Enhancement of nursing students’ moral competencies through support the formation of professional identity

Background: Moral care provision is an essential part of nursing work. Nursing schools are responsible for developing moral competencies in nursing students. The aim of this study was to assess the relationship between the formation of professional identity and development of morality in nursing students. Methods: This study was designed as a descriptive-correlational study. The study population consisted of nursing students who were enrolled in nursing schools at the time of the study. Two hundred and twenty-one nursing students completed the study tools. The research tools were a demographic questionnaire, Moral Development Scale for Professionals (MDSP), and Professional Identity Scale for Nursing Students (PISNS). Results: The mean (SD) of MDSP and PISNS scores were 45.69±5.90 and 55.61±12.75, respectively. There was a significant statistical relationship between MSDP and PISNS scores (p<0.05). A significant equation was found (f (2, 218) = 16.68, p<0.001) with an R2 of 0.113. The MSDP scores increased 0.136 for each score of PISNS, and married students had 2.452 scores higher than single students. Conclusions: There was a significant correlation between the formation of professional identity and development of morality in nursing students. By supporting the formation of professional identity, nursing schools can help the development of moral competencies in nursing students.


Background
Moral care provision is an essential part of nursing work (1). It needs ethical nursing practice which is increasingly challenging by technological and technical growth in health sciences (2). Therefore, new strategies are needed to support the nurses' moral care provision (3). One of the recommended strategies is strengthening professional competencies. The assumption of this strategy is that people who are more professionally competent can do their duties more professionally. Moral competency, the capability to make moral decisions and judgments and to act in accordance with them, is one of the main competencies in nursing (4).
Development of moral competence in nursing begins from college years. However, recent studies have shown that the degree of moral competence development in all students is not equal and satisfactory (5,6). Acquisition of moral competences happens in a process called moral development.
Moral development is defined as the change in moral behavior over time (7). Moral behavior is the capacity to distinguish between right and wrong and to act accordingly (8). While the nursing shortage became a global problem, many nursing students, who should replace with retired nurses, do not have the required moral competence to deal with workplace issues at graduation (9). It is the responsibility of nursing education institutes to develop professional competencies, especially moral competence in their students.
Nursing education faces several challenges such as the high rate of retirement of registered nurses and nursing educators (10,11), low level of competencies among nursing graduates (12) including moral competence (7,13,14). Considering the commission and the Global Health Workforce Alliance report which indicates that professional education has not kept up the speed of health care challenges (15), these challenges will be worsened in the future decade. It is also because the demands for nurses will increase globally with the aging societies and new ethical dilemmas will raise by technological innovations (16). Due to these challenges, the training of nurses who can provide moral care is increasingly challenging.
Moral competence is an abstract concept, and it consists of cognitive, affective and behavioral components (17). While nursing programs have ethical courses, evaluation of their outcomes may not be easy. At the beginning of their career, measuring nurses' moral competences is not easy, as well.
How can nurses' professional competencies be more effectively developed? and how can their professional competences be predicted at the start of their career? The results of a recent study showed that there is probably a relationship between moral development and the formation of professional identity in nursing students (6). The findings indicate that the development of morality may be connected to the formation of professional identity. Professional identity is defined as a selfperception about the profession based on attitudes, beliefs, feelings, values, motivations, and experiences (18,19). The formation of professional identity, is an essential factor in increasing selfconfidence, feeling of belonging to the profession and establishing interpersonal communication among nurses (20,21).
Since the measurement of professional identity is more accessible than moral development, it can be used in prediction of the moral development of nurses. Also, if there is a relationship between these two variables, then nursing programs can benefit from helping the formation of professional identity in the development of moral competencies. Based on this hypothesis, the aim of this study was to assess the relationship between the formation of professional identity and development of morality in nursing students.

Methods
This was a descriptive-correlational study that was carried out at three nursing schools in Iran's capital, Tehran. The sample was recruited by random stratified sampling from undergraduate nursing students in three nursing schools in Tehran, Capital of Iran. The minimum sample size was calculated using G*power software. The number of samples in each school was calculated based on the number of students studying at the time of sampling. The students in nursing schools recruited using a purposive method. Each item scored on 5-point Likert from 1 (Strongly Disagree) to 5 (Strongly Agree). The MDSP scores range from 12 to 60, with higher scores indicating higher moral development. Skisland, Bjornestad (22) reported construct validity and Cronbach's alpha coefficient (0.67) for it. The MDSP was translated to Persian by a bilingual individual whose first language was Persian. It was then backtranslated to English by a bilingual person whose mother language was English. The face and content validity of the questionnaire was assessed by 10 nursing experts, who examined the clarity of the translated items. Cronbach's alpha was calculated to assess internal reliability (α = 0.74).

The Professional Identity Scale for Nursing Students (PISNS)
The Professional Identity Scale for Nursing Students (PISNS) has 17 items (23). It consists of five dimensions including 1) social modeling, 2) independence of career choice, 3) social comparison and self-reflection, 4) benefit of retention and the risk of turnover and 5) Professional self-image. Scale items are scored on a 5-point Likert from Strongly Disagree (1) to Strongly Agree (5). Construct validity showed five factors model explaining 58.9% of the total variance. Cronbach's alpha and splithalf reliability were 0.83 and 0.84 respectively. The PISNS scores range from 17 to 85, with higher scores indicating higher professional identity. The face and content validity of the questionnaire was assessed by 10 nursing experts. They examined the clarity and simplicity of the translated items.
The researchers took written permission from the schools' management. In each School, all students were asked to participate in the study. Two hundred and forty-two questionnaires were distributed among students who were willing to participate in the study.

Results
Two hundred and twenty-one (90%) of the 242 distributed questionnaire were returned from the participants. The demographic characteristics of the study subjects are presented in Table 1.  Table 2 The correlation between professional identity and moral development dimensions with an R 2 of 0.113. The MSDP scores increased 0.136 for each score of PISNS, and married students had 2.452 scores higher than single students (Table 3).

Discussion
The aim of the study was to determine the correlation between the formation of professional identity and the level of moral development in nursing students. Results showed that there was a significant correlation between moral development and professional identity scores. Based on our result, the formation of professional identity influences students' moral development. Therefore, by helping the formation of professional identity in nursing students, it can be expected that moral competencies will be more developed in them.
Moral development and professional identity separately were the subjects of several studies, but the correlation between them was not assessed before. In a study conducted by Rahimaghaee, Nayeri (24) there was a significant correlation between inner commitment to work morally and nurses' professional identity. The result of previous studies showed that having a positive professional identity was related to higher job satisfaction and job retention (25)(26)(27). This relationship indicates that the growth of professional identity may be related to increasing the interest in the profession or vice versa. While the literature related to the correlation between job satisfaction and moral competencies is limited, the results of the research showed that there could be a relationship between these two variables (28). We did not find any studies that assess the relationship between moral development and professional identity formation.
Health care providers need a high level of moral competence to face growing moral issues in their work environments. Nurses are the front lines of healthcare delivery (29) and they need to have enough moral competence to deliver high-quality care (30). To understand moral competence, we One of the main limitations of this study was that the participants were recruited from just one city.
Including other cities and more universities would help generalizability of the results. Another limitation is related to instruments. Using self-reported instruments to measure moral development and professional identity may also have affected the results. A future study is needed to evaluate these two variables more objectively.

Conclusions
The study showed that the moral competency of nursing students is related to their professional identity formation. Nursing shortage may cause hiring nurses without sufficient selection criteria.
Nurses must be at the highest level of moral development in order to be able to do their job ethically.
Nursing schools can provide a curriculum based on professional values to improve the status of professional identity. Based on our results nurses with well-formed professional identity are in higher levels of moral development. This result indicates that in order to develop morality in nursing students, educators can use techniques which effect on the formation of professional identity. Also in the nursing sector managers can grow their employee skills by emphasizing on the professional identity of nurses. Another implication of these results in research is to investigate this relationship more carefully. Based on the results of our current research and previous studies, we believe that nursing and identifying oneself as a nurse will affect the moral performance of nurses.

Consent for publication
This Manuscript is Author's own work

Availability of data and materials
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Competing interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Not Applicable
Authors' contributions H.R. wrote the manuscript draft, S.H. and F.B. designed the study and conducted the data gathering,