College of Health Sciences, Mindanao State University-Iligan Institute of Technology, Tibanga, Iligan City, 9200 Philippines
*Corresponding Author’s Email: roselyn.butalid@g.msuiit.edu.ph
Keywords: Compassion Fatigue; Morals; Professional Burnout; Workload
Moral competence in nursing is a crucial factor that impacts ethical decision-making and the quality of patient care. It entails having the ability to act morally and in accordance with deeply held beliefs, helping nurses effectively manage challenges and conflicts in the workplace (Haghighat et al., 2020; Bronikowska et al., 2019). This competence also includes altruistic behavior and respect for the moral perspectives of others (Ma, 2012; Johnstone, 2015). According to Maluwa et al. (2018), the following characteristics define moral competence: kindness, compassion, caring, critical thinking, ethical decision-making, problem-solving, responsibility, discipline, accountability, communication, solidarity, honesty, and respect for human values, dignity, and rights.
Nurses with high moral competence are trusted to deliver quality care and effectively advocate for patients while managing ethical dilemmas involving various stakeholders (Zafarnia et al., 2017). Enhancing moral competence is crucial for improving nursing practice, as it enables nurses to meet patient needs and increases public satisfaction with healthcare services (Maluwa et al., 2018). Studies indicate that moral competence is linked to better patient outcomes and reduced instances of missed nursing care, highlighting its importance in fostering ethical nursing practices (Nazari et al., 2024).
Most existing research on nurses’ moral competence predominantly centers on the perspectives of a single group, most commonly nurses themselves or nursing educators, which limits the depth and breadth of understanding that could be gained from including patients’ viewpoints (Gastmans et al., 2025). Several reviews also highlight that studies into the factors shaping nurses’ moral competence tend to emphasize professional development, often neglecting patients’ experiences and expectations (Wiisak et al., 2024). This trend is also evident in the Philippines, where research has explored various dimensions of nurses’ competencies, from cultural and clinical to moral, professional, and core skills, but there continues to be a noticeable lack of studies that delve specifically into moral competence from the patient’s perspective. For example, Butalid (2023) concentrated on the moral dilemmas nurses face and their coping strategies but did not address how patients perceive these moral competencies. These observations underscore the importance of understanding patients’ experiences, as this insight is vital for identifying factors that either support or hinder the moral conduct of nurses. Consequently, this study aimed to explore and understand how patients in Iligan City, Philippines, perceive the moral competence of the nurses who care for them.
This study is grounded in Jean Watson’s Theory of Human Caring, which emphasizes that caring, rather than medical interventions alone, is fundamental to effective nursing practice (Watson, 2007). The theory highlights the importance of forming deep connections with patients and recognizing their emotional and spiritual needs. This focus on holistic, interpersonal care aligns with the study’s aim to understand patients’ experiences with nurses’ moral competence.
Watson’s ten "carative factors," such as building trust and supporting patients, guide moral and holistic nursing care. The theory’s cultural adaptability also makes it suitable for diverse settings like Iligan City. Overall, Watson’s theory provides a strong, relevant framework for examining how nurses’ caring behaviors impact moral competence and patient experiences.
This study employed a qualitative descriptive design to gain deep insights on how patients perceived the moral competence of their nurses. This design focuses on presenting phenomena as they naturally occur, without extensive interpretation or theoretical explanation, with the primary aim of providing a clear, comprehensive, and straightforward account of events or experiences (Ayton et al., 2023). The study adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines to enhance methodological rigor and ensure transparency throughout the research process (Tong et al., 2007).
The research was conducted in the patient wards of one government hospital and one private hospital in Iligan City, Philippines, providing a relevant clinical context to explore patients’ perceptions of nurses’ moral competence. Hospitals allow for direct observation of nurse- patient interactions during vulnerable periods, making them ideal for capturing lived experiences. This setting effectively addresses the gap in understanding how patients experience nurses’ moral competence within the local healthcare system.
This study included 23 participants recruited through a purposive sampling technique based on these criteria: admitted for at least three days in the facility, aged 18 and older, and willing to participate in the study regardless of sex, diagnosis, socio-economic status, ethnicity, and religion. Purposive sampling was employed to choose small, information-rich samples that provide deep insights, with qualitative research generally involving between one and approximately 20 participants (Subedi, 2021). The sample size of 23 participants was considered sufficient because data saturation was reached, no new themes emerged after these interviews. Reaching data saturation signifies that the phenomenon under study has been sufficiently examined, allowing the researcher to discontinue data collection without missing significant insights (Ahmed, 2025). Diversity was ensured through purposive sampling with broad inclusion criteria that allowed participation regardless of sex, diagnosis, socio-economic status, ethnicity, or religion. Participants were recruited from both a government and a private hospital, capturing varied patient experiences across distinct healthcare environments. Selecting two sites and purposive sampling ensured diverse patient perspectives, enhancing the study’s depth and applicability. Only primary participants (patients) were included; no secondary informants, such as family members or healthcare staff, were involved.
An ethics review committee approved the study before its final conduct. Permission from the hospitals and informed consent were secured before the in-depth one-on-one interviews, and all ethical considerations were applied. A researcher-developed interview guide, successfully pretested with five patients from a hospital outside the main study, was effectively utilized. Open-ended questions facilitated rich discussions during the semi-structured interviews, which continued until no new themes emerged. Each interview lasted for 30-60 minutes with an audio recording. The data collection lasted two months, from February to March 2025.
The responses were transcribed word-for-word and translated from the local language into English using back-translation method. Back translation was done by translating the source text (Cebuano) into the target language (English), then a different translator converted it back into the original language without access to the original text. The original and back-translated texts were compared to identify differences in meaning, clarity, and cultural appropriateness. No significant discrepancies arose.
The responses were analyzed according to the six key steps of qualitative data analysis outlined by Clarke and Braun (2013). The researchers first familiarized themselves with the interview transcripts by reading them multiple times and noting key topics. Next, initial codes were generated from the data. These codes were then grouped into clusters with similar meanings, which were further combined into broader themes. The themes were reviewed to ensure they accurately represented the data, then clearly named and defined to capture their core meanings. Finally, the findings were written up and interpreted in a comprehensive report.
This study employed five criteria to ensure research trustworthiness: bracketing, credibility, transferability, dependability, and confirmability (Tong et al., 2007). Bracketing was upheld through continuous self-reflection by the researchers to set aside personal biases and faithfully represent the participants’ experiences. Credibility was established through in-depth engagement with the data and conducting member checks to validate the accuracy of the findings. Transferability was enhanced by using purposive sampling to capture a diverse range of participant experiences, increasing the relevance of the results to other recovery contexts. Dependability was maintained by producing verbatim transcripts of audio-recorded interviews and thoroughly documenting the data analysis process. Confirmability was strengthened through investigator triangulation, wherein four researchers participated in data collection and analysis, thereby ensuring that the findings remained firmly grounded in the participants’ perspectives and reducing the potential for researcher bias. Additionally, peer validation was conducted, involving the review and critical appraisal of the study by other researchers.
The article received ethical approval from the Ethics Review Committee, College of Health Sciences, Mindanao State University-Iligan Institute of Technology, Philippines with reference number CHS-0035-2024 on 11th February, 2025.
The study formulated three themes and eleven subthemes that describe the moral competence of nurses in Iligan City, Philippines based on patients’ experiences with their careH (Table 1).
Table 1: The Themes and Subthemes of the Study
Themes | Sub-themes |
1 Patient-centered care | Compassionate support |
Responsiveness to needs | |
2 Ethically grounded clinical proficiency | Effective communication |
Skilled task execution | |
Preserving patient autonomy | |
Fairness and non-negligence | |
3 Challenges affecting moral competence | Workload and burnout |
Overlooking harm prevention | |
Irritability | |
Delays in care | |
Compassion fatigue |
The first theme, “patient-centered care,” refers to the healthcare approach that prioritizes the patient's specific needs, values, preferences, and overall well-being in the delivery of care. It embraces a holistic approach by considering not only symptoms and medical history but also the emotional, social, financial, and family aspects of a patient's life. It has two subthemes: compassionate support, and responsiveness to needs.
This subtheme refers to the nurse's care characterized by genuine kindness, empathy, and emotional sensitivity, which helps build trust and promotes healing. The participants shared the following accounts.
The nurse greets and checks on me in a gentle voice and calm way despite being busy with her tasks. – P3
The nurse provided education on adhering to the full course of antibiotics to promote complete recovery. – P9
I liked how he approached and cared for me. He’s like a son checking on his mother. – P18 When nurses take time to calmly check on how I’m feeling; and ask if something bothers me, it helps me feel more at ease and supported. – P21
This subtheme refers to the ability of the nurses to respond promptly to patients' needs and concerns, ensuring timely care. This also includes how the nurses can assure their patients that they will return if immediate attention is not possible. The participants shared the following accounts.
When I had complaints, the nurses came right away to check on me, which made me feel valued and respected. – P12
There was a time when I called the nurse, she came to ask about my concern and assured me she would return shortly. True to her word, she came back after a little while. – P3
This theme reflects the integration of clinical proficiency and ethical responsibility in nursing care. It encompasses the knowledge, skills, attitudes, and values required for nurses to deliver safe, effective, and morally sound care. It has four subthemes: Effective Communication, Skilled Task Execution, Preserving Patient Autonomy, and Fairness and Non-Negligence.
This subtheme reflects the nurses’ ability to clearly explain the patients’ respective conditions and treatments to reduce anxiety and promote better health outcomes. The participants shared the following accounts.
I requested the removal of my retention catheter because it is inconvenient to move. The nurse promptly explained that I must wait for the doctor’s evaluation and order. – P1
I like my nurse because he explained my condition, and the indications of my treatments and medications. – P18
This subtheme refers to the nurse’s ability to efficiently and safely complete tasks and responsibilities. This includes proper administration of medications, gentle handling during procedures, and appropriate adjustment of techniques based on the patient’s situation. The participant shared the following account.
They took good care of me in administering my IV fluids and Oxygen inhalation, drawing blood specimens, and checking my blood pressure. – P11.
This subtheme refers to how nurses involve patients in decision-making by asking for consent before any procedure. The participants shared the following accounts:
The nurse asked permission to dress my wound and take my vital signs. – P6
They secured consent before the surgery. – P7
This subtheme ensures equal attention to all patients and demonstrates fairness in care delivery. The participants shared the following statements.
They show equal treatment to all patients without discrimination. – P3
They assure me they’ll come back if they can’t attend to my needs immediately. – P19
The third theme refers to the obstacles nurses face in effectively applying ethical principles and values in clinical practice. These challenges stem from systemic, educational, and interpersonal factors, often hindering the nurse’s ability to act in alignment with moral responsibilities. It has five subthemes: Workload and Burnout, Overlooking Harm Prevention, Irritability, Delays in Care, and Compassion Fatigue.
This subtheme describes the heavy burden of excessive job demands in nursing, including physical, mental, emotional, and time-related pressures. It also highlights the emotional exhaustion, stress, and reduced sense of achievement that occur when these demands are continuous and overwhelming. The participant shared the following account.
Sometimes, they fall short in their service. When I complained of difficulty breathing, the nurses were unable to respond. I considered the situation because they were busy attending another patient’s emergency. – P18
This subtheme describes instances where the nurse failed to identify the potential harm being inflicted on the patient. The participant shared the following statement.
There is a nurse who, when administering medication, causes my IV site to become dislodged because she injects too quickly. I asked her to inject more slowly, but she did not heed my request. – P1
This subtheme refers to the irritable behavior of nurses toward patients characterized by feelings of anger, annoyance, impatience, or frustration that nurses may exhibit during interactions with patients. The participants shared the following accounts.
Some nurses are irritable; they don’t answer when asked. – P4
One nurse responded to me in a loud voice or raised her voice. – P19
This subtheme refers to situations where essential nursing tasks or interventions are postponed, partially completed, or not performed within the expected or required timeframe. This can include delayed administration of medications, treatments, patient assessments, or other necessary care activities. The participant shared this account.
Some nurses respond with "later" when called and take a long time to attend. If you don’t keep calling them repeatedly, they may not come at all. – P8
This subtheme refers to the irregular demonstration of compassionate, caring, and attentive actions among nurses toward patients. This inconsistency means some nurses may show kindness and fully engage with patients’ emotional and holistic needs, while others may appear indifferent, task-focused, or emotionally detached. The participant shared the following account.
Some nurses are good, they explain things well and have a kind approach, while others just give medicine and go. – P18
The findings of this study offer valuable insights into patients’ experiences and perceptions of nurses’ moral competence, highlighting the pivotal role of a patient-centered approach and ethical conduct in healthcare delivery. Nurses embody moral values through their actions, which serve to optimize patient benefits (Hussein & Hashish, 2023). A salient theme formulated was patient-centered care, conceptualized as a holistic framework that views the individual as an integrated whole, encompassing mind, body, and spirit. Alharbi (2025) asserts that holistic care enhances patient satisfaction and the quality of care, especially when delivered with empathy and attentiveness.
Within this framework, nurses demonstrated patient-centered care through two key dimensions: compassionate support and responsiveness to patient needs. Compassion, a vital aspect of moral competence, reflects a deep sensitivity to others’ suffering coupled with a committed desire to provide relief and support (Maluwa et al., 2018). The nurses demonstrated compassion through warm greetings, gentle communication, attentiveness to patient concerns, and creating an atmosphere that felt like family, greatly contributing to a therapeutic and emotionally safe environment. Moreover, the nurse’s provision of education regarding the importance of completing the full course of antibiotics exemplifies compassionate, patient- centered care by conveying empathy, respect, and concern. This supportive educational approach empowers patients to achieve full recovery, extending beyond mere procedural instruction. These findings are consistent with Watson’s (2007) Theory of Human Caring,
which posits that cultivating a helping-trust relationship is fundamental to promoting emotional well-being. Additionally, empirical studies by Kwon et al. (2022) and Kim et al. (2021) corroborate the direct impact of empathy and respect in nursing on enhancing patient satisfaction and clinical outcomes.
Responsiveness to needs captured how nurses’ attentiveness and timeliness contributed to a sense of security and support among patients. Patients expressed appreciation when nurses responded quickly to pain, visited regularly, and followed up after brief delays. Even in situations when nurses could not immediately attend to requests, their verbal reassurance and timely return translate as acts of moral accountability and professionalism. This aligns with the finding of Gastmans et al. (2025), that patient-centered responsiveness, attuned to both verbal and nonverbal cues, is a fundamental component of moral competence and vital for establishing therapeutic relationships.
The study also emphasized the critical importance of communication skills, particularly the nurses' ability to provide clear explanations. Patients who were thoroughly informed about their condition and treatment experienced lower anxiety and a stronger sense of trust in nurses. This finding is supported by Pratiwi et al. (2021), that therapeutic communication reduces preoperative anxiety, and by Bahari et al. (2024), who found that perceived quality of care improves with clear communication. Moreover, Kreps (2018) highlighted the risks associated with misunderstanding critical information, demonstrating the moral responsibility of nurses to ensure clarity.
Participants frequently highlighted how timely intravenous insertions, medication administration, and vital signs monitoring positively influenced their perceptions of nursing care. Aiken et al. (2018) and Griffiths et al. (2018) confirmed that clinical competence directly impacts patients’ perception of care quality and satisfaction. Skillful and timely execution of duties reassured patients of the nurses’ professionalism and contributed to building trust. Nurses who obtained informed consent before procedures demonstrated deep regard for patient rights and dignity, contributing to trust and collaboration. This aligns with Rahmani et al. (2024), who emphasized that upholding autonomy is foundational to moral competence.
Moreover, fairness and non-negligence were evident when nurses managed their time well, reassured patients, and provided equal attention despite workload pressures. These behaviors reflect the ethical principle of justice, as discussed by Wiisak et al. (2024), which requires equitable treatment of all patients, regardless of circumstances. Workload and burnout not only harm nurses’ well-being but also reduce their moral competence, leading to ethical dilemmas, moral distress, and compromised patient care. Systemic issues like understaffing and high patient-to-nurse ratios hinder nurses’ ability to provide ethical care. A meta-analysis by Li et al. (2024) found nurse burnout, marked by emotional exhaustion and depersonalization, is strongly linked to poorer patient safety, lower satisfaction, and reduced care quality. Burnout creates a gap between nurses’ ethical knowledge and actions, risking moral distress and professional dissatisfaction. Addressing nurse well-being is therefore essential to ensure patient safety and uphold ethical nursing practice. When a nurse regularly administers medication that irritates the intravenous site, she may overlook patients' complaints of pain. This represents a failure to uphold the principle of non-maleficence, or "do no harm." The nurse must be sensitive to the patient’s concerns to avoid causing pain or any form of harm. Patients are entitled to be free from injury, and the principle of non-maleficence obligates nurses to prevent causing any danger to them (Haddad & Geiger, 2023).
Irritability often arises from stress, fatigue, or challenging clinical situations and may manifest as short temper, irresponsiveness, or abrupt communication. Job stress negatively impacts nurses’ quality of life and can diminish the quality of care they deliver by reducing positive professional behaviors, which may, in turn, affect patient outcomes (Huff et al., 2023). Most participants found their nurses attentive, but some reported delays in care/response especially during urgent situations, which led to feelings of neglect and lack of support. One participant noted that care in public hospitals seemed less responsive than in private ones, possibly due to economic factors, and that patients in public settings felt less able to voice concerns or expect timely attention. Petrovici et al. (2025) found that private hospitals generally rank higher than public hospitals on key service dimensions including responsiveness, empathy, and reliability, indicating patients often perceive care in public settings as less responsive than in private ones. Despite these challenges, participants empathized with heavy workload of nurses. Nevertheless, slow or inattentive care still leave patients emotionally and physically affected. Gastmans et al. (2025) emphasized that when nurses deliberately attend to patients and keep their commitments despite stressful conditions, they effectively convey that patients are valued; and their concerns acknowledged. Compassion fatigue refers to the emotional and physical exhaustion healthcare providers face from prolonged stress (Ye et al., 2024). Compassion fatigue affects healthcare providers’ psychological health and professional functioning, including its impact on nurses’ ability to engage empathically with patients (Garnett et al., 2023). Participants noted inconsistency in nurses’ moral competence, some were compassionate and attentive, while others appeared indifferent or rude. This variability affects patients’ emotional well-being, trust, and satisfaction. Gastmans et al. (2025) describe morally competent nurses as person-centered, blending technical skills with empathy and respect. Participant 18 observed that some nurses are kind and approachable, but others seem mechanical or dismissive, revealing gaps in communication, respect, and moral reflection. Harrison et al. (2025) found that while patients generally rate nurses as respectful and caring, there are notable deficits in aspects of communication such as involving patients in shared decision-making and discussing care plans, highlighting variation in nurse-patient interactions.
This study comprehensively elucidated patients' perceptions of nurses' moral competence, affirming its profound impact on the healthcare experience. Patients consistently valued nurses who exhibited patient-centered care through compassion and responsiveness. Integral to this was ethically grounded clinical proficiency, demonstrated by clear communication, skilled technical execution, informed consent practices, and fairness in care delivery. However, the study also revealed significant systemic and individual factors that challenge consistent moral competence. Workload, Burnout, Irritability, Care Delays, and Compassion Fatigue emerged as critical impediments, underscoring the gap between ideal moral practice and the realities of nursing. These findings highlight that while nurses strive for ethical care, external pressures and internal strain can compromise their ability to consistently meet patients' moral expectations.
This study has several limitations. The small sample size of 23 patients from only two hospitals in Iligan City limits the generalizability of the findings. Purposive sampling excluded patients with shorter stays and did not include nurses or family members, reducing the breadth of perspectives. Data relied on self-reported interviews subject to recall and social desirability biases, and despite careful translation, some cultural nuances may have been lost. The study’s focus on Jean Watson’s Theory may have constrained the exploration of other aspects of moral competence. Being cross-sectional, it captures perceptions at a single point in time. Despite efforts to reduce researcher bias, fully eliminating it in qualitative research remains challenging.
Additionally, participant bias was possible, as patients might have provided socially desirable responses or felt hesitant to share negative experiences due to power dynamics or fear of repercussions. The presence of the interviewer during in-depth interviews could also have influenced patient responses, potentially leading to response bias or withholding of sensitive information. These factors should be considered when interpreting the findings.
This study underscores nurses’ moral competence as vital to patients’ healthcare experiences, centered on holistic, patient-focused care. Nurses show moral competence through compassion, responsiveness, clear communication, clinical skills, respect for autonomy, and fairness. However, factors like Workload, Burnout, Overlooking Harm, Irritability, Care Delays, and Compassion Fatigue often hinder consistent ethical practice, creating a gap between knowledge and care delivery that impacts patient trust and satisfaction. Addressing both personal and systemic barriers is crucial to strengthening moral competence and improving nursing quality.
To enhance nurses’ moral competence and patient care quality, practical efforts should reduce burnout and compassion fatigue through manageable workloads and support programs. Training in empathetic communication and patients’ rights advocacy is essential. Theoretically, research should extend beyond Watson’s theory to include diverse perspectives and longitudinal analysis. Integrating moral competence frameworks into nursing education and training strengthens ethical decision-making, communication, holistic care, moral resilience, and stress management, better preparing nurses for clinical challenges. Policies should address moral distress, ensure adequate staffing and resources, mandate ethics training, and promote patient-centered care to uphold patients’ dignity and well-being.
Future research should include nursing perspectives, assessing burnout’s impact, and develop strategies to improve ethical nursing practice. Expanding studies across diverse settings will enhance understanding of moral competence. Focus should be on reducing workload, burnout, and compassion fatigue, strengthening education and policies for ethical decision-making and patient-centered care. Additionally, improving nurse-patient-family collaboration and fostering moral resilience can advance nursing education, workplace support, and care quality.
The writers assert that they have no conflicting financial or other interests.
The authors are thankful to the study participants for generously sharing their time and experiences, and the hospital administrators for granting permission and support in the conduct of this research.
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