Factors facilitating the process of the acquisition of moral competence in nursing managers: A qualitative content analysis

Abstract

BACKGROUND:

One of the essential dimensions of managerial competencies is moral competence. The purpose of this study was to explain the factors that facilitate the acquisition of moral competence in nursing managers in Iranian culture.

MATERIALS AND METHODS:

This qualitative study employed a content analysis approach to investigate the viewpoints and experiences of 14 nursing managers working in educational medical centers across Iran, Golestan province in 2023. Participants were purposefully sampled to ensure maximum diversity in terms of age, work experience, management experience, educational background, professional position, and gender. Data collection involved conducting 18 in-depth interviews, utilizing both nonstructured and semistructured formats. Subsequent data analysis employed contractual content analysis techniques, facilitated by coding using MAXQDA software version 20. To ensure the trustworthiness and credibility of the findings, Lincoln and Guba’s criteria were rigorously applied.

RESULTS:

The data analysis resulted in the extraction of 18 subcategories and 5 main categories. The main categories included: interactive learning, inspiration from the model, social-cultural learning environment, multimedia education, and an excellent organizational climate.

CONCLUSION:

In this study, several facilitating factors were identified in the acquisition of moral competence of nursing managers. It is recommended to use these factors as a framework for acquiring and improving the moral competencies of nursing managers in order to face ethical issues, make informed decisions, and create an ethical climate in the organization.

Introduction

In nursing management, competence can be defined as the correct combination and application of knowledge, attitude, and management skills.[1] Identifying and categorizing the primary competencies is essential for enhancing productivity in hospitals, as the role of hospitals within the community continues to evolve. The competencies of hospital managers play a crucial role in this regard[2] and are a paramount factor in ensuring the ongoing success of every organization.[3] The adept application of these skills can greatly enhance organizational effectiveness while simultaneously improving employee performance aligned with the organization’s objectives and goals.[4] González García and colleagues (2020) introduced ethical principles as one of the core competencies of nursing managers.[5] Ethical competence centers on valuing the input of followers and is rooted in ethical principles.[6] Ethical competence is a vital quality or skill that nursing managers must possess in their day-to-day work, enabling them to identify ethical implications present in their decision-making. By harnessing ethical competence, managers and healthcare professionals are empowered to pursue the most favorable outcomes for the welfare of their patients.[7] The ethical competence of managers has positive consequences, such as helping to identify the professional expectations of individuals, determining the minimum acceptable standards in the profession, providing boundaries for acceptable behaviors of nursing managers, shaping and guiding ethical behaviors, creating a framework for ethical decision-making to solve daily problems, enhancing ethical performance, facilitating professionalization, preventing unethical or illegal actions of managers, protecting individuals from legal problems, fostering an ethical environment, promoting the ethical culture of employees and organization, improving the quality of nursing care, and respecting the rights of patients.[8,9,10,11] Also it causes foster trust-based relationships among employees. These relationships, in turn, contribute to positive work outcomes, including improved performance and increased innovation, at the individual, team, and organizational levels.[12] Nursing is a profession that requires ethical knowledge to guide action, develop the knowledge base, and resolve complexities and ambiguities of the discipline.[13] Ethical action is a vital aspect of nursing care and the development of ethical competencies is essential for the present and future of nursing; this development requires the recognition of effective factors in acquiring ethical competence.[14] Identifying the factors that promote and facilitate the growth of nursing managers can aid in the cultivation of managers who prioritize the fair and merit-based selection and development of individuals.[15]

On the other hand, nursing managers are more exposed to the risk of ethical conflict due to various social challenges such as technological advancement, lack of resources and human resources, problems related to personnel, organization, and also increasing number of patients in need of special care that will create multiple questions and ethical decisions.[16,17] So, identifying the effective and facilitating factors of the process of acquiring moral competence helps nursing managers to plan for acquiring moral competencies in confronting ethical challenges, making logical and accurate judgments, and improving nursing care. Qualitative content analysis within the comprehensive naturalistic framework allows researchers to explain and reveal the depth, richness, and complexity hidden in the life and work of nursing managers and their process of acquiring moral competence.

Engaging in an exploration of meanings, assigning significance to the perspectives of study participants, embracing the notion of multiple realities, and conducting research in authentic settings contribute to a more profound comprehension of the phenomenon under investigation.[18] The authors of this article conducted an extensive search in medical science article databases, but they did not find any research that specifically addresses the facilitating factors of ethical competence in nursing managers. Therefore, considering the vital role of moral competence in nursing managers and its impact on all aspects of the nursing work environment and climate, this qualitative study was conducted with the aim of explaining the facilitating factors of acquiring moral competence in nursing managers.

Materials and Methods

Study design and setting

This study was conducted based on the naturalistic research paradigm and using a qualitative design and the method of conventional content analysis. This approach serves as a systematic methodology for a comprehensive exploration of the phenomenon, particularly when there is a scarcity of existing theories and studies related to the subject matter. It is particularly well-suited for investigating individuals’ experiences and perceptions surrounding a specific topic, enabling a thorough examination of the phenomenon in question.[19] This study was conducted in the city of Gorgan (northern Iran) in 2023.

Study participants and sampling

A purposive and nonrandom sampling method was used to recruit participants for this study.

The participants were nursing managers (in all three levels of management: head nurse, supervisor, and matron) working in educational centers affiliated with Golestan University of Medical Sciences (Iran). The entry criterion for the study was having at least 2 years of nursing management experience. The first participant was the head nurse of the women’s surgery ward, who had an ethical reputation, met the conditions for participation in the study, was interested in sharing her experiences, and was invited by the researcher for an interview. After making the necessary arrangements and obtaining the oral informed consent and explaining the objectives of the project, the interview was conducted in the head nurse’s room. In this way, the subsequent interviews continued until data saturation. Sampling was done with maximum diversity in terms of management levels, management experience, gender, age, marital status, and education level. Fourteen participants were included in the study, and a total of 18 interviews were conducted. It should be noted that with four participants, the interview was conducted twice (participant numbers 1, 2, 3, 5). The second interview was based on specific and detailed points that were unclear in the first interview and also because the interview was half-finished due to lack of time.

Data collection tool and technique

The main method of data collection was unstructured and semistructured interviews. The interviews were conducted in the head nurse’s room with prior appointment and at the suggestion of the participant. The researcher started the interview with a general and open question like “Tell me about your workday in the ward” and then used main and probing questions as needed. So that the participants could express their experiences. The main question that was asked of the participants in the interviews was “What factors affect your ethical competence as a nursing manager?”, and in the continuation of the interview, more specific questions were asked about the “influential factors (facilitators)” from the participants. The interview guide questions are provided in Table 1.

Table 1.

The interview guide questions

Describe a typical workday in your department.

When I mention moral competence, what comes to your mind? Please share your experiences in this regard.

How do you assess yourself as a manager/nurse leader in terms of moral competence? Please provide examples from your experiences.

Please explain the moral competencies you have acquired or developed during your tenure as a nursing manager.

Based on your background and experience, what ethical aspects do you consider and implement in department management?

How did you acquire this ethical ability (mentioned by the participant)? Please share your personal experience in this regard.

Based on your experience, how has the acquisition and observance of these ethical aspects influenced your work and department management?

Each interview lasted between 50 and 70 min (average 60 min), depending on the situation, the cooperation of the participant, and the environmental conditions. The whole flow of the interview was recorded by a Samsung Note 8 mobile phone with the permission and coordination of the participants and then transferred to Word software on the computer as audio files. The process of conducting the interviews was evaluated and criticized by the authors of the article, who were experts in qualitative research. Along with data collection, analysis was performed using the conventional content analysis method. After typing the text of all the interviews, the data were entered into the Max-QDA software version 20 for ease of organization; the method suggested by Graneheim and Lundman was used for data analysis.[20] First, the interview text was examined and reread several times, and based on this, the units of meaning were identified as sentences or paragraphs from the statements and texts of the interview, and a code was given to each keyword or sentence; in this stage, the initial codes or open codes were extracted from them, and in the next step, the similar initial codes were grouped together and, thus, the initial categories or subcategories were formed. Then, by performing the constant comparison, similar subcategories were merged and finally main categories were abstracted. The flow of analysis continued continuously, and with the addition of each interview, codes and categories were modified.

To ensure the rigor of the findings, four criteria of Lincoln and Guba were used.[21,22] The credibility of the data was achieved through member checking by the participants or interviewees. In some cases, after conducting and implementing the interview, the text along with an analysis of the interview was provided to the interviewee to verify the accuracy of the information obtained in the interview. To confirm the data, all the text of the interviews, the codes, and the extracted classes were reviewed and confirmed by the authors of this study and one faculty member outside the research team. For the reliability of the findings, the steps and process of the research were recorded and reported as accurately and step by step as possible. The participants were selected with maximum diversity in terms of management levels, management experience, gender, age, marital status, and education level, which also helped the transferability of the findings.

Ethical consideration

All ethical considerations were observed in this study. The necessary permission was obtained from the Ethics Committee of the University (with the ethics code: (IR.GOUMS.REC.1401.365). Informed consent was obtained from all participants regarding participation in the research by stating the purpose, nature, and method of work. The location, time, and duration of the interview were selected based on the opinions of the participants. The comfort and privacy of the interviewee were considered during the interview. The participants were assured of the confidentiality of the information and audio files.

Results

Participants’ characteristics

Of the 14 participants in the present study, 8 were male and 6 were female. The mean age, work experience, and management experience of the participants were 43.76 years, 21.3 years, and 12.61 years, respectively. Three nursing managers had a bachelor’s degree and 11 others had a master’s degree in nursing. In total, nine head nurses and five matrons and supervisors entered the study.

In total, 369 initial codes were extracted, from which five main categories were derived, including “interactive learning”, ““inspiration from the model”, “socio-cultural educational context”, “multimedia education”, and “excellent organizational climate”[Table 2].

Table 2.

Subcategories and main categories from participant interviews

Main category		Subcategory
Interactive learning		Participation and teamwork
		Friendly and intimate atmosphere
		Reinforcing feedback
		Managerial consultation
Inspiration from the model		Modeling from the nurse
		Modeling from the managers
		Modeling from the physician
		Modeling from the university professor
		Ethical attitude of peers
Social-cultural learning environment		Constructive spiritual beliefs
		Positive and reinforcing cultural/religious beliefs
		The role of education in school/university
		The educational and nurturing environment of the family
Multimedia education		Mass media reminding ethical behaviors
		Using various opportunities for theoretical education
Excellent organizational climate		The professional rules and regulations
		Support from the superiors
		The positive impact of the organization on acquiring values

Interactive learning

This concept is abstracted from four subcategories: participation and teamwork, inspiration from the friendly and intimate atmosphere, reinforcing feedback, and managerial consultation. It indicates the impact of the interactions of nursing managers with nurses and other hospital managers on learning ethical competence.

Participation and teamwork

The participants admitted that one of the important factors in acquiring ethical competence is participation and teamwork because teamwork creates a stress-free, calm, and consistent condition in the ward, which leads to learning ethical virtues from each other. The nursing manager stated in this regard:

“We are now in a situation where we need the participation of everyone to solve the problems of the ward, teamwork makes everyone learn to feel responsible and this responsibility made the work of the ward very fast and without problems” (Participant No. 12).

“Teamwork in the ward gives a coherence to the work and makes everyone use a unified approach, for example, work conscience is very well learned in teamwork, because everyone is obliged to observe it and no one can work against the group and team” (Participant No. 3).

Friendly and intimate atmosphere

Some of the participants mentioned a friendly atmosphere in the ward as an effective environment for acquiring ethical competence, for example, the nursing manager said:

“The nurses in the ward told me a lot that they forget that you are the head nurse of the ward because you created a friendly and intimate atmosphere for us and you behaved well with us like a real friend. This friendly atmosphere made us learn to be kind like you” (Participant No. 6).

Reinforcing feedback

The experience of nursing managers showed that positive feedback from the patient, the patient’s family, the physician, the ward colleague, or the upper managers are effective in learning and strengthening different aspects of ethics. For example, a manager stated in this regard: “One of the factors that made me strengthen my work conscience was the positive feedback and satisfaction of the patients from my conscientious performance, for example, when we faced a crisis like Corona, the patients, when they saw how conscientiously I worked as the head nurse, they all thanked me and this gratitude and satisfaction strengthened this ethical aspect in me, considering that my father had passed away, when they said God bless your father, it gave me a good feeling” (Participant No. 13).

Managerial consultation

Attending management meetings and also taking continuous advice from ethical managers can be effective in acquiring ethical competence. For example, the nursing manager admitted: “Since I became the head nurse, I usually consult with managers who are trustworthy and honest. During my consultations, I learned from them many times not to play party at all. For example, when I first became the head nurse, they told me not to admit your acquaintances and relatives directly in your ward. Whatever you do in your ward, it may hit you with the label of party playing and paying more attention to that patient” (Participant No. 6).

Inspiration from the model

This concept is derived from five subcategories: modeling from the nurse, managers, physicians, university professors, and ethical attitude of peers. It indicates the effective role of models in acquiring virtues and different aspects of ethics.

Modeling from the nurse

The role of colleagues, especially experienced nurses who are ethical models in the ward and hospital, is indispensable in acquiring ethical competence and most nursing managers admitted that observing the behavior, performance, and speech of nurses with ethical models had a learning aspect for them. One of the participants said in this regard: “I learned this compassion from the nurses in my ward, when Covid-19 was there and they had changed our ward from CCU to Covid ward, I really learned compassionate care from my staffs there, in those days maybe some colleagues were looking for sick leave to not come to the hospital, but the nurses in my ward really didn’t take sick leave at all and they always said that we don’t feel like it and it hurts us to take sick leave, because people are dying, they even didn’t go to their deserved leave” (Participant No. 6).

Modeling from the managers

The experience of most participants indicates that the behavior and conduct of ethical managers can influence the learning of managers and subordinates. A manager who observes ethical issues in all situations and conditions can expect the observance of those issues from his subordinates. For example, a manager stated in this regard: “To pay the arrears of the nurses’ salaries, the matron was very persistent, I saw how hard he tried to get the rights of the nursing children to them sooner, in one of the meetings with the deputy of treatment and the head of the hospital, there the deputy of treatment asked the matron with a smile why are you so persistent, don’t you want to be a candidate for the nursing system or the city council, to which the matron replied I am also in pain for the nurses, I understand them, I myself was like them one day, I know what hard conditions they are going through now, really this feeling of sympathy of the matron, created a good feeling in me, I also learned to be like him, believe me, my motivation went up when I saw the feeling of sympathy of the matron” (Participant No. 5).

Modeling from the physician

According to most nursing managers, some of the hospital physicians were also their ethical models, for example, participant number 11 said in this regard: “We had a pediatric surgeon specialist in the hospital, he was really a responsible person and I remember one of the days he entered the hospital late and I asked him doctor, you always came on time, he said I was in Mashhad (city name) and on the stairs of the plane that I was coming to Gorgan (city), my patient called me and when he realized that I was in Mashhad, he asked me for something, I also canceled my flight and fulfilled his request, I had to come by bus, when we realized we were really shocked, … I learned from him”.

Modeling from the university professor

Observing ethical issues by the university professor has influenced the formation of ethical aspects of students during their studies and of course it is effective in their clinical performance and future career. One of the nursing managers said in this regard: “I remember in the university days, it was the defense day of one of my senior students’ thesis, that day one of the jury professors was from outside the university who happened to be newly retired, when I saw that most of my professors, especially my supervisor and advisor, went to the entrance door of the faculty to enter that jury and guided him to the amphitheater hall with dignity and respect, it was very interesting that my professors were so good and excellent, they preserved the honor and dignity of their colleague in front of us, this was a lesson that I learned from seeing these scenes” (Participant No. 2).

Ethical attitude of peers

The experience of some of the participants showed that the attitude (positive/negative) of the nursing staff in the ward on the issue of ethics had an impact on acquiring and maintaining their ethical competence. For example, the head nurse said in this regard: “In the CCU ward, considering the patients who are hospitalized, cardiopulmonary resuscitation is done a lot. In one of the shifts, we had a patient who had a DNR (Non-CPR order), but our children did the resuscitation operation because of their work conscience and the attitude they had in their mind that if they did not do this, they would commit an unethical act. I remember I also got motivated because of this attitude and this work conscience of my colleagues, I let the staff do their best, it was really instructive this movement of the nurses in my ward” (Participant No. 8).

Educational social-cultural context

According to the majority of nursing managers, there are various factors and environments beyond the workplace that have influenced the acquisition of ethical competence. These environments play a direct and influential role in shaping the moral character of managers even before they enter the clinical setting, and based on the ethical aspects acquired within these environments, they manage and oversee their respective departments and hospitals. These factors and environments encompass constructive spiritual beliefs, positive and empowering cultural/religious beliefs, the role of social education in schools/universities, and the instructive and nurturing foundation provided by families. It is within the framework of these subcategories that the concept of a social learning environment, as an abstract entity, emerges as a constructive cultural platform for fostering ethical development.

Constructive spiritual beliefs

The experiences of most participants have shown that there are certain moral aspects inherently present in humans, which are recognized as spiritual beliefs. Depending on specific spatial and temporal contexts, managers utilize these spiritual beliefs in their management practices. A nursing manager acknowledged, “Kindness is an inherent quality that exists within all individuals, and we can strengthen it through practice and repetition. Once, I gave my three-year-old child a doll, and they showed affection towards it and interacted with kindness, demonstrating that this aspect of kindness exists within the child” (Participant 6).

Positive and empowering cultural/religious beliefs

The emphasis of all nursing managers has been on the positive influence of religious teachings, beliefs, and the guidance of religious and cultural elders on the acquisition of moral virtues at the community level. A nursing manager expressed, “From ancient times, we were told that prophets and imams treated their subordinates with respect, meaning that in our religious and cultural beliefs, this was the essence…. I heard a saying from the Prophet that was as follows: ‘Whoever respects and honors their fellow believer has respected and honored God’…. and how much it impacted me and my work. From the next day, whenever I was performing a task, I felt as if God was in front of me, and my whole effort was focused on treating everyone with respect” (Participant 5).

The role of social education in schools/universities

Schools and universities have been recognized as social educational platforms according to the perspectives of the participants. In other words, observing ethical behaviors during school and university years has been influential in students’ acquisition of ethical values. One participant stated, “I learned a lot of ethical things at university…. How much the professors taught us about respecting the patient, all the classes emphasized that respecting the patient is a fundamental principle in nursing, to preserve their dignity. Before performing any procedure, we would have extensive discussions, show respect, and then start the task. I remember when we did our internship, we respectfully provided bed baths” (Participant 10).

The family as an educational and upbringing environment

The family was identified as the most significant and fundamental factor in acquiring moral virtues, as expressed by nursing managers. Most of them acknowledged that individuals learn many ethical qualities within the family environment and carry them forward into the subsequent stages of their lives. A nursing manager stated, “I witnessed justice numerous times in my own family and learned from it. I remember whenever my sisters and I went to the market, my mother always tried to buy things for us while maintaining fairness for all three of us. She would always say, ‘I love you all equally and look at you with the same eye. By God, if she spent one million for me, she would spend one million per person for my sisters.’ My mother’s emphasis on justice within our family was continuous and constant. Even our birthday gifts were equal” (Participant 3).

Multimedia education

The concept of multimedia education encompasses two subcategories: mass media as a communicator of ethical behaviors and diverse opportunities for abstract theoretical education. According to the beliefs and experiences of all nursing managers, various educational methods such as reading books and magazines, participating in refresher courses, conferences, journal clubs, etc., whether in-person or virtually, have been effective in acquiring and enhancing ethical competencies.

Mass media as a communicator of ethical behaviors

The undeniable role of the virtual space in educating various ethical aspects is evident. In today’s world, considering the existence of various social networks in the virtual space and membership in different Telegram and WhatsApp groups, as well as exposure to various series and videos, acquiring ethical competencies has become easier. For example, a participant in this regard stated, “We, as nursing managers, have a WhatsApp group where ethical issues are discussed from time to time. Solutions are provided, and we hold ourselves accoun and committed to implementing them” (Participant 9).

Utilizing diverse table opportunities for theoretical education

The experiences of most participants indicate that various educational methods, such as participating in refresher courses, attending scientific conferences, group therapy sessions, studying ethics-related books, and receiving individual ethics training, have been effective in acquiring different ethical aspects. “The educational supervisor at the children’s hospital where I worked was an active individual who regularly conducted ethics and professional behavior training sessions. It truly had an impact on me, such as teaching proper behavior with children, respectful interaction with patient companions who are mothers, and a variety of training courses that all had a learning aspect to them” (Participant 12).

Excellent organizational climate

The experiences of nursing managers have shown that a supportive and prevailing organizational climate in which individuals are engaged can have an impact on the growth and excellence of managerial ethical qualities and characteristics. In this study, the concept of an excellent organizational climate emerged, encompassing subcategories such as the role of governing laws and professional regulations, support from upper-level managers, as well as the positive influence of the organization itself (support and policies).

Role of governing laws and professional regulations

According to most nursing managers, the existence of ethical codes and professional regulations in the hospital can be effective not only in acquiring ethical competencies but also as a preventive measure against unethical conduct. “In the hospital, there are guidelines and regulations such as the conformity plan that assists us in learning and implementing this matter. The conformity plan suggests that we select nurses of the same gender as the patient whenever possible, so that both parties feel comfortable” (Participant 2).

Upper-level support

One of the effective factors in achieving ethical excellence is the support, positive feedback, and encouragement provided by upper-level managers when ethical issues are observed and practiced by managers and subordinates in the department and hospital. Such support creates motivation and promotes the repetition of ethical behaviors in individuals. Participant 1 stated, “When I received encouragement from upper-level managers for my accountability, my motivation doubled…. and when I received excellent ratings and witnessed the admiration of top-level managers, it gave me a sense of great value.”

Positive influence of the organization in acquiring values

Most nursing managers acknowledge that the organization itself plays a significantly positive and crucial role in the acquisition of ethical competency by the healthcare staff through continuous support, implementation of appropriate policies, and providing necessary conditions.

“In our hospital, all managers and nurses are taught that if they are found to lack integrity in their work, they will be easily dismissed, and if the misconduct is repeated, they will be terminated. An example of this is our colleague who spoke ill of another colleague behind their back, causing a crisis in the hospital. Later, it was discovered that they had lied. The hospital management promptly dismissed them, and this action served as a lesson for everyone, emphasizing that the organization does not tolerate joking around and will easily let go of those lacking integrity” (Participant 9).

Discussion

Given the crucial importance of moral competence in nursing managers and its significant influence on the nursing work environment, this qualitative study was conducted in Iran to explore the factors that facilitate the development of moral competence in nursing managers. In this study, nursing managers’ experiences regarding facilitative factors in acquiring ethical competency were elucidated. The results indicated that various factors, including interactive learning, inspiration from role models, an educative socio-cultural environment, media-based training, and an excellent organizational climate, have facilitated the process of ethical competency acquisition among managers.

The study conducted by Saif (2017) revealed that the results suggest an indirect relationship between ethical behavior components and nurses’ caring behavior, which is mediated by the moderating effects of ethical climate and organizational loyalty. The study highlights the importance of hospital managers implementing ethical behavior components within the nursing department, as this has the potential to positively influence the ethical climate of the hospital and subsequently lead to enhanced levels of nurses’ caring behaviors and organizational loyalty.[23] Furthermore, in the study by Dehghani et al.,[24] facilitative factors for acquiring professional ethical standards included the presence of experienced mentors for professional ethics education, increasing the level of knowledge of nurses, the existence of nursing ethics committees, practical ethics training, inclusion of ethical subjects in the curriculum, employing appropriate teaching methods, and utilizing ethical models and frameworks. However, the most significant facilitative factor for ethical acquisition in the managerial dimension was identified as proper interpersonal communication between managers and nurses. In the present study, interactive learning was also identified as a key factor in acquiring ethical competency, which is consistent with the aforementioned results. Therefore, it can be concluded that upper-level managers can contribute to the dissemination of various ethical aspects to lower-level managers and even subordinate personnel through participation, creating a friendly atmosphere, and providing constructive positive feedback in both meetings and clinical settings.

One of the findings of the present study is the inspiration derived from role models in acquiring ethical competencies, which is consistent with the results of the study by Soltaninejad et al.[25] demonstrating that ethical training through modeling and exemplifying ethical principles and behaviors in ethical situations by an ethical role model enhances individuals’ ethical performance. Additionally, Bastani’s review study has identified drawing inspiration from ethical models as an effective method for promoting and improving professional ethics in nursing.[26] If medical education and healthcare services are accompanied by adherence to and preservation of ethical principles, they can better meet the needs of patients with higher quality. Having a suitable ethical model is considered one of the best foundations for instigating transformation in an individual since it enables individuals to transform observed behaviors into skillful behaviors.[27] Therefore, the use of ethical models in hospitals can contribute to the consolidation and institutionalization of ethical performance and adherence to professional ethics among nursing managers.

Another finding of the study is the influence of the organizational climate, which can have an impact on excellence and ethical competencies. In this regard, Jalali et al.[28] state the significance of the organizational climate or, more precisely, the ethical climate that affects all relationships and the ethical conduct of nursing staff and managers. They write, “The ethical climate reflects individuals’ perception of their organization and influences the attitudes and behaviors of all organizational members, serving as a framework for employees’ performance”. This type of climate provides a context for the occurrence of behaviors and decision-making and is essentially an organizational variable that can change or improve working conditions. Considering the experiences of nursing managers, the enforcement of professional laws and regulations, support from higher-level managers, and the positive influence of the organization (support and policies), all of which are highly influential factors in the organizational climate, have a significant impact on acquiring ethical competencies. Additionally, Khayat Moghadam and Tabataba’i, in their qualitative research, have introduced organizational ethics components, including organizational rules and regulations, organizational culture, and organizational structure that institutionalize ethical management, as organizational ethics factors.[29]

One of the significant facilitators in acquiring ethical competencies among nursing managers is the utilization of multimedia educational resources, such as participating in refresher courses, virtual training, watching films and series, etc. Saeeidi et al.[30] identified the most important facilitating factor, according to nurses, for acquiring and practicing ethics in clinical settings, as gaining sufficient scientific knowledge and awareness through educational courses. Nasiriani et al.,[31] in their quasi-experimental study, demonstrated that virtual ethics training enhances the ethical attributes of nurses in specialized care units. Other studies have also shown that using simulated situations, exposure to challenging scenarios, film presentations, creating situations similar to what they encounter in practice, or role-playing methods can have a more significant impact on ethical competency and growth than mere theoretical training.[32] Considering that one of the primary concerns in nursing education and nursing management is always how to increase sensitivity and capabilities in dealing with ethical situations, it can be said that various educational methods are effective in acquiring ethical competencies. Nursing managers should be familiar with ethical theories that determine and validate professional behaviors, be aware of professional ethical principles, regulations, practical standards, and laws related to the rights of subordinate nurses and patients. Understanding how to recognize ethical problems, distinguishing between ethical issues and legal matters, knowing ethical principles and norms, and being able to apply them in ethical decision-making are factors that contribute to the effective process of acquiring ethical competencies among managers.

One of the significant findings of the study is the impact of the socio-cultural educational environment on the acquisition of ethical competencies among managers. In the present study, nurse managers believed that religious beliefs, as well as the ethical atmosphere within their families, schools, and universities, have played a role in shaping various ethical aspects to some extent before they entered the clinical setting. A study conducted by Imanifar (2022)[33] demonstrated that nursing ethics education, delivered through narrative-based and lecture-based instructional methods, resulted in a notable improvement in nurses’ patient advocacy skills. Regarding the influence of schools on the acquisition of various ethical aspects, Ghayoomi and Ahari[34] stated in their study that various factors such as teachers, the ethical climate, school management, religious beliefs, and group P values influence the ethical growth and development of students. Therefore, it can be said that ethical growth in early ages is the most critical part of individuals’ lives, and the school, as a place where the initial ethical foundations and behavioral and ethical characters of individuals are formed, is of utmost importance.

The undeniable role of the family as the most significant facilitating factor in acquiring moral virtues has been identified from the perspective of nurse managers. From the very beginning of life, individuals have a natural inclination toward ethical values. Ethics is not something that is suddenly created in humans; it must be practiced from childhood. The family is the most important and fundamental institution in society, playing a crucial role in the upbringing of individuals in society and the formation of ethics in them.[35] With these interpretations, it can be concluded that to some extent, virtues and ethical competencies are shaped during the preemployment period of managers, which further emphasizes the heavier responsibility of families, teachers, and professors.

The strengths of this study include its qualitative approach, diverse sample, rigorous data collection and analysis methods, and the identification of several facilitating factors for the acquisition of moral competence in nursing managers.

Limitation and recommendation

The limitations of the present study were the use of one data collection method, the difficult access to nursing managers due to their workload, and the caution in generalizability. Therefore, maximum effort was made to enhance the rigor of the study data. The present study focused only on the facilitating factors of acquiring moral competence in nursing managers, and it is suggested that a tool for measuring the moral competencies of nursing managers be developed and psychometrically tested in future studies.

Conclusion

Based on our findings, we identified several key factors that contribute to the development of moral competence in nursing managers. To strengthen ethical practices and create an environment conducive to ethical decision-making, we recommend the following:

Nursing managers should actively engage in professional development programs that focus on ethical decision-making and moral competence. This could include workshops, seminars, or continuing education courses specifically tailored to enhance ethical competencies.

Organizations should prioritize the integration of ethical considerations into their policies and procedures. This could involve the development of ethical guidelines and protocols that provide clear guidance on how to handle ethical dilemmas in nursing practice. Policy makers should recognize the importance of moral competence in nursing management and incorporate it into healthcare policies and regulations. This may involve establishing standards and requirements for nursing managers to demonstrate and maintain moral competence. Supportive and open communication channels should be established within healthcare organizations, allowing nursing managers to seek guidance and support when facing ethical challenges. This could include regular ethical discussions, ethics committees, or access to ethics consultants. By implementing these recommendations, nursing managers and policy makers can contribute to the cultivation of a morally competent nursing workforce and promote ethical decision-making in healthcare settings.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.