Concept Analysis of Ethical Competence of Nursing Students and Nurses

[Aim] This study aimed to conduct a concept analysis and clarification of ethical competence of nursing students and nurses, and further clarify the components. [Method] Rodger’s concept analysis method was used. A literature search was conducted using the ICHUSHI database, MEDLINE, and CINAHL databases. The keywords included in the search were ethical competence. A total of 24 published articles were analyzed. [Results] As a concept of ethical competence among nursing students and nurses, five categories of [ethical sensitivity], [ethical reasoning], [ethical decision making], [ethical practice], [ethical reflection], obviously became. As a component, two categories of antecedent factors and three categories of consequences were identified. I defined ethical competence in nursing students and nurses, “including nursing students and nurses thinking processes and nursing practice and reflection to solve ethical problems Behavioral characteristics”. [Conclusion] Review of nursing practice from an ethical perspective [ethical reflection] is indispensable for clarifying self-tasks and deepening better nursing practice.


Introduction
With the rapid advancement and increasing complexity of medical care and development, as well as the establishment of comprehensive community care systems, nurses are now facing various new ethical issues. To address these issues, ethical judgment is required. In the "Code of Ethics for Nurses", the Japan Nursing Association clearly specifies guidelines for nurses' behavior and the scope of nurses' professional responsibilities [1]. In particular, for nurses to possess the ability to respond to ethical issues, the nurses' code of ethics suggests ness, burnout, and career turnover. Thus, it is necessary for such students to systematically accumulate ethical competence, beginning in basic nursing education, and proceeding through continuing education.
Ethical competence has been defined as "the ability to appropriately resolve issues through applying ethics-related thinking and decision-making" [3], and also as "nurses implementing, based on subjective recognition, actions they feel to be most appropriate for the situation" [4]. Thus, ethical competence has been defined in different ways by researchers, and there remains no clear definition of its concepts and components. Therefore, in order to improve the ethical competence of nursing students and nurses by providing systematic nursing-ethics education, and to develop associated scientific and empirical research programs, it is first necessary to clarify the concept. Considering this, the present study aims to clarify the definition of ethical competence for nursing students and nurses, as well as its associated concepts and components.

Research Method
The approach used in the present study involves Rodgers' evolutionary concept analysis [5]. Rodgers' analysis is based on a philosophical perspective, suggesting that concepts are fluid and change with context, such as the passage of time and social background [5]. In the present study, we consider "ethical competence" to represent a concept that changes with alterations in medical and social environments; thus, we considered Rodger's approach to conceptual analysis to be suitable for this study.

Data-Collection Method
In educational psychology, behavior is considered an "competence," and in behavioral science knowledge and judgment are regarded as behavioral characteristics. For this reason, in the present study, we considered behavior to be based on knowledge and judgment, and chose as our keyword "ethical competence." A literature search was conducted of EBSCO (specifically, the MEDLINE and CINAHL databases) and the ICHUSHI database. Domestic (i.e., Japan-based) studies were extracted from the ICHUSHI database, using "ethical competence" Among the extracted documents, we read the abstracts and excluded reviews, articles concerning scale development, and documents that did not concern nursing students and nurses. Meanwhile, a search for overseas literature was performed using EBSCO (MEDLINE, CINAHL), again using "ethical competence" as the keyword and without limiting the year of publication. Among the extracted documents, we read the abstracts and excluded papers that were reviews, scale-development articles, and those that were not related to nursing students and nurses.

Data-Analysis Method
Based on Rodgers' evolutionary concept analysis method [5], we began by creating a data sheet to extract attributes that form the concept, the requirements necessary for the concept to exist, and descriptions of the consequences of the concept. Then, the extracted contents were coded and categorized.
Next, we examined the relationships between the categories relating to nurses and nursing students. Below, categories are presented by enclosing them in square brackets ([ ]).

Results
After performing, through a literature review, a conceptual analysis of ethical competence among nurses and nursing students using Rodgers' evolutionary concept analysis [5], we found that there were two categories of requirements, five categories of attributes, and three categories of consequences.
Below, the categories extracted as attributes, requirements, and consequences are presented by enclosing them in square brackets ([ ]), subcategories are enclosed in angle brackets (< >), and the described literature is classified into whether it relates to nursing students or nurses (Table 1).

Result of the Literature Search
Through our keyword search, 28 domestic studies were initially returned; then, after applying the exclusion criteria, a total of six studies were extracted: three concerning nurses and three concerning nursing students. On the other hand, 87 nondomestic papers were returned, with 18 remaining after applying the exclusion criteria. These comprised 12 papers concerning nurses and six concerning nursing students.
Thus, in total we analyzed 24 cases.

Antecedents
As  [7], and ethical concepts [8]. Such sources also provide a means of continuing education and debate [9], and case studies allow students to familiarize themselves with the practices applied in decision-making [10].
Meanwhile, [opportunities to encounter ethical issues] was defined as exposure to situations in which nurses and nursing students encounter ethical problems during interaction with patients or with other health-care professionals.
Ethical issues relating to patients include patient privacy and dignity [3], confidentiality [11], and communication [9]. Further, administering cardiopulmonary resuscitation to patients has also been reported to create an issue in this regard [10]. Meanwhile, ethical issues related to health-care workers include witnessing colleagues perform unsafe (or premature) medical practices [11] and the insufficient administering of care as a result of a lack of nurses [6] [9].

Attributes
Categories [Ethical sensitivity] was defined as developing an ability to notice, during daily nursing, aspects that are out of the ordinary and patient discomfort. This includes noticing incongruities (e.g., finding certain situations "strange" [12]), and recognizing discomfort, such as moistening [13].
[Ethical reasoning] was defined as collecting information related to unusual situations and clarifying the ethical issue by interpreting the needs and behaviors of each party involved (patients, family members, other health-care professionals, etc.). Examples from the extracted literature include: gathering information by applying a four-step approach [14], discussing why the nurse/nursing student felt a situation was "strange" [13], discussing the situation with others [3] [12], learning about the situation [3] [6] [15], and highlighting the relevant ethical issues.
[Ethical decision-making] was defined as making decisions regarding the direction of care and formulating specific action plans and clear priorities for re-solving ethical problems. In the papers we examined [12], feasible nursing [12] [13], utilizing ethical principles [13], and choosing approaches that are beneficial for patients [3] were mentioned. Additionally, one paper reported that decision-making was influenced by a lack of awareness of ethical issues [16].
[Ethical practice] was defined as providing planned and principles-based care in order to resolve ethical problems. The nurse provided the content discussed at the conference and the care deemed necessary for the patient [3] [13] [17]. In addition, we practice nursing according to the nursing code of ethics: respect and protect the human rights of patients [12] respond to patient needs [6] [18] [19]; communicate with patients and understand their issues [3] [12] [20]; provide explanations to patients and their families and, with their consent, help them [3]; be mindful of how information is managed [3] [14] [18]; and seek to provide safe and comfortable assistance for patients [3] [17].
[Ethical reflection] was defined as learning by considering personal feelings regarding ethical issues and reviewing ethical practices in terms of the ethical reasoning and ethical decision-making involved. Such consideration can include whether a judgment was correct [3], whether an action that was performed was based on ethical guidelines [21], and whether the action benefitted the patient [17]. In addition, sharing and discussing problems can alleviate mentally complex feelings [22] and help nurses/nursing students reconsider their related attitudes [18]. Furthermore, as a nurse, he learned seriously about the patient, reviewed the nursing provided, made an ethical decision, and learned to act with knowledge and skills [3].
Based on these five categories, the ethical competence of nursing students and nurses can be expressed as comprising the following: "The thinking process (ethical sensitivity, ethical reasoning, ethical decision-making) used to resolve ethical problems and to adopt appropriate behaviors, which include performing appropriate nursing practice and reflection."

Consequences
Categories concerning consequences comprised: [improvement of the quality of nursing practice], [development of ethics], and [improvement of autonomy as a nursing professional]. Here, six subcategories were extracted: <improved ethical competence among individuals> and <improved ethical behavior in depart-ments>; <change in personal ethical awareness> and <change in personal ethical behavior>; and <acting as a nursing professional>, <taking responsibility for care, as a nursing professional>, respectively.
[Improvement of the quality of nursing practice] was defined as fostering ethical competence in individuals and nursing departments. Through nursing, she gained the ability to grasp the main relationships associated with the problem [10]; further, by considering the patient's feelings, she developed a closer relationship with the patient [15] [23], and she fostered her ethical-reasoning ability through reflection [6]. There was also a workplace culture in which departments could easily consider ethical issues [12] [24].  [20]. I also realized that I was able to think about ethics in the context of my nursing behavior [14].
[Improvement of autonomy as a nursing professional] was defined as practic-

A Conceptual Model of Ethical Competence for Nursing Students and Nurses
Based on the concepts identified through analysis of the requirements, attributes, and consequences, we developed a conceptual model ( Figure 1). First, as a pre-requisite, nursing students must learn ethical nursing through lectures and exercises; this relates to the category of [knowledge regarding ethical issues]. Knowledge [8], learning knowledge necessary for decision making [10]. In addition, in order to resolve ethical problems, nurses require a forum for discussion [9] and should strengthen their skills by conducting case studies [10]. Additionally, nursing students and nurses have opportunities to encounter ethical problems during their nursing practice, such as issues regarding patient privacy and dignity [3], a lack of confidentiality [11], and communication with patients [9].
When encountering ethical problems, nursing students and nurses noticed patient discomfort (such as something that seemed "strange"), which relates to the category of [ethical sensitivity] [12], and also felt personal discomfort, such as uncertainty [13]. Consequently, through [ethical reasoning], nurses collected information by applying a four-step method [14], discussed why they felt "strange" [13], discussed the situation with others [12] [13], obtained information regarding the cause of the issue [3] [6] [15], and reported the ethical problems. In [ethical decision-making], in order to resolve ethical problems nursing that accords with the code of ethics and ethical principles should be utilized [12] [13]. Further, the health-care team should collaboratively determine the most appropriate treatment methods for patients [3]. In accordance with the category of [ethical practice], meetings should be held regarding the necessary care for patients, and the approaches that are decided upon in these meetings should be implemented [13] [17], along with nursing that accords with the nursing code of ethics. Nursing students and nurses should conduct [ethical reflection] throughout the implementation of these four processes (ethical sensitivity, reasoning, decision-making, and practice). In other words, nursing students and Open Journal of Nursing nurses should perform reviews after each process in order to determine whether their judgments were correct [3], and whether they acted in accordance with ethical guidelines [21]. Moreover, they should also objectively consider whether their actions benefited the patient [17].
Through such an approach, [improvement of the quality of nursing practice] (for example, by fostering ethical sensitivity and ethical reasoning) is developed.
Further, the ability to grasp the overall relationships related to such problems is enhanced and patients' feelings are improved; in particular, by considering patients' feelings, a closer nurse-patient relationship is fostered [2] [3] [15].
Changes also occur in regard to workplace culture, as departments more readily consider ethical issues [12] [24]. I felt that ethics was nurtured through experience, such as being able to consider ethics based on my nursing actions [14],

Commonalities and Differences between Nursing Students and Nurses Regarding Ethical Competence
There were commonalities and differences between the nursing students and nurses regarding ethical competence.

Characteristics of the Concept of Ethical Competence among Nursing Students and Nurses
Through the concept analysis conducted in the present study, we determined that the ethical competence of nursing students and nurses can be expressed as follows: "The thinking process (ethical sensitivity, ethical reasoning, ethical decision-making) used to resolve ethical problems and to adopt appropriate behaviors, which include performing appropriate nursing practice and reflection." Waithe [29] stated that ethical competence comprises 1) ethical sensitivity, 2) ethical reasoning, 3) attitudes, and 4) realization. However, in this conceptual analysis, we found the concept of "ethical reflection" to be an important feature of the concept of "ethical competence among nursing students and nurses." Schon [30] divides reflection into two categories: "reflection in action" and "reflection on action." Reflection in action" occurs in practice and affects decision-making and the provision of care. For the present study, this relates to nurses/nursing students considering whether a judgment is correct or whether ethical considerations have been implemented [3]. He looked back and forth and changed his subsequent behavior. In addition, he said that "reflection on actions" occurs after the event and contributes to the development of practical skills. In the present study, the actions to be taken were identified, and this led to concrete actions. Today, as medical care becomes more complex, various new ethical issues arise. For this reason, "ethical reflection," which involves reviewing nursing practice from an ethical perspective, is indispensable for clarifying issues relating to personal approaches and for improving nursing practice.
The analysis conducted in the present study showed that knowledge regarding ethical issues represents a foundation, and encountering ethical issues leads to ethical competence. Furthermore, in daily nursing, noticing incongruities (e.g., feeling something is "strange"), considering the cause, discovering behavior, practicing ethically and, through ethical reflection, fostering ethical competence, clarifies that ethical competence can be cultivated. The conceptual model based on these results indicates that basic nursing education provides opportunities to learn knowledge regarding nursing ethics and to acquire sufficient ethical competence to address the ethical problems that can be encountered in nursing practice. Notably, these results suggest that it is important for nursing-ethics education to emphasize ethical reflection. Furthermore, for continuous nursing educa-Open Journal of Nursing tion, constructing and providing nursing-ethics education that particularly emphasizes introspection, both for individuals and organizations, regarding ethical issues is suggested. The importance of constructing and providing nursing ethics education tailored to the latter stage was also suggested.

Application of Ethical Competence for Nursing Students and Nurses, and Points to Note
To illustrate how nursing students and nurses can practically demonstrate the concept of ethical competence defined in this analysis, in this section we provide example cases, and also list points that should be considered when applying ethical competence.

Examples of the Application of Ethical Competence, Using Model Cases 1) Nursing student case
Nursing student A is a fourth-year student at a nursing university [1]. In the second year of university, students were given instruction regarding ethical competence, which involved an explanation of nurses' ethical principles and the conducting of case studies using analytical tools to resolve ethical problems. In the third year of geriatric nursing practice, nursing student A witnessed nurse C apply a wheelchair restraint to patient B.
Nursing student A felt that nurse C's restraining of the patient was unusual, and felt discomfort regarding the incident. After examining the patient's electronic medical record, nursing student A found that patient B had dementia and a history of falls, and also that the patient had osteoporosis, meaning there was a high risk of fracture from falls. Nursing student A now understood nurse C's decision to restrain the patient. However, nursing student A still felt that the physical restraint limited patient B's activities and motion, and could also cause physical and mental pain; consequently, nursing student A sought to find a less restrictive method of protecting patient B. In particular, nursing student A thought that patient B must have a reason for trying to leave the wheelchair, so he asked the patient where he wanted to go, and helped him reach his goal. As a result of this approach, patient B ceased trying to leave the wheelchair. Nursing student A objectively reviewed his judgments and actions at each stage of the process, examining whether his judgments were correct, whether ethical consideration was implemented, and whether the best assistance was being implemented. In addition, by discussing at a meeting whether patient B was safe after the care was administered, it was possible to identify the approaches that most benefitted the patient.
Nursing student A felt that patient B's safety and comfort were ensured by applying an approach that involved respecting patient B's dignity while considering how to protect his safety, and by then implementing nursing that was tailored to his personal characteristics. Nursing student A felt that nurse C's controlling of the patient was unusual, so he analyzed his personal feelings regard-Open Journal of Nursing ing the situation, clarified the relevant care policy, and confirmed whether patient B's safety could be protected in a less restrictive manner. As a result of the discussions at the health-care team's meeting, the nursing student felt that not only his own ethical competence, but that of all students present, was strengthened. Nursing student A felt that it was important for nurses to consider solutions and act ethically instead of ignoring situations that caused them discomfort. In the future, when I feel a sense of incongruity, I plan to act independently.
2) Nurse's case Nurse D is a nurse with three years of experience. At university, he was taught the knowledge necessary for ethical competence, such as the code of ethics and ethical principles for nurses, and attended ethics conferences during nursing practice. Furthermore, during the training he received as a new employee at the hospital, he learned of ethical problems that are likely to occur in hospitals, and examined real cases of ethical problems, applying a four-step approach to resolve them.
One day, during practice, Nurse D noticed that a colleague, Nurse E, left an electronic medical record in the hospital room.
Nurse D felt that electronic medical records should not be left in hospital rooms that nonmedical personnel can freely access. Investigating why the electronic medical record was left in the patient's room, Nurse D found that Nurse E had left the room to respond to another patient's call for a nurse. Nurse D felt that nurses should be responsible for protecting patients' personal information at all times, regardless of the situation; however, he also felt that this was a possible case when a sudden response was required on the part of Nurse E. Nurse D thought that this was an issue that should be addressed by the organization, not by himself, in order to protect the patient's personal information, and he had an opportunity to consult and discuss with the nurse. At the ward meeting, nurse D explained the situation and the need to protect patients' personal information. If he left the electronic medical record in the ward for a short time, he was overconfident that there was no information leakage. Some of the nurses present stated that they did not think this was important, that they had a hard time, or that they already made conscious efforts to protect personal information. As a result of the conference, opinions such as returning the PC to the nurse station, logging out of the PC, and requesting other nurses take responsibility for the record were suggested, and an organizational policy was consequently decided.
After the conference, the electronic medical records were no longer left in rooms, and nurses spoke to each other to protect patients' personal information.
Nurse D objectively reviewed his judgment and behavior at each stage of the process and considered whether the organization's judgment was correct and whether there was an appropriate means of protecting patients' personal information. In addition, he was able to reexamine his ethical competence as a nurse by discussing the issue at the meeting and collaborating in the decision-making regarding whether patients' personal information could be protected. Nurse D thought it was unusual that a patient's personal information was not protected. By raising and discussing the problem at the ward meeting, the policy was consequently clarified and individual nurses were given instruction regarding how to act autonomously to protect personal information. He felt that not only his own ethical competence, but that of the entire ward was strengthened.
When Nurse D felt discomfort regarding the practice he had witnessed, he felt that it was important for nurses to consider solutions and to act ethically. In the future, when I felt a sense of incongruity in my daily practice, I wanted to work actively with the organization and act ethically.

Points to Note When Applying the Concept Model
The characteristics of nursing ethics cause the commonalities and differences that exist between nursing students and nurses regarding ethical competence.
Ethical ability develops continuously over time rather than remaining at a mere minimum standard, and even students need to possess a comprehensive degree of ethical ability. In other words, both students and nurses continue to develop their ethical competence, and students should receive training in this behavioral characteristic. Varying levels of competence may be the reason nursing students and nurses are perceived as having differing ethical competencies.
There are three types of behaviors in this regard: action-based (skill-dependent), rule-based, and knowledge-based. These three performance levels are influenced by both psychological (conscious, hybrid, automatic) and situational factors (novel problems, problems for which nurses have received training, routines).
An overview of ethical competence in regard to these three behavior types shows that nursing students transition from a skill base based on conscious action to a mixed-rule base, while nurses are moving from a mixed rule base, which resembles an automated knowledge base. Indeed, in [ethical practice], students are consciously thinking of and acting to address novel problems based solely on knowledge and rules they have learned, because they have little experience; this is considered to be a mixed-rule base from a knowledge base that acts in accordance with. On the other hand, because nurses have experience of various situations, they act not only according to rules, but also provide <care in accordance with judgements made regarding the characteristics of the situation>, which can be considered to represent an automated knowledge base.
Based on the above, we believe that this concept model should only be applied after considering the commonalities and differences between nursing students and nurses.

Limitations to This Study
Of the 24 articles examined in this study, only six were domestic. Ethical competence is affected by cultural environment and background; therefore, it is necessary to more accurately verify whether this concept model applies to the ethical competence of nurses and nursing students in Japan. In order to verify this, future studies should evaluate, based on the analysis result of this concept,

Conclusion
Ethical competence among nursing students and nurses is defined as "the thinking process (ethical sensitivity, ethical reasoning, ethical decision-making) used to resolve ethical problems and to adopt appropriate behaviors, which include performing appropriate nursing practice and reflection".