Factors that influence ethical competence among nurses in health facilities in Malawi.

Background: Clinical nurses' (CNs) ethical competence (EC) is essential for nursing practice because it facilitates high-quality care to patients.To develop ethically competent nurses, factors that positively affect EC must be explored and promoted. Few studies have explored ethical issues in Malawi and the aim of this study was to explore the factors that affect EC.
Methods: This study used a qualitative exploratory design to collect data through in-depth interviews from 10 key informants (KI) and 9 focus group discussions (FGD) in the selected government, CHAM and private hospitals in Malawi. It was conducted between April and May 2019.Data were analysed manually using thematic content analysis. The data were coded, and words with similar meaning were organized into categories from which themes and sub themes were developed. The themes and sub themes are reported as the results of the study.
Results: One major theme emerged from the thematic content analysis namely: systems influencing EC among nurses in Malawi. The study has identified continuing professional development in ethics, supportive supervision, availability of resources and leadership to be among the major factors that facilitate EC. Factors that hinder EC among the nurses included; inadequate supervision, inadequate resources, lack of teamwork, increased workload coupled with inadequate nursing staff.
Conclusion: This study has exposed the factors that influence EC in health facilities and shown that nurse leaders are key to enhancing EC through continuing ethics education, supportive supervision, staffing and provision of resources. Therefore, all the stakeholders in nursing should support the efforts to remove the factors that hinder EC in the health facilities.

Introduction

Ethical competence is defined as ethical behaviour and actions that require ethical knowledge and ethical reflection for solving ethical problems in nursing practice1. EC among nurses in healthcare delivery system is important for both present and future nursing practice because it concerns better quality of care to patients. It forms the basis for ethical performance, 2 professional nursing competence, 3 patient safety, improved patient outcomes and health promotion in the nursing practice environment1. There are three dimensions of EC namely: ethical perception, ethical reflection and ethical behaviour3. Compassion, accountability, responsibility, kindness, honesty and respect for human dignity, values and rights are some of the attributes of EC3.

EC in nursing practice helps nurses to think critically, analyse issues, make ethical decisions, solve ethical problems, ethical dilemmas, improve interpersonal relationships and behave ethically and responsibly during their daily deliberations in the health facilities2–8. Studies have shown that EC among health workers including nurses is promoted by ethics education, existence of conducive ethical climate. The climate includes inter-professional collaboration and respectful communication, inter-professional relationships, supportive supervision, organizational support, availability of resources, availability ethics committee, ethics round, clear job descriptions and conducive infrastructure2,4,8–11. Furthermore, the studies have revealed that lack of: adequate support and guidance on ethical issues; respect; effective communication; human and material resources; poor interpersonal relationships and inadequate supervision are barriers to development of EC2,9,12–14.

In Malawi, there is evidence of unethical practice among nurses15–20. The Ministry of Health (MOH) in Malawi is aware that the performance of health workers including nurses is not satisfactory as alluded to in the National Health Policy for Malawi for 2017 to 2022 and the Nursing and Midwifery policy21,22. This may be an indication of inadequate EC among the nurses. Consequently, the MOH through the Health Sector Strategic Plan (HSSP) for 2017 to 2022 is committed to improve the performance and motivation of human resource for health including nurses to ensure effective, efficient and equitable health service delivery23. Furthermore, improving workforce for health service delivery in Malawi is in the country's health research agenda24. However, studies in regard to EC among nurses in Malawi are scanty. In addition, studies conducted regarding ethical issues in Nursing in Malawi by Solum et al, Msiska et al, and Solum et al,15,17,20 solicited information from student nurses and nurse educators rather than clinical nurses. There is therefore, a need to establish evidence regarding EC among the clinical nurses in Malawi in order to establish evidence based strategies that can enhance EC among nurses in Malawi. As such, this study aimed at exploring factors that influence EC among clinical nurses in selected hospitals in Malawi.

Methods

Study design

This study was conducted between April and May 2019. This qualitative exploratory study collected data on factors that influence EC among nurses in four selected hospitals in Malawi namely (Queen Elizabeth Central Hospital, Kasungu District Hospital, Mwaiwathu Private Hospital and Ekwendeni Mission Hospital. The central hospital and the district hospital are government hospitals while Ekwendeni is a mission hospital and Mwaiwathu is a private hospital. The facilities were randomly selected using stratified sampling. The strata were government, Christian Health Association of Malawi (CHAM) and private facilities.

Study population

The target population for this study comprised the clinical nurses and nurse managers both male and female who were trained in Malawi with minimum six months of working experience. In this study clinical nurses were: registered nurses (RN), registered nurses and midwives (RNM), enrolled nurses and midwives (ENM) or nursing midwifery technicians (NMT) working in the wards and departments of the selected facilities. Nurse Managers were in-charges of wards and departments and matrons of the health facilities. For the matrons to participate in this study, they were required to have been trained in Malawi and with more than five years working experience.

Sample size and data collection

Data were collected through FGDs and in-depth interviews. Nine FGDs were conducted each having on average 7 participants and 10 KI were interviewed in the four selected hospitals. All the participants were purposefully selected. There were two in-depth interviews with nurse managers as key informants and two focus group discussions from nursing midwifery technicians and registered nurses midwives per health facility respectively except for the Central Hospital. There were four in-depth interviews from nurse managers and three FGDs comprising NMTs, RNMs and ward in-charges at the Central hospital. Unstructured interview guides were used to obtain qualitative data.

The participants in the FGDs and the (KI) were asked to explain in their own understanding the factors that promote or hinder development of EC among nurses in the hospitals. The CNs were asked to explain in their own understanding how they would want to be supported by the nurse managers. The KIs were also asked to explain how they support the CNs in developing EC. Both groups were asked to explain their knowledge of the revised codes of ethics for both nurses and midwives. Demographic data (age, marital status, ward/department, work experience, qualification, type of facility and current position) were collected from both groups. The FGDs and in-depth interviews were audio taped. The time taken for each interview ranged from forty to sixty minutes. The data were collected with the help of three well experienced research assistants. The FGD members and the key informants were given secret identification codes to maintain confidentiality.

Data analysis

Data were analysed manually using thematic content analysis. The audio data from FGDs and key informants interviews were transcribed verbatim. The data were coded, and words with similar meaning were organized into categories from which sub themes and a theme were developed. The theme and sub themes are reported as the results of the study.

Ethical consideration

The study was approved by the College of Medicine Research Ethics Committee (COMREC) under the University of Malawi certificate number P.02/19/2611 on 6th March, 2019.

Written approval from the Directors of the study sites and written consent from the participants were obtained. Participants' confidentiality and privacy were observed. The participants were informed that their participation in this study was voluntary and that they would not be paid any money. However, the participants were given $3 (K2, 500) for refreshments and transport reimbursement.

Research findings

Demographic Characteristics of the participants

The total of 73 participants were recruited in this study. Their ages ranged from 21 to above 40 years. The majority of the participants (n = 56) were female while the rest (n =17) were male. There were 44 RN/RNMs including the nurse managers and 29 ENM/NMT. There were 37 that were married, 31 were single and 5 were either widowed, separated or divorced. Almost all the respondents (n = 72) were Christians and only one was a Moslem. The participants had either certificate, diploma, bachelor's degree or master's degree. Their work experience ranged from 6 months to above 20 years.

One main theme deductively emerged from the objective and two sub themes were inductively formed from the narratives of the participants as indicated in Table 1.

Table 1

The Main theme and subthemes

Main Theme

Sub Theme

Systems influencing EC among CNs in Malawi

1. Perceptions of clinical nurses on nurse managers' roles in influencing EC (CPD in ethics, supportive supervision, availability of ethics committees, regular meetings, availability of resources, interpersonal relationships, effective communication skills, performance appraisal, recognition and award of best practices/performance, disciplinary measures and team work spirit). 2. Nurses' perceptions on the nurse leaders' attributes that influence EC (Knowledgeable on ethics, respectful, humble, approachable, exemplary, flexible, effective communication skills.

Nurse Managers' roles in influencing EC

The participants reported a number of factors that promote EC among the nurses in the health facilities. The commonly mentioned factors included regular supportive supervision, CPD in ethics, availability of ethics committees, performance appraisal, regular meetings with the nurses, recognition and award of best practices, performance, reinforcement of discipline, encouraging team work among the clinical nurses and exercising good communication skills in the health facility. However, both the nurse managers and the clinical nurses exposed factors that hinder the development of EC among the nurses in the health facilities. Some of the narrations depicting the factors that promote or hinder development of EC are as follows:

The participants reported that through regular supportive supervision nurse managers are able to provide support and encouragement to the CNs and also identify ethical gaps regarding ethical conduct and consequently, help them accordingly.

Mostly EC can be promoted through regular supervision in the wards and departments because it enables us the identification of ethical issues during the provision of care to patients. Then you can help if there is something amiss in their ethical conduct (KI# 7).

However, the participants revealed that nurse managers' supervision is neither done regularly nor adequately.

“I must admit we fail to do regular supervision” (KI# 1).

I cannot remember the last time the matron came to our ward for supervision. When you call for help, she is nowhere to be found. Sometimes she comes but she just greets one or two patients off she goes. In such manner she cannot appreciate what we go through in the wards. We lack nurse leaders to guide us on ethical issues (FGD1NMT # 6).

The nurses mentioned that holding regular meetings allow them to communicate with one another. As a result, interpersonal relationships and teamwork among nurses, as well as between nurse managers and nurses, are strengthened.

Regular meetings with nurses are very helpful. We build strong relationships. You know when relationships are good, there is good teamwork spirit. We promote team work because it is an ethical conduct and where there is team work patients benefit because there is quality care (KI # 3).

The CNs, on the other hand, complained that most of the meetings were not adequately held because they were not scheduled and instead were treated as an emergency.

“There are no planned ethical meetings in our facilities. Sometimes ethical issues are discussed during ward meetings when nurses have done something wrong. So nurses will be there just to be accused, embarrassed and sometimes shouted at.” (FGD1NMT # 8).

Despite the fact that participants indicated that good interpersonal relationships among health workers improve EC, nurses revealed that interpersonal relationships among health workers including nurse leaders in health facilities are weak. The participants were concerned that lack of flexibility among nurse leaders, poor communication and interpersonal relationships among nurses harmed teamwork and had a negative effect on the patient's outcome.

Sometimes you may have some personal issues with someone else and you may not want to work with that person, but you are both on duty. The other nurse may not want to communicate with anyone. This is harmful because both of you may end up giving same drugs to the same patient but different times because of poor communication. (FGD 8RNM # 6).

“We fail to verbalise our concerns because we know our leaders are not flexible; they think they are right always.” (FGD7NMT# 6)

The nurse managers and the nurse participants both reported that EC can be enhanced through attendance of regular continuous professional development (CPD). They stated that it is through CPD on ethical issues among other topical issues that nurses' knowledge, skills and attitudes are updated and improved.

“We try to do CPD every week for our nurses to ensure they are up to date in all aspects of patient care in order to provide quality nursing care.. .” (KI# 4).

“... CPD offers learning opportunities to improve our knowledge, skills and attitudes.” (FGD7 NMT# 5).

The participants however, reported that nurse leaders lack expertise to facilitate CPD on ethical topics and that CPD is not a regular activity as expected.

“We stopped having CPD sessions around last year. When we had CPD, there were no ethics topics covered ... (FGD9 NM # 1).

“It is lack of adequate knowledge on ethics that made our CPD facilitators fail to include topics on ethical issues in the CPD schedule.” (FGD2 RNM#3).

The nurse managers reported that it was their role to ensure availability of resources including guidelines, rules and protocols as part of material resources required for the nurses to provide the required quality ethical care to patients.

We ensure provision of resources to enable nurses to perform ethically as much as possible. For example lockable cabinet to ensure confidentiality in terms of patients' files; supplies; lobbing for financial resources to ensure that nurses have adequate and required nurses uniform; development of guidelines, protocols and on job training to reinforce ethical guidelines and rules (KI# 5).

However, the nurse participants' narratives revealed a discrepancy between what the nurse managers said about material resources like guidelines and protocols. The front-line nurses revealed that there are no adequate supplies including ethical guidelines or protocols in place. They further reported that there are no any frameworks to guide nurses and midwives in ethical decision making. They explained that even though they may desire to follow ethical standards, they fail because of scarcity of resources they encounter in the health facilities which force them to use shortcuts.

In addition to lack of adequate guidelines or rules, there is lack of ethical guidelines, frameworks and protocols to guide us on what to do when faced with ethical problems. In addition, there are no ethics committees to remind or help us on how to resolve ethical issues we usually encounter in our health facilities (FGD2 RNM# 1).

“Unavailability of resources is our biggest challenge whereby we fail to provide proper ethical care to patients. For example, we cannot provide privacy because we do not have bed screens.” (FGD7NMT# 3). In addition, another nurse, narrated as follows:

There are times when you are alone or may be two, the patients expect the nurses to do everything to patients perfectly. I will give an example of paediatric ward, the doctor would say nebulise these babies, and then there are 5 of them within that particular hour. If you start, you find that another one has also come and is looking for you and another patient is convulsing there, but if you look at the staff resources versus time resource it's not possible to do all accordingly. So you start doing short cuts (FGD8RNM# 5).

Although the NMCM revised the code of ethics for nurses and midwives in 2016, the participants reported that most CNs in health facilities were unaware of the changes and lacked the updated codes of ethics for both nurses and midwives.

“We are not aware of the revised codes of ethics. This means that we do not have them and we have not been oriented to these updated codes of ethics in our wards.” (FGD1NMT# 4).

“No one here has ever seen or heard about the revised codes of ethics. You can ask the colleagues. We don't know; it is news to hear we have new ethical codes.” (FGD4 NMT# 6).

“I don't remember to have attended orientation meeting on the revised codes of ethics by the NMCM.” (KI # 1).

The CNs reported that another nurse managers' role in enhancing EC among the nurses is to exercise disciplinary action on nurses who portray unethical behaviour. Some participants reported that disciplinary procedures including disciplinary committees were available and functioning in some health facilities. The participants reported that disciplinary actions help nurses behave appropriately and do right actions in so doing ethical behaviour is promoted.

“When the patient has complained about a nurse's behaviour or actions the nurse appears before the nurse managers for discipline.” (FGD 5NMT#2).

“Anyone who is not behaving well, is brought before the disciplinary committee to be warned so that there is appropriate desired change. We believe that disciplining unethical behaviour among the nurses serves as a warning and a lesson to others.” (FGD3RNM# 4).

However, some CNs revealed that there is lack of discipline among the nurses in public health facilities. The nurse participants expressed concern over the nurse managers whom they alleged that overlook nurses' unethical conduct to the extent that some hard working nurses get discouraged. The nurse participants admitted that disciplinary procedures are available but they are not consistently followed.

Some nurses always report late for duties and some speak to patients without respect, yet no any disciplinary measures are taken against them in any way despite reporting them to relevant authorities. Patients and guardians are ever complaining about unethical conduct of some of the nurses but none of the nurses here have ever been brought or subjected to disciplinary hearing. This is discouraging to many nurses out there. I feel our nurse leaders are not fulfilling their role in this area (FGD1 NMT# 3)

Conducting performance appraisal was mentioned by the participants as an enhancer of EC among the CNs because through performance appraisal they get feedback on the progress of work and areas for improvement are noted and acted upon.

“As nurse manager I ensure that I conduct open performance appraisal on every nurse. I think, this is another way of promoting EC. Any challenges are discussed and we map together the way forward for improvement.” (KI#5)

“I think staff appraisals would also motivate nurses to continue with the required ethical and professional conduct.” (FGD 7NMT# 9).

However, some participants revealed that although performance appraisal is important in promoting EC, it is not done or if it is done it is done inappropriately in some health facilities.

I think performance appraisal promotes EC because you know where to improve but it is not done here. This is my fifth year; since I started working here I have never been called for performance appraisal. (FGD 8 RNM# 5)

The nurse participants reported that another role of the nurse managers is to recognise and reward those nurses who demonstrate ethical behaviour and hardworking spirit in the health facilities with the intention of encouraging them and others. The nurse participants recommended awards to be given to nurses accordingly and also indicated that verbal recognition is much better than nothing at all.

Like myself at one time I was commended verbally, so that was enough to make me feel good and I wish it is to be done more often. (FGD7 NMT# 5).

The practice of having nurse of the year, nurse of the month awards facilitates EC because nurses want to be recognized therefore, nurses are motivated to work harder and behave well....” (FGD 6RNM # 3).

However, some CNs reported that there is lack of recognition of well-behaved nurses by the nurse leaders in the health facilities. The nurses stated that they lack motivation because even when they work hard they are not recognised. They further explained that when the nurses have done something wrong, they are scolded without remembering any of the good things they have ever done.

Our nurse managers do no motivate us, you know, even when you have worked hard they cannot recognise you even verbally they can't. But when you have made a mistake they will brush you and brush you as if you have never done something good (FGD7NMT # 3)

In addition, the participants reported that sometimes they are discouraged from working hard by their peers. They reported that there are some nurses who mock the hard working nurses which in turn tends to reduce the hard workers' morale.

Sometimes the peers, when you are a hard worker mock you, saying this one wants to be a ‘good’ nurse. So when you hear such words you are demotivated. Instead of working hard you turn to be like them. Sometimes you get tired, because they leave everything to you. So at the end of the day you just say hmm! Am tired so you join the band wagon (FGD2NMT# 5).

The nurses further revealed that some nurse managers show bias in their choice of who should attend workshops and seminars. According to the CNs, attending workshops and seminars is perceived as a form of reward. The findings indicate that the nurses condemn favouritism.

“It is sad to learn that some nurses are favoured more than others. It will be the same name being chosen to go for workshops.” (FGD1NMT# 3).

Nurse Managers' leadership attributes that influence EC

The nurse participants reported the attributes which they perceived that the nurse managers ought to have in order to enhance EC among nurses in the health facilities in Malawi. The attributes include leading by example, being approachable, having effective communication skills, teamwork spirit, being knowledgeable, humble, polite/respectful and flexible.

Nurses and nurse managers believe that nurse leaders are mentors and role models, according to the results of this report. According to the participants, nurse leaders are required to lead by example in every area of their professional lives including punctuality, observing proper dressing code, and a sense of accountability and responsibility.

When you are head of the ward or matron you must lead by example in all your actions. Be punctual, be in full uniform at all times so that your juniors are not misled when they follow what you do. You are a role model. You should be responsible to do what you teach. (FGD7NMT# 2).

However, the nurse participants revealed that some nurse managers do not lead by example as expected in the health facilities. Consequently, the nurses feel discouraged when the leaders are doing the opposite of what is expected of them.

“Our leaders come late and knock off earlier. They leave when we have excessive work load. Our leaders do not put on full uniform yet they expect us to be in complete uniform. We feel discouraged.” (FGD7NMT#5).

The nurses reported that the nurse leaders should have effective communication skills in order to enhance EC among the nurses in the health facilities.

“We propose to be given feedback on how we are working immediately so that we know our areas to improve including ethical conduct. I think constructive feedback and not destructive feedback is useful for ethical conduct improvement.” (FGD8#4).

“We learn well when the nurse leaders treat us with respect. The matrons should know that shouting is unethical conduct.” (FGD7NMT# 5).

The participants reported that the nurse leaders ought to be humble to enhance EC among the nurses.

“For me a nurse leader must be humble because to be humble is a professional characteristic of a nurse. Nurse Leaders can influence nurses' ethical conduct if she has a humble spirit.” (KI#4)

Discussion

Factors that promote EC

The factors that promote EC among the nurses in the health facilities according to this study included continuous professional development on ethical issues; supportive supervision; availability of both human and material resources; working in collaboration; being appreciated; effective nursing leadership; ward/departmental meetings, availability of ethics committees, policies and guidelines; and effective communication among health workers. These factors are in line with the findings by Poikkeus, et al and Doran et al13,25. In their study on “support for EC of nurses” Poikkeus et al., indicated that multidisciplinary collaboration, effective leadership, effective communication, supportive environment, availability of written ethics policies, guidelines and procedures, staff meetings, clinical ethics meetings, ethics education personal values and intuition were promoters of EC in the clinical area26.

According to Schaefer & Junges11, these factors including the support that nurse leaders and managers provide to nurses, form a favourable ethical climate in the health facilities. Other researchers added that ethical climate is a conducive work environment where clinical nurses and other health workers are able to discuss ethical and legal issues openly when they arise. Additionally, professional values and views of health workers are respected in such a climate14. Furthermore, ethical climate in health facilities imply that nurses are given opportunities to be involved in decision making; given ethical support by management through provision of policies and guidelines; supervised; appraised, appreciated and recognised2,11,14,27–31. The studies conducted by Schaefer & Junges11 and Storch et al.32 indicate that nurse employers and nurse leaders have the obligation to provide a favourable ethical environment to enable the CNs enrich interpersonal interaction between service providers and nurse leaders; improve adherence to ethical standards and guidelines; reduce conflicts and absenteeism; increase job satisfaction, increased motivation, reduce burnout and improve performance1,10,27,28,30.

Factors that hinder of EC

The inhibiting factors of EC according to this study included lack of adequate resources, inadequate ethics education, lack of guidelines, poor communication and relationship among health workers, work overload, lack of recognition and lack of disciplinary measures among others. Similar barriers were identified by Poikkeus et al.26 These results are also consistent with the findings of a study by Dehghani et al33 whose findings showed that work overload, insufficient nursing staff per shift, inadequate nursing ethics education, miscommunication, lack of policies and guidelines, lack of team work and inadequate supervision hinder EC. The implication of these barriers is that they create a stressful environment for CNs when discharging their duties consequently impacting negatively the patients' quality of care and also tarnishes the image of the nursing profession11,13,19,33. Borhani et al.34 stressed that even if nurses may wish to do their best, it is impossible for them to provide adequate ethical nursing care in the presence of these barriers. It is unrealistic to expect nurses to provide quality ethical nursing care when they are not given adequate resources and the support they require. Therefore, efforts to deal with EC barriers should be given priority in the clinical area.

The role of nurse leaders

This results have shown that nurse leaders are key to promoting EC. In support to this finding, recent studies indicated that nurse leaders provide task assistance; offer social and emotional support and facilitate quality interpersonal interaction27,28,35. More importantly the study has revealed that nurse leaders can promote EC through CPD. However, the study has revealed lack of ethical knowledge as a hindrance. This is consistent with what Maluwa et al revealed in a study that Malawian nurses lack ethical knowledge and skills19.

EC is promoted through leaders' ability to offer tangible work related advice, teaching, instruction and coaching. This is possible when a nurse leader has ability to listen to staff concerns. In addition, the nurse leaders are required to listen when the nurses are explaining about the challenges they meet in the course of their job. The nurse leaders must also be able to provide positive statements, appreciate, and relate to the needs of the nurses when overwhelmed, strained, or confused by their work27,28,32,35.

Furthermore, the nurse leaders need to communicate effectively to staff, give constructive and timely feedback, be approachable and flexible27,28,32,35. The nurse leaders conduct objective performance appraisal of staff and are able to recognise and award best practices fairly. Consequently, these activities improve job performance, increase the motivation of staff towards work and job satisfaction which in turn promote positive patients' outcomes. Therefore, nurse leaders in the health facilities need to be greatly supported for them to enhance EC among the nurses.

Limitation

The participants of this study may have given biased information regarding factors influencing EC among the CNs. However, the factors were obtained from both nurse managers and the clinical nurses.

Conclusion and Recommendations

This study has identified factors that influence EC among the clinical nurses in the health facilities. Some of the factors include supportive supervision, continuing ethics education, availability of both human and material resources, leadership attributes and availability clinical ethics committees. The study has shown that nurse leaders are key to promoting EC. It is proposed that the Nurses and Midwives Council of Malawi should include ethics topics among the mandatory CPD modules for the nurses and should also ensure availability and accessibility of the ethical codes to the CNs. The nurse leaders and other nursing stakeholders should provide effective supportive supervision including adequate resources to the health facilities to ensure CNs obtain the maximum support they deserve to develop EC.