Original Manuscript
Ethical competence: A concept analysis
Nursing Ethics 1–12 ª The Author(s) 2015 Reprints and permission: sagepub.co.uk/journalsPermissions.nav 10.1177/0969733014567025 nej.sagepub.com
Kati Kulju, Minna Stolt, Riitta Suhonen and Helena Leino-Kilpi University of Turku, Finland
Abstract Background: Exploring the concept of ethical competence in the context of healthcare is essential as it pertains to better quality of care. The concept still lacks a comprehensive definition covering the aspects of ethical expertise, ethical knowledge and action of a health professional. Objective: This article aims to report an analysis of the concept of ethical competence. Method: A modified strategy suggested by Walker and Avant was used to analyse the concept. Results: As a result, the concept of ethical competence can be defined in terms of character strength, ethical awareness, moral judgement skills and willingness to do good. Virtuous professional, experience of a professional, human communication, ethical knowledge and supporting surroundings in the organisation can be seen as prerequisites for ethical competence. Ethical competence results in the best possible solutions for the patient, reduced moral distress at work and development and democratisation of society. Conclusion: The results of the analysis establish a basis for an instrument to evaluate health professionals’ ethical competence. It will guide educators, as well as managers in healthcare, to support the development of ethical conduct in healthcare. Keywords Concept analysis, ethical competence, healthcare, moral competence, nursing
Introduction Ethics is seen as a foundational competency in healthcare.1 Investigating the concept of ethical competence is internationally relevant. In the European Qualifications Framework, the European Commission2 describes ethical competence as meta-competence, an integral part of knowledge, skills and competence, and as essential for the development of responsibility and autonomy. In addition, the World Health Organization (WHO) Global Competency Model states several core qualities that are related to the concept of ethical competence, for example, active listening and respecting individual differences.3 The UK Clinical Ethics Network has made a consensus statement about core competencies for clinical ethics committees, for example, the definition of competencies required for the provision of ethics support and guidance for health professionals, including knowledge, skills and personal attitudes.4 Ethical competence can be seen as a part of professional competence5,6 and honesty and loyalty to patients.7 It is assumed to be learned through role models and experience,7 consisting of virtues, principles
Corresponding author: Kati Kulju, Department of Nursing Science, University of Turku, FI-20014 Turku, Finland. Email: [email protected]
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and critical reflection.8 In the literature, the concept of ethical competence has been used, for example, in nursing and physiotherapy curricula and described in multiple ways. This concept, however, still lacks a comprehensive definition covering even some of the aspects of ethical expertise, ethical knowledge and action of a healthcare professional. Furthermore, no previous analyses of the concept have been done. The concept of ethical competence is worth exploring as it pertains to competence development of healthcare staff, effective professional and continuing ethics education and, finally, better quality of care. The modern healthcare environment with increased financial and organisational changes requires wide professional competencies including ethical competence in handling moral problems.9 Healthcare educators, leaders and researchers need to give high priority to the development of ethical competence of health professionals.1 Health professionals encounter situations in which they have to make decisions affecting other people. These decisions can sometimes be hard. That is why those professionals need to have the ability to see the ethical dimensions of their work – besides the technical competence.10 In healthcare, the processes should also be human-oriented, recognising an individual patient’s needs, as well as social and cultural backgrounds, to ensure dignity and respect in care.6 The aim of this study was to analyse the concept of ethical competence. The goal is to develop an operational definition of the concept to be used and studied in the empirical world of healthcare.
Background To identify the concept under investigation, the concepts ethical and competence need to be defined separately, because the term ‘ethical competence’ is made up of two nouns and the dictionaries do not offer a definition for the concept ‘ethical competence’. In this study, the concepts ethical competence and moral competence are treated as synonyms for the following reasons: Both ethics and morals have been defined as theories about wrong and right actions.11 In nursing literature, the concepts have often been used synonymously and interchangeably6,12,13 even if the distinction between these terms can also be found. Moral refers to standards of behaviour followed by individuals, including rules and individual values. Ethical refers to a science or study of morals, ethical principles and decision-making skills.13 Because it was important to find all the relevant literature in this area, both concepts were included in the analysis (Figure 1). In dictionary definitions, the term ethical is defined as ‘pertaining to morality or the science of ethics’23 or as ‘relating to moral principles or the branch of knowledge dealing with these: ethical issues in nursing, ethical standards’.24 According to Merriam-Webster Online Dictionary,18 the term ethical involves or expresses ‘moral approval or disapproval’, ‘conforming to accepted standards of conduct’. In addition, the term moral is seen as a synonym of the term ethical,18 which is an essential remark in this study aiming to focus on the concept of ethical competence. The definition of competence varies between theoretical and philosophical contexts. According to Merriam-Webster Online Dictionary,18 competence is defined as ‘a sufficiency of means for the necessities and conveniences of life’ and ‘having sufficient knowledge’ to enable an action. Oxford English Dictionary23 states that competence is ‘sufficiency of qualification; capacity to deal adequately with a subject’. Some concept analyses of the concept of competence in the context of healthcare have been done.25–28 Competence in nursing is seen as knowledge or skills,9,25–27 actions,25,27 professional standards or role models25,27 and internal regulation or self-assessment skills.25,26 Garside and Nhemachena28 see competence as an integration of performance and capability. Also, Lind29 sees competence not only as the concept of subject knowledge but also as responsibility for and understanding of one’s own action. Competence in the context of intensive and critical care nursing has, according to Lakanmaa,30 five dimensions: knowledge base, skill base, attitude and value base, nursing experience base and personal base. Ethical competence cannot be distinct from other competencies but is a generic competence guiding the others.22 In this study, it was assumed that ethical competence is 2
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Ethical competence
Synonymous usage of the
Moral competence
(e.g. Kavathatzopoulos14;
concepts ethical and moral
(e.g. Jomsri et al.19;
Kävlemark Sporrong
(e.g. Bolmsjö et al.16;
Duriez and Soenens20;
et al.9; Baerøe and
Eriksson et al.8; Paganini
Ma21; Park and
and Egry6; Buzgová and
Peterson22)
Norheim15)
Sikorová17; MerriamWebster Online Dictionary18)
Inclusion of the concepts ethical and moral competence in this analysis
Figure 1. Clarification of the inclusion of the concepts ethical and moral competence in the concept analysis.
implicitly a part of all the dimensions of competence in the healthcare context as an umbrella concept. Hence, it was essential to investigate the concept of ethical competence through a concept analysis to find out if it could add something that is common to all the dimensions of competence in healthcare.
Method Concept analysis was chosen as a method to describe the concept of ethical competence. It is essential to be able to capture the critical elements and develop an operational definition of the concept under examination. That way, it is possible to strengthen the evidence base for practice in healthcare and to promote understanding about the phenomena of interest.31 In the analysis of the concept of ethical competence, an entity theoretic strategy based on Wilson’s31 method and modified by Walker and Avant32 was employed, because professionals’ ethical competence in healthcare needs to become observable and professionals’ competence is increasingly being evaluated in the organisations. This method has earlier been used to analyse ethical concepts in nursing science, for example, consent,33 autonomy,34,35 equity,36 empathy37 and compassion fatigue.38 The key elements of this method are the eight steps as follows: (1) select a concept, (2) determine the aims and purposes of the analysis, (3) identify all concept uses, (4) determine defining attributes, (5) establish a model case, (6) examine additional cases, (7) acknowledge antecedents and consequences and (8) define empirical referents.31 The first two steps are completed in the ‘Introduction’ and ‘Background’ sections of this article. A literature search was conducted to identify all the possible uses of the concept, allowing the inclusion of diverse methodologies in research reviewed, combining both theoretical and empirical reports, and hereby reaching deeper understanding of the concept.39 In this study, the method of Walker and Avant was modified as steps 5 and 6 were excluded from the analysis. Defining attributes (4), antecedents 3
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and consequences (7) as well as empirical referents (8) were identified as follows, to gain maturity for the concept, which is essential before the concept can be operationalised.40
Data sources A literature search of the CINAHL, MEDLINE and ERIC databases was conducted using the search terms ‘ethical competence’ or ‘moral competence’ from the earliest date possible to May 2012, yielding a total of 358 citations. The search was updated in December 2013. Although the concept ‘ethical competence’ was under examination, it was also essential to clarify the meaning and the uses of the concept ‘moral competence’, as both terms have been used synonymously (see Figure 1.), and it was important to find all the relevant literature in this area. It was essential to include the education literature database ERIC in the search as the starting point for professional competence development lies in professional education. A search was also made via hand-searching of reference lists, books and dictionaries. The abstracts were examined against the inclusion and exclusion criteria. The inclusion criteria were English language, abstract available and a theoretical or empirical article. The exclusion criteria were an anonymous article, a book review, a commentary or an editorial. The articles irrelevant to the topic and duplicates were excluded. It appeared that most of the research in the area has been done in healthcare, but also in educational sciences, in psychology and in business. A total of 61 abstracts were taken into further analysis and read independently by two researchers (K.K., M.S.). Finally, altogether 18 articles, 12 theoretical and 6 empirical ones defining the concept of ethical competence and ranging from the year 1993 to 2012 were included and analysed using inductive content analysis. The contents of the answers were categorised into groups by using words, phrases or sentences as units of analysis and divided into meaning units, which were condensed. Condensation as a process of shortening the text was used to preserve the core of the text. The condensed meaning units were then abstracted and sorted into categories – into attributes, antecedents and consequences.41
Results The first two steps – selection of the concept and determining the purposes of this analysis – are completed in the ‘Introduction’ and ‘Background’ sections of this article. In the third step of the analysis, as many uses of the concept as possible were sought by using available literature widely and open-mindedly. This stage is essential in supporting and validating the choices of the defining attributes.31
Use of the concept The uses of the concept have been sought from the literature chosen.42 The literature reveals four main contexts for the use of the concept: (a) human growth, (b) skill and knowledge, (c) education and (d) evaluation of professionals. Human growth. Ethical competence is used as a core concept in some ethical theories describing human growth in the ethical sense; this can be identified at least in the following theories: In the fourcomponent model of moral behaviour, each component – moral sensitivity, moral judgement, moral motivation and moral character – is needed for moral act, building moral competence.43 Strengthening these components may have a positive effect on an individual’s ethical competence.15 Kohlberg’s six stages theory of moral development describes morality as a competence to make judgements and decisions in line with ethical principles. He uses the term moral competence as the capacity to make moral decisions and judgements and to act in accordance with the decisions.44 4
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According to Jomsri et al.,19 moral competence in nursing context has been used as ability or capacity of persons to recognise their feelings as they influence what is good or bad in particular situations and then to reflect on these feelings, to make their decision, and to act in ways that bring about the highest level of benefit for patients.
Eight attributes for the concept moral competence were defined, derived from personal, social and professional values and including virtues such as honesty, kindness and compassion. As a result, a model of moral competence was constructed representing the conceptualisation of moral competence in nursing in Thailand.19 The concept ethical competence is also used in the context of a Communicative-Based Model, which suggests being (virtues), doing (rules and principles) and knowing (critical reflection) to be the elements in the development of ethical competence in healthcare,8 as well as in Sandman’s Teleological model.16 In this model, decision-making in nursing is combined with central values in healthcare. One of the basic ethical considerations in this model is the nurses’ ethical competence.16 Skill and knowledge. Ethical competence has been used as a psychological skill, ‘based on the psychological ability described as autonomy’. It is based on skills, but theoretical ethical knowledge is also important in ethical competence building.14 The concept has been used related to an ability to notice the ethical aspect and to realise one’s responsibilities in the situation, and to an ability to act in a certain way in a situation in which there occurs an ethical problem.14,16 It includes communication skills to find out a person’s value priorities in a certain situation, being also a part of a teleological model for the analysis of everyday ethical situations.16 The use of the concept ethical competence can also be seen in WHO Global Competency Model, which states several core qualities that can be considered as related to ethical competence: active listening, time and understanding in communication with others, responsibility for one’s own work, collegiality, ability to identify conflicts, respecting others’ individuality, acting confidentially, according to the ethical and legal framework and personal values.7 In this study, clinical and professional as well as personal competences are handled as one component, in which ethical competence plays a significant role. The idea of the use of the concept ethical competence as a development of knowledge and skills can be reached with the hierarchy of competence, the approach of Know-Can-Do,45 in which the first dimension includes the body of the knowledge needed to identify ethical dilemmas, the second dimension includes analysing of the conflict and being sensitive to competing values and principles and the third one ensuring the decisions to come true.46,47 It must be noticed that people who have theoretical knowledge in ethics are not automatically ethically competent individuals.9 On the other hand, it has been stated that ethical competence is not always something that every healthcare professional should have a certain amount of, but rather something that the whole care team should have.16 The concept moral competence has been used as related to altruistic behaviour and ability to advanced, consistent and logical moral judgement.21 It can be seen as an ability to make an ethical decision, and deal with ethical issues in practice.19,29 Ka¨vlemark Sporrong et al.9 state that ethical competence is also essential in preventing or reducing moral distress. Along with moral reasoning, it has been used as a component of moral judgement competence.29,44 Education of professionals. Ethical competence has been used as and learned through a combination between knowledge, practice and experience. Thompson et al.13 introduce four different approaches to teaching ethics, in the core of which is sensitivity and willingness to identify the needs of a human being, practical wisdom and ability to critical thinking. Some research in healthcare and also in business14,48 has been done for the purpose to build a knowledge base for the assessment of ethical competence. 5
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Evaluation of professionals. Assessment of ethical competence is important, for example, to be able to offer and evaluate effective ethics teaching and education, ethical knowledge and skills achieved through education, and for curriculum development,49 as well as for achieving higher effectiveness at the organisational level14 – ethical competence should be continuously re-evaluated.6 Few instruments have been used to measure ethical competence or parts of it. In healthcare, the assessment of ethical competence is done mostly as a small part of clinical competence evaluation tools.50–52 The dimension of ethical competence as a part of competence assessment seems to be one large dimension – the ethical sub-themes occurring through the measurement tool’s themes51,53 – and should be examined as an important individual dimension of competence in healthcare.
Defining attributes The fourth step of the analysis, defining the attributes, is an attempt to find the characteristics that most frequently occur in relation to the concept in the literature.31 This was an essential stage of the concept analysis because the attributes are important when transforming the concept to a more abstract level and subsequent operationalisation.40,42 As a result of the concept analysis, the following attributes defining ethical competence were repeatedly presented by seven different authors in the reviewed literature. They all illustrate the professional’s personal characteristics and can be outlined as follows: (a) character strength, (b) ethical awareness, (c) moral judgement skills and (d) willingness to do good. Character strength. At the core of ethical competence – guiding the person to desire and do good – is character strength.4,16,19,22 Ethical competence is a function of individual characteristics,16 which, at the organisational level, includes the ability and strength to support ethical processes.14 Without character strength, an individual does not have the desire to do what is right, the temperance, humanity or courage to implement the right action.22 Ethical awareness. Ethical awareness, meaning ethical perception, attentiveness or sensitivity to identify an ethical problem, is an important attribute to ethical competence when dealing with a situation in which it is difficult to recognise what constitutes good or bad.14–16,19,49 A professional also needs to have the awareness to recognise the individual needs and social and cultural background of a patient.6 Moral judgement skills. An ethically competent person is able to think and act openly, without moral fixations or automatic ways of action; having the ability to consider critically and logically all values, principles, needs and beliefs; and making moral judgements consistently, from the alternatives involved in an ethically demanding situation.14,16,19,21,47,49 This attribute includes also that the professional is autonomous in his or her thinking.14 Willingness to do good. Ethical competence is willingness to implement the decisions made and act for the benefit of other people.14,16,19,54 A professional person needs to have motivation and a desire to do the good thing,22 so willingness to do good was named to be an essential part of ethical competence.
Antecedents At step 7 of the analysis, antecedents are preconditions to the existence of the concept to come true and need to appear before the concept.31 As a result of the concept analysis, the following antecedents that must exist prior to ethical competence were alternatingly presented by 12 authors and are (a) virtuous professional, 6
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(b) experience of a professional, (c) human communication, (d) ethical knowledge and (e) supporting surroundings in the organisation. Ethical competence has a few prerequisites which can be found in professionals’ individual, virtuous characteristics.8,16,54 First, to be able to act in an ethically competent way, an individual needs to have the ability to and practise virtues such as empathy55 and practical wisdom, which is seen as a capacity that motivates and is required to judiciously choose the right actions in a situation.13,54 Ethical competence cannot be developed without virtues.8,56 Along with individual characteristics, some other antecedents can be found: Second, ethical competence derives from experience of a professional person6,7,54,57 and can be enhanced through the career.58 Third, it requires human communication, meaning the ability to express oneself clearly14,16 and to participate, influence and be listened to.8 Fourth, ethical knowledge which can be acquired through education9,14,20,29,54 seems to be the one prerequisite occurring before ethical competence and should be emphasised in promotion of ethical competence.6 Finally, the organisation structure plays a significant role in either hindering or enabling the professional’s acting in an ethically competent way. That is, besides the caregiver’s individual character, the structural situation and organisational support are the factors helping him or her to follow the preferred action.7,14,16,59
Consequences At the eighth step of the analysis, the consequences are the outcomes of the concept, resulting from the realisation of the attributes.31 The consequences of ethical competence are positive in nature, which is impending. In summary, the consequences of ethical competence in profession, which were repeatedly present in the literature by six different authors, are (a) the best possible solutions for the patient, (b) reduced moral distress at work and (c) development and democratisation of society. At the professional level, the most apparent consequence resulting from an ethically competent act is to be able to provide as good care as possible and the best solutions for the patient,16 including increased moral equality in care15 and enhanced safety.14 Second, it has been stated that ethical competence has an important role in preventing and reducing moral distress.9 Reduced ethical tensions in care and, as a result, reduced moral distress at work7,9,14,15 occurred in literature as a consequence of health professionals’ ethical competence. Finally, at the society level, as a result of ethical competence, development and democratisation of society is possible.20,60 As Lind60 has stated, widely shared general and universal moral principles and ideals are a precondition for a democratic society. Moral judgement skills are essential for the development of community. This concept analysis supports this point of view. Ethical competence leads to well-being.20 The antecedents, consequences and attributes as well as uses of the concept of ethical competence are summarised in Figure 2.
Empirical referents To identify empirical referents for the defining attributes was the final step in the concept analysis. Empirical referents can be used to measure the concept.31 The existence of the concept ethical competence in the reality can be demonstrated by introducing the research instruments that have been developed to measure ethical competence of professionals and can be identified in the reviewed literature. All the attributes defined in this concept analysis seem to be realised as somehow measurable in one existing instrument, Moral Competence Scale (MCS),61 which is based on the model of moral competence in nursing practice in Thailand. The model derives from personal, social and professional Thai nursing values.19 This model of moral competence seems to illustrate all the attributes defined in this study, with the 7
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ETHICAL COMPETENCE USE OF THE CONCEPT OF ETHICAL COMPETENCE •
Human growth
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Skill and knowledge
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Education of professionals
•
Evaluation of professionals
ANTECEDENTS •
•
ATTRIBUTES
virtuous
•
character strength
professional
•
ethical awareness
solutions for the
experience of a
•
moral judgment
patient
professional •
CONSEQUENCES
human
skills •
communication
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reduced moral distress at work
willingness to do good
the best possible
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development and
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ethical knowledge
democratisation of
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supporting
society
surroundings in the organisation
A DEFINITION AND OPERATIONALISATION OF THE CONCEPT OF ETHICAL COMPETENCE
Figure 2. Uses, antecedents, attributes and consequences of the concept of ethical competence.
instrument including five scenarios presenting ethical issues in nursing practice,61 hence making the phenomenon operationalised and measurable. However, because of the cultural differences in Asian and Western countries, it is difficult to conclude how the empirical referents of the concept of ethical competence in this study are represented with the MCS.
Discussion The aim of this study was to analyse the concept of ethical competence. The goal was to develop an operational definition of the concept to be used and studied in the empirical world of healthcare. 8
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When the attributes are combined with antecedents and consequences, a definition of a concept of ethical competence and a building block of theory construction is formed. Based on the results, ethical competence can be defined in terms of character strength, ethical awareness, moral judgement skills and willingness to do good. The main focus in this study was to identify the attributes, antecedents and consequences of the concept to gain maturity of the concept for the purpose of operationalisation.40 The antecedents and consequences were used to guide the identification of the attributes62 and vice versa, and as the amount of the literature was reasonable and coherent as well, presentation of the fabricated model case or additional cases to illustrate the concept ethical competence was not considered necessary. In addition, the model case developed deductively from the predetermined attributes does not increase the reliability of the results.42 Hence, the researchers decided to modify that part of the concept analysis method of Walker and Avant. Exploring the concept of ethical competence is essential as it pertains to competence development of the healthcare staff and effective professional and continuing ethics education. To support ethical competence of healthcare professionals, there have been multidisciplinary ethics committees in healthcare organisations and also ethics consultation and education available. Nowadays, the possibilities still vary among organisations to get consultation in ethical issues, for example, in the form of discussion groups and education. Considering the attributes this study reveals to be essential for the existence of ethical competence, there should be possibilities for all healthcare professionals to strengthen their ethical competence. That could be done via developing ethical awareness and courage, for example, in ethics clubs discussing about the different ethical cases, or via strengthening moral judgement skills in virtual ethics labs or with ethics games. The results of the analysis have some similarities with ethical decision-making models in nursing,13,16 but also in the model of fundamental patterns of knowing, which is based on Carper’s (1978) description and extended by Chinn and Kramer.63 According to this model, ethical knowledge is strengthened through dialogue and justification and will lead to ethical comportment.12 When looking at the concepts through the Rest’s four-component model framework, it can be noticed that attributes defining the concepts also have something in common with this model’s components.43 In further study, the results of this concept analysis will be used for describing and developing ethical competence as an explanatory middle-range theory in healthcare context and further for the development of a tool to evaluate practising healthcare professionals’ and students’ ethical competence. As the empirical referents show, an instrument to measure ethical competence exists, but not a comprehensive instrument which could measure all the aspects of ethical competence in the Western World that this study reveals.
Limitations and strengths This study has some limitations. Even if the concept analysis aimed to be rigorous, the results are still tentative: The chosen concept analysis method illustrates situation based on existing literature. The method, steps in the concept analysis of Walker and Avant, is clearly presented in the literature, but this is not the case with the process of the analysis itself. As the applied concept analysis method has an entity theoretic approach,31 the attributes found in the analysis must be defined to become observable and measurable. With ethical concepts, this might be challenging – however, the authors found it important to analyse the concept so that it can be tested in the empirical world. Considering the reliability of the results, it must be noticed that even if the literature reveals these dimensions presented in Figure 2, the concept of ethical competence has not been previously described this broadly in the literature. Hence, when the concept has been operationalised and actually the validity of the analysis tested40 – ethical competence assessed empirically and objectively in a clinical environment – this concept analysis can be taken under re-examination at a new level. 9
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Conclusion The results of this concept analysis produced a definition of the concept ethical competence. Ethical competence in healthcare is a personal capacity including ethical awareness, courage, willingness and skills in decision-making and ethical action. It requires support from the organisation, and at the personal level emerges from experience, knowledge and communication. It results in positive outcomes for the patient, professional and society. The results provide new knowledge and insight to the area of healthcare. Ethical competence is pictured and implemented in curricula all over Europe – the results will be used in evaluation of ethical competence to begin with the context of physiotherapy, and for planning professional ethics education. They can help healthcare education programmes to support ethical development to prepare students for transition in the clinical practice as well as provide tools for continuing ethics education in workplaces. For researchers, the results of this concept analysis can be used as a framework in further study in developing a structured instrument to evaluate ethical competence of health professionals in practice and during education. For practice implications, it is important to pay attention to the ethical conduct of the healthcare professionals already during education to be able to provide care of ethically high standard. The analysis of the concept ethical competence can guide the educators, as well as managers in healthcare, to support the development of ethical conduct. Moreover, the subject is important at the organisational and society level because the questions of ethical care are much discussed nowadays and will be nationally even more important in the future, as changes in the population structure in most countries will increase the needs of people. Healthcare organisations are becoming more complicated and, as a result of technological advancement, patient information will be more widely available and accessible. Ethical competence is also important when people spend shorter periods in hospital care, and healthcare in the patient’s private area, at home, has increased. Conflict of interest The authors declare that there is no conflict of interest. Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. References 1. Dierckx de Casterle B, Izumi S, Godfrey NS, et al. Nurses’ responses to ethical dilemmas in nursing practice: meta-analysis. J Adv Nurs 2008; 68(6): 540–549. 2. European Commission. Explaining the European Qualifications Framework for lifelong learning. http://ec.europa. eu/ploteus/sites/eac-eqf/files/brochexp_en.pdf (2008, accessed 21 November 2013). 3. World Health Organization. WHO Global Competency Model. http://www.who.int/employment/WHO_competencies_EN.pdf (2012, accessed 23 August 2013). 4. Larcher V, Watson A and Slowther A. Core competencies for Clinical Ethics Committees. A consensus statement from the UK Clinical Ethics Network. http://www.ukcen.net/uploads/docs/education_resources/core_competencies1.pdf (2007, accessed 23 August 2013). 5. Cheetham G and Chivers G. Towards a holistic model of professional competence. J Eur Ind Train 1996; 20(5): 20–23. 6. Paganini MC and Egry EY. The ethical component of professional competence in nursing: an analysis. Nurs Ethics 2011; 18(4): 571–582. 7. Ho¨glund AT, Eriksson S and Helgesson G. The role of guidelines in ethical competence-building: perceptions among research nurses and physicians. Clin Ethics 2010; 5(2): 95–102. 10
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8. Eriksson S, Helgesson G and Ho¨glund AT. Being, doing and knowing: developing ethical competence in health care. J Acad Ethics 2007; 5(2–4):207–216. 9. Ka¨vlemark Sporrong S, Arnetz B, Hansson MG, et al. Developing ethical competence in health care organisations. Nurs Ethics 2007; 14(6): 825–837. 10. Myyry L. Components of morality. A professional ethics perspective on moral motivation, moral sensitivity, moral reasoning and related constructs among university students. PhD Thesis, University of Helsinki, Helsinki, 2003. 11. Freeman SJ, Engels DW and Altegruse MK. Foundations for ethical standards and codes: the role of moral philosophy and theory in ethics. Counsel Val 2004; 48(3): 163–173. 12. Chinn PL and Kramer MK. Integrated knowledge development in nursing. St. Louis, MO: Mosby, 2004. 13. Thompson I, Melia K, Boyd K, et al. Nursing ethics. Edinburgh: Churchill Livingstone, 2006. 14. Kavathatzopoulos I. The use of information and communication technology in the training for ethical competence in business. J Bus Ethics 2003; 48: 43–51. 15. Baerøe K and Norheim OF. Mapping out structural features in clinical care calling for ethical sensitivity: a theoretical approach to promote ethical competence in healthcare personnel and clinical ethical support services (CESS). Bioethics 2011; 25(7): 394–402. ˚ , Edberg A-K and Sandman L. Everyday ethical problems in dementia care: a teleological model. Nurs 16. Bolmsjo¨ IA Ethics 2006; 13(4): 340–359. 17. Buzgova´ R and Sikorova´ L. Moral judgment competence of nursing students in the Czech Republic. Nurse Educ Today 2013; 33(10): 1201–1206. 18. Merriam-Webster Online Dictionary. http://www.merriam-webster.com/dictionary (2013, accessed 14 August 2013). 19. Jomsri P, Kunaviktikul W, Ketefian S, et al. Moral competence in nursing practice. Nurs Ethics 2005; 12(6): 582–594. 20. Duriez B and Soenens B. Religiosity, moral attitudes and moral competence: a critical investigation of the religiosity-morality relation. Int J Behav Dev 2006; 30(1): 76–83. 21. Ma HK. Moral competence as a positive youth development construct: conceptual bases and implications for curriculum development. Int J Adolesc Med Health 2006; 18(3): 371–378. 22. Park N and Peterson C. Moral competence and character strengths among adolescents: the development and validation of the Values in Action Inventory of Strengths for Youth. J Adolesc 2006; 29(6): 891–909. 23. Oxford English Dictionary. Oxford University Press. http://www.oed.com.ezproxy.utu.fi:2048/view/Entry/ 64756#eid5292719 (2013, accessed 15 August 2013). 24. Oxford Dictionaries. http://oxforddictionaries.com/definition/english/ (2013, accessed 14 August 2013). 25. Axley L. Competency: a concept analysis. Nurs Forum 2008; 43(4): 214–222. 26. Scott Tilley DD. Competency in nursing: a concept analysis. J Contin Educ Nurs 2008; 39(2): 58–64. 27. Valloze J. Competence: a concept analysis. Teach Learn Nurs 2009; 4(4): 115–118. 28. Garside J and Nhemachena JZZ. A concept analysis of competence and its transition in nursing. Nurse Educ Today. Epub ahead of print 17 January 2012. DOI: 10.1016/j.nedt.2011.12.007. 29. Lind G. Moral competence and democratic ways of life. In: Weber WG, Thoma M, Ostendorf A, et al. (eds) Democratic competences and social practices in organisations. Wiesbaden: Springer VS, 2012, pp. 62–85. 30. Lakanmaa R-L. Competence in intensive and critical care nursing – development of a basic assessment scale for graduating nursing students. PhD Thesis, Turku, University of Turku, 2012. 31. Walker LO and Avant KC. Strategies for theory construction in nursing. Upper Saddle River, NJ: Prentice Hall, 2005. 32. Wilson J. Thinking with concepts. Cambridge: Cambridge University Press, 1963. 33. Brennan M. A concept analysis of consent. J Adv Nurs 1997; 25(3): 477–484. 34. Ballou KA. A concept analysis of autonomy. J Prof Nurs 1998; 14(2): 102–110. 35. Keenan J. A concept analysis of autonomy. J Adv Nurs 2009; 29(3): 556–562. 36. Almond P. An analysis of the concept of equity and its application to health visiting. J Adv Nurs 2002; 37(6): 598–606. 11
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37. Wiseman T. A concept analysis of empathy. J Adv Nurs 2008; 23(6): 1162–1167. 38. Jenkins B and Warren NA. Concept analysis: compassion fatigue and effects upon critical care nurses. Crit Care Nurs Q 2012; 35(4): 388–395. 39. Whittemore R and Knafl K. The integrative review: updated methodology. J Adv Nurs 2005; 52(5): 546–553. 40. Morse JM, Mitcham C, Hupcey JE, et al. Criteria for concept evaluation. J Adv Nurs 1996; 24(2): 385–390. 41. Graneheim UH and Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today 2004; 24(2): 105–112. 42. Hupcey JE, Morse JM, Lenz ER, et al. Methods of concept analysis in nursing: a critique of Wilsonian methods. In: Gift AG (ed.) Clarifying concepts in nursing research. New York: Springer Publishing Company, 1997, pp. 3–28. 43. Rest JR. Background: theory and research. In: Rest JR and Narvaez D (eds) Moral development in the professions: psychology and applied ethics. Hillsdale, NJ: Erlbaum, 1994, pp. 1–26. 44. Kohlberg L. The philosophy of moral development. San Francisco, CA: Harper & Row Publishers, 1981. 45. Norman G. Can an examination predict competence? The role of recertification in maintenance of competence. Ann Roy Coll Physic 1991; 34: 121–124. 46. Larkin GL. Evaluating professionalism in emergency medicine: clinical ethical competence. Acad Emerg Med 1999; 6(4): 302–309. 47. Mitchell KR, Myser C and Kerridge IH. Assessing the clinical ethical competence of undergraduate medical students. J Med Ethics 1993; 19: 230–236. 48. Institute for Ethical Leadership. Ethical competence framework. http://www.ethicalleadership.com/EthicalLeadershipScales.html (2012, accessed 14 December 2013). 49. Savulescu J, Crisp R, Fulford KWM, et al. Evaluating ethics competence in medical education. J Med Ethics 1999; 25(5): 367–374. ¨ , Mert H and Beser A. A study on development of a scale to assess nursing students’ performance in 50. Karayurt O clinical settings. J Clin Nurs 2008; 18(8): 1123–1130. 51. Dalton M, Davidson M and Keating J. The Assessment of Physiotherapy Practice (APP) is a valid measure of professional competence of physiotherapy students: a cross-sectional study with Rasch analysis. J Physiother 2011; 57(4): 239–246. 52. Holt J, Coates C, Cotterill D, et al. Identifying common competences in health and social care: an example of multi-institutional and inter-professional working. Nurse Educ Today 2010; 30(3): 264–270. 53. Wilkinson TJ, Wade WB and Knock LD. A blueprint to assess professionalism: results of a systematic review. Acad Med 2009; 84(5): 551–558. 54. Olthuis G and Dekkers W. Professional competence and palliative care: an ethical perspective. J Palliat Care 2003; 19(3): 192–197. 55. Dupoux E and Jacob P. Universal moral grammar: a critical appraisal. Trends Cogn Sci 2007; 11(9): 373–378. 56. Begley AM. Practising virtue: a challenge to the view that a virtue centred approach to ethics lacks practical content. Nurs Ethics 2005; 12(6): 622–637. 57. Hansson MG. Imaginative ethics – bringing ethical praxis into sharper relief. Med Health Care Philos 2002; 5(1): 33–42. 58. Hanson SL and Kerkhoff TR. The APA Ethical Principles as a foundational competency: application to rehabilitation psychology. Rehabil Psychol 2011; 56(3): 219–230. 59. Scanlon C. Developing and maintaining ethical competence. HEC Forum 1997; 9(1): 85–92. 60. Aridag NC and Yuksel A. Analysis of the relationship between moral judgment competences and empathic skills of university students. Educ Sci Theor Pract 2010; 10(2): 707–724. 61. Jomsri P, Kunaviktikul W, Chaowalit A, et al. Development of Moral Competence Scale (MCS) in nursing practice in Thailand. Thai J Nurs Res 2004; 8(2): 144–158. 62. Trendall J. Concept analysis: chronic fatigue. J Adv Nurs 2000; 32(8): 1126–1131. 63. Carper B. Fundamental patterns of knowing in nursing. Adv Nurs Sci 1978; 1(1): 13–23. 12
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Ethical competence: A concept analysis
Nursing Ethics 1–12 ª The Author(s) 2015 Reprints and permission: sagepub.co.uk/journalsPermissions.nav 10.1177/0969733014567025 nej.sagepub.com
Kati Kulju, Minna Stolt, Riitta Suhonen and Helena Leino-Kilpi University of Turku, Finland
Abstract Background: Exploring the concept of ethical competence in the context of healthcare is essential as it pertains to better quality of care. The concept still lacks a comprehensive definition covering the aspects of ethical expertise, ethical knowledge and action of a health professional. Objective: This article aims to report an analysis of the concept of ethical competence. Method: A modified strategy suggested by Walker and Avant was used to analyse the concept. Results: As a result, the concept of ethical competence can be defined in terms of character strength, ethical awareness, moral judgement skills and willingness to do good. Virtuous professional, experience of a professional, human communication, ethical knowledge and supporting surroundings in the organisation can be seen as prerequisites for ethical competence. Ethical competence results in the best possible solutions for the patient, reduced moral distress at work and development and democratisation of society. Conclusion: The results of the analysis establish a basis for an instrument to evaluate health professionals’ ethical competence. It will guide educators, as well as managers in healthcare, to support the development of ethical conduct in healthcare. Keywords Concept analysis, ethical competence, healthcare, moral competence, nursing
Introduction Ethics is seen as a foundational competency in healthcare.1 Investigating the concept of ethical competence is internationally relevant. In the European Qualifications Framework, the European Commission2 describes ethical competence as meta-competence, an integral part of knowledge, skills and competence, and as essential for the development of responsibility and autonomy. In addition, the World Health Organization (WHO) Global Competency Model states several core qualities that are related to the concept of ethical competence, for example, active listening and respecting individual differences.3 The UK Clinical Ethics Network has made a consensus statement about core competencies for clinical ethics committees, for example, the definition of competencies required for the provision of ethics support and guidance for health professionals, including knowledge, skills and personal attitudes.4 Ethical competence can be seen as a part of professional competence5,6 and honesty and loyalty to patients.7 It is assumed to be learned through role models and experience,7 consisting of virtues, principles
Corresponding author: Kati Kulju, Department of Nursing Science, University of Turku, FI-20014 Turku, Finland. Email: [email protected]
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and critical reflection.8 In the literature, the concept of ethical competence has been used, for example, in nursing and physiotherapy curricula and described in multiple ways. This concept, however, still lacks a comprehensive definition covering even some of the aspects of ethical expertise, ethical knowledge and action of a healthcare professional. Furthermore, no previous analyses of the concept have been done. The concept of ethical competence is worth exploring as it pertains to competence development of healthcare staff, effective professional and continuing ethics education and, finally, better quality of care. The modern healthcare environment with increased financial and organisational changes requires wide professional competencies including ethical competence in handling moral problems.9 Healthcare educators, leaders and researchers need to give high priority to the development of ethical competence of health professionals.1 Health professionals encounter situations in which they have to make decisions affecting other people. These decisions can sometimes be hard. That is why those professionals need to have the ability to see the ethical dimensions of their work – besides the technical competence.10 In healthcare, the processes should also be human-oriented, recognising an individual patient’s needs, as well as social and cultural backgrounds, to ensure dignity and respect in care.6 The aim of this study was to analyse the concept of ethical competence. The goal is to develop an operational definition of the concept to be used and studied in the empirical world of healthcare.
Background To identify the concept under investigation, the concepts ethical and competence need to be defined separately, because the term ‘ethical competence’ is made up of two nouns and the dictionaries do not offer a definition for the concept ‘ethical competence’. In this study, the concepts ethical competence and moral competence are treated as synonyms for the following reasons: Both ethics and morals have been defined as theories about wrong and right actions.11 In nursing literature, the concepts have often been used synonymously and interchangeably6,12,13 even if the distinction between these terms can also be found. Moral refers to standards of behaviour followed by individuals, including rules and individual values. Ethical refers to a science or study of morals, ethical principles and decision-making skills.13 Because it was important to find all the relevant literature in this area, both concepts were included in the analysis (Figure 1). In dictionary definitions, the term ethical is defined as ‘pertaining to morality or the science of ethics’23 or as ‘relating to moral principles or the branch of knowledge dealing with these: ethical issues in nursing, ethical standards’.24 According to Merriam-Webster Online Dictionary,18 the term ethical involves or expresses ‘moral approval or disapproval’, ‘conforming to accepted standards of conduct’. In addition, the term moral is seen as a synonym of the term ethical,18 which is an essential remark in this study aiming to focus on the concept of ethical competence. The definition of competence varies between theoretical and philosophical contexts. According to Merriam-Webster Online Dictionary,18 competence is defined as ‘a sufficiency of means for the necessities and conveniences of life’ and ‘having sufficient knowledge’ to enable an action. Oxford English Dictionary23 states that competence is ‘sufficiency of qualification; capacity to deal adequately with a subject’. Some concept analyses of the concept of competence in the context of healthcare have been done.25–28 Competence in nursing is seen as knowledge or skills,9,25–27 actions,25,27 professional standards or role models25,27 and internal regulation or self-assessment skills.25,26 Garside and Nhemachena28 see competence as an integration of performance and capability. Also, Lind29 sees competence not only as the concept of subject knowledge but also as responsibility for and understanding of one’s own action. Competence in the context of intensive and critical care nursing has, according to Lakanmaa,30 five dimensions: knowledge base, skill base, attitude and value base, nursing experience base and personal base. Ethical competence cannot be distinct from other competencies but is a generic competence guiding the others.22 In this study, it was assumed that ethical competence is 2
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Ethical competence
Synonymous usage of the
Moral competence
(e.g. Kavathatzopoulos14;
concepts ethical and moral
(e.g. Jomsri et al.19;
Kävlemark Sporrong
(e.g. Bolmsjö et al.16;
Duriez and Soenens20;
et al.9; Baerøe and
Eriksson et al.8; Paganini
Ma21; Park and
and Egry6; Buzgová and
Peterson22)
Norheim15)
Sikorová17; MerriamWebster Online Dictionary18)
Inclusion of the concepts ethical and moral competence in this analysis
Figure 1. Clarification of the inclusion of the concepts ethical and moral competence in the concept analysis.
implicitly a part of all the dimensions of competence in the healthcare context as an umbrella concept. Hence, it was essential to investigate the concept of ethical competence through a concept analysis to find out if it could add something that is common to all the dimensions of competence in healthcare.
Method Concept analysis was chosen as a method to describe the concept of ethical competence. It is essential to be able to capture the critical elements and develop an operational definition of the concept under examination. That way, it is possible to strengthen the evidence base for practice in healthcare and to promote understanding about the phenomena of interest.31 In the analysis of the concept of ethical competence, an entity theoretic strategy based on Wilson’s31 method and modified by Walker and Avant32 was employed, because professionals’ ethical competence in healthcare needs to become observable and professionals’ competence is increasingly being evaluated in the organisations. This method has earlier been used to analyse ethical concepts in nursing science, for example, consent,33 autonomy,34,35 equity,36 empathy37 and compassion fatigue.38 The key elements of this method are the eight steps as follows: (1) select a concept, (2) determine the aims and purposes of the analysis, (3) identify all concept uses, (4) determine defining attributes, (5) establish a model case, (6) examine additional cases, (7) acknowledge antecedents and consequences and (8) define empirical referents.31 The first two steps are completed in the ‘Introduction’ and ‘Background’ sections of this article. A literature search was conducted to identify all the possible uses of the concept, allowing the inclusion of diverse methodologies in research reviewed, combining both theoretical and empirical reports, and hereby reaching deeper understanding of the concept.39 In this study, the method of Walker and Avant was modified as steps 5 and 6 were excluded from the analysis. Defining attributes (4), antecedents 3
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and consequences (7) as well as empirical referents (8) were identified as follows, to gain maturity for the concept, which is essential before the concept can be operationalised.40
Data sources A literature search of the CINAHL, MEDLINE and ERIC databases was conducted using the search terms ‘ethical competence’ or ‘moral competence’ from the earliest date possible to May 2012, yielding a total of 358 citations. The search was updated in December 2013. Although the concept ‘ethical competence’ was under examination, it was also essential to clarify the meaning and the uses of the concept ‘moral competence’, as both terms have been used synonymously (see Figure 1.), and it was important to find all the relevant literature in this area. It was essential to include the education literature database ERIC in the search as the starting point for professional competence development lies in professional education. A search was also made via hand-searching of reference lists, books and dictionaries. The abstracts were examined against the inclusion and exclusion criteria. The inclusion criteria were English language, abstract available and a theoretical or empirical article. The exclusion criteria were an anonymous article, a book review, a commentary or an editorial. The articles irrelevant to the topic and duplicates were excluded. It appeared that most of the research in the area has been done in healthcare, but also in educational sciences, in psychology and in business. A total of 61 abstracts were taken into further analysis and read independently by two researchers (K.K., M.S.). Finally, altogether 18 articles, 12 theoretical and 6 empirical ones defining the concept of ethical competence and ranging from the year 1993 to 2012 were included and analysed using inductive content analysis. The contents of the answers were categorised into groups by using words, phrases or sentences as units of analysis and divided into meaning units, which were condensed. Condensation as a process of shortening the text was used to preserve the core of the text. The condensed meaning units were then abstracted and sorted into categories – into attributes, antecedents and consequences.41
Results The first two steps – selection of the concept and determining the purposes of this analysis – are completed in the ‘Introduction’ and ‘Background’ sections of this article. In the third step of the analysis, as many uses of the concept as possible were sought by using available literature widely and open-mindedly. This stage is essential in supporting and validating the choices of the defining attributes.31
Use of the concept The uses of the concept have been sought from the literature chosen.42 The literature reveals four main contexts for the use of the concept: (a) human growth, (b) skill and knowledge, (c) education and (d) evaluation of professionals. Human growth. Ethical competence is used as a core concept in some ethical theories describing human growth in the ethical sense; this can be identified at least in the following theories: In the fourcomponent model of moral behaviour, each component – moral sensitivity, moral judgement, moral motivation and moral character – is needed for moral act, building moral competence.43 Strengthening these components may have a positive effect on an individual’s ethical competence.15 Kohlberg’s six stages theory of moral development describes morality as a competence to make judgements and decisions in line with ethical principles. He uses the term moral competence as the capacity to make moral decisions and judgements and to act in accordance with the decisions.44 4
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According to Jomsri et al.,19 moral competence in nursing context has been used as ability or capacity of persons to recognise their feelings as they influence what is good or bad in particular situations and then to reflect on these feelings, to make their decision, and to act in ways that bring about the highest level of benefit for patients.
Eight attributes for the concept moral competence were defined, derived from personal, social and professional values and including virtues such as honesty, kindness and compassion. As a result, a model of moral competence was constructed representing the conceptualisation of moral competence in nursing in Thailand.19 The concept ethical competence is also used in the context of a Communicative-Based Model, which suggests being (virtues), doing (rules and principles) and knowing (critical reflection) to be the elements in the development of ethical competence in healthcare,8 as well as in Sandman’s Teleological model.16 In this model, decision-making in nursing is combined with central values in healthcare. One of the basic ethical considerations in this model is the nurses’ ethical competence.16 Skill and knowledge. Ethical competence has been used as a psychological skill, ‘based on the psychological ability described as autonomy’. It is based on skills, but theoretical ethical knowledge is also important in ethical competence building.14 The concept has been used related to an ability to notice the ethical aspect and to realise one’s responsibilities in the situation, and to an ability to act in a certain way in a situation in which there occurs an ethical problem.14,16 It includes communication skills to find out a person’s value priorities in a certain situation, being also a part of a teleological model for the analysis of everyday ethical situations.16 The use of the concept ethical competence can also be seen in WHO Global Competency Model, which states several core qualities that can be considered as related to ethical competence: active listening, time and understanding in communication with others, responsibility for one’s own work, collegiality, ability to identify conflicts, respecting others’ individuality, acting confidentially, according to the ethical and legal framework and personal values.7 In this study, clinical and professional as well as personal competences are handled as one component, in which ethical competence plays a significant role. The idea of the use of the concept ethical competence as a development of knowledge and skills can be reached with the hierarchy of competence, the approach of Know-Can-Do,45 in which the first dimension includes the body of the knowledge needed to identify ethical dilemmas, the second dimension includes analysing of the conflict and being sensitive to competing values and principles and the third one ensuring the decisions to come true.46,47 It must be noticed that people who have theoretical knowledge in ethics are not automatically ethically competent individuals.9 On the other hand, it has been stated that ethical competence is not always something that every healthcare professional should have a certain amount of, but rather something that the whole care team should have.16 The concept moral competence has been used as related to altruistic behaviour and ability to advanced, consistent and logical moral judgement.21 It can be seen as an ability to make an ethical decision, and deal with ethical issues in practice.19,29 Ka¨vlemark Sporrong et al.9 state that ethical competence is also essential in preventing or reducing moral distress. Along with moral reasoning, it has been used as a component of moral judgement competence.29,44 Education of professionals. Ethical competence has been used as and learned through a combination between knowledge, practice and experience. Thompson et al.13 introduce four different approaches to teaching ethics, in the core of which is sensitivity and willingness to identify the needs of a human being, practical wisdom and ability to critical thinking. Some research in healthcare and also in business14,48 has been done for the purpose to build a knowledge base for the assessment of ethical competence. 5
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Evaluation of professionals. Assessment of ethical competence is important, for example, to be able to offer and evaluate effective ethics teaching and education, ethical knowledge and skills achieved through education, and for curriculum development,49 as well as for achieving higher effectiveness at the organisational level14 – ethical competence should be continuously re-evaluated.6 Few instruments have been used to measure ethical competence or parts of it. In healthcare, the assessment of ethical competence is done mostly as a small part of clinical competence evaluation tools.50–52 The dimension of ethical competence as a part of competence assessment seems to be one large dimension – the ethical sub-themes occurring through the measurement tool’s themes51,53 – and should be examined as an important individual dimension of competence in healthcare.
Defining attributes The fourth step of the analysis, defining the attributes, is an attempt to find the characteristics that most frequently occur in relation to the concept in the literature.31 This was an essential stage of the concept analysis because the attributes are important when transforming the concept to a more abstract level and subsequent operationalisation.40,42 As a result of the concept analysis, the following attributes defining ethical competence were repeatedly presented by seven different authors in the reviewed literature. They all illustrate the professional’s personal characteristics and can be outlined as follows: (a) character strength, (b) ethical awareness, (c) moral judgement skills and (d) willingness to do good. Character strength. At the core of ethical competence – guiding the person to desire and do good – is character strength.4,16,19,22 Ethical competence is a function of individual characteristics,16 which, at the organisational level, includes the ability and strength to support ethical processes.14 Without character strength, an individual does not have the desire to do what is right, the temperance, humanity or courage to implement the right action.22 Ethical awareness. Ethical awareness, meaning ethical perception, attentiveness or sensitivity to identify an ethical problem, is an important attribute to ethical competence when dealing with a situation in which it is difficult to recognise what constitutes good or bad.14–16,19,49 A professional also needs to have the awareness to recognise the individual needs and social and cultural background of a patient.6 Moral judgement skills. An ethically competent person is able to think and act openly, without moral fixations or automatic ways of action; having the ability to consider critically and logically all values, principles, needs and beliefs; and making moral judgements consistently, from the alternatives involved in an ethically demanding situation.14,16,19,21,47,49 This attribute includes also that the professional is autonomous in his or her thinking.14 Willingness to do good. Ethical competence is willingness to implement the decisions made and act for the benefit of other people.14,16,19,54 A professional person needs to have motivation and a desire to do the good thing,22 so willingness to do good was named to be an essential part of ethical competence.
Antecedents At step 7 of the analysis, antecedents are preconditions to the existence of the concept to come true and need to appear before the concept.31 As a result of the concept analysis, the following antecedents that must exist prior to ethical competence were alternatingly presented by 12 authors and are (a) virtuous professional, 6
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(b) experience of a professional, (c) human communication, (d) ethical knowledge and (e) supporting surroundings in the organisation. Ethical competence has a few prerequisites which can be found in professionals’ individual, virtuous characteristics.8,16,54 First, to be able to act in an ethically competent way, an individual needs to have the ability to and practise virtues such as empathy55 and practical wisdom, which is seen as a capacity that motivates and is required to judiciously choose the right actions in a situation.13,54 Ethical competence cannot be developed without virtues.8,56 Along with individual characteristics, some other antecedents can be found: Second, ethical competence derives from experience of a professional person6,7,54,57 and can be enhanced through the career.58 Third, it requires human communication, meaning the ability to express oneself clearly14,16 and to participate, influence and be listened to.8 Fourth, ethical knowledge which can be acquired through education9,14,20,29,54 seems to be the one prerequisite occurring before ethical competence and should be emphasised in promotion of ethical competence.6 Finally, the organisation structure plays a significant role in either hindering or enabling the professional’s acting in an ethically competent way. That is, besides the caregiver’s individual character, the structural situation and organisational support are the factors helping him or her to follow the preferred action.7,14,16,59
Consequences At the eighth step of the analysis, the consequences are the outcomes of the concept, resulting from the realisation of the attributes.31 The consequences of ethical competence are positive in nature, which is impending. In summary, the consequences of ethical competence in profession, which were repeatedly present in the literature by six different authors, are (a) the best possible solutions for the patient, (b) reduced moral distress at work and (c) development and democratisation of society. At the professional level, the most apparent consequence resulting from an ethically competent act is to be able to provide as good care as possible and the best solutions for the patient,16 including increased moral equality in care15 and enhanced safety.14 Second, it has been stated that ethical competence has an important role in preventing and reducing moral distress.9 Reduced ethical tensions in care and, as a result, reduced moral distress at work7,9,14,15 occurred in literature as a consequence of health professionals’ ethical competence. Finally, at the society level, as a result of ethical competence, development and democratisation of society is possible.20,60 As Lind60 has stated, widely shared general and universal moral principles and ideals are a precondition for a democratic society. Moral judgement skills are essential for the development of community. This concept analysis supports this point of view. Ethical competence leads to well-being.20 The antecedents, consequences and attributes as well as uses of the concept of ethical competence are summarised in Figure 2.
Empirical referents To identify empirical referents for the defining attributes was the final step in the concept analysis. Empirical referents can be used to measure the concept.31 The existence of the concept ethical competence in the reality can be demonstrated by introducing the research instruments that have been developed to measure ethical competence of professionals and can be identified in the reviewed literature. All the attributes defined in this concept analysis seem to be realised as somehow measurable in one existing instrument, Moral Competence Scale (MCS),61 which is based on the model of moral competence in nursing practice in Thailand. The model derives from personal, social and professional Thai nursing values.19 This model of moral competence seems to illustrate all the attributes defined in this study, with the 7
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ETHICAL COMPETENCE USE OF THE CONCEPT OF ETHICAL COMPETENCE •
Human growth
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Skill and knowledge
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Education of professionals
•
Evaluation of professionals
ANTECEDENTS •
•
ATTRIBUTES
virtuous
•
character strength
professional
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ethical awareness
solutions for the
experience of a
•
moral judgment
patient
professional •
CONSEQUENCES
human
skills •
communication
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•
reduced moral distress at work
willingness to do good
the best possible
•
development and
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ethical knowledge
democratisation of
•
supporting
society
surroundings in the organisation
A DEFINITION AND OPERATIONALISATION OF THE CONCEPT OF ETHICAL COMPETENCE
Figure 2. Uses, antecedents, attributes and consequences of the concept of ethical competence.
instrument including five scenarios presenting ethical issues in nursing practice,61 hence making the phenomenon operationalised and measurable. However, because of the cultural differences in Asian and Western countries, it is difficult to conclude how the empirical referents of the concept of ethical competence in this study are represented with the MCS.
Discussion The aim of this study was to analyse the concept of ethical competence. The goal was to develop an operational definition of the concept to be used and studied in the empirical world of healthcare. 8
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When the attributes are combined with antecedents and consequences, a definition of a concept of ethical competence and a building block of theory construction is formed. Based on the results, ethical competence can be defined in terms of character strength, ethical awareness, moral judgement skills and willingness to do good. The main focus in this study was to identify the attributes, antecedents and consequences of the concept to gain maturity of the concept for the purpose of operationalisation.40 The antecedents and consequences were used to guide the identification of the attributes62 and vice versa, and as the amount of the literature was reasonable and coherent as well, presentation of the fabricated model case or additional cases to illustrate the concept ethical competence was not considered necessary. In addition, the model case developed deductively from the predetermined attributes does not increase the reliability of the results.42 Hence, the researchers decided to modify that part of the concept analysis method of Walker and Avant. Exploring the concept of ethical competence is essential as it pertains to competence development of the healthcare staff and effective professional and continuing ethics education. To support ethical competence of healthcare professionals, there have been multidisciplinary ethics committees in healthcare organisations and also ethics consultation and education available. Nowadays, the possibilities still vary among organisations to get consultation in ethical issues, for example, in the form of discussion groups and education. Considering the attributes this study reveals to be essential for the existence of ethical competence, there should be possibilities for all healthcare professionals to strengthen their ethical competence. That could be done via developing ethical awareness and courage, for example, in ethics clubs discussing about the different ethical cases, or via strengthening moral judgement skills in virtual ethics labs or with ethics games. The results of the analysis have some similarities with ethical decision-making models in nursing,13,16 but also in the model of fundamental patterns of knowing, which is based on Carper’s (1978) description and extended by Chinn and Kramer.63 According to this model, ethical knowledge is strengthened through dialogue and justification and will lead to ethical comportment.12 When looking at the concepts through the Rest’s four-component model framework, it can be noticed that attributes defining the concepts also have something in common with this model’s components.43 In further study, the results of this concept analysis will be used for describing and developing ethical competence as an explanatory middle-range theory in healthcare context and further for the development of a tool to evaluate practising healthcare professionals’ and students’ ethical competence. As the empirical referents show, an instrument to measure ethical competence exists, but not a comprehensive instrument which could measure all the aspects of ethical competence in the Western World that this study reveals.
Limitations and strengths This study has some limitations. Even if the concept analysis aimed to be rigorous, the results are still tentative: The chosen concept analysis method illustrates situation based on existing literature. The method, steps in the concept analysis of Walker and Avant, is clearly presented in the literature, but this is not the case with the process of the analysis itself. As the applied concept analysis method has an entity theoretic approach,31 the attributes found in the analysis must be defined to become observable and measurable. With ethical concepts, this might be challenging – however, the authors found it important to analyse the concept so that it can be tested in the empirical world. Considering the reliability of the results, it must be noticed that even if the literature reveals these dimensions presented in Figure 2, the concept of ethical competence has not been previously described this broadly in the literature. Hence, when the concept has been operationalised and actually the validity of the analysis tested40 – ethical competence assessed empirically and objectively in a clinical environment – this concept analysis can be taken under re-examination at a new level. 9
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Conclusion The results of this concept analysis produced a definition of the concept ethical competence. Ethical competence in healthcare is a personal capacity including ethical awareness, courage, willingness and skills in decision-making and ethical action. It requires support from the organisation, and at the personal level emerges from experience, knowledge and communication. It results in positive outcomes for the patient, professional and society. The results provide new knowledge and insight to the area of healthcare. Ethical competence is pictured and implemented in curricula all over Europe – the results will be used in evaluation of ethical competence to begin with the context of physiotherapy, and for planning professional ethics education. They can help healthcare education programmes to support ethical development to prepare students for transition in the clinical practice as well as provide tools for continuing ethics education in workplaces. For researchers, the results of this concept analysis can be used as a framework in further study in developing a structured instrument to evaluate ethical competence of health professionals in practice and during education. For practice implications, it is important to pay attention to the ethical conduct of the healthcare professionals already during education to be able to provide care of ethically high standard. The analysis of the concept ethical competence can guide the educators, as well as managers in healthcare, to support the development of ethical conduct. Moreover, the subject is important at the organisational and society level because the questions of ethical care are much discussed nowadays and will be nationally even more important in the future, as changes in the population structure in most countries will increase the needs of people. Healthcare organisations are becoming more complicated and, as a result of technological advancement, patient information will be more widely available and accessible. Ethical competence is also important when people spend shorter periods in hospital care, and healthcare in the patient’s private area, at home, has increased. Conflict of interest The authors declare that there is no conflict of interest. Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. References 1. Dierckx de Casterle B, Izumi S, Godfrey NS, et al. Nurses’ responses to ethical dilemmas in nursing practice: meta-analysis. J Adv Nurs 2008; 68(6): 540–549. 2. European Commission. Explaining the European Qualifications Framework for lifelong learning. http://ec.europa. eu/ploteus/sites/eac-eqf/files/brochexp_en.pdf (2008, accessed 21 November 2013). 3. World Health Organization. WHO Global Competency Model. http://www.who.int/employment/WHO_competencies_EN.pdf (2012, accessed 23 August 2013). 4. Larcher V, Watson A and Slowther A. Core competencies for Clinical Ethics Committees. A consensus statement from the UK Clinical Ethics Network. http://www.ukcen.net/uploads/docs/education_resources/core_competencies1.pdf (2007, accessed 23 August 2013). 5. Cheetham G and Chivers G. Towards a holistic model of professional competence. J Eur Ind Train 1996; 20(5): 20–23. 6. Paganini MC and Egry EY. The ethical component of professional competence in nursing: an analysis. Nurs Ethics 2011; 18(4): 571–582. 7. Ho¨glund AT, Eriksson S and Helgesson G. The role of guidelines in ethical competence-building: perceptions among research nurses and physicians. Clin Ethics 2010; 5(2): 95–102. 10
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