Nurses face various ethical problems due to changes in the social environment, such as advances in medical technology, a heightened awareness of people’s rights, and the diversification of values. In Japan, a wide variety of ethical issues are experienced by nurses, as shown in the 35 items listed as ethical issues experienced by clinical nurses  by Ogawa et al. Above all, the debate about the pros and cons of physical restraint and artificial nutrition via gastrostomy is a stumbling block for nurses in developed countries because they are either aiming to protect the medical judgment and dignity of the subject or trying to be advocates [2,3,4,5]. There are also common and everyday ethical issues related to nursing .
However, in the busy daily work of nursing, there is little room to fully consider ethical issues and improve one’s practical skills; many nurses are worried about ‘remorse for patient involvement’, ‘avoidance of problem involvement’, and ‘negative feelings about people who have conflicting ideas’ in their current situation . There are also reports that clinical nurses with high levels of ‘moral sensitivity’ suffer from greater fatigue , while nurses with low levels of ethical sensitivity have lower burnout levels than nurses with high levels of ethical sensitivity .
There are challenges related to an ethical education that enhances individual ethical practices and fosters an organizational culture that can actively tackle ethical issues and support staff who are suffering, because the ethical practices of nurses currently affect the quality of care . It has also been shown that improving the ethical environment is related to the job satisfaction of nurses and their effective collaboration with physicians [11, 12]. From the perspective of team-oriented medical care, it is also necessary to have the ability to actively comment from a nursing standpoint and to discuss ethical issues in the field of multidisciplinary collaboration. While it is evident that strengthening ethical practices is becoming more important, a concrete practical list of what is ethically competent and practiced has not been clear until now.
The World Health Organization (WHO) Global Competency Model includes definitions and effective behaviors and emphasizes the relationship of these behaviors to professional competencies in ethics as ‘behaviors consistently in accordance with clear personal ethics and values’.  From the perspective of the United States and WHO European countries, the term ‘competence’ relates to a combination of knowledge, skills, attitudes, and values. Competency is therefore a combination of attributes underlying some aspect of successful professional performance .
Lechasseur et al. showed that the most frequently used terms with regard to ethical competence in nursing are ethical sensitivity, ethical knowledge, ethical reflection, ethical decision-making, ethical action, and ethical behavior . Kulju et al. defined the concept of ethical competence in the context of health care settings as character strength, ethical awareness, moral judgment skills and the willingness to do good . Maluwa also showed a high degree of abstraction of moral competence  but did not create a list of specific ways that nurses should practice. In nursing practice, the process of thinking and the actions that accompany this process are emphasized. According to Gallagher and Jormsri et al., moral or ethical competence in nursing practice includes the perception or recognition of ethical situations and the judgment of whether an action is in the best interest of the people who require nursing care [18, 19]. These studies, however, do not contain a concrete practical list of ethical caring competencies. Although there are tools for measuring ethical competence in a particular area of nursing [20,21,22], these tools are difficult to generalize widely because they are specialized in a specific area.
Katayama et al. extracted the Ethical Caring Competencies List (ECCL) in nursing, which is based on issues such as concreteness and versatility and includes the aspects of thinking and behavior shown above . Furthermore, based on the ECCL, Katayama et al. prepared a draft of the Ethical Caring Competency Scale (ECCS) .
Conceptual framework of the ECCS
Here, we first give an overview of the philosophical foundations of the moral competence scales that have been developed and used thus far and then explain the conceptual framework of the ECCS.
Kohlberg defined moral judgment competence as ‘the capacity to make decisions and judgments which are moral (i.e., based on internal principles) and to act in accordance with such judgments’.  Colby et al. developed the Moral Judgment Interview (MJI) , and Lind developed the Moral Judgment Test  to measure moral judgment/reasoning based on Kohlberg’s theory of moral development. Additionally, Rest developed the Defining Issues Test (DIT)  based on Kohlberg’s theory. Rest indicated that moral behavior is formulated by four psychological components, namely, ‘moral sensitivity’, ‘moral judgment’, ‘moral motivation’, and ‘moral character’ . The DIT has been used in several studies in more than 40 countries, especially in the 1970s and 1980s . The MJI and the DIT have been mainly utilized in nursing studies [29, 30].
However, the results of nursing studies that have used these tools have indicated that nurses and nursing students have consistently lower than expected levels of moral reasoning . Furthermore, the results regarding the relationships among the variables of moral judgment, education level, and ethical behavior for nurses or nursing students are unclear [29, 30, 32, 33]. In response to these results, many nursing researchers have criticized Kohlberg’s theory for focusing on a justice-oriented conception of morality, which is used more frequently by men [29, 30, 32, 34]. A justice-oriented conception of morality is a theory that judges an act based on whether or not the act is consistent with a specific ‘ethical obligation’. These authors have also suggested that Gilligan’s sex-related theory  should be considered; consequently, the use of MJI and DIT has declined in nursing research.
Koskenvuori et al. introduced the four most recent scales in a scoping review of health care professionals’ ethical competence . These are the Moral Competence Scale for Home Care Nurses (MCSHCN) , the Moral Competence Questionnaire for Public Health Nurses (MCQ-PHN) , the Moral Competence Scale (MCS) , and the Moral Skills Inventory (MSI) . In three of these scales (the MCSHCN, the MCQ-PHN, and the MSI), the structure of the instrument follows the four-component model for determining moral behavior described by Rest . The other scale does not follow any previous model. These facts mean that, despite the criticisms of Kohlberg’s theory and suggestions to consider Gilligan’s sex-related theory, no such measuring tool has yet been developed.
Gilligan’s theory is also known as ‘ethics of care’ or ‘care ethics’. Ethics of care is the opposite of a justice-oriented conception of morality. Ethics of care focuses on the responsibilities of multiple people in disagreement and their networks and explains these responsibilities in a contextual and narrative way of thinking. Recently, Toronto has shown four ethical elements of caring, namely, attentiveness, responsibility, competence, and responsiveness . Although the ECCL was derived from a qualitative and descriptive analysis of the data obtained from interviews, it has been shown to fit very well into these four ethical elements. Therefore, the ECCL is currently viewed as a rare list of competencies for health care professionals with a theoretical background in ethics of care.
Preparation of an ECCS draft
In assessing nursing competence, it is important to consider the context within which it is to be used [19, 40]. This is especially important for moral competence assessment, as such assessment should reflect the actual behavior of nurses in ethical situations . Additionally, the nursing competence required for effective performance in nursing practice has been mainly defined as an integrated set of knowledge, skills, traits, and attitudes [41,42,43,44,45]. Even though Fry and Johnstone  acknowledged the importance of ethical practice in producing quality care, and moral competence has been described as one of the professional components in nursing , a highly applicable scale to measure nurses’ ethical competence has not been developed.
The draft ECCS, which is based on the concept of caring ethics, was created by Katayama et al. through a qualitative and descriptive study and has confirmed content validity and criterion validity [23, 24]. The data used for qualitative descriptive analysis were obtained from interviews held with 15 nurses (mean age, 41.5 ± 5.2 years; mean work experience as a nurse, 19.9 ± 5.2 years). The draft ECCS consists of the four core competencies and a total of 22 items of competency. The consistency between Toronto’s theory and the ECCS has been confirmed as follows. Toronto’s first element, namely, ‘attentiveness’, is included in ECCS items such as ‘Estimates the patient’s subjective distress from physical assessment’ and ‘Feeling conflicted and uncomfortable about situations where good care is not being provided’. The second element, namely, ‘responsibility’, is included in ECCS items such as ‘Expresses values about good care in individual cases’ and ‘Explores diverse values and awareness without sticking to own values’. The third element, namely, ‘competence’, is included in ECCS items such as ‘Introduces evidence into practice with appropriate procedures’ and ‘Disseminates and raises issues without ignoring the challenges of performing good care’. The fourth element, namely, ‘responsiveness’, is exactly the same as the ECCS item of ‘The evaluation of care is based on reactions such as the words and behavior of the patient and/or their family’. The draft ECCS can be used as an action guideline for ethical care. Moreover, the draft ECCS can be used in the creation, evaluation, and operation of an in-service education program for each difficulty level of evidence-based nursing ethics after statistical verification.
Katayama et al. also suggested that it is necessary to select the 22 competency related items by difficulty level according to the proficiency level of nurses, referring to the Dreyfus model . This is because nursing skills change qualitatively according to experience and proficiency, as seen in the application of Benner’s Dreyfus model of the acquisition of nursing skills . The ECCS can be used as a behavioral guideline for ethical care. In addition, the draft ECCS will be available for the creation, evaluation, and operation of evidence-based nursing ethics nurse education programs after statistical validation.
Problem, research goals, and aim
Little has been written regarding establishing a basis for an instrument to evaluate health professionals’ concrete ethical caring competence. If a concrete ethical competence list could be developed, such a list could guide educators, as well as managers, in health care in supporting the development of ethical conduct in health care, which could lead to the possible assessment of ethical competence. Although the draft ECCS has confirmed content validity and criterion validity, its reliability and validity as an evaluation scale for each difficulty level have not yet been confirmed. In addition, statistical verification is required to examine whether the conditions of the Rubric Scale of Ethical Caring Competency (RECC) are satisfied.
Therefore, the research goals under consideration in this study were as follows:
To conduct the statistical verification of the reliability and validity of the ECCS as a scale and determine whether differences in ethical caring competency can be measured; and
To determine the possible use of the ECCS in a rubric format.
The aim of this study was to verify the reliability and validity of the difficulty setting of the items found in the draft ECCS and to obtain suggestions for the use of the scale as a RECC.
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