Introduction
Ethical competency is an individual capacity for ethical awareness, courage, decision-making, and willingness to act ethically [1]. It is the ability of managers to recognize moral issues within their organizational contexts, coupled with the capacity to make sound moral judgments and take appropriate actions [1]. This competency is crucial for individuals in leadership roles, particularly within organizations that uphold high ethical standards [2]. As front-line managers, head nurses serve as the pivotal bridge between senior management and clinical nurses, and their ethical competence is vital to maintaining ethical practices within the nursing organization [3]. It helps head nurses think critically, analysis ethical issues, make decisions, solve moral problems, and behave in a way that upholds professional values during practice [4] .Ethical competency is crucial in nursing practice as it promotes patient safety and the quality of care [5]. Head nurses face challenges such as managing complaints, allocating resource, making critical decisions, meeting the demands of patient and family, and mediating staff conflicts Head nurses exemplify ethical competency by resisting the temptation to collapse or compromise, even when confronted with adversity or fear [6]. They rely on their inner strength and resilience to adhere to their ethical principles, adeptly managing their emotions and behaviors in a constructive, effective, and principled way [7, 8].
The importance of ethical competence in nursing ethics is underscored by its potential to promote positive outcomes both organizationally and for patients [3, 9]. Previous studies examined ethical competence and its associated factors(e.g., organizational and individual support [10], ethical climate [11], moral resilience [11]). Research indicates a range in ethical competence among head nurses, with some scoring highly and others scoring low [12]. Although ethical competence is a multidimensional concept, most of previous studies examined it by using the variable-oriented approach. This approach used variables to identify differences among individuals and statistical methods to calculate group averages, such as mean values, factor analysis, correlation analysis, and regression analysis [13]. Therefore, the results generated by these methods lack interpretability at the individual level and fail to describe the overall profiles of individuals. Training based on those results called ‘one-size-fits-all’ training which may not be well suited for developing ethical decision-making skills among nurses [14] .These limitations could be addressed by using Latent Profile Analysis (LPA).
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LPA is a person-centered approach that classifies individuals into subgroups and identifies differences between them, offering more nuanced insights than total score-based classifications [15, 16]. LPA uses a multivariate statistical model to identify underlying subgroups s within a dataset based on a set of indicators [17]. Based on maximum likelihood estimation, this classification method not only minimizes variability of indicator within groups and maximizes it between groups. It also uses objective statistical indicators to assess the accuracy and validity of classification [18]. Therefore, our research used LPA to explore different profiles of ethical competence among head nurses, thus helping nursing administrators and policy-makers tailor targeted ethical competence training programs.
Ethical competence is an antecedent of transformational leadership [19]. Ethical competence, a concept derived from “ethical judgment competence” and based on the cognitive-structural assumption of Kohlberg’s theory, is essential for transformational leadership [19]. Because ethical competence is an integral part of leadership, practice it could shape head nurses’ transformational leadership. This style of leadership necessitates a high level of a mature moral development [20]. Transformational leadership is defined as “leaders and followers raising one another to higher levels of motivation and morality” [21]. Transformative leadership involves leaders providing care and guidance to team members in the middle of organizational reforms. It is characterized by the establishment of a trusting environment, the awakening of high-level needs in team members, and the motivation of individuals to unleash their potential for the collective benefit of the organization [22]. Transformational leadership has become the preferred style of nursing leadership. This leadership is associated with patient safety and high-quality care. Importantly, leaders who adopt this style are more like to articulate a vision, set challenging goals, and motivate their staff nurse [23‐25]. Transformational leadership is correlated with positive work outcomes, such as enhanced nurse satisfaction, psychological engagement, innovative work behaviour [26, 27], organizational commitment, reduced burnout [28], employee well-being and willingness to stay in organization [29]. Head nurses with transformational leadership can motivate their teams to improve their nursing skills and achieve exceptional performance.
Head nurses’ transformative leadership could be evaluated by themselves or staff nurses [30, 31] .Self-ratings contain accurate components, challenging the assumption that others’ ratings are consistently more accurate. When compared to the ratings of others, self-ratings may provide an indication of a leader’s level of self-awareness. If head nurses exhibit deficiencies in leadership practice, they receive training, mentoring, or are assigned fewer supervisory responsibilities. However, a lack of self-awareness can impact the effectiveness of self-assessment [32]. If head nurses exhibit ineffective leadership, but they believe they are performing well hence overestimating their leadership practice [33]. Despite this, self-assessment of transformational leadership is crucial as it enables head nurses to identify and address challenges, leading to personal and organizational growth [34].Limited research explored the link between ethical competence and transformational leadership among head nurses. Ethical competence enables head nurses to navigate complex moral dilemmas and uphold fairness and integrity qualities vital to effective transformational leadership. Therefore, another key aim of the study was to explore the relationship between transformative leadership and latent profiles of ethical competence among head nurses. This exploration is essential for developing targeted training programs that enhance ethical competence and strengthen transformational leadership, ultimately improving outcomes in healthcare settings.
Methods
Study design
This study adopts a multicenter cross-sectional design with an exploratory LPA and was reported by following the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist.
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Study setting and sampling
Between July and August 2023, a combination of stratified and whole cluster sampling was used to select participants from four tertiary general hospitals in Changsha, Hunan Province, China. As the capital and most populous city in Hunan Province, Central South China, Changsha, is geographically divided into the eastern and western banks of the Xiangjiang River. Within each region, two tertiary general hospitals with more than 2,000 beds were randomly selected using random number generation software. The city is equipped with 34 tertiary hospitals which provides specialized health services, medical education, and research. The selected hospitals were comparable in terms of working conditions, income levels, organizational structure, and development, ensuring the representativeness of the sample. Within each selected hospital, all head nurses who met the eligibility criteria were invited to participate using whole cluster sampling. The inclusion criteria were: (1) being a registered nurses in the position of head nurses or assistant head nurses; and (2) having at least one year of full-time service in the role. We exclude head nurses who were retired or re-employed, as well as those who were on leave, including sick leave or maternity leave. The flow of participant recruitment are shown in Fig. 1.
Fig. 1
Flowchart of participant recruitment
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Sample size
The sample size was calculated using the formula N = [Max (number of items) × 5], with a 10% adjustment for invalid responses [35]. The two main scales in this study-the Ethical Competence Questionnaire (27 items) and the Head Nurse’s Transformational Leadership Self-rating Scale (25 items)-required a minimum sample size of 286. Nylund-Gibson and Choi [36] recommend a minimum sample size of 300 cases for LPA to ensure accurate identification of smaller profiles. So, following the recommendation of Nylund-Gibson and Choi and a 10% of invalid questionnaires, we increased the sample size to 340.
Data collection
A web-based survey was conducted using Wenjuanxing which is similar to SurveyMonkey. Initially, researchers explained the survey’s purpose to the chief nursing officers to gain their consent and provided them with the link to the questionnaire. These officers then forwarded the invitations and link to their head nurses. The front page of the questionnaire outlined the inclusion criterion. Participants were informed that (1) participation was voluntary and anonymous, (2) the data would be solely used for research purposes, and (3) they could withdraw at any time before data analysis.
We conducted a pilot survey with 15 participants to validate the clarity of questions and that the questionnaire instructions were logical and easy to understand. Participants were required to sign an online consent form before completing the questionnaire. Each IP address was restricted to one submission. Participants could contact the researchers by phone if they had any questions during the process. The questionnaire took approximately 10 min to complete. We excluded surveys (n = 11) that had missing items, completion times under 180 s, or identical responses for all items, resulting in 329 valid responses for analysis.
Measurements
This online survey included a custom-designed questionnaire and two instruments. The custom-designed questionnaire gathered socio-demographic data, including gender, age, marital status, degree, years of nursing experience, professional title, years as a head nurse, work area, and ethics related training. We selected instruments previously used with head nurses and validated in Chinese with strong psychometric properties: the Ethical Competence Questionnaire and the Head Nurse’s Transformational Leadership Self-rating Scale.
Ethical competence questionnaire
The ethical competence questionnaire was compiled by Poikkeus [10] and translated into Chinese by Xu et al. [37]. This questionnaire is designed to assess clinical nurses’ ethical competence and consists of 27 items divided across five dimensions: knowledge of laws and regulations (seven items), knowledge of values and principles (six items), ethical reflection (five items), ethical decision-making (five items), and ethical behavior and activities (four items). It uses a Likert 5-point rating scale, with options ranging from “strongly disagree” to “strongly agree” and scores ranging from 1 to 5 points. The total score can range from 27 to 135, with higher scores indicating greater ethical competence. This scale has been validated among Finland [10] head nurses (Cronbach’s α = 0.75 ~ 0.89). In our study, the Cronbach’s alpha coefficient was 0.959. We have obtained the permission from the authors.
Head Nurse’s transformational leadership self-rating scale
The head nurse’s transformational leadership abilities was assessed using the Head Nurse’s Transformational Leadership Self-rating Scale, developed by Wang et al. [22]. It includes 25 items and four dimensions: personalized care (six items), moral inspiration (five items), vision sharing (five items), and intelligence stimulation (nine items). Each item is rated on a 5-point Likert scale from “1 = never” to “5 = always,” with total scores ranging from 25 to 125 points. Higher scores indicate stronger transformational leadership. This scale has been validated among China [22] head nurses (Cronbach’s α = 0.940).In our study, the Cronbach’s alpha coefficient of the scale was 0.956. We have obtained the permission from the authors.
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Data analysis
Data analysis was performed using SPSS 26.0 and Mplus 8.3 software. Statistical descriptions included frequencies and percentages for categorical variables and means with standard deviations for continuous variables. Pearson correlations were employed to examine the relationships between ethical competence and transformational leadership. The transformational leadership of head nurses was analyzed based on the general characteristics of the study participants using one-way ANOVA and independent t-tests. LPA was conducted based on five dimensions of ethical competence. Major fit indices included the log-likelihood ratio (LL), Akaike Information Criterion (AIC), Bayesian Information Criterion (BIC), entropy, Likelihood Ratio Test (LMRT), and Bootstrap Likelihood Ratio Test (BLRT) [38]. In this study, acceptable model fit was defined as: (1) the smallest AIC, BIC, and sample-size-adjusted BIC (SSA-BIC) values [39] ; (2) the entropy were the largest and is above 0.80 [40]; (3) LMR and BLRT were significant (p < 0.05) [41]. One-way ANOVA and the Student–Newman–Keuls (SNK) test were used to assess differences in the transformational leadership practice scores across latent profiles.
Results
Descriptive statistics
As shown in Table 1, the majority of our participants were female (98.176%), and their age were between 41 and 45 years old (43.465%). Significant differences in ethical competence were observed based on ethics-related training (p = 0.002). There were significant differences in transformational leadership by degree (p = 0.042), professional title (p = 0.028), working years as a nurse manager (p = 0.037), and ethics-related training (p = 0.049).
Table 1
Social-demographic differences in ethical competence and transformational leadership practice (N = 329)
Demographics | n (%) | Ethical competence | Transformational leadership practice | |||||
|---|---|---|---|---|---|---|---|---|
M ± SD | F/t | p | M ± SD | F/t | p | |||
Gender | 0.087 | 0.930 | 0.993 | 0.321 | ||||
Women | 323(98.176) | 109.22 ± 10.598 | 113.954 ± 10.469 | |||||
Men | 6(1.824) | 108.83 ± 13.136 | 109.667 ± 10.708 | |||||
Age | 0.226 | 0.878 | 0.153 | 0.928 | ||||
≤35 | 20(6.079) | 110.05 ± 7.763 | 114.850 ± 11.212 | |||||
36–40 | 95(28.875) | 109.67 ± 10.197 | 113.400 ± 10.206 | |||||
41–45 | 143(43.465) | 109.17 ± 11.205 | 113.867 ± 11.014 | |||||
> 45 | 71(21.581) | 109.21 ± 10.625 | 114.254 ± 9.654 | |||||
Marital status | 1.522 | 0.220 | 3.706 | 0.026 | ||||
Single | 3(0.912) | 99.67 ± 7.024 | 100.000 ± 19.000 | |||||
Married | 313(95.137) | 109.39 ± 10.775 | 114.169 ± 10.159 | |||||
Widowed or separated | 13(3.951) | 107.08 ± 10.625 | 110.000 ± 13.717 | |||||
Degree | 1.354 | 0.177 | 2.043 | 0.042 | ||||
Bachelor’s degree | 133(40.426) | 108.25 ± 10.289 | 112.451 ± 11.411 | |||||
Master’s degree or above | 196(59.574) | 109.86 ± 10.825 | 114.842 ± 9.697 | |||||
Years of nursing experience | 0.936 | 0.424 | 0.877 | 0.453 | ||||
≤15 | 62(18.845) | 108.87 ± 10.016 | 112.000 ± 11.254 | |||||
16–20 | 74(22.492) | 110.07 ± 10.572 | 114.541 ± 9.428 | |||||
21–25 | 96(29.179) | 110.13 ± 10.807 | 114.500 ± 11.224 | |||||
> 25 | 97(29.484) | 107.87 ± 10.869 | 113.949 ± 9.951 | |||||
Professional title | 0.576 | 0.565 | 2.208 | 0.028 | ||||
Intermediate title | 178(54.103) | 108.90 ± 10.024 | 112.708 ± 11.003 | |||||
Senior title | 151(45.897) | 109.58 ± 11.316 | 115.252 ± 9.669 | |||||
Years as a head nurse | 0.170 | 0.916 | 2.864 | 0.037 | ||||
≤ 5 | 112(34.043) | 109.74 ± 9.964 | 114.545 ± 10.257 | |||||
6–10 | 103(31.307) | 108.90 ± 10.855 | 111.466 ± 11.666 | |||||
11–15 | 63(19.149) | 108.70 ± 10.970 | 115.064 ± 9.480 | |||||
> 16 | 51(15.501) | 109.29 ± 10.625 | 115.804 ± 8.854 | |||||
Work area | 0.328 | 0.922 | 0.740 | 0.618 | ||||
Ambulatory and ER | 34(10.335) | 110.50 ± 12.736 | 114.294 ± 12.014 | |||||
Internal medicine | 98(29.787) | 108.34 ± 10.520 | 114.255 ± 10.303 | |||||
Surgical units | 100(30.395) | 109.45 ± 9.528 | 114.460 ± 10.462 | |||||
ICU | 24(7.295) | 110.46 ± 14.920 | 114.125 ± 10.373 | |||||
Operating room | 13(3.951) | 107.31 ± 12.243 | 113.308 ± 10.323 | |||||
Obstetrics gynaecology and paediatrics | 21(6.383) | 109.29 ± 8.113 | 109.381 ± 10.989 | |||||
Other | 39(11.854) | 109.49 ± 9.591 | 113.513 ± 9.492 | |||||
Ethics related training | 6.361 | 0.002 | 3.040 | 0.049 | ||||
0 | 66(20.061) | 106.95 ± 10.030 | 111.667 ± 11.582 | |||||
1–2 | 209(63.526) | 108.80 ± 10.498 | 113.928 ± 10.292 | |||||
> 2 | 54(16.413) | 113.56 ± 10.796 | 116.370 ± 9.284 | |||||
As shown in Table 2, the total mean of ethical competence was 4.045 (± 0.394), and the scores in the sub-dimensions were as follows: knowledge of laws and regulations 3.989 (± 0.478), knowledge of values and principles 4.068 (± 0.467), ethical reflection 3.998 (± 0.488), ethical decision-making 3.987 (± 0.483), and ethical behavior and activities 4.240 (± 0.468). The total mean of transformational leadership was 4.555 (± 0.419), and the scores in the sub-dimensions were as follows: personalized care 4.496 (± 0.488), moral inspiration 4.759 (± 0.378), vision sharing 4.519 (± 0.541), and intelligence stimulation 4.501 (± 0.521). Ethical competence was moderate positively correlated with head nurse’s transformational leadership (r = 0.391**).
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Table 2
Descriptive statistics
Variable | Mean | SD | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
1 Ethical competence | 4.045 | 0.394 | 1 | ||||||||||
2 Knowledge of laws and regulations | 3.989 | 0.478 | 0.827** | 1 | |||||||||
3 Knowledge of values and principles | 4.068 | 0.467 | 0.882** | 0.703** | 1 | ||||||||
4 Ethical reflection | 3.998 | 0.488 | 0.874** | 0.601** | 0.716** | 1 | |||||||
5 Ethical decision-making | 3.987 | 0.483 | 0.814** | 0.512** | 0.604** | 0.758** | 1 | ||||||
6 Ethical behavior and activities | 4.240 | 0.468 | 0.689** | 0.408** | 0.542** | 0.534** | 0.522** | 1 | |||||
7 Transformational leadership practice | 4.555 | 0.419 | 0.391** | 0.195** | 0.335** | 0.396** | 0.426** | 0.302** | 1 | ||||
8 Personalized care | 4.496 | 0.488 | 0.355** | 0.193** | 0.288** | 0.335** | 0.373** | 0.322** | 0.808** | 1 | |||
9 Moral inspiration | 4.759 | 0.378 | 0.308** | 0.174** | 0.270** | 0.282** | 0.273** | 0.314** | 0.784** | 0.652** | 1 | ||
10 Vision sharing | 4.519 | 0.541 | 0.329** | 0.170** | 0.299** | 0.349** | 0.365** | 0.193** | 0.868** | 0.585** | 0.595** | 1 | |
11 Intelligence stimulation | 4.501 | 0.521 | 0.337** | 0.148** | 0.287** | 0.360** | 0.399** | 0.237** | 0.913** | 0.579** | 0.599** | 0.756** | 1 |
Latent profile analysis
According to the guidelines of Nylund et al., [38] we began by specifying two latent profiles and increased the number until the increase in model fit no longer merited the reduction in parsimony achieved by specifying another latent class. The fitting indices of the four models are shown in Table 3. The LMRT suggests the exclusion of four- and five- profile models for statistical insignificance. Although the entry value of the two-profile model is the highest, the values for AIC, BIC, and aBIC decrease the most from the two-profile to the three-profile model. The three-profile model is the most reasonable.
Table 3
Results of latent profile analysis
Number of profiles | FP | Log(L) | AIC | BIC | aBIC | Entropy | LMR(P) | BLRT(P) | Probabilities of classes |
|---|---|---|---|---|---|---|---|---|---|
1 | 54 | -7471.965 | 15051.930 | 15256.917 | 15085.629 | - | - | - | 1 |
2 | 82 | -5747.873 | 11659.746 | 11971.022 | 11710.919 | 0.993 | 0.000 | 0.000 | 0.818/0.182 |
3 | 110 | -5167.141 | 10554.281 | 10971.848 | 10622.929 | 0.987 | 0.009 | 0.000 | 0.182/0.660/0.158 |
4 | 138 | -4855.873 | 9987.745 | 10511.601 | 10073.866 | 0.991 | 0.248 | 0.000 | 0.179/0.590/0.094/0.137 |
5 | 166 | -4668.601 | 9669.202 | 10299.347 | 9772.796 | 0.988 | 0.785 | 0.000 | 0.057/0.134/0.578/0.094/0.137 |
Figure 2; Table 4 present the latent profile structure of ethical competence. We labeled the first profile as low ethical competence (profile 1), representing 18.2% of participants. This profile had participants who had lowest score in all dimensions: ethical reflection (M = 3.390, SD = 0.328), low ethical decision-making (M = 3.410, SD = 0.383), knowledge of laws and regulations (M = 3.531, SD = 0.447), knowledge of values and principles (M = 3.628, SD = 0.387), and sense of ethical behavior and activities (M = 4.013, SD = 0.501). We named the second profile as moderate ethical competence (profile 2), representing 66.0% of participants. This profile had participants who had moderate score in all dimensions: sense of knowledge of laws and regulations (M = 3.963, SD = 0.311), knowledge of values and principles (M = 3.997, SD = 0.251), ethical reflection (M = 3.956, SD = 0.168) and ethical decision-making (M = 3.968, SD = 0.222), and ethical behavior and activities (M = 4.161, SD = 0.371). We named the third profile as high ethical competence (profile 3), representing15.8% of participants. This profile had participants who had highest score in all dimensions: knowledge of laws and regulations (M = 4.626, SD = 0.408), knowledge of values and principles (M = 4.872, SD = 0.233), ethical reflection (M = 4.873, SD = 0.254), ethical decision-making (M = 4.731, SD = 0.406), and ethical behavior and activities (M = 4.832, SD = 0.300).
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Fig. 2
Latent profiles of ethical competence
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Table 4
Descriptive information for the three-profile model
Profile % of sample | Knowledge of laws and regulations | Knowledge of values and principles | Ethical reflection | Ethical decision-making | Ethical behavior and activities | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Mean | SD | Mean | SD | Mean | SD | Mean | SD | Mean | SD | ||||||
1 | 18.2 | 3.531 | 0.447 | 3.628 | 0.387 | 3.390 | 0.328 | 3.410 | 0.383 | 4.013 | 0.501 | ||||
2 | 66.0 | 3.963 | 0.311 | 3.997 | 0.251 | 3.956 | 0.168 | 3.968 | 0.222 | 4.161 | 0.371 | ||||
3 | 15.8 | 4.626 | 0.408 | 4.872 | 0.233 | 4.873 | 0.254 | 4.731 | 0.406 | 4.832 | 0.300 | ||||
The association between profiles of ethic competence and transformation leadership
Analysis of variance was conducted to examine the differences in transformational leadership practices among the three profiles, as shown in Fig. 3; Table 5. The average transformational leadership scores in Profiles 1, 2, and 3 were 4.287 (SD = 0.412), 4.565 (SD = 0.403), and 4.822 (SD = 0.418) among head nurses, respectively; there was significant statistical differences across the profiles in all four dimensions (p < 0.001). Furthermore, the SNK test indicated that the “high ethical competence” group had the highest mean score, while the “low ethical competence” group had the lowest.
Fig. 3
Comparisons of the outcomes in each profile
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Table 5
Transformational leadership practice difference between the three profiles, M ± SD
Variable | Profile 1 (n = 60) | Profile 2 (n = 217) | Profile 3 (n = 52) | F | P | SNK |
|---|---|---|---|---|---|---|
Transformational leadership practice | 4.287 ± 0.412 | 4.565 ± 0.403 | 4.822 ± 0.418 | 26.446 | 0.000 | 3 > 2 > 1 |
Personalized care | 4.222 ± 0.544 | 4.506 ± 0.448 | 4.769 ± 0.416 | 19.616 | 0.000 | 3 > 2 > 1 |
Moral inspiration | 4.603 ± 0.425 | 4.761 ± 0.378 | 4.931 ± 0.217 | 11.088 | 0.000 | 3 > 2 > 1 |
Vision sharing | 4.186 ± 0.623 | 4.540 ± 0.507 | 4.812 ± 0.353 | 21.476 | 0.000 | 3 > 2 > 1 |
Intelligence stimulation | 4.211 ± 0.512 | 4.509 ± 0.514 | 4.803 ± 0.520 | 20.230 | 0.000 | 3 > 2 > 1 |
Discussion
This study aimed to identify the distinct profiles of ethical competence and their association with transformation leadership among head nurses. LPA found that head nurse could be divided into three subgroups, and most (66%) were in the group of moderate ethical competence. Additionally, Head nurses with higher ethical competence were more likely to have higher transformational leadership. The contribution of this work lies in providing an explanation for the distinct relationships between types of ethical competence and transformational leadership. Our findings suggest that hospital managers should comprehend the potential patterns of ethical competence and transformational leadership to develop precise intervention programs for head nurses.
LPA suggested a three-profile model, and the largest profile was moderate ethical competence (n = 217; 66.0%). These profiles include a low ethical competence group (profile 1; 18.2%), a substantial moderate ethical competence group (profile 2; 66.0%), and a high ethical competence group (profile 3; 15.8%). This result suggests a moderate level of the ethical competence among head nurses is at, which is consistent with the findings of Poikkeus et al. [12]and Taşkıran et al. [42], but higher than those of Maluwa et al. [43]. The difference may be due to Maluwa et al.‘s study involving 271 clinical nurses, including registered nurses/midwives and technicians, which could result in lower ethical competence levels. Our study concentrated on head nurses, who typically hold greater responsibilities in leadership and decision-making. Notably, 83.58% of head nurses in our study had participated in ethics-related training, underscoring the importance of such education in enhancing ethical competence. As a result, hospital leaders should equip head nurses with competency programs based on ethical framework. This programs should include different learning modules tailored to different profiles of ethical competence, mentorship opportunities pairing less experienced head nurses with those exhibiting high ethical competence, and access to comprehensive resources such as online databases of legal regulations and ethical guidelines. These are designed to demonstrate the critical components of a successful leader, promoting nurses’ engagement, enhancing patient experience, and fostering excellence in nursing [44] .
Our findings demonstrate that in each latent profile, head nurses have low knowledge of laws and regulations. Consistently, a prior study indicated that nurses had low knowledge of the laws and regulations [45]. The majority of nurses had poor/inadequate to fair/moderate levels of knowledge of the legal liability of their clinical practices [46]. Reflecting on the knowledge and attitudes of nurses toward legal issues in India, it was similarly found that the majority of respondents (44.5%) had poor levels of knowledge [47] .Nurses require adequate knowledge towards legal sides of the nurses, as it increases the excellence care and also provide legal safeguard to the nurses [48] .Nursing is a learned profession built on a core body of knowledge governed by law and rules and guided by ethical behavior and decision-making [49]. Law and ethics are distinctly interwoven into the profession of nursing [49]. The most important basis for head nurses’ ethical competence is ethical knowledge of legislation [50]. Therefore, hospitals should prioritize offering targeted training programs, workshops, and continuous education initiatives to enhance legal literacy of head nurses. Hospitals can equip head nurses with the necessary knowledge and skills, therefore improving ability of ethical decision-making and patient outcomes.
Our study found that the average score of transformational leadership in the “high ethical competence” group was significantly higher than that of the other two groups, indicating that head nurses with greater ethical competence are more likely to exhibit stronger transformational leadership. Consistently, previous studies have classified ethics as a fundamental leadership competency [51, 52]. Ethical competence helps leaders and followers resolve value conflicts and align actions with stated values [53]. Transformational leadership theory highlights the leader’s role in enhancing followers’ motivation and performance through behaviors such as idealized influence and individualized support [54]. Head nurses who model high ethical standards inspire trust and admiration, which are essential for effective transformational leadership [55]. Morality is essential in leadership; without it, even transformational leadership can lead to into a disastrous outcome. This suggests that ethical competence plays an important role in shaping transformational leadership behaviors among head nurses.
Our results indicate that all three latent profiles exhibit relatively high levels of moral inspiration in transformational leadership, aligning with findings of previous studies [56, 57]. This trend may be attributed to distinctive cultural background and the rigorous selection of head nurses in mainland China. Morality holds fundamental significance both for individuals and society [58] .The primary consideration in personal and professional conduct is the cultivation of moral virtues [59]. In their managerial role, head nurses are expected to set an example, serving as role models to influence the work behavior of nurses. In their managerial roles, head nurses are expected to set an example, influencing nursing behavior through their own actions. Nurse leaders play a key role in fostering ethical competence by establishing frameworks, checklists, and case studies, and by integrating ethical standards into recruitment, training, and evaluation processes [60].Encouraging ongoing ethical discussions and integrating ethics into leadership programs are essential for fostering nurses’ ethical growth [60]. Institutions should prioritize candidates with high moral caliber when selecting head nurses, as they are more likely to both model and inspire ethical practices among their teams. Promoting nurses based on ethical competence ensures that leaders are committed to ethical standards, improving patient care and organizational effectiveness.
Limitations
First, a cross-sectional design of this study limits the ability to capture changes of head nurses’ ethical competence over time, and it may change with experience or situational factors, future research should adopt longitudinal designs to track these changes for a more dynamic understanding.
Second, self-reported data of ethical competence and transformational leadership may lead to bias in this study, because results of self-assessment might not align with that of external assessments. The absence of external assessments such as 360-degree feedback means the findings only reflect the perspectives of the head nurses, potentially overlooking discrepancies between self-assessment and external assessments of ethical behavior and leadership. This self-report may bias could skew the accuracy of competence and leadership.
Furthermore, future research could explore a broader range of factors that influence transformational leadership, including organizational culture, support systems, and external stressors. Despite these limitations, our study offers important insights into the relationship between ethical competence and transformational leadership among head nurses. To provide a more comprehensive view, future research should incorporate longitudinal designs and multi-source assessments, such as peer, subordinate, and supervisor evaluations.
Conclusion
Our study categorizes head nurses into three distinct profile of ethical competence groups and reveals significant differences in their transformational leaderships. The majority falls within the profile of moderate ethical competence, indicating a balanced ethical competence. Head nurses with higher ethical competence were more likely to have higher transformational leadership. These findings highlight the importance of tailoring interventions based on ethical competence to enhance leadership, which in turn can improve patient outcomes and overall healthcare quality. Hospitals should implement comprehensive training programs focusing on legal literacy, ethical decision-making, and leadership development to empower head nurses to make informed, ethical decisions and foster a culture of safety and respect. This perspective underscores how ethical competence can be used to monitor transformational leadership and guide nursing ethics management strategies. Policymakers and healthcare administrators should incorporate ethical competence assessments into recruitment, training, and promotion policies. This ensures that leadership positions are occupied by individuals who can champion ethical practices, thereby ensuring sustained improvements in patient care and organizational effectiveness.
Acknowledgements
We would like to thank all participants who agreed to participate in this research study.
Declarations
Ethics approval and consent to participate
This study adhered to the ethical guidelines outlined in the Helsinki Declaration and the standards of the institution and national research committee. Ethical approval was obtained from the Institutional Review Board of Xiangya Nursing School of Central South University (No. E2023146) prior to data collection. Informed consent was required on the first page of the survey. Respondents formally participated in the survey by selecting the option “Informed and agreed to participate voluntarily in the survey.” Completing the set of self-report questionnaires was considered an expression of consent to participate in the study. The survey did not collect names or other identifying information from the respondents, and all data were anonymous and confidential. Informed consent was obtained from all participants in the study.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Statistics statement
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