Submitted:
03 April 2026
Posted:
03 April 2026
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Abstract
Background: With the rapid aging of populations worldwide, strengthening the professional capacity of long-term care (LTC) workers has become a critical priority for health systems. While competency-based training frameworks are widely implemented, it remains unclear which domains of competency are most closely associated with ethical professionalism in daily care practice. Methods: A cross-sectional survey was conducted with 268 LTC workers across home-based, community-based, and institutional settings in Taiwan. Multiple linear regression analyses were performed to examine the associations between core competency domains and perceived ethical professionalism. Results: Participants reported relatively high levels of overall competency and ethical professionalism. Among the competency domains, interpersonal communication (β = .345, p < .001), psychological support (β = .184, p = .020), and teamwork (β = .111, p = .045) were significantly associated with ethical professionalism. In contrast, technical competencies, including physical care, daily living care, and emergency management, were not significantly associated (p > .05). Conclusion: The findings suggest that ethical professionalism in LTC practice is more strongly associated with relational and psychosocial competencies than with technical skills. These results highlight the importance of incorporating communication, emotional support, and teamwork training into workforce development programs. Strengthening these competencies may enhance care quality, workforce sustainability, and person-centered care delivery in aging societies.
Keywords:
long-term care
; workforce
; competency
; ethical professionalism
; communication
; Taiwan
Introduction
Global Context: Aging and the Professionalization of Long-Term Care
Population aging is one of the most significant social transformations in the Asia-Pacific region, generating growing demand for long-term care (LTC) and professional caregiving services. Strengthening the competency and professionalism of care workers has therefore become central to sustainable health and welfare systems (Rowe & Fried, 2013). Globally, population aging and the increasing complexity of chronic conditions have intensified pressures to ensure ethical, high-quality, and person-centered care (Song et al., 2022). Across OECD countries, the LTC workforce faces high turnover, heavy workloads, and emotionally demanding tasks, underscoring the need for professional development and ethical support (OECD, 2023). Workforce sustainability requires policy frameworks that integrate skill development with moral responsibility (Llena-Nozal, 2022). Evidence from workforce development models highlights the importance of cross-sector collaboration, competency-based training, and supportive organizational structures, particularly in underserved areas (Donlon & Williams, 2018; Barclay et al., 2025).
Competency Frameworks and the Foundations of Professionalism
Professionalism in long-term care (LTC) is closely linked to competency frameworks that define practitioners’ essential knowledge, skills, and values (Batt, Tavares, & Williams, 2020). These frameworks standardize expectations, guide curricula, and support professional assessment across care settings. Batt, Williams, Rich, and Tavares (2020) proposed a six-step model integrating systems thinking, continuous evaluation, and the inclusion of ethical and relational competencies alongside technical performance. Their subsequent CONFERD-HP reporting guideline further emphasizes methodological transparency and stakeholder collaboration to ensure relevance in evolving healthcare contexts (Batt et al., 2023).
The effectiveness of competency frameworks depends on meaningful stakeholder engagement. Lepre et al. (2021) highlighted the inclusion of practitioners, policymakers, and service users to reflect real-world values, while Al Jabri et al. (2021) identified core competencies clustering around teamwork, ethics, and continuous learning. Despite the proliferation of competency frameworks, many national standards—including Taiwan’s Long-Term Care 2.0 policy—tend to prioritize measurable, technical tasks over the more nuanced, relational dimensions of care. This technical orientation creates a conceptual gap where ethical practice is often treated as a peripheral “soft skill” rather than a fundamental component of clinical excellence. There is an urgent need to examine whether high levels of technical proficiency automatically translate into ethical professionalism, or if ethical practice is rooted in distinct relational capacities.
Ethical Competence and Emotional Intelligence in Care Work
Ethical practice is a cornerstone of professionalism in long-term care. Care workers frequently encounter ethical dilemmas, such as balancing autonomy and safety or managing end-of-life decisions, which require both institutional and interpersonal ethical capacities (Arjama, Suhonen, & Kangasniemi, 2024). McCullough’s (2007) professional ethics model emphasizes moral agency and virtue-based responsibility beyond rule-based bioethics. Similarly, ethical education and reflective practice have been shown to enhance professional accountability and patient satisfaction (Akbari et al., 2023).
Professionalism in LTC also depends on soft skills and emotional intelligence. Emotional competencies—including empathy, conflict management, and emotional regulation—support ethical responsiveness and care quality (Dimitrov & Vazova, 2020). Ethical competence further develops through moral sensitivity, deliberation, and action, supported by pedagogical strategies such as simulation, narrative reflection, and ethical debate (Lechasseur et al., 2023). Together, these studies highlight professionalism as the integration of ethical reasoning, emotion, and reflection in everyday practice.
Workplace Learning and Organizational Conditions for Professional Growth
Workplace learning theory offers an important lens for understanding the professional development of long-term care (LTC) workers. Billett (2016) conceptualized learning as a social and participatory process that occurs through engagement and reflection in practice environments. Ellström, Ekholm, and Ellström (2008) further distinguished between enabling and constraining learning environments, highlighting the roles of autonomy, reflection, and collaborative problem-solving in fostering adaptive learning.
Empirical studies support this perspective. Fitzgerald et al. (2023) showed that team-based reflection and psychological safety are essential for effective workplace learning in LTC settings. Sarti (2014) similarly emphasized job resources—such as autonomy, feedback, and supervisory support—as key drivers of engagement and retention, consistent with the job demands–resources model (OECD, 2023). Recent studies further underscore the importance of relational and ethical competencies in LTC work, particularly in aging societies facing workforce instability and moral strain (Batt et al., 2023; OECD, 2023; Doyle et al., 2023).
Ethical Governance and Systemic Support
Professional ethics guide individual behavior while reinforcing organizational accountability and public trust. Sarihi Sfestani and Peykani (2017) conceptualized professional ethics as a multi-level construct encompassing individual virtue, institutional culture, and systemic transparency. Empirical evidence from Bordbar, Khoshkesht, and Moradi (2025) supports this view, identifying management support, balanced workload, and patient-centered communication as key factors associated with adherence to ethical codes and improved care quality.
At the same time, technological and structural changes further complicate ethical practice in care settings. Vogt et al. (2023) noted that the use of robotic devices and information technologies in Japan’s long-term care facilities enhances efficiency but introduces new ethical challenges that require balancing technical competence with empathy. As digital transformation reshapes caregiving roles, integrating ethics, technology, and human interaction becomes central to future workforce development.
Relational Ethics and Interdisciplinary Professionalism in LTC
Relational Ethics and Interdisciplinary Professionalism in LTC In the Asia-Pacific context, ethical care is increasingly viewed through the lens of relational ethics and community development. From this perspective, professional ethics is not merely a set of normative rules but a dynamic practice shaped by interpersonal accountability and respect for human dignity. While traditionally rooted in social work values, these principles resonate deeply with the ethic of care, emphasizing that ethical professionalism is enacted through everyday interaction and emotional attunement. By integrating relational agency into the competency framework, we can better understand how care workers navigate the moral complexities of aging societies.
Conceptual Integration and Analytical Framework
Drawing on competency-based education, workplace learning theory, and social work ethics, this study integrates these perspectives into a unified conceptual framework for examining ethical professionalism in long-term care work. Professional training provides the structural foundation for developing core competencies, while workplace learning environments shape how these competencies are enacted and sustained in practice. Ethical professionalism is conceptualized not as a standalone outcome, but as a relational and context-dependent dimension embedded within core competencies—particularly interpersonal communication, psychological support, and teamwork. From a social work perspective, ethical practice emerges through interaction, reflexivity, and relational accountability, providing the theoretical basis for analyzing the structural alignment between competency domains and ethical professionalism.
The Taiwanese Context and Study Purpose
In Taiwan, as in other Asia-Pacific societies, long-term care is increasingly framed as part of social work practice, linking caregiving ethics with community empowerment and social development goals. The Long-Term Care 2.0 initiative has expanded community-based services but also revealed workforce challenges, including a predominance of middle-aged female workers, limited training, and high turnover, highlighting the need to strengthen both technical and ethical competencies (Doyle et al., 2023).
Grounded in international frameworks, this study investigates the structural associations between specific competency domains and ethical professionalism among LTC workers in Taiwan. A key objective is to test whether ethical professionalism is an independent outcome of technical training or a relationally embedded dimension of psychosocial competencies. By utilizing regression analysis as a heuristic tool, this research highlights the potential dissociation between task-oriented proficiency and moral practice, offering critical insights for the ethical governance of the LTC workforce across the Asia-Pacific region.
Methods
Study Design and Purpose
This study employed a quantitative, cross-sectional design to examine the relationships between professional training, core competencies, and ethical professionalism among long-term care (LTC) workers in Taiwan. The study aimed to identify factors associated with competency development and to explore how interpersonal and supportive skills relate to ethical professionalism across home-based, community-based, and institutional care settings.
A cross-sectional, self-reported approach was intentionally adopted to capture workforce-wide perceptions of competencies and ethical professionalism across diverse LTC contexts. Given the study’s focus on examining structural associations within an integrated competency framework—rather than establishing causal relationships—this design is appropriate for identifying patterns of alignment among competency domains at a single point in time. Self-reported measures were particularly appropriate for this study, as ethical professionalism and relational competencies involve internal moral reasoning and subjective interpersonal experiences that are often inaccessible through objective administrative data or external observation alone. By focusing on the practitioners’ own perceptions, the study captures the ‘lived’ ethical dimensions and moral agency required in daily caregiving practice. The cross-sectional design allows for the identification of associations among variables; however, causal relationships cannot be inferred. Future longitudinal studies are recommended.
Participants and Sampling
Participants were 268 LTC service workers recruited through purposive and snowball sampling from multiple long-term care facilities and community care stations across central and southern Taiwan. Inclusion criteria were: (1) currently employed as a certified LTC service worker or care aide, (2) having at least six months of work experience, and (3) willingness to participate voluntarily. Individuals in administrative or non-direct care roles were excluded.
Of the 268 valid responses, 88.1% were female and 11.9% male, with the majority aged between 40 and 59 years. Approximately 39.2% held a college degree or above, and more than 44% had over five years of caregiving experience. Around half (51.1%) worked in institutional care, 31.7% in home-based care, and 17.2% in community-based service settings.
Measures
- Core Competency Scale
The Core Competency Scale for Long-Term Care Service Workers was adapted from Taiwan’s National Core Competency Framework for Care Professionals and revised based on expert consultation. It consists of seven core competency dimensions—physical care, daily living care, emergency management, psychological support, interpersonal communication, activity facilitation, and teamwork—plus an additional domain of professional ethics.
Each item was rated on a 5-point Likert scale ranging from 1 (“strongly disagree”) to 5 (“strongly agree”), with higher scores representing greater perceived competency. Cronbach’s α coefficients for the subscales ranged from .87 to .95, and .96 for the overall scale, indicating high internal consistency reliability.
- Demographic and Work Variables
Demographic variables included gender, age, education level, marital status, and work experience (in years). Work-related variables included service setting (home-based, community-based, or institutional), employment type, and participation in professional training programs. These variables were used to explore workforce characteristics and as predictors in regression analyses.
- Instrument Validity and Ethical Considerations
The Core Competency Scale was reviewed by five domain experts in long-term care and social work education to ensure content validity and cultural relevance. The Content Validity Index (CVI) exceeded 0.90, and exploratory factor analysis confirmed the eight-dimensional structure. All procedures adhered to ethical principles aligned with the IFSW Code of Ethics (2018) and Taiwan’s Human Subjects Research Act, emphasizing respect, confidentiality, and voluntary participation. While the expert review enhanced content validity, the sample was primarily drawn from central Taiwan, and regional diversity should be considered in future replications.
Data Collection Procedures
Data were collected from August to October 2024 through structured self-administered questionnaires distributed by trained research assistants. Questionnaires were either paper-based or digital, depending on the preference and accessibility of participants. Participation was voluntary, and informed consent was obtained from all respondents before data collection. Respondents completed the survey anonymously within approximately 15–20 min.
Data Analysis
All analyses were conducted using IBM SPSS Statistics 26.0. Descriptive statistics were used to summarize demographic characteristics and competency scores. To address potential common method bias arising from the self-reported nature of the survey, Harman’s single-factor test was performed. The results indicated that no single factor accounted for more than 50% of the variance, suggesting that common method bias was not a significant concern in this study. Group differences across work settings were examined using independent-sample t-tests and one-way analysis of variance (ANOVA) with Tukey’s HSD post hoc tests. To examine relationships among workforce characteristics, core competencies, and ethical professionalism, two-stage multiple linear regression analyses were performed.
Ethical Considerations
The data used in this study were originally collected as part of routine workforce training and service evaluation activities in long-term care settings. The primary purpose of data collection (August to October 2024) was for program monitoring and workforce development rather than for research.
All participants were informed about the purpose of the data collection, and written informed consent was obtained prior to participation. The data were collected anonymously, and no personally identifiable information was recorded. Participation or withdrawal had no impact on employment or training.
Ethical approval was subsequently obtained from the Institutional Review Board of Jen-Ai Hospital, Taichung, Taiwan (Approval No. 202500023B0; approved on February 19, 2025) for the secondary analysis and academic use of the dataset. The study was conducted in accordance with the Declaration of Helsinki and Taiwan’s Ministry of Health and Welfare regulations.
Results
Participant Characteristics
A total of 268 long-term care (LTC) service workers participated in this study (Table 1). Most were female (88.1%), with a mean age of 44.2 years (SD = 8.7), reflecting the gendered structure of Taiwan’s LTC workforce. Nearly half had completed vocational or senior high school (45.5%), and 39.2% held a college degree or higher. Regarding experience, 44.0% had more than five years in care work. Participants were employed across institutional facilities (51.1%), home-based care (31.7%), and community stations (17.2%), indicating diverse service settings and training backgrounds representative of Taiwan’s LTC system.
Descriptive Analysis of Core Competencies
Table 2 summarizes descriptive statistics for eight core competency domains among LTC workers. Overall self-rated competence was moderately high (M = 4.18, SD = 0.54 on a 5-point scale). The highest scores were observed in professional ethics (M = 4.33, SD = 0.48) and interpersonal communication (M = 4.31, SD = 0.47), followed by teamwork (M = 4.27, SD = 0.50), physical care (M = 4.22, SD = 0.53), and emergency management (M = 4.17, SD = 0.58). Daily living care (M = 4.09, SD = 0.55), psychological support (M = 4.05, SD = 0.57), and activity facilitation (M = 3.98, SD = 0.61) showed comparatively lower scores, indicating potential areas for improvement. The relatively narrow SD range (0.47–0.61) suggests consistent competency levels across participants.
Differences in Core Competencies by Work Setting
A one-way ANOVA examined differences in competency levels by work setting (Table 3). Significant differences were found in physical care (F = 6.82, p = .001) and emergency management (F = 5.34, p = .005), with institutional care workers reporting higher scores than those in home- and community-based services. This likely reflects greater exposure to intensive care tasks and safety protocols in institutional settings. In contrast, no significant differences were observed for interpersonal communication, teamwork, or professional ethics (p > .05), suggesting that relational and ethical competencies are relatively stable across service environments. Community-based workers showed slightly higher mean scores in activity facilitation and psychological support, indicating a stronger emphasis on social engagement and emotional support in community contexts.
Predictors of Overall Core Competency
A multiple regression analysis examined demographic and employment factors associated with overall core competency (Table 4). The model was significant, F(5, 262) = 12.46, p < .001, explaining 19.2% of the variance. Education level (β = .215, p = .004) and work setting (β = .198, p = .003) were significantly associated with competency, with higher education and institutional employment linked to stronger competencies. Gender (β = .062, p = .374), age (β = .073, p = .241), and work experience (β = .081, p = .198) were not significant. These findings underscore the importance of educational background and institutional learning environments in competency development.
Predictors of Professional Ethics
To further explore the determinants of ethical professionalism, a separate regression analysis was performed using the seven core competency domains as predictors (Table 5). Consistent with the study’s conceptual positioning, this model was not intended to establish independent causal predictors of ethical practice, but to illustrate the relative structural associations between different competency domains and professional ethics within an integrated competency framework.
The overall model was statistically significant, F(7, 260) = 119.46, p < .001, explaining 76.3% of the variance in professional ethics scores (R² = .763). Among the competency domains, interpersonal communication demonstrated the strongest association with ethical professionalism (β = .345, p < .001), followed by psychological support (β = .184, p = .020) and teamwork (β = .111, p = .045). These findings indicate that relational and psychosocial competencies are most closely aligned with ethical professionalism in long-term care work. Although the model explained a relatively high proportion of variance, this may reflect conceptual overlap among self-reported competency domains. Variance inflation factors (VIFs) were examined and all values were below 5, indicating that multicollinearity was not a serious concern.
In contrast, technical and task-oriented competencies—including physical care, daily living care, activity facilitation, and emergency management—were not significantly associated with professional ethics (p > .05). Rather than indicating a lack of importance, these non-significant associations suggest that ethical professionalism in care work is less closely linked to procedural proficiency and more deeply embedded in relational interaction, emotional attunement, and collaborative practice.
Summary of Findings
Overall, the findings portray a professional workforce characterized by strong interpersonal, ethical, and teamwork competencies, supported by moderate-to-high levels of technical proficiency. Education and institutional exposure emerged as key structural factors influencing competency development, whereas relational and emotional capacities predicted ethical professionalism.
These results collectively suggest that workforce development strategies in Taiwan’s LTC sector should adopt an integrated approach—linking competency-based education, ethics-centered training, and workplace learning systems—to sustain both skill advancement and moral resilience among care workers. From a social work perspective, these findings indicate that moral competence and communication-based professionalism are essential capacities for empowering both caregivers and care recipients in community settings.
Overall, the findings indicate a workforce profile characterized by relatively strong interpersonal, ethical, and teamwork competencies alongside moderate-to-high levels of technical proficiency. Education level and institutional exposure were associated with overall competency development. Among all competency domains, interpersonal communication, psychological support, and teamwork emerged as the most theoretically salient dimensions, as they showed the strongest structural alignment with ethical professionalism.
Discussion
Integrating Competency Frameworks and Ethical Professionalism
This study contributes to the growing literature suggesting that professional competency and ethical practice are not separate dimensions of long-term care (LTC) professionalism but are deeply interconnected within integrated competency frameworks. Rather than treating ethical practice as an external standard or independent outcome, the findings indicate that ethical professionalism is structurally embedded within specific core competency domains, particularly those involving relational and psychosocial engagement. This perspective extends competency-based approaches by emphasizing the internal alignment between ethical practice and everyday caregiving work.
Consistent with prior research, competency frameworks shape not only technical skills but also ethical reasoning and professional identity (Batt et al., 2021; Batt et al., 2023). In line with the CONFERD-HP model, the findings underscore the importance of systematic framework design that reflects real-world care contexts, interprofessional collaboration, and moral responsibility (Batt et al., 2021; Lepre et al., 2021). Importantly, the results suggest that not all competency domains are equally aligned with ethical professionalism, highlighting a distinction between task-oriented and relational competencies.
The strong alignment between ethical professionalism and interpersonal communication, psychological support, and teamwork resonates with educational approaches such as Entrustable Professional Activities, which conceptualize professionalism through trust, accountability, and situated practice (de Graaf et al., 2021). Although the relatively high explanatory power (R² = .763) warrants methodological caution due to shared measurement and self-report bias, it may also reflect the extent to which ethical professionalism is embedded within relational competencies. Taken together, these findings suggest that LTC workforce development may benefit from integrating competency-based education, ethics-oriented training, and workplace learning. From a social work perspective, moral competence and communication-based professionalism emerge as central capacities for empowering caregivers and care recipients in community-based care settings.
Building on these findings, the practical implications for workforce development warrant further consideration. Current competency-based training programs often emphasize technical and task-oriented skills, such as physical care and emergency response. However, the present results suggest that these domains may not be the primary drivers of ethical professionalism in daily care practice.
Instead, relational and psychosocial competencies—particularly interpersonal communication, psychological support, and teamwork—appear to play a more central role. These competencies are essential for building trust, supporting emotional well-being, and facilitating collaborative care, all of which are critical components of person-centered care.
For policymakers and training institutions, these findings indicate the need to rebalance competency frameworks by integrating relational skill development into standard training curricula. This may include structured communication training, reflective practice sessions, and interdisciplinary teamwork exercises. Additionally, incorporating these elements into certification and continuing education programs may contribute to improved care quality and workforce retention.
Overall, strengthening relational competencies may serve as a feasible and scalable strategy to enhance both ethical practice and service outcomes in long-term care systems, particularly in rapidly aging societies.
Why Technical Competencies Did Not Align with Ethical Professionalism
An important finding of this study is that technical and task-oriented competencies—including physical care, daily living care, emergency management, and activity facilitation—were not significantly associated with ethical professionalism. Rather than indicating that these competencies are unimportant, this pattern suggests that ethical professionalism in long-term care is less closely tied to procedural proficiency and more deeply embedded in relational and psychosocial dimensions of care work.
Ethical challenges in long-term care practice typically arise in interpersonal contexts, such as respecting older adults’ autonomy, responding to emotional vulnerability, negotiating boundaries, and engaging in collaborative decision-making with families and care teams. These situations require moral judgment, empathy, and reflexivity rather than the execution of routinized technical tasks. From a social work perspective, this finding aligns with relational and care ethics frameworks that emphasize attentiveness, responsibility, and respect for human dignity.
Accordingly, technical competencies may be understood as necessary but not sufficient for ethical professionalism. While they ensure safety and service quality, ethical professionalism is enacted through communication, interpretation, and engagement in morally complex contexts, explaining the stronger alignment of relational and psychosocial competencies observed in this study.
Ethical Competence and Emotional Intelligence as Core Professional Capacities
Ethical competence emerged as a key component of professional identity and care quality. Consistent with prior research, ethical reasoning and moral sensitivity can be cultivated through educational strategies such as case-based learning, simulation, and ethical dialogue (Lechasseur et al., 2023). Emotional intelligence—including empathy, self-regulation, and conflict management—has also been identified as a foundational capacity shaping ethical responsiveness in care work (Dimitrov & Vazova, 2020). Together, these findings highlight the importance of intentional educational and supervisory practices in fostering ethically consistent care relationships.
Empirical studies further suggest that ethical competence and moral accountability are associated with patient satisfaction, organizational trust, and reduced moral distress (Bordbar et al., 2025; Fantahun et al., 2014). Institutional approaches that support ethical reflection and dialogue, such as the Moral Empowerment System proposed by Alonso-Prieto et al. (2025), reinforce the view that ethical professionalism extends beyond procedural compliance and involves moral agency, responsibility, and integrity.
Workplace Learning and Organizational Support
Workplace learning was another critical factor in sustaining professionalism. This study’s findings are consistent with Billett’s (2016) “learning through work” theory, which posits that engagement, reflection, and participation are essential mechanisms for developing professional competence. Ellström et al. (2008) further distinguished between “enabling” and “constraining” learning environments, showing that autonomy, collaboration, and reflective dialogue promote innovation and ethical maturity. Similarly, Fitzgerald et al. (2023) demonstrated that team-based reflection and psychological safety are prerequisites for effective workplace learning in LTC, transforming everyday work into opportunities for professional growth.
Sarti (2014) and Hsu and Yang (2022) both found that job resources such as feedback, autonomy, and supportive leadership serve as antecedents of engagement and retention among care workers. When employees experience organizational empowerment and moral recognition, they are more likely to demonstrate organizational citizenship behaviors and ethical commitment. These findings confirm the interdependence of ethical practice and workforce sustainability, supporting Llena-Nozal’s (2022) call for integrated policy approaches that enhance job conditions, professional identity, and career pathways.
Educational Innovations and Competency-Based Training
At the educational level, several recent studies underscore the need to integrate geriatric, ethical, and emotional learning into health professional curricula. Papillon-Ferland et al. (2025) revealed that geriatric competencies remain underrepresented in training programs globally, despite the growing demographic demand. Their scoping review identified a gap between competency frameworks and practice, emphasizing the importance of interprofessional collaboration and ethics-based education. Similarly, Ho et al. (2023) found that students’ intention to work in aged care is significantly influenced by their exposure to experiential learning, ethical reflection, and technological competence. These findings suggest that embedding value-driven learning early in education can improve future workforce commitment and professional engagement.
Lin and Liu (2025) provided additional insight by developing and validating the Eating Support for Healthcare Aides (ESHA) Questionnaire, which evaluates competencies in nutrition, feeding safety, and oral care. Their results underline that care professionalism should encompass both technical and ethical respect for residents’ autonomy and dignity in eating. These findings align with ethical frameworks that view caregiving as a moral practice rooted in respect and person-centered care (Rowe & Fried, 2013; OECD, 2023).
Ethical Practice, Reflection, and Resilience
The interplay between ethical practice and resilience also emerged as a recurrent theme. Arjama et al. (2024) and Alonso-Prieto et al. (2025) both demonstrated that moral distress in LTC settings can undermine well-being and professionalism unless supported by reflective and dialogical systems. The KAP model studies by Yu et al. (2025) and Hsu et al. (2025) further support this argument, showing that knowledge alone is insufficient to foster ethical practice. Instead, attitudes and self-efficacy mediate behavioral change, suggesting that emotional engagement and ethical reflection are key mechanisms linking training to ethical outcomes.
These insights also resonate with Nordic nursing scholarship, which frames caregiving as a relational and value-based profession emphasizing empathy and dignity. Embedding structured reflection sessions, storytelling, or peer discussions into ongoing LTC training could thus promote moral resilience and mitigate ethical fatigue.
Systemic Ethics and Policy Implications
From a policy perspective, professional ethics also serves as a mechanism for organizational accountability and transparency (Sarihi Sfestani & Peykani, 2017). Ethical governance frameworks that combine institutional support, supervision, and feedback systems can foster a culture of trust. Technological innovation adds a new ethical frontier: as Tanioka et al. (2021) highlighted, robotics and ICT can improve efficiency but also challenge the emotional and moral dimensions of caregiving. Policymakers and educators must ensure that digital integration in LTC does not erode human-centered care but instead enhances ethical decision-making.
At the macro level, workforce strategies should integrate ethics with competency-based career development. Following the OECD (2023) report, sustainable LTC systems require professional recognition, fair compensation, and moral empowerment as intrinsic motivators. As demonstrated by the MES framework (Alonso-Prieto et al., 2025) and reflective learning models (Lechasseur et al., 2023; Knox, 2017), ethical practice must be reinforced institutionally through dialogue, supervision, and peer support rather than left to individual discretion. These macro-level reflections also invite a broader regional comparison across Asia-Pacific countries, where similar ethical and workforce challenges are unfolding
Regional Implications in Asia-Pacific
Across the Asia-Pacific region—including Japan, Korea, and Singapore—long-term care reforms increasingly emphasize the moral and social dimensions of caregiving, particularly respect for elders and intergenerational solidarity. Taiwan’s LTC 2.0 initiative shares similar challenges—workforce feminization, intergenerational expectations, and uneven resource distribution. By integrating social work perspectives into LTC professionalization, Taiwan can contribute a culturally grounded model of ethical workforce development that balances efficiency with relational ethics. This aligns with the journal’s broader mission to advance social work and development in the region.
Implications for Taiwan’s Long-Term Care Workforce
Within Taiwan’s rapidly evolving LTC 2.0 system, the results affirm the need to strengthen both technical and ethical competencies through structured professional training. The uneven distribution of educational resources and high turnover rates among care workers highlight the same challenges observed internationally (Llena-Nozal, 2022; Doyle et al., 2023). Establishing competency frameworks that include emotional intelligence, moral reasoning, and reflective practice can bridge gaps between policy expectations and on-the-ground realities.
Integrating the ESHA framework (Lin & Liu, 2025), EPAs (de Graaf et al., 2021), and reflective ethics training (Knox, 2017; Lechasseur et al., 2023) could create a hybrid model for Taiwan—one that aligns measurable competencies with moral empowerment. Such a system would not only enhance care quality but also promote retention and well-being, ensuring a resilient, ethically grounded LTC workforce. The Taiwanese experience may thus serve as a transferable model for other Asia-Pacific nations seeking to integrate social work ethics into long-term care workforce development.
Limitations
Several limitations should be considered when interpreting the findings. First, the cross-sectional design precludes causal inference between professional competencies and ethical professionalism; longitudinal studies are needed to examine developmental dynamics over time. Second, reliance on self-reported measures may introduce social desirability bias and shared measurement effects. Third, although participants were drawn from diverse LTC settings, the sample was predominantly female, relatively well educated, and concentrated in central Taiwan, reflecting workforce characteristics but potentially limiting generalizability to other regions, male workers, or those with lower educational attainment. Educational background may also influence interpretations of ethical concepts and self-assessments of competence. Finally, purposive and snowball sampling may have produced clustering effects and response homogeneity due to shared organizational norms. Future research using multi-site probability sampling, longitudinal designs, and multi-source data (e.g., supervisor ratings, observations, or qualitative interviews) would provide a more comprehensive understanding of ethical professionalism in long-term care contexts.
Conclusion
This study highlights the close structural alignment between core competencies and ethical professionalism in Taiwan’s long-term care workforce. The findings demonstrate that interpersonal communication, psychological support, and teamwork are more strongly associated with ethical professionalism than technical competencies, underscoring the central role of relational and psychosocial skills in everyday care practice.
Rather than functioning as a standalone outcome, ethical professionalism appears to be embedded in how care workers engage, communicate, and collaborate in complex care contexts. These results suggest that workforce development strategies should move beyond a narrow focus on technical proficiency and instead incorporate relational, emotional, and communication-based competencies into training and evaluation systems.
From a practical perspective, integrating these competencies into standardized training programs, certification processes, and continuing education may enhance care quality, support workforce sustainability, and strengthen person-centered care delivery. These findings provide actionable insights for policymakers and training institutions seeking to improve long-term care systems in rapidly aging societies.
Author Contributions
Conceptualization, Liang Kai-Lin; Methodology, Yi-Chun Hung and Liang Kai-Lin; Software, Yi-Chun Hung; Investigation, Mei-Lin Liao; Resources, Mei-Lin Liao and Liang Kai-Lin; Data curation, Mei-Lin Liao; Writing—original draft, Liang Kai-Lin; Writing—review & editing, Liang Kai-Lin; Supervision, Liang Kai-Lin. All authors have read and agreed to the published version of the manuscript.
Institutional Review Board Statement
The study was conducted in accordance with the Declaration of Helsinki, and approved by the Institutional Review Board (or Ethics Committee) of NAME OF INSTITUTE (protocol code XXX and date of approval).
Informed Consent Statement
Informed consent was obtained from all subjects involved in the study.
Data Availability Statement
The original contributions presented in this study are included in the article/supplementary material. Further inquiries can be directed to the corresponding author(s).
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Table 1.
Demographic Characteristics of Long-Term Care Service Workers (N = 268).
| Variable | Category | n | % |
|---|---|---|---|
| Gender | Female | 236 | 88.1 |
| Male | 32 | 11.9 | |
| Age group (years) | 20–29 | 24 | 9.0 |
| 30–39 | 56 | 20.9 | |
| 40–49 | 82 | 30.6 | |
| 50–59 | 74 | 27.6 | |
| 60+ | 32 | 11.9 | |
| Education | Junior high or below | 41 | 15.3 |
| Senior/vocational high school | 122 | 45.5 | |
| College or above | 105 | 39.2 | |
| Work experience (years) | < 3 | 57 | 21.3 |
| 3–5 | 92 | 34.3 | |
| > 5 | 119 | 44.4 | |
| Work setting | Home-based | 85 | 31.7 |
| Community-based | 46 | 17.2 | |
| Institutional | 137 | 51.1 |
Note. Data are presented as frequencies and percentages. Percentages may not total 100 due to rounding.
Table 2.
Descriptive Statistics of Core Competency Dimensions (N = 268).
| Competency Dimension | Mean (M) | SD |
|---|---|---|
| Physical care | 4.22 | 0.53 |
| Daily living care | 4.09 | 0.55 |
| Emergency management | 4.17 | 0.58 |
| Psychological support | 4.05 | 0.57 |
| Interpersonal communication | 4.31 | 0.47 |
| Activity facilitation | 3.98 | 0.61 |
| Teamwork | 4.27 | 0.50 |
| Professional ethics | 4.33 | 0.48 |
Note. Each item was rated on a 5-point Likert scale ranging from 1 (“strongly disagree”) to 5 (“strongly agree”). Higher scores indicate higher self-perceived competence.
Table 3.
Differences in Core Competency Scores by Work Setting (One-Way ANOVA).
| Competency Dimension | F | p | Post hoc (Tukey HSD) |
|---|---|---|---|
| Physical care | 6.82 | .001 | Institutional > Home, Community |
| Daily living care | 1.24 | .293 | n.s. |
| Emergency management | 5.34 | .005 | Institutional > Community |
| Psychological support | 2.11 | .123 | n.s. |
| Interpersonal communication | 1.89 | .153 | n.s. |
| Activity facilitation | 0.97 | .379 | n.s. |
| Teamwork | 1.34 | .264 | n.s. |
| Professional ethics | 2.47 | .087 | n.s. |
Note. n.s. = not significant at p < .05. Work setting categories include home-based, community-based, and institutional care.
Table 4.
Multiple Regression Analysis of Demographic Predictors of Overall Core Competency.
| Predictor | B | SE B | β | t | p |
|---|---|---|---|---|---|
| (Constant) | 3.54 | 0.42 | — | 8.43 | < .001 |
| Gender (female=1) | 0.08 | 0.06 | .052 | 1.31 | .192 |
| Age | 0.02 | 0.01 | .074 | 1.18 | .238 |
| Education level | 0.11 | 0.04 | .215 | 2.94 | .004 |
| Work experience | 0.03 | 0.02 | .066 | 1.12 | .263 |
| Work setting (institutional=1) | 0.21 | 0.07 | .198 | 2.99 | .003 |
Model summary: F(5,262) = 12.46, p < .001, R² = .192, Adjusted R² = .174. Note. Dependent variable = overall core competency score (mean of eight subscales).
Table 5.
Multiple Regression Analysis of Core Competency Dimensions Predicting Professional Ethics.
| Predictor | B | SE B | β | t | p |
|---|---|---|---|---|---|
| (Constant) | 4.39 | 0.99 | — | 4.42 | < .001 |
| Physical care | 0.03 | 0.02 | .075 | 1.19 | .234 |
| Daily living care | 0.05 | 0.03 | .132 | 1.49 | .138 |
| Emergency management | 0.10 | 0.05 | .104 | 1.89 | .059 |
| Interpersonal communication | 0.46 | 0.10 | .345 | 4.55 | < .001 |
| Psychological support | 0.18 | 0.08 | .184 | 2.34 | .020 |
| Teamwork | 0.12 | 0.06 | .111 | 2.02 | .045 |
| Activity facilitation | 0.00 | 0.04 | .002 | 0.03 | .976 |
Model summary: F(7,260) = 119.46, p < .001, R² = .763, Adjusted R² = .756. Note. Dependent variable = professional ethics score. Higher β values indicate stronger positive relationships between competency dimensions and ethical practice.
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