Healthcare professionals’ ethical competence: A scoping review

Abstract Aim The aim of this study was to examine the extent and nature of the available research literature on healthcare professionals’ ethical competence and to summarize the research findings in this field. Design A scoping review guided by Arksey and O'Malleys methodological framework was conducted. Methods Six databases including Pubmed/Medline, CINAHL, Web of Science Core Collection, PsycInfo, Philosophers’ Index, and Scopus were searched systematically. Of 1,476 nonduplicate citations, 17 matched the inclusion criteria. Results Findings revealed that healthcare professionals’ ethical competence is a limited but topical research area. The focus areas of the studies were conceptualization, measuring, and realization of the ethical competence. The studies provided varying definitions and constructions for ethical competence and a few instruments to measure ethical competence were identified. Research in this area seems to be in a transition phase from theorization to empirical measurement. Methodologically, the research was rather heterogeneous and mainly focused on nurses.


| INTRODUC TI ON
In recent decades, ethical demands on healthcare professionals have increased due to factors such as scarce resources (Kälvemark, Höglund, Hansson, Westerholm, & Arnetz, 2004), need for prioritization (de Groot et al., 2017) and improved medical and technological advances which expand treatment and care options (Fleck, 2013). To meet this development, different ethical codes and guidelines have been developed to guide healthcare professionals' behaviours and actions (Dahnke, 2014;Numminen, Arend, & Leino-Kilpi, 2009).
Furthermore, ethics courses have been included in curricula for healthcare professionals, and ethical committees, ethical rounds, and educations have been implemented into healthcare organizations to support healthcare professionals in handling ethically demanding situations (Chao, Chang, Yang, & Clark, 2017;Molewijk, Zadelhoff, Lendemeijer, & Widdershoven, 2008). Such guidance, education, and support are reasonable as healthcare professionals have an important role and considerable responsibility in analysing and resolving ethical issues encountered in their daily practice (Rees, Lindy, & Schmitz, 2009). To achieve this, being ethically competent is a necessity.
Theoretical understanding of the concept of ethical competence seems to vary. Ethical competence, also referred to as moral competence, is considered as one component of professional competence (Jormsri, Kunaviktikul, Ketefian, & Chaowalit, 2005;Paganini & Egry, 2011) consisting of the knowledge, skills, and attitudes required to address ethical issues (Robichaux, 2016). According to another consideration, ethical competence consists of a moral agent's ability to identify value conflicts and ethical dimensions, ability to choose one value over another based on logical reasoning, and ability to act based on the judgement that has been performed. (Jormsri et al., 2005). Furthermore, ethical competence has been seen as a matter of being (personal characteristics), doing (acting according to the judgements made based on the principles and rules), and knowing (being familiar with the ethical laws and guidelines) (Eriksson, Helgesson, & Höglund, 2007). Despite the somewhat differing terminology used in the definitions, there seems to be an understanding that ethical competence is a crucial factor enabling healthcare professionals to make complex, value-based decisions and to implement ethically sustainable care (Clark & Taxis, 2003) and hence, to restrain mistreatment and ethically obscure actions in healthcare. (Bolmsjö, Sandman, & Andersson, 2006;Nordström & Wangmo, 2017).
Given the importance of healthcare professionals' ethical competence in providing quality and good patient care with respect to patients' rights, a scoping review was conducted. The objective of this scoping review was to examine the extent and nature of the available research literature on healthcare professionals' ethical competence and to summarize the research findings in this field. We identified gaps in the evidence base where no or limited research has been conducted and point out the needs for further research. This knowledge is valuable, especially for researchers. A variety of definitions for ethical competence have been given in the literature, and we did not refer to any sole definition. Instead, we wanted to include a variety of scope in the relevant literature focusing on ethical competence of healthcare professionals.

| ME THODS
This scoping review was guided by Arksey and O'Malley's (2005) methodological framework including five different stages: (a) identifying the research questions, (b) identifying relevant studies, (c) study selection, (d) charting the data, and (e) collating, summarizing, and reporting the results. Scoping review is an increasingly popular literature review method, especially in healthcare research, allowing researchers to map a specific research field for relevant research literature with broad research questions to summarize research findings and find gaps in the research field in question (Arksey & O'Malley, 2005).
To answer the research objective, the authors identified the research questions as follows:

| E THI C S
As this was a scoping review, ethical approval was not required. The review was conducted according to good scientific integrity.

| Focus areas
Three main focus areas were identified as follows: (a) conceptualization, (b) measuring, and (c) realization of the ethical competence.
The second focus area of the studies was measuring ethical competence. The studies developed and evaluated new instruments to measure healthcare professionals' ethical competence in terms of moral competence (Asahara et al., 2015;Asahara, Ono, Kobayashi, Omori, & Todome, 2013;Jormsri et al., 2004) and moral skills (Chambers, 2011). Measuring the level of ethical competence and perceptions of support for it have also been focal points of studies (Poikkeus et al., 2016;Poikkeus, Numminen, et al., 2014).
The third focus area of the studies was the realization of ethical competence as they explored the role of ethical competence in coping with moral distress (Schaefer & Vieira, 2015), fostering hope (Peter et al., 2015) and handling conflicts of interest (Falkenström et al., 2016). Furthermore, the studies have focused on moral case deliberation in terms of improving ethical competence (Molewijk, Verkerk, et al., 2008) and on supporting nurses' ethical competence (Poikkeus, Leino-Kilpi, & Katajisto, 2014).

| Research findings
The research findings are summarized and presented in accordance with the previously identified main focus areas: (a) conceptualization,   (Jormsri et al., 2004). Nurses were not the only profession group having an instrument to measure ethical competence as Chambers (2011)  needed before the use of this instrument could be recommended (Chambers, 2011).
As a part of measuring, estimation of the level of ethical competence was self-assessed by nurses and nurse leaders. Nurses estimated their own ethical competence to be at an average level, whereas nurse leaders estimated their own competence to be at a high level. Nurses' and nurse leaders' perceptions of support provided for nurses' ethical competence was not at a high level (Poikkeus et al., 2016). However, nurse leaders supported nurses' ethical competence more often during performance reviews than during recruitment (Poikkeus, Numminen, et al., 2014).
The realization of ethical competence appeared through other substances. More specifically, it was studied how ethical competence posed itself as a coping resource, hope sustainment and when handling conflicts of interests. Ethical competencies as resources used by professionals to cope with moral distress were divided into positive and negative resources. Positive resources included discussion with work colleagues, holding meetings, reflection, learning from earlier experiences, changes in protocols, creativity and collective actions. Negative ones included avoiding ethically difficult situations, nondiscussion or reflection of the case and the option to change jobs (Schaefer & Vieira, 2015).
Nurses' moral competence related to fostering hope in patients and their families was identified as "Reimagining hopeful possibilities," "Exercising caution within the social-moral space of nursing" and "Maintaining nurses' own hope" (Peter et al., 2015 providing opportunities for nurses to enhance their ethical competence . Healthcare professionals' moral competencies (i.e., knowledge, attitude, and skills) could be improved through moral case deliberations (Molewijk, Verkerk, et al., 2008).

| Research designs
The studies were conducted using varying research designs, none of them being clearly predominant. Seven (41%) studies were quantitative, using a descriptive design. Five (29%) studies were qualitative, and they used descriptive (N = 3), explorative (N = 2), and critical qualitative approach (N = 1) designs. One (6%) study was a mixedmethods study, using an interactive responsive evaluation design.
Of all studies, three (18%) were literature reviews, four (24%) were instrument development and validation studies and one (6%) was concept analysis (Table 1).

| Participants
The study participants were mainly nurses. In quantitative studies, the total number of nurses was 5,742, the sample sizes ranging from 46 to 3,409. In qualitative studies, the total number of nurses was 73 and the sample sizes ranged from 6 to 52. Other participant groups

Qualitative studies
Höglund et al. One study used a combination of healthcare professionals (N = 118) without specifying the participant groups. Response rates were indicated in 5 (63%) studies using quantitative data, and they ranged from 16% to 73% (Table 1).

| Data collection
The authors used instruments that they had developed themselves to measure ethical competence and to collect the data in all quantitative studies. In three studies (Asahara et al., 2015(Asahara et al., , 2013Chambers, 2011), the structure of the instrument followed the Four-component model for determining moral behaviour described by Rest (1994).
Semistructured interviews (N = 5), in-depth interviews (N = 2), and ethnographic participant observation (N = 1) were used for data collection in qualitative studies. All literature reviews and the concept analysis study retrieved the data from relevant databases while the number of papers reviewed/analysed ranged from 18-89.

| Data analysis
The data analysis methods varied based on the designs applied in different studies. The majority of the studies used statistical analysis methods, followed by content analysis. Description of the data analysis process was not provided or the description was vague in three studies (Cusveller & Schep-Akkerman, 2016;Lechasseur et al., 2016;Schaefer & Vieira, 2015).

| Reliability and validity assessments
The reliability and validity assessments of the studies were addressed at different levels of sophistication. In quantitative studies, internal consistency using Cronbach's alpha was the most commonly stated (N = 6) reliability assessment. Other commonly described assessments referring to reliability and validity were face validity In qualitative studies as well as in literature reviews and concept analysis studies, researcher validation was the most commonly addressed validity assessment (N = 4), followed by saturation of the data (N = 3). One study used a specific criterion (credibility, confirmability, dependability, transferability) to address the validity of the study. General discussion about study validity without any specific criterion was provided in six studies. Six studies provided no reliability or validity assessments, or the discussion on these matters was vague (Cusveller & Schep-Akkerman, 2016;Höglund et al., 2010;Lechasseur et al., 2016;Peter et al., 2015;Schaefer & Vieira, 2015).
Most commonly, limitations of the studies dealt with low response rates, sampling/participant biases, and limitations to the instruments. Attention was also paid to self-report bias, lack of generalization, and social desirable bias. Six studies provided no discussion about the study limitations (Table 2).

| D ISCUSS I ON
Ethical competence is a precondition for quality health care.
Healthcare reforms, development of new technology, and allocation of resources pose several challenges to healthcare professionals' ethical competence. To maintain and promote high-quality ethical care, several international and national guidelines have been published (Deshpande, Joseph, & Prasad, 2006;ICHRN, 2010). All these guidelines emphasize the need for research in the field of ethical competence.
This review identified a limited amount of research in the field of ethical competence. However, the interest toward ethical competence seems to be increasing as the majority of the studies were published recently. This increasing interest might be explained by the emphasis on ethical environment (Lin et al., 2013) and ethical integrity (Eby, Hartley, Hodges, & Hoffpauir, 2017). Furthermore, current ethically charged issues, such as priority setting (Norheim, 2016) and care rationing (Rooddehghan, Yekta, & Nasrabad, 2016), are evoking ethical concerns. Recognition of the role of ethical competence in managing these might have contributed to the increase in interest in this research area.
Ethical competence can be approached from three focus areas: conceptualization, measuring, and realization of ethical competence.
The emphasis of the research seems to be on the first and the second. This is natural, as the conceptualization of ethical competence is a rather recent phenomenon (Jormsri et al., 2004), there are not many research groups interested in the topic and research base and theoretical understanding develops slowly. Furthermore, the three focus areas still fail to form a homogenous picture of the research area, leaving it scattered.
Theoretically and empirically, ethical competence seems to be a multidefinitional concept lacking a convergent understanding of its definition and construction. This is understandable as the whole research area is limited and at its early stages. Furthermore, competence in itself is often considered a difficult combination of knowledge, skills, and attitudes (Stoof, Martens, Merriënboer, & Basties, 2002), not to mention ethical competence, where the term "ethical" also entails a complicated mix of content areas. This makes the conceptualization even more complicated. However, the theoretical base of the concept has been seen as sufficient as a transition phase from conceptualization to measuring ethical competence is clearly ongoing. Intervention studies using educational interventions may offer a possibility to have an impact on the ethical competence of healthcare professionals (Stolt, Leino-Kilpi, Ruokonen, Repo, & Suhonen, 2018). Most commonly, studies reported low-response rates and sampling/participant bias as their limitations. More attention should be paid on sampling procedures to tackle these issues and to recruit samples with generalizable results (Suhonen, Stolt, Katajisto, & Leino-Kilpi, 2015). However, these limitations do not concern only research on ethical competence; they seem to be very common in many areas of healthcare research, especially in research on empirical ethics (Koskenvuori, Numminen, & Suhonen, 2017;Suhonen, Stolt, Virtanen, & Leino-Kilpi, 2011).
Research on ethical competence seems to be focusing on nurses. This is interesting, as the codes of ethics have been used in all professional groups. Although nurses form the largest professional group in clinical practice (WHO., 2006), it would be beneficial to study ethical competence of other healthcare professionals as care is predominantly multiprofessional. Furthermore, it is important to continue the research among healthcare managers.
Ethical competence of managers relates to ethical sensitivity and the ability to identify and solve ethical problems among employees (Poikkeus et al., 2016).
Colleagues and leaders were determined to have a key role in enhancing ethical competence .
Furthermore, moral competencies could be improved through moral case deliberations (Molewijk, Verkerk, et al., 2008). This knowledge provides a good start, but more research on these is-

| Strengths and limitations
This scoping review followed a predetermined systematic protocol (Arksey & O'Malley, 2005). The data were retrieved from six international scientific databases in the field of health sciences and philosophy. The literature search produced a large number of hits and overlap between the databases was evident as indicated by the high number of duplicates (N = 539), which were removed in the first phase. Although Medline covers a wide range of research in health sciences (Bahaadinbeigy, Yogesan, & Wootton, 2006), it is recommended to use other databases as well to ensure comprehensiveness of the search (Seaton, 2006). The search terms used in this review were on general level, such as ethical/moral competence and ethical/moral skills. This wide approach led to a multitude of information, which is desirable in scoping reviews (Davis, Drey, & Gould, 2009).
Although research quality evaluation is not an initial part in scoping reviews, we performed critical appraisal of the studies using international evaluation criteria (Joanna Briggs Institute, 2017). A suitable evaluation tool was selected according to each study design. The use of these tools was not without problems.
The methodological quality of the studies varied, leading to uncertainty as to which methods were used in these particular studies.
To overcome this uncertainty, quality evaluations were conducted within the research group where each researcher evaluated six studies. These evaluations were cross checked within the group and consensus was achieved. Based on quality evaluations, no studies were excluded which might have led to incomplete data synthesis and findings. However, we aimed to gather a comprehensive perspective to ethical competence and therefore including all studies is reasonable.
Analysis of the studies was started by tabularization of the descriptive information and main findings. This work sheet was designed for the purposes of this review to ensure the focus on key issues. The terms and sentences used by the original authors were used as they appeared in the text, and no interpretations were made.

| CON CLUS IONS
Ethical competence is an ultimate necessity to guarantee high-quality health care in the future. Research in this field is limited but seems to be increasing. The focus areas of the research can be classified into the following three: conceptualization, measuring, and realization of the ethical competence. The focus areas still do not seem to form a homogeneous picture of the research area, leaving it scattered. Conceptualization of ethical competence is rather new and the definitions and constructions provided vary. However, the theoretical base of the concept has been seen as sufficient as the research seems to be in a transition phase from theorization to empirical measurement. Thus, the measurements identified need more validations. Methodologically, the research is rather heterogeneous. To gain a deeper understanding, multidimensional research designs are needed. Furthermore, issues affecting generalizability of the research results need more attention. Research in this area is nurse oriented, but it would be beneficial to expand the research to other healthcare professionals as well. In addition, research on the improvement, enhancement, and growth of ethical competence is needed. These can be used to support healthcare reforms and to promote quality in health care.

CO N FLI C T O F I NTE R E S T
Authors declare no conflicts of interest.

AUTH O R CO NTR I B UTI O N
All authors have agreed on the final version and meet at least one of the following criteria [recommended by the ICMJE (https://www. icmje.org/recommendations/)]: • substantial contributions to conception and design, acquisition of data or analysis and interpretation of data; • drafting the article or revising it critically for important intellectual content.