Current status and influencing factors of empathy and moral decision-making among Chinese clinical intern nurses — a cross-sectional study

Abstract

Background

Moral decision-making in clinical nursing interns is a critical aspect of core nursing competencies. Empathy plays a dual role in moral decision-making, with both positive and negative influences. This study aimed to explore the impact of empathy on the moral decision-making of clinical nursing interns as well as other factors that influence their moral decision-making.

Methods

A cross-sectional study was conducted in July 2024 among 528 clinical nursing interns rotating through hospitals affiliated with six universities. Data were collected using a general information questionnaire, the Ethical Decision-Making Competence Scale (EDM-CS), and the Interpersonal Reactivity Index-C (IRI-C). Statistical analysis was performed using SPSS version 22.0.

Results

The level of empathy among clinical nursing interns was found to be moderately low. Notably, there was a weak correlation between empathy and the level of moral decision-making among the interns. Additionally, moral decision-making was associated with maintaining good relationships with mentors or patients during the internship period.

Conclusion

Strengthening ethical education and interpersonal communication skills before nursing students enter their clinical internship phase is crucial. Particular emphasis should be placed on shaping the personality traits of nursing students, appropriately maintaining their empathy, and finding a balanced distance between empathetic engagement and rational thinking.

Clinical trial number

Not applicable.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-025-03352-x.

Background

Nursing is rooted in ethical and moral issues. The basic principle of nursing practice is to respect the dignity, values, and rights of all individuals. In daily practice, nursing staff not only make moral decisions in situations involving life and death, but also need to make decisions on routine ethical issues [1–3]. Moral decision-making is an individual’s chosen response to different social situations. Before performing a moral act, individuals engage in moral reflection and then make an ethical decision. At the same time, the outcome of the ethical decision is reflected in their corresponding moral behaviour [4]. Effective moral decision-making is one of the core competencies of nursing staff. Developing decision-making skills can help to address ethical issues that arise in nursing practice. The level of decision-making ability among nursing staff directly affects the quality of nursing care and the relationship between nurses and patients [5].

Nursing students often face challenges with moral decision-making during their first internship [6]. Although their responsibilities may be limited, they are still capable of recognizing unethical behaviour. When trying to provide care according to ethical norms, nursing students often experience moral dilemmas, such as whether to accept unethical behaviour in nursing, how to handle neglectful behaviour in patient care, and whether to compromise in their efforts to provide ethical care while lacking autonomy in decision-making [7]. Nursing students are vulnerable to moral distress when faced with ethical dilemmas, and moral distress is detrimental to their mental health, professional identity, and career development. Therefore, it is crucial for nursing students to make decisions in line with ethical principles when facing such challenges [8]. Research has shown that the attitudes of role models in clinical practice, such as nurses, mentors, lecturers; resources related to clinical practice, such as laboratories, hospitals, classrooms, and health system hospital policies and school policies; personal differences, such as emotional or logical behaviour [9], interpersonal relationships [10], self-control [11], stress [12], empathy [13], stereotypes [14], unpredictable events [15], and moral dilemmas [16] can all affect moral decision-making.

Ethical decision-making is influenced by cognitive and emotional systems [14]. Moral decision-making often involves a dilemma between “protecting self-interest” and “preventing harm to others”, and this trade-off can lead decision-makers to experience varying degrees of cognitive conflict and negative emotional experiences in different social situations [4]. Cognitive systems process information through moral judgments and regulate the resulting emotional responses. However, prolonged reflection does not alter intuitive judgments or form new rational perspectives; it merely reinforces the rationalisation of intuitive judgments [14, 17]. Therefore, intuitive judgments caused by personal traits may be an important factor in moral decision-making [18]. Empathy refers to an individual’s cognitive ability to understand the feelings of others, encompassing not only emotional resonance but also the willingness to respond appropriately to others’ needs [5]. This is the foundational element of humanistic medicine [19]. Empathy can motivate people to undertake actions that are correct, even if they are challenging or personally disadvantageous, thereby enhancing their sense of moral responsibility [20].

Empathy is a crucial skill in nursing. Nurses can understand the needs of patients and their families at an emotional level through empathy, facilitating effective communication and enhancing cooperation, leading to positive treatment outcomes [21, 22]. Although empathy is an important tool, it has several limitations. Empathy is not always evenly distributed but is influenced by various factors, such as cultural background, social identity, and personal experiences. This asymmetry in empathy can lead to excessive emotional responses toward certain groups while ignoring the needs of others, creating ‘emotional bias’ that may narrow one’s moral perspective. This can cause individuals to become overly emotional in the decision-making process, neglecting logical analysis and resulting in irrational moral decisions [23, 24]. Moreover, prolonged exposure to the suffering of others, particularly when felt through empathy, can result in emotional exhaustion and ‘compassion fatigue.’ This not only affects an individual’s mental health but may also weaken their ability to continue engaging in moral actions [25]. Ethical leadership can alleviate these negative effects by creating a psychologically safe work environment. In teams with high psychological safety, nurses’ empathy may shift from emotional exhaustion to moral responsibility, prompting more rational decision-making behaviour [26]. In summary, the role of empathy in nursing students’ moral decision-making is currently inconclusive.

Current research predominantly explores the impact of empathy on moral decision-making in extreme ethical dilemmas (i.e. life-and-death situations), with a lack of corresponding research support for its influence on everyday moral situations [27]. Therefore, this study aimed to investigate not only the correlation between clinical interns’ empathy and moral decision-making but also examine other influencing factors in moral decision-making.

Methods

Design and participants

This cross-sectional study employed convenience sampling to recruit nursing students actively undergoing clinical internships at six medical colleges across four cities in three northeastern Chinese provinces in July 2024. Eligible participants were required to (1) be formally enrolled in medical universities, (2) demonstrate intact comprehension abilities, and (3) provide informed consent with an explicit willingness to participate. The exclusion criteria included individuals with psychiatric diagnoses (e.g. depression and anxiety) verified through three approaches: (a) psychological status assessments via consultations by the research team with university counsellors, (b) institutional mental health evaluations during matriculation, or (c) self-reported history of psychiatric medication use (current/past) in the final questionnaire responses. Given the lack of prior data, we used G-Power to estimate that the effect size could range from small (Cohen’s f²=0.02) to medium (f²=0.15), resulting in a required sample size between 199 and 1405. Ultimately, considering human and material resources, 550 participants were selected for the study.

Measures

This study used a general information questionnaire, the Moral Decision-Making Competence Scale (EDM-CS), and the Interpersonal Reactivity Index (IRI-C).

The general information questionnaire included researcher-designed questions on the following characteristics of nursing students: gender, age, educational background, only child status, residence, clinical practice duration, hospitalisation, or prior nursing experience, whether they had studied nursing ethics courses, relationship with the teaching teacher during internship, relationship with patients during internship, and whether there was pressure in clinical work.

The EDM-CS, developed by Taiwanese scholar Hsiang-Chu Pai, was designed to evaluate nursing students’ moral decision-making abilities. This 18-item scale measures four dimensions: ethical judgment, sensitivity, motivation, and action. Utilising a 5-point Likert scale, the total scores range from 0 to 72, with higher scores indicating greater moral decision-making competence. Initial validation studies demonstrated high reliability, showing a Cronbach’s α of 0.90 for the full scale and subscale α coefficients ranging from 0.73 to 0.80, confirming good internal consistency [28]. After obtaining formal permission from the scale developer, a cultural adaptation process was conducted. Five clinical nursing education experts evaluated the terminology for cultural appropriateness. A subsequent pilot test (N = 30) confirmed the clarity of item wording, with no ambiguous terms reported. In this study, the scale maintained excellent reliability, with subscale α coefficients ranging from 0.914 to 0.935 and an overall α of 0.972, further supporting its strong internal consistency.

The revised Interpersonal Reactivity Index (IRI-C, Chinese version) by Zhan Zhiyu comprises 22 items across four dimensions: Perspective-Taking (PT, five items), Personal Distress (PD, five items), Fantasy Scale (FS, six items), and Empathic Concern (EC, six items). PT and FS constitute cognitive components, whereas PD and EC represent affective components. Notably, items 2, 5, 10, 11, and 14 were reverse scored, with the remaining items scored positively. Responses were recorded on a 5-point Likert scale, yielding total scores ranging from 0 to 88, with higher scores reflecting stronger empathic ability. The original developer reported a Cronbach’s α coefficient between 0.746 and 0.751 [29]. The scale was validated among nursing interns in China, demonstrating a total Cronbach’s α of 0.706. The Cronbach’s α for subscales ranged from 0.529 to 0.693 [30]. In the current study, subscale reliability coefficients ranged from 0.663 to 0.835, with an overall scale α of 0.885.

Data collection

Data were collected from July 23rd to 26th, 2024, during which participants completed an average of over two months of internship. To ensure optimal data validity, three key mechanisms were implemented: (1) the interns were fully acclimated to the organisational workflow and team dynamics, minimising behavioural variations linked to the initial adjustment period; (2) data collection was timed prior to the end of the internship, effectively isolating confounding factors such as job-seeking activities, academic exams, and end-of-term distractions; and (3) a fixed annual internship schedule eliminated seasonal fluctuation effects.

The questionnaire was administered via Wen Juan Xing (Questionnaire Star), a widely used online data-collection platform in China. All items were mandatory to prevent incomplete responses and to ensure a 100% response rate for all variables. To avoid duplication, each IP address or device was restricted to a single submission. Prior to distribution, consent was obtained from the nursing school director, and a pre-survey was conducted with 30 clinical nursing students to refine the questionnaire design for simplicity and clarity.

The participants required approximately 10–15 min to complete the questionnaire. After collection, the data were imported directly to the backend of the platform. Two team members independently screened the data to eliminate questionnaires with unreasonably short completion times, obvious response patterns, or consistent answers. The data classification and calculations were double-entered and rigorously verified for accuracy. After the removal of ineligible questionnaires, 528 students were ultimately included, achieving an effective response rate of 96%.

Statistical analysis

Quantitative variables were described using mean ± standard deviation, and count data were presented as percentages. The normality of distributions was systematically evaluated using the Kolmogorov-Smirnov test (applied for samples exceeding 50 observations), which indicated significant deviations from normality for all variables (p < 0.05). Accordingly, non-parametric methods, specifically Spearman’s correlation analysis, were used for comparative analyses. Finally, multiple logistic regression analysis was used to calculate the risk of the influencing factors. Statistical significance was set at α = 0.05, with p < 0.05 considered statistically significant. All analyses were conducted using SPSS 22.0 (IBM Corp).

Results

Personal characteristics

A total of 528 interns were included in the study, of whom 90.9% were female, with the majority aged 20–25 years old. Of the students, 94.5% had clinical internships of more than 6 months. Almost all the students had studied nursing ethics. In terms of interpersonal relationships, 59.1% had close relationships with their teachers, whereas 40.0% had more neutral relationships. Of these, 69.7% had close relationships with the patients, while 29.4% had neutral relationships. Further details are listed in Table 1.

Table 1.

Sociodemographic data of the participants(n = 528)

Variable		N (%)	t/F-Value		95% CI		P-Value
Gender	Male	48(9.1)	-1.975		-8.668-0.668		0.054
	Female	480(90.9)
Age	≤ 20	2(0.4)	1.501		-48.8-141.8		0.224
	21–25	487(92.2)			47.41–49.51
	26–30	39(7.4)			48.46–55.13
Education background	Bachelor’s Degree	470(89.0)	-0.483		-3.991-2.416		0.629
	Graduate Student	58(11.0)
Only child	Yes	296(56.1)	-0.467		-2.498-1.538		0.641
	No	232(43.9)
Residence	City	325(61.6)	0.477		47.67–50.33		0.621
	Countryside	174(33.0)			46.82–50.07
	Urban-rural Fringe	29(5.4)			42.66–51.20
Clinical practice time(month)	≤ 3	13(2.5)	1.779		37.07–46.78		0.150
	3–6	16(3.0)			38.98–53.52
	6–9	216(40.9)			47.59–50.49
	≥ 9	283(53.6)			47.45–50.33
Whether there is hospitalization or nursing experience	Yes	302(57.2)	0.468		-1.542-2.507		0.640
	No	226(42.78)
Whether have studied nursing ethics courses	Yes	517(97.9)	0.330		-5.834-8.194		0.741
	No	11(2.1)
Relationship with the teaching teacher during internship	Intimate	312(59.1)	17.196		49.74–52.51		0.000
	ordinary	211(40.0)			43.93–46.55
	Indifferent	5(0.9)			34.99–51.41
Relationship with patients during internship	Intimate	368(69.7)	15.481		49.25–51.67		0.000
	ordinary	155(29.4)			43.29–46.47
	Indifferent	7(0.9)			11.63–63.57
Whether there is pressure in clinical work	Yes	432(81.8)	-2.447		-5.801-0.634		0.015
	No	96(18.2)

The correlation between empathy and moral decision-making

The empathy score of intern nurses was 46.0 ± 11.58, and the ethical decision-making score was 48.70 ± 0.51. Empathy showed positive correlations with all four dimensions of ethical decision-making and its total score (p < 0.05). The cognitive component of empathy was also positively correlated with moral decision-making (p < 0.05). The details are presented in Table 2.

Table 2.

Correlation between empathy and moral decision-making

Variable		Points (x̄± SD)	Empathy	Ethical decision-making
Empathy		46.01 ± 11.58	1	0.159**
	Cognitive(PT + FS)	23.41 ± 6.132	—	0.244**
	Affective(PD + EC)	22.61 ± 6.261	—	No correlation
Ethical decision-making		48.70 ± 11.71	0.159**	1
	Ethical judgment	13.23 ± 3.391	0.106*	—
	Ethical sensitivity	13.66 ± 3.544	0.150**	—
	Ethical motivation	10.83 ± 2.903	0.152**	—
	Ethical action	10.98 ± 2.794	0.183**	—

**<0.001, *<0.05

Results of single factor analysis of moral decision-making

The relationship between the intern and the teaching teacher, the relationship between the intern and patients, and the clinical work pressure during the internship were statistically significant (p < 0.05). Further details are listed in Table 1.

Results of multiple linear regression analysis of moral decision-making

The variables that were significant in the single-factor analysis were included in the regression analysis. The results of the multiple linear regression analysis showed statistically significant differences in the relationship between the intern and the teaching teacher (p = 0.004) and the relationship between the intern and the patients (p = 0.016). The details are presented in Table 3.

Table 3.

Results of multiple linear regression analysis for ethical decision-making

	B	SE	β	t	P-Value	95.0% CI
(Constant)	56.611	2.529		22.387	0.000	51.643–61.578
Relationship with the Teacher during Internship	-3.610	1.240	-0.158	-2.911	0.004	-6.046–1.173
Relationship with Patients during Internship	-3.141	1.298	-0.130	-2.420	0.016	-5.692–0.591
Stress in Clinical Work	1.129	1.324	0.037	0.852	0.394	-1.472-3.729

B = regression coefficient; SE = standard error; R = 0.272; R2 = 0.074; R2 corrected = 0.068; P < 0.05

Discussion

The relationship between empathy levels and moral Decision-Making in intern nurses

The empathy score of nursing interns in this study was 46.01 ± 11.58, slightly lower than findings from other Chinese nursing student studies [21, 31, 32]. The results revealed a weak correlation with moral decision-making, suggesting that while empathy influences emotional responses during ethical decision-making, it does not significantly affect final moral choices. Notably, this weak correlation might stem from the following mechanisms. First, moral decision-making involves multidimensional influencing factors, where empathy’s effect may be indirectly mediated through variables such as moral resilience [33], moral reasoning ability, professional values [5], and moral sensitivity [34]. Significant decision-making impacts require integrating empathy with other factors rather than relying solely on its intensity [35]. Second, certain personality traits (e.g. agreeableness) and social expectations might exert more stable influences on ethical decision-making than empathy itself. Despite the limited direct impact of empathy, these traits can dominate the decision-making process [36]. Finally, during their transition from students to professional healthcare providers, nursing interns may prioritise adherence to professional norms and ethical guidelines over emotion-driven decision-making. Additionally, moral decision-making in clinical practice often occurs in high-risk scenarios. Due to their limited clinical experience, nursing students tend to adopt conservative strategies to mitigate potential risks.

The dual nature of empathy’s role

Empathy has a dual role in nursing practice. It helps prevent conflict, builds trust between nurses and patients, and enhances care quality and patient satisfaction [5]. Individuals lacking empathy tend to make utilitarian choices [13], which may appear effective short-term but compromise long-term patient care outcomes. Conversely, excessive empathy may lead to emotional exhaustion [37] and ‘overemotional responses in ethical dilemmas’, where decision-makers prioritise emotional impulses over logical analysis [23], potentially resulting in suboptimal ethical decisions [38]. This paradox is also manifested in nursing students. During early adulthood, nursing interns demonstrate lower affective empathy intensity, while cognitive empathy provides crucial pathways to balance ethical standards with clinical demands by rationally analysing others’ circumstances and predicting behavioural consequences [39]. Therefore, educational practices should guide nursing students to establish a dynamic equilibrium between professional detachment and emotional engagement.

The influence mechanism of environmental factors on moral Decision-Making

Research indicates that environmental factors significantly influence moral decision-making during clinical internships. Close mentor-student relationships enhance decision-making capabilities through knowledge transfer [40] and improve communication skills [41], while strategies such as fostering ethical climates and enhancing communication techniques have proven effective [42]. Simultaneously, strong nurse-patient rapport promotes patient-centred decisions by intensifying empathy [13] and cultural understanding [1]. However, vigilance is required regarding interpersonal biases in resource allocation, as studies have demonstrated stronger altruistic tendencies toward individuals with closer relational bonds [43].

Model limitations and gender differences: insights

The current model demonstrated limited explanatory power (R²=0.074), potentially attributable to unaccounted-for contextual factors such as social values [44] and safety climate [45], which interact with individual experiences and character strengths to shape ethical decision-making competencies [9]. Gender analysis revealed that while male and female nursing students exhibited differences in ethical sensitivity and ethical action dimensions, no statistically significant disparities emerged in empathy levels or overall ethical decision-making capacity, a finding consistent with Zhao et al. [46] but contrasting with Rosen JB’s conclusion (women showed stronger altruistic decision-making tendencies due to higher empathy levels [47]). These results may reflect the nursing profession’s self-selection effect; male practitioners might inherently possess elevated empathy levels compared to the general population, thereby obscuring gender differences through occupational characteristics.

The practical pathways of educational interventions

Educational interventions for ethical decision-making have significant implications for patient recovery, healthcare cost reduction, and service quality improvement when nurses act appropriately at critical moments [48, 49]. Given the trainable nature of ethical decision-making [50], innovative pedagogical approaches such as flipped jigsaw learning models [51] and ethical empowerment programmes [52] are recommended. However, standalone curricular training is insufficient to address clinical complexities [53, 54]; ethical principles must be operationalised into decision-making competencies through practice reinforcement [55]. Future educational designs should prioritise overcoming the ‘knowing-doing gap’ by establishing integrated training systems that combine institutional support, experiential reflection, and skill development, thereby equipping nursing students to navigate moral challenges inherent in evolving nursing roles [56].

Limitations

This study has some limitations. First, the sample primarily comprised Han Chinese students from northeastern China, limiting its generalisability to other ethnic groups and regions. Subsequent research should expand to diverse geographic areas across China to explore the cultural-geographic moderating effects through cross-regional comparisons. Second, while the study identified associations between empathy and ethical decision-making, the cross-sectional design precludes causal inferences. Longitudinal studies are needed to clarify these directional relationships and validate the potential mediating mechanisms. Third, While our sample size addressed the uncertainty in effect sizes, it may still be insufficient to detect extremely small effects. Future studies will need to conduct large-scale investigations or meta-analyses.

Conclusions

The results indicated that nursing students with lower empathy also exhibited lower capabilities across all dimensions of moral decision-making. The ability to make moral decisions is related to maintaining good relationships with preceptors or patients during internships. Therefore, it is important to strengthen ethical education and interpersonal communication skills before nursing students enter clinical internships. Particular emphasis should be placed on shaping the personality traits of nursing students, appropriately preserving their empathy and finding a balanced distance between empathetic engagement and rational thinking.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Author contributions

Zhao XY and Zhang YY conceived and wrote the paper; Zhang J, Zhao XY conducted literature search; Zhao XY, Luan Jh and Zhang J collected and analyzed the data; Luan ZG and Zhang J revised the whole paper.

Funding

Funding Name: 1. Free Exploration Project of China Medical University (YDXF2024039). 2. Supporting Program for National-level Research Projects of the School of Nursing, China Medical University (2024-FC4).

Data availability

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Declarations

Ethical approval

This study was conducted in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. Approval was obtained from the Ethics Committee of Medical Research in the First Affiliated Hospital of China Medical University (Approval number: [2024]710) before the study. The interviewees were informed of the contents of the consent form and the purposes and methods of the study. They had the right to withdraw from the study at any time. The interview materials were used for the study only. All these ensured the anonymity and confidentiality of the interviewees during the whole study. All subjects signed the written informed consent before the study.

Competing interests

The authors declare no competing interests.