

Measurements

Data for the study were collected using a four-part questionnaire. The questionnaire consisted of the following sections:

Socio-demographic characteristics

This section aimed to gather information about the participants’ age, sex, educational level, marital status, number of children, work experience, shift work, income level, working hours per month, overtime hours per month, type of department, specific diseases or problems, the health status of acquaintances, adherence to precautionary measures, and areas of concern.

The moral identity questionnaire

The 28-item questionnaire developed by Black and Reynolds (2016)²⁹ consists of two subscales: moral self (items 1–8) and moral integrity (items 9–20). Participants rate their agreement on a Likert scale ranging from 1 (strongly disagree) to 6 (strongly agree). The scoring for the moral self is direct, while the scoring for the moral integrity subscale is reverse. The minimum and maximum scores for the questionnaire are 28 and 128, respectively. The questionnaire demonstrates high stability, with Cronbach’s alpha coefficients of 0.84, 0.87, and 0.90 for the moral self, moral integrity, and the overall scale, respectively.²⁹ In Iran, Abbasi et al. (2020) translated the moral identity questionnaire using the forward–backward method. The Iranian version of the questionnaire includes 15 acceptable questions, with items 1–7 belonging to the moral self and items 8–15 belonging to the moral integrity. Participants rate their agreement on a 6-point Likert scale ranging from 1 (strongly disagree) to 6 (strongly agree). The moral identity questionnaire is suitable for individuals aged 18 years and above and demonstrates acceptable validity and reliability. The Cronbach’s alpha coefficients for the subscales and the overall scale ranged from 0.80 to 0.85.³⁰

The moral injury symptom scale-healthcare professionals version

In a study conducted by Mantri et al. (2020), the moral injury of healthcare workers was measured using this questionnaire. The internal reliability of the scale was reported to be 0.75.²⁴ To ensure the face and content validity of the scale, it was presented to supervisors and advisors who provided feedback and suggestions for improvement. After incorporating their comments and making necessary corrections to some items, the questionnaire was used. The reliability coefficient of the scale was calculated using Cronbach’s alpha formula, resulting in a value of 0.74. The MISS-HP scale consists of 10 items, each rated on a visual analog scale ranging from 1 (strongly disagree) to 10 (strongly agree). To minimize response bias, four items are positively worded, while six items are negatively worded. After coding items 5, 6, 7, and 10 positively, the scores of all items are summed up to obtain an overall score ranging from 10 to 100. Higher scores indicate a higher level of moral injury. In Iran, Malakoutikhah et al. (2014) reported a Cronbach’s alpha coefficient of 0.70 for the Iranian version of this questionnaire.³¹

The competency inventory for registered nurse

The inventory used in this study was originally published by the International Council of Nurses in 2003 to assess nurses’ clinical competence in various situations. This self-report questionnaire demonstrated good validity and reliability and was developed based on the conceptual framework of general nurses’ competence. Liu et al. (2009)³² conducted a validation study of the questionnaire in Macao, China, confirming its 55-item structure with seven dimensions: clinical care, leadership, interpersonal relations, orientation to ethical/legal practice, engagement in professional development, teaching or coaching to patients and staff, and tendency toward research/critical thinking. The internal reliability of the questionnaire was established with a total Cronbach’s alpha coefficient of 0.908 (ranging from 0.903 to 0.718). The items in the CIRN are scored on a five-point Likert scale, ranging from 0 to 4. The total score ranges from 0 to 220 points, with higher scores indicating higher levels of competence. In Iran, Ghasemi et al. (2014) reported Cronbach’s alpha coefficients ranging from 0.68 to 0.97 for the Iranian version of this questionnaire.³³

Data collection

After obtaining the required permissions from Rafsanjan University of Medical Sciences, the researcher visited hospital and identified nurses who met the inclusion criteria. The sampling process took place during various shift work periods, taking into consideration the specific conditions of each department and workplace. The researcher provided a clear explanation of the study objectives and methodology to the nurses and scheduled a convenient time for them to complete the questionnaires. The sampling period extended from May 2021 to September 2021.

Data analysis

The data were analyzed using SPSS25. Descriptive statistics, including frequency, percentage, mean, and standard deviation, were employed to summarize the demographic characteristics and information related to the MIQ, the MISS-HP, and the CIRN variables. To assess the relationship between demographic information and the CIRN variables, ANOVA, independent t-tests, and, in some cases, Mann–Whitney U and Kruskal–Wallis H tests were conducted. Pearson’s coefficient was used to determine the relationship among the MIQ, the MISS-HP, and the CIRN variables, with a significance level of 0.05.

Furthermore, multiple regression models using the backward method were employed to investigate how demographic variables and other study variables predict clinical competence.

Ethical considerations

The present study received approval from the research ethics committee of Rafsanjan University of Medical Sciences, with project No. 99267 and code of ethics No. IR. RUMS.REC.1399.262. Prior to the commencement of the research, the researcher provided the nurses with a consent form. The nurses were thoroughly informed about the study objectives, the confidentiality of their information, and their full authority to withdraw from the study at any point.

Results

The mean age of the participants was 35.84 ± 7.67 years (min = 22 and max = 63). The majority of the samples were female (n = 171; 68.1%), married (n = 186; 74.1%), and held bachelor’s degree (n = 216; 86.1%). Regarding their shift schedule, most of the participants had an unfixed shift (n = 207; 82.5%). In terms of COVID-19 infection, 51.4% of the nurses (n = 129) reported being infected themselves. Additionally, 76.5% of the nurses (n = 129) reported that their relatives or friends had also been infected with COVID-19. Furthermore, 79.7% of the nurses (n = 200) expressed concerns about their families being infected with COVID-19.

In the study, the mean score of clinical competency was 161.48 ± 31.83. Out of the participants, 106 (42.2%) had high competency, 129 (51.4%) had moderate competency, and 16 (6.4%) had low competency. The mean score of moral identity was 74.63 ± 11.54, which was higher than the midpoint of the questionnaire (45). The mean score of moral injury was 42.01 ± 11.33, and 167 participants (66.5%) reported experiencing moral injury (Table 1).

Table 1.

Association between demographic characteristics and clinical competency during the COVID-19 outbreak (N = 251).

Variables	Frequency (valid percent)	Clinical competency		Statistical test	p-Value
Variables	Frequency (valid percent)	Mean	SD	Statistical test	p-Value
Sex
Male	80 (31.9)	158.00	30.09	t = −1.18	0.23
Female	171 (68.1)	163.11	32.57	t = −1.18	0.23
Age (yr.)
≤30	75 (29.9)	156.13	26.70	t = −1.74	0.08
>30	176 (70.1)	163.76	33.59	t = −1.74	0.08
Marital status
Married	186 (74.1)	163.75	32.66	t = 1.92	0.05
Unmarried/other	65 (29.9)	154.98	28.58	t = 1.92	0.05
Educational level
Bachelor’s	216 (86.1)	160.78	32.02	Z = −0.86	0.38
Master’s	35 (13.9)	165.88	30.73	Z = −0.86	0.38
Income (million toman)
<7	94 (37.5)	161.70	31.71	Z = −0.17	0.86
>7	157 (62.5)	161.35	32.00	Z = −0.17	0.86
Type of employment
Hired	137 (54.6)	162.51	34.03	Z = −0.65	0.51
Contract recruiters^a and committed^b	114 (45.4)	160.23	29.07	Z = −0.65	0.51
Work experience (yr.)
>5	66 (26.3)	161.51	26.87	F = 2.65	0.04
5–10	64 (25.5)	154.18	29.98
11–15	65 (25.9)	160.90	35.25
>15	56 (22.3)	170.44	33.66
Ward
Critical/intensive	64 (25.5)	165.60	30.54	F = 0.55	0.64
Emergency	35 (13.9)	157.97	33.23
Medical	96 (38.2)	160.97	32.89
Others	56 (22.4)	159.82	30.91
Shift
Fixed	44 (17.5)	159.04	36.81	t = −0.49	0.62
Unfixed	207 (82.5)	162.00	30.75	t = −0.49	0.62
Overtime (h)
0–30	34 (13.5)	154.64	30.35	F = 1.53	0.20
31–60	97 (38.6)	163.83	32.04
61–90	83 (33.2)	158.45	32.22
>90	37 (14.7)	168.37	31.01
Chronic illness
Yes	48 (19.1)	159.75	32.67	Z = −0.62	0.52
No	203 (80.9)	161.89	31.70	Z = −0.62	0.52
Direct contact with the COVID-19 patients
Yes	179 (71.3)	162.24	30.35	t = 0.56	0.57
No	72 (28.7)	159.58	35.41	t = 0.56	0.57
Infected with the coronavirus
Yes	129 (51.4)	163.36	31.35	t = 0.96	0.33
No	122 (48.6)	159.49	32.34	t = 0.96	0.33
Relatives/friends infected with the coronavirus
Yes	192 (76.5)	160.80	31.18	t = −0.61	0.54
No	59 (23.5)	163.69	34.04	t = −0.61	0.54
The most important concern about the coronavirus
My family getting sick	200 (79.7)	161.62	31.52	t = 0.14	0.88
Others^c	51 (20.3)	160.92	33.34	t = 0.14	0.88

^aAnnually contracted with payment similar to hired nurses.

^bIt is obligatory to work for government for 2 years at a lower rate of pay. SD = standard deviation, t = independent t test, F = analysis of variance, Z = Mann–Whitney U.

^cDeath, getting sick, quarantine, hospitalization, and no concern.

The analysis revealed a significant positive correlation between moral identity and clinical competency (p < .001). However, there was a significant negative correlation among moral injury, clinical competency, and moral identity (p < .001) (Table 2).

Table 2.

Correlation among clinical competency, moral identity, and moral injury during the COVID-19 outbreak (N = 251).

Variable	Mean ± SD	Range	Pearson’s rho correlation coefficient (p-value)
Variable	Mean ± SD	Range	1	2	3	4	5	6	7	8	9
1. Moral identity	74.63 ± 11.54	44–90	1
2. Moral injury	42.01 ± 11.31	12–77	−0.31 (<0.001)	1
3. Clinical care	29.29 ± 6.16	14–40	0.29 (<0.001)	−0.24 (<0.001)	1
4. Leadership	27.09 ± 5.43	13–36	0.24 (<0.001)	−0.23 (<0.001)	0.83 (<0.001)	1
5. Interpersonal relationships	23.86 ± 4.72	12–32	0.25 (<0.001)	−0.20 (<0.001)	0.86 (<0.001)	0.87 (<0.001)	1
6. Ethical/legal performance	23.62 ± 4.93	11–32	0.24 (<0.001)	−0.19 (0.002)	0.86 (<0.001)	0.87 (<0.001)	0.85 (<0.001)	1
7. Professional development	16.77 ± 4.38	6–24	0.21 (<0.001)	−0.25 (<0.001)	0.77 (<0.001)	0.73 (<0.001)	0.80 (<0.001)	0.75 (<0.001)	1
8. Coaching/training	17.60 ± 3.77	8–24	0.23 (<0.001)	−0.21 (<0.001)	0.86 (<0.001)	0.86 (<0.001)	0.86 (<0.001)	0.87 (<0.001)	0.75 (<0.001)	1
9. Desire for research/critical thinking	23.22 ± 4.90	10–32	0.19 (0.002)	−0.22 (<0.001)	0.85 (<0.001)	0.81 (<0.001)	0.86 (<0.001)	0.86 (<0.001)	0.82 (<0.001)	0.85 (<0.001)	1
10. Clinical competency	161.48 ± 31.83	84–220	0.26 (<0.001)	−0.24 (<0.001)	0.93 (<0.001)	0.92 (<0.001)	0.94 (<0.001)	0.93 (<0.001)	0.86 (<0.001)	0.93 (<0.001)	0.93 (<0.001)

SD = standard deviation.

Among the demographic variables, only work experience showed a significant relationship with clinical competency (p = .04).

The results showed that the R² for nurses’ clinical competency was 0.107, so all independent variables (moral identity and moral injury) could predict nearly 10% of the variance of clinical competency in nurses. The results of the path analysis indicated a significantly direct correlation between the variables, meaning a positive association between moral identity and clinical competency (standardized β = 0.19, 95% confidence interval = 0.20–0.89, p value = .002) but a negative correlation between moral injury and clinical competency (standardized β = −0.18, 95% confidence interval = −0.86 to −0.16, p value = .004) (Table 3) (Figure 1).

Table 3.

Standardized path coefficients of the modified model (n = 251).

Direct path	Estimate	S.E.	C.R.	p-Value
Nurses’ clinical competency <-- moral identity	0.56	0.17	3.22	0.001
Nurses’ clinical competency <-- moral injury	−0.50	0.17	−2.82	0.005

S.E: standard error; C.R: critical ratio.

Figure 1.

Standard coefficients of the modified model.

The multiple regression analysis using the backward method was conducted to examine how demographic variables could predict clinical competency. Table 4 indicates that moral identity, moral injury, age, and overtime collectively predicted 10% of the variance in clinical competency. Among these predictors, moral identity was found to be the strongest and most significant predictor (p < .001).

Table 4.

Multiple regression analysis summary for underlying variables of the clinical competence of nurses during the COVID-19 outbreak (N = 251).

Variable		B	SE^a	β	T	p	95% Confidence interval for B	R²
Clinical competence	(Constant)	135.01	17.40	—	7.75	<0.001	100.73 _ 169.28	%10
	Moral identity	0.54	0.17	0.19	3.12	0.002	0.20 _ 0.89
	Moral injury	−0.51	0.17	−0.18	−2.87	0.004	−0.86 _ −0.16
	Work experience	2.95	1.73	0.10	1.70	0.090	−0.46 _ 6.36

^aStandard error.

Discussion

The present study aimed to examine the correlation among nurses’ moral identity, moral injury, and clinical competence during the COVID-19 epidemic. The findings of the study revealed that 42.2% of the participants demonstrated high clinical competence, while 51.4% exhibited moderate clinical competence. These results are consistent with the findings of Zakari et al. (2020), who reported that 36.1% of nurses displayed high clinical competence, while 57% demonstrated moderate clinical competence.³⁴ Additionally, Faraji et al. (2019) reported favorable mean scores of clinical competencies among nurses,³⁵ and Adib Hajbaghery and Eshraghi Arani (2018) found that nurses exhibited a good level of clinical competence.³⁶ According to Nabizadeh-Gharghozar et al. (2021), clinical competence is acquired through the acquisition of knowledge, values, attitudes, and skills via practice and repetition over time.³⁷ Therefore, it is crucial for nurses to develop personal, social, and professional competencies to enhance their clinical competence. Nurse managers should implement effective interventions to enhance nurses’ clinical competence, ultimately leading to improved patient care.

The study findings revealed a positive association between moral identity and clinical competence. This aligns with the findings of Mestvirishvili et al. (2020), who also identified a significant positive relationship between moral identity and competence.³⁸ Haghighat et al. (2020) further supported this notion by observing a positive correlation between professional identity and ethics in nursing students. They emphasized the importance of nurses acquiring high levels of moral competence by strengthening their moral values, as they often encounter moral decisions in clinical settings.³⁹ Therefore, it is crucial for nurse managers to prioritize the enhancement of nurses’ moral competence. Given the cultural and social differences across societies, further research is necessary to gain a more comprehensive understanding of the ethical implications on clinical care.

Our study also identified a negative correlation between moral injury and clinical competence. This finding is supported by Jafari et al. (2019), who acknowledged that incompetent colleagues could contribute to moral injury.⁴⁰ Healthcare environments often contain potential moral stressors that can lead to moral injury in nurses.⁴¹ These stressors may arise from situations such as performing CPR on a patient or sudden changes in a patient’s clinical condition.⁴² Additionally, interpersonal conflicts and working with professionally incompetent colleagues can also contribute to moral injury and a sense of incompetence among nurses.^41,43 To address these issues, it is essential for nursing curricula to be expanded and given more attention to enhance the knowledge and competencies of nursing personnel.⁴⁰ Therefore, nurse managers should have a comprehensive understanding of the causes of moral injury, particularly during crises like the COVID-19 outbreak, in order to effectively support their nursing staff.

We found a negative correlation between moral identity and moral injury.

It has been demonstrated that when nurses act against their beliefs and values, they may provide poor care and compromise their professional identity, which can lead to moral injury (Haahr et al., 2020).⁴⁴ The moral values held by nurses are integral to their moral identity,⁴⁵ and moral injury occurs when individuals engage in actions that undermine these values.⁴⁶ To attain high levels of moral competence, clinical nurses must effectively navigate complex ethical challenges in healthcare settings. Therefore, managers should prioritize the moral identity of nurses to mitigate moral injury, empower them to cultivate a strong moral identity and competence, and implement strategies such as continuing ethics training, establishing ethics committees, and providing supportive supervision to enhance moral competence.⁴⁷ Future studies should further explore the impact of nurses’ moral identity in clinical environments.

Furthermore, our study indicated that moral identity and moral injury accounted for 10% of the variance in clinical competence. The literature review also suggests the influence of various factors on clinical competence. For instance, Kheirandish et al. (2022) found that moral intelligence played a significant role in predicting nurses’ clinical competence, explaining 43% of the variance in nurses’ competence.⁴⁸

Also a relationship among nurses’ compassion satisfaction, compassion fatigue, and clinical competence was demonstrated (Zakeri et al. 2021).³⁴ However, Ramezanzade Tabriz et al. (2017) found no correlation between professional ethics and clinical competence.⁴⁹ These differing results could be attributed to variations in sampling, the use of different measurement tools, and cultural differences. Nonetheless, it is important for managers and personnel to be aware of the level of clinical competence and moral status of nurses, as this information can be valuable in developing effective in-service training programs and improving the quality of nursing services. Holding educational workshops can also contribute to strengthening attitudes toward the clinical competence of nurses.⁴⁸

Limitations

The present study had several limitations that should be acknowledged. Firstly, the reliance on self-assessment by nurses to measure their competency may have introduced subjectivity and potential inaccuracies in the results. To address this limitation, we recommend that head nurses and managers provide assessments to ensure more objective and comparable results.

Another limitation of the study was the scarcity of research on moral injury during the COVID-19 outbreak. This lack of existing literature on the topic should be taken into consideration when interpreting the results.

Additionally, as a cross-sectional study, it was not possible to establish cause and effect relationships. Future research should consider longitudinal studies that can provide more robust evidence.

Conclusion

The study results revealed that over 40% of the nurses demonstrated high clinical competence, while more than 60% of the participants experienced moral injury. This highlights the importance of understanding the relationship among moral identity, moral injury, and clinical competence among nurses during the COVID-19 outbreak. Given that clinical competence is a crucial factor in delivering quality and safe care, it is essential for nurses to possess adequate competence. One potential solution is for managers to organize in-service training courses to enhance the knowledge and skills of nurses.

The COVID-19 crisis has heightened the risk of moral injuries among nurses, making it imperative to provide them with training on how to effectively cope with such injuries. Further research is necessary to explore the effects of crises on the moral status of nurses, in order to gain a broader perspective and develop strategies to address these moral dilemmas.

Recommendations for the practice

Experiencing a crisis heightens the vulnerability of nurses to moral distress. As a result, it is crucial for managers and policymakers to proactively address these moral injuries and identify the factors that contribute to them. By being cognizant of the level of clinical competence and moral well-being of nurses, managers can gather valuable insights to develop effective training programs aimed at enhancing the quality of nursing services. It is worth noting that moral identity and competences can be nurtured through practical experience. Therefore, fostering the moral identity of nurses, starting from their academic education, can guide them toward embracing appropriate moral goals and navigating ethical challenges throughout their careers.

Footnotes

Acknowledgments

This study is a part of the research project (project No. 99267). We would like thank the authorities of the Social Determinants of Health Research Centre, Clinical Research Development Unit, Ali-Ibn Abi-Talib Hospital, Rafsanjan University of Medical Sciences, Rafsanjan, Iran. Additionally, we extend our heartfelt appreciation to all the nurses who participated in this study from various locations across Iran.

Declaration of conflicting interests

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

Funding

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

ORCID iDs

Yue Teng

Mahlagha Dehghan

Mohammad Ali Zakeri

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