Abstract
Objective
Ethical practice is a core professional expectation in nursing, yet nursing interns may vary substantially in how they enact ethical principles during clinical placements. This study examined ethical behavior among nursing interns through latent profile analysis and explored personal and environmental determinants.
Methods
A cross-sectional survey was conducted in October 2024 with 369 nursing interns from a tertiary hospital in Wuhan, China. Instruments included a demographic questionnaire, the Ethical Behavior Scale for Nurses, and the Nurses’ Moral Courage Scale. Latent profile analysis was used to classify nursing interns’ ethical behavior into different profiles. Univariate group-comparison tests and multinomial logistic regression were used to determine factors that were associated with different profiles.
Results
Three distinct ethical behavior profiles were identified: Moderate–Balanced (37.7%), Technical-Priority & Fairness-Neglect (13.6%), and Consistent High-Scorer (48.8%). Compared with Consistent High-Scorers, males and those who had received patient complaints were more likely to belong to the Moderate–Balanced or Technical-Priority & Fairness-Neglect profiles. Higher moral courage and stronger professional passion were associated with lower odds of Moderate–Balanced profile membership.
Conclusion
More than half of the interns were classified into suboptimal profiles, highlighting the need to strengthen everyday ethical practice. Educational methods need to transcend uniform approaches, emphasizing the development of moral courage and professional enthusiasm through ethics-centered simulations. Establishing supportive clinical environments with structured feedback mechanisms is essential to guide interns toward consistently high ethical performance.
Keywords: Nursing interns, Ethical behavior, Moral courage, Latent profile analysis
Introduction
Nursing ethical behavior refers to the extent to which core ethical principles are enacted in nursing practice, including respect for autonomy, beneficence, non-maleficence, and justice [1]. Such practice is integral to nursing and constitutes a fundamental component of high quality care. At the international level, the ICN Code of Ethics for Nurses (2021) sets out ethical values and responsibilities that guide practice worldwide [2]. In the United States, the ANA Code of Ethics for Nurses (2025) serves as the definitive contemporary standard [3]. In China, the State Council’s Regulations on Nurses (2008) legally require standardized nursing conduct to safeguard patient safety and public health [4]. However, the existence of formal ethical codes and regulations does not automatically ensure consistent ethical enactment in clinical practice, and discrepancies between ethical standards and actual professional behavior have been widely reported in nursing education and practice [5–7].
These discrepancies are particularly salient during the clinical internship period, which represents a critical phase of ethical socialization rather than merely a transition of technical skills. The internship is a vital ethical socialization phase where students navigate the ‘theory-practice gap’ between theoretical knowledge and the practical challenges of ward life [8, 9]. This transition imposes a dual challenge: attaining technical proficiency while simultaneously internalizing professional ethical standards [10]. Interns must learn to translate abstract principles into daily practice under the pressures of real-world clinical environments [9, 11]. While existing studies have predominantly focused on cognitive dimensions such as ethical sensitivity, moral courage, or perceived competence [12–14], the direct assessment of ethical behavior in real clinical settings remains limited. This distinction is critical, as accumulating empirical evidence indicates that ethical awareness and moral reasoning do not necessarily translate into consistent ethical action, resulting in a persistent gap between ethical cognition and behavioral enactment [6, 15–17].
Social Cognitive Theory (SCT) provides a robust theoretical lens to explain this discrepancy. SCT posits that human behavior is the product of triadic reciprocal determinism, involving the continuous interaction between personal attributes, environmental influences, and the behavior itself [18]. For nursing interns, personal attributes such as moral courage and professional passion shape their readiness to act ethically [19]. Simultaneously, external stressors including patient complaints and mentor evaluations serve as critical environmental catalysts or barriers to ethical conduct [20, 21]. Understanding how these multi-dimensional factors interact to produce specific behavioral patterns is essential for bridging the gap between ethical knowledge and clinical conduct.
To capture this complexity, a person-centered approach such as latent profile analysis (LPA) is well suited. Whereas variable-centered methods that assess average correlations within a complete population, LPA identifies unobserved subgroups of individuals who show similar response patterns [22, 23]. In medical education, this approach offers a way to identify distinct learner profiles with different needs for supervision, feedback, and curriculum emphasis during clinical training [23]. However, person-centered analyses remain uncommon in nursing ethics research, and little is known about how personal and clinical factors jointly relate to interns’ ethical behavior patterns. This study addresses these gaps by applying LPA to classify the ethical behavior of nursing interns and examine the predictors of profile membership. Specifically, the study aimed to: (1) identify latent ethical behavior profiles among nursing interns; and (2) determine how personal attributes and clinical environmental factors influence these classifications. The findings aimed to provide an empirical basis for tailored educational strategies, shifting away from uniform training to develop a more ethically robust nursing workforce.
Methods
Study design and participants
A cross-sectional survey was conducted in October 2024 at a tertiary Grade A hospital in Wuhan, China. The survey targeted the entire cohort of undergraduate nursing students undertaking clinical internships at the hospital during this period. Eligibility criteria included an internship duration of at least three months and provision of informed consent, while students with shorter placements were excluded. Based on the logistic regression sample size estimation method [24], the sample size must be at least ten times the number of independent variables. With 19 variables, at least 190 participants were required; an additional 20% allowance for potential non-response yielded a target of 237. Ultimately, 369 valid questionnaires were collected from 371 distributed, resulting in a response rate of 99.46%.
Measures
General information questionnaire
A self-developed questionnaire was used to collect demographic and professional information, including gender, age, political affiliation, personality traits, urban or rural origin, only-child status, family economic level, whether relatives worked in healthcare, leadership roles during school or internship, choice of nursing major, degree of professional passion, career development plan, satisfaction with internship department and mentor, received praise or complaints from patients, and exposure to nurse–patient disputes.
Ethical behavior scale for nurses
The Ethical Behavior Scale for Nurses (EBSN) was developed by Ode [25] based on the four principles of biomedical ethics. To strengthen measurement precision, the instrument was refined by Ode [26], resulting in the revised version (EBSN-R). The EBSN-R consists of 15 items across three dimensions: risk avoidance (items 3, 5, 7, 8, 12), good care (items 2, 4, 10, 13, 15), and fair care (items 1, 6, 9, 11, 14), with fair care items reverse-scored. Each item is rated on a 6-point Likert scale (1 = strongly disagree to 6 = strongly agree). Total scores range from 15 to 90, with higher scores reflecting stronger ethical behavior. The Chinese version of EBSN-R was translated and culturally adapted by Chen et al. [27]. It demonstrated good internal consistency, with Cronbach’s α of 0.892. In this study, the Cronbach’s α was 0.842.
Nurses’ moral courage scale
The Nurses’ Moral Courage Scale (NMCS) was developed by Numminen et al. [28]. It consists of 21 items across four dimensions: moral integrity, commitment to good care, compassion and genuine presence, and moral responsibility. Each item is rated on a 5-point Likert scale (1 = does not describe me at all to 5 = describes me very well). Total scores range from 21 to 105, with higher scores indicating greater moral courage. The Chinese version of NMCS was translated and culturally adapted by Wang et al. [29] and demonstrated good internal consistency, with Cronbach’s α of 0.905. In this study, the Cronbach’s α was 0.952.
Data collection
Data were collected electronically using the Questionnaire Star platform. Participants received standardized instructions, provided informed consent online, and completed the questionnaire anonymously. To ensure data quality while protecting anonymity, participants completed the survey independently. The platform required completion of all items and restricted duplicate submissions from the same IP address, thereby ensuring the completeness and accuracy of the dataset.
Data analysis
Statistical analyses were performed using Mplus 8.3 and R software (Version 4.2.1). Latent profile analysis (LPA) was performed with Mplus to classify patterns of ethical behavior. Model fit was evaluated using the Akaike Information Criterion (AIC), Bayesian Information Criterion (BIC), adjusted Bayesian Information Criterion (aBIC), and entropy. The Lo–Mendell–Rubin adjusted likelihood ratio test (LMRT) and bootstrapped likelihood ratio test (BLRT) were applied to determine the optimal number of profiles, with significant p-values (p < 0.05) indicating a better fit for the k-profile model compared to the k-1 model. Model selection was guided by a combination of statistical fit indices, classification accuracy, and substantive interpretability.
Differences among profiles according to the demographic information, moral courage and ethical behavior of nursing were analyzed using the one-way ANOVA, Kruskal-Wallis H test, Pearson’s chi-square test (χ2) or Fisher’s exact test. Multinomial logistic regression was used to identify predictors of profile membership and determine factors associated with different profiles of ethical behavior. Statistical significance was set at p < 0.05.
Results
General characteristics of nursing interns
Of the 369 participants, 79.67% were female and 20.33% male, with the majority aged 20 ~ 23 years. Detailed demographic and professional characteristics are presented in Table 1.
Table 1.
Characteristics of interns across ethical behavior profiles with univariate comparisons
| Variable | Overall, (n = 369) | Moderate-Balanced profile (n = 139)1 | Technical-Priority & Fairness-Neglect profile (n = 50)1 | Consistent High-Scorer profile (n = 180)1 | Statistics (χ²/H/F) | P |
|---|---|---|---|---|---|---|
| Gender | 18.458 | < 0.001 | ||||
| Male | 75 (20.33%) | 40 (28.78%) | 15 (30.00%) | 20 (11.11%) | ||
| Female | 294 (79.67%) | 99 (71.22%) | 35 (70.00%) | 160 (88.89%) | ||
| Age | 21.00 [21.00, 21.00] | 21.00 [21.00, 21.00] | 21.00 [21.00, 22.00] | 21.00 [21.00, 21.00] | 3.306 | 0.191 |
| Political Affiliation | 0.071 | |||||
| Communist Party of China Member | 14 (3.79%) | 2 (1.44%) | 6 (12.00%) | 6 (3.33%) | ||
| Probationary Communist Party of China Member | 56 (15.18%) | 18 (12.95%) | 7 (14.00%) | 31 (17.22%) | ||
| Communist Youth League Member | 240 (65.04%) | 92 (66.19%) | 31 (62.00%) | 117 (65.00%) | ||
| Non-League member | 59 (15.99%) | 27 (19.42%) | 6 (12.00%) | 26 (14.44%) | ||
| Personal Character | 5.942 | 0.204 | ||||
| Extroverted | 78 (21.14%) | 23 (16.55%) | 15 (30.00%) | 40 (22.22%) | ||
| Introverted | 234 (63.41%) | 89 (64.03%) | 29 (58.00%) | 116 (64.44%) | ||
| In-between | 57 (15.45%) | 27 (19.42%) | 6 (12.00%) | 24 (13.33%) | ||
| Type of Origin | 0.449 | 0.799 | ||||
| Urban | 138 (37.40%) | 55 (39.57%) | 18 (36.00%) | 65 (36.11%) | ||
| Rural | 231 (62.60%) | 84 (60.43%) | 32 (64.00%) | 115 (63.89%) | ||
| Only Child Status | 1.950 | 0.377 | ||||
| Yes | 123 (33.33%) | 52 (37.41%) | 17 (34.00%) | 54 (30.00%) | ||
| No | 246 (66.67%) | 87 (62.59%) | 33 (66.00%) | 126 (70.00%) | ||
| Family Economic Situation | 0.029 | |||||
| Good | 16 (4.34%) | 9 (6.47%) | 2 (4.00%) | 5 (2.78%) | ||
| Average | 305 (82.66%) | 114 (82.01%) | 35 (70.00%) | 156 (86.67%) | ||
| Poor | 48 (13.01%) | 16 (11.51%) | 13 (26.00%) | 19 (10.56%) | ||
| Family Members in Healthcare | 1.059 | 0.589 | ||||
| Yes | 116 (31.44%) | 47 (33.81%) | 17 (34.00%) | 52 (28.89%) | ||
| No | 253 (68.56%) | 92 (66.19%) | 33 (66.00%) | 128 (71.11%) | ||
| Positions Held During School | 9.211 | 0.010 | ||||
| Student Leader | 187 (50.68%) | 60 (43.17%) | 34 (68.00%) | 93 (51.67%) | ||
| Non-Student Leader | 182 (49.32%) | 79 (56.83%) | 16 (32.00%) | 87 (48.33%) | ||
| Positions Held During Internship | 5.221 | 0.073 | ||||
| Internship Leader | 49 (13.28%) | 13 (9.35%) | 11 (22.00%) | 25 (13.89%) | ||
| No Position | 320 (86.72%) | 126 (90.65%) | 39 (78.00%) | 155 (86.11%) | ||
| Choice of Nursing Major | 8.080 | 0.018 | ||||
| Voluntary | 296 (80.22%) | 101 (72.66%) | 43 (86.00%) | 152 (84.44%) | ||
| Adjusted | 73 (19.78%) | 38 (27.34%) | 7 (14.00%) | 28 (15.56%) | ||
| Level of Professional Passion | < 0.001 | |||||
| Passionate | 188 (50.95%) | 40 (28.78%) | 32 (64.00%) | 116 (64.44%) | ||
| Average | 172 (46.61%) | 92 (66.19%) | 17 (34.00%) | 63 (35.00%) | ||
| Not Passionate | 9 (2.44%) | 7 (5.04%) | 1 (2.00%) | 1 (0.56%) | ||
| Career Development Plan | 0.023 | |||||
| Nursing | 344 (93.22%) | 123 (88.49%) | 48 (96.00%) | 173 (96.11%) | ||
| Non-Nursing | 25 (6.78%) | 16 (11.51%) | 2 (4.00%) | 7 (3.89%) | ||
| Satisfied with Clinical Mentor | 0.052 | |||||
| Yes | 364 (98.64%) | 135 (97.12%) | 49 (98.00%) | 180 (100.00%) | ||
| No | 5 (1.36%) | 4 (2.88%) | 1 (2.00%) | 0 (0.00%) | ||
| Satisfied with Internship Department | 0.577 | |||||
| Yes | 358 (97.02%) | 133 (95.68%) | 49 (98.00%) | 176 (97.78%) | ||
| No | 11 (2.98%) | 6 (4.32%) | 1 (2.00%) | 4 (2.22%) | ||
| Praised by Patients | 0.053 | |||||
| Yes | 316 (85.64%) | 112 (80.58%) | 47 (94.00%) | 157 (87.22%) | ||
| No | 53 (14.36%) | 27 (19.42%) | 3 (6.00%) | 23 (12.78%) | ||
| Received Patient Complaints | 9.258 | 0.010 | ||||
| Yes | 46 (12.47%) | 23 (16.55%) | 10 (20.00%) | 13 (7.22%) | ||
| No | 323 (87.53%) | 116 (83.45%) | 40 (80.00%) | 167 (92.78%) | ||
| Experienced Nurse-Patient Dispute | 0.374 | |||||
| Personal Experience | 30 (8.13%) | 15 (10.79%) | 4 (8.00%) | 11 (6.11%) | ||
| Classmate Experienced | 11 (2.98%) | 5 (3.60%) | 3 (6.00%) | 3 (1.67%) | ||
| Witnessed | 165 (44.72%) | 61 (43.88%) | 19 (38.00%) | 85 (47.22%) | ||
| Never Witnessed | 163 (44.17%) | 58 (41.73%) | 24 (48.00%) | 81 (45.00%) | ||
| Moral Courage | 68.00 [63.00, 79.00] | 63.00 [62.00, 69.00] | 72.00 [63.00, 84.75] | 73.50 [64.00, 84.00] | 53.380 | < 0.001 |
Note: 1n (%); Median [IQR]; χ² = Pearson’s chi-square test; F = one-way analysis of variance (ANOVA); H = Kruskal–Wallis H test; Fisher’s exact test was used when expected cell counts were < 5
Latent profile analysis of nursing interns’ ethical behavior
Model fit indices are summarized in Table 2. A three-profile solution demonstrated the best fit, with lower AIC, BIC, and adjusted BIC values and the highest entropy (0.954). Likelihood ratio tests further supported this model. Although the 4-profile model yielded lower AIC and BIC values, the LMRT did not reach statistical significance (p = 0.054). This suggests that the 4-profile solution did not provide a statistically superior fit compared to the 3-profile model. In contrast, the 3-profile solution demonstrated a significant LMRT p-value (p = 0.048) and high Entropy (0.954). Therefore, the 3-profile model was retained as the optimal solution based on both statistical fit and parsimony.
Table 2.
Fit indices for latent profile models of nursing interns’ ethical behavior
| Model | AIC | BIC | aBIC | p | Entropy | Proportion | |
|---|---|---|---|---|---|---|---|
| LMRT | BLRT | ||||||
| 1 | 17856.547 | 17973.871 | 17878.691 | - | - | - | - |
| 2 | 16372.937 | 16552.834 | 16406.892 | < 0.001 | < 0.001 | 0.923 | 0.423, 0.577 |
| 3 | 15559.759 | 15802.228 | 15605.524 | 0.048 | < 0.001 | 0.954 | 0.377, 0.135, 0.488 |
| 4 | 15174.249 | 15479.291 | 15231.824 | 0.054 | < 0.001 | 0.954 | 0.127, 0.371, 0.385, 0.117 |
Note: AIC Akaike Information Criterion, BIC Bayesian Information Criterion, aBIC Adjusted BIC, LMRT Lo–Mendell–Rubin adjusted likelihood ratio test, BLRT Bootstrapped likelihood ratio test
Characterization of latent profiles of nursing interns’ ethical behavior
Figure 1 provides a visual summary of the three latent ethical behavior profiles across the four ethical dimensions. Differences in ethical behavior scores among the three profiles were further examined using one-way ANOVA, with detailed results presented in Table 3. As illustrated in Fig. 1, interns’ ethical behavior was classified into three distinct profiles. The classification was robust, as indicated by high average posterior probabilities for class assignment (97.3% for Class 1, 96.1% for Class 2, and 98.7% for Class 3).
Fig. 1.
Item-level latent profiles of ethical behavior among nursing interns. Note: Items are grouped into risk avoidance (Items 3, 5, 7, 8, 12), good care (Items 2, 4, 10, 13, 15), and fair care (Items 1, 6, 9, 11, 14). Fair care items were reverse-coded so that higher scores indicate better ethical behavior across all items and dimensions
Table 3.
Comparison of ethical behavior scores across latent profiles
| Dimension | Moderate-Balanced profile (n = 139) | Technical-Priority & Fairness-Neglect profile (n = 50) | Consistent High-Scorer profile (n = 180) | F | P |
|---|---|---|---|---|---|
| Good care | 18.83 ± 2.72 | 26.90 ± 2.80 | 24.56 ± 3.05 | 213.949 | < 0.001 |
| Risk avoidance | 19.19 ± 2.93 | 27.10 ± 2.60 | 25.78 ± 2.57 | 281.516 | < 0.001 |
| Fair care | 19.01 ± 3.62 | 10.36 ± 4.15 | 24.44 ± 3.47 | 313.686 | < 0.001 |
| Ethical behavior | 57.04 ± 4.93 | 64.36 ± 4.49 | 74.78 ± 6.21 | 407.412 | < 0.001 |
Moderate–Balanced Profile (n = 139, 37.67%): Interns scored at a moderate level across all dimensions, indicating adherence to basic standards without marked strengths. Technical-Priority & Fairness-Neglect Profile (n = 50, 13.55%): Interns scored highest in quality and safety but lowest in fairness, reflecting an emphasis on technical performance at the expense of justice. Consistent High-Scorer Profile (n = 180, 48.78%): Interns achieved consistently high scores across all dimensions. Profile labels were assigned based on the relative pattern of scores across ethical dimensions rather than absolute score levels alone.
Univariate analysis of profile differences
Univariate comparisons among the three profiles are presented in Table 1. The results indicated significant differences in terms of gender, family economic situation, positions held during school, choice of nursing major, degree of professional passion, career development plans, received patient complaints, and moral courage.
Predictors of profile membership
Variables with p < 0.05 in univariate analyses were entered into the multinomial logistic regression model, with the “Consistent High-Scorer profile” as the reference group. The detailed results are presented in Table 4. Relative to Consistent High-Scorers profile, interns in the Moderate–Balanced profile were more likely to be male likely to be male (OR = 4.26, 95% CI 2.00-9.07) and to have received patient complaints (OR = 4.76, 95% CI 1.90-11.92), indicating that male interns and those with prior complaint experiences had more than fourfold higher odds of exhibiting a moderate, rather than consistently high, level of ethical behavior. In contrast, higher moral courage (OR = 0.92, 95% CI 0.90–0.94) and stronger professional passion (OR = 0.06, 95% CI 0.01–0.62) were associated with substantially lower odds of belonging to this profile. Specifically, each one-point increase in moral courage corresponded to an approximately 8% reduction in the likelihood of Moderate-Balanced profile membership, while high professional passion was associated with a marked decrease in the likelihood of belonging to the Moderate-Balanced profile.
Table 4.
Multinomial logistic regression for latent profile membership in ethical behavior
| Variable | Moderate-Balanced profile (n = 139) | Technical-Priority & Fairness-Neglect pofile (n = 50) |
||||||
|---|---|---|---|---|---|---|---|---|
| β | P | OR | 95% CI | β | P | OR | 95% CI | |
| Moral courage | -0.085 | < 0.001 | 0.92 | (0.90, 0.94) | -0.015 | 0.270 | 0.99 | (0.96, 1.01) |
| Male | 1.449 | < 0.001 | 4.26 | (2.00, 9.07) | 0.949 | 0.028 | 2.58 | (1.11, 6.03) |
| Level of professional passion | ||||||||
| Passionate | -2.829 | 0.018 | 0.06 | (0.01, 0.62) | -1.356 | 0.367 | 0.26 | (0.01, 4.89) |
| Average | -1.332 | 0.258 | 0.26 | (0.03, 2.65) | -1.037 | 0.487 | 0.36 | (0.02, 6.60) |
| Received patient complaints | 1.559 | 0.001 | 4.76 | (1.90, 11.92) | 1.125 | 0.024 | 3.08 | (1.16, 8.18) |
Note: Consistent High-Scorer profile served as the reference group
Similarly, interns classified into the Technical-Priority & Fairness-Neglect profile were also more likely to be male (OR = 2.58, 95% CI 1.11–6.03) and to have received patient complaints (OR = 3.08, 95% CI 1.16–8.18), suggesting that these factors more than doubled or tripled the odds of prioritizing technical performance at the expense of fairness-related ethical considerations. Overall, male gender and experiences of patient complaints emerged as salient risk factors for membership in suboptimal ethical behavior profiles, whereas higher moral courage and strong professional passion functioned as key protective factors associated with consistently high ethical performance.
Discussion
To our knowledge, this study is among the first to investigate nursing interns’ ethical behavior using a person-centered latent profile approach. By linking profile membership to modifiable factors, the study offers actionable entry points for competency-based ethics education and workplace learning support. While the overall average ethical behavior score of our sample (76.7 ± 9.9) suggests a foundational ethical orientation comparable to practicing nurses [30], such variable-centered metrics often obscure critical internal variations. This study identified three distinct ethical behaviorbehavior profiles among nursing interns. Nearly half of the participants (48.8%) were classified as Consistent High-Scorers, followed by 37.7% in the Moderate–Balanced profile, and 13.6% in the Technical-Priority & Fairness-Neglect profile. Consistent with recent calls for more nuanced assessments of professional ethics in nursing education [12, 15], this distribution highlights the urgent necessity for targeted educational interventions tailored to these specific behavioral patterns.
From an ethical development perspective, the three profiles identified in this study may reflect different configurations of ethical competence. Rest’s four-component model proposes that ethical behavior emerges from the integration of moral sensitivity, moral judgment, moral motivation, and moral character [6]. The Consistent High-Scorer profile, the largest profile, appears to demonstrate not only ethical sensitivity but also sufficient moral motivation and character to translate ethical judgment into consistent action. Conversely, the Moderate–Balanced profile, which accounted for more than one-third of the sample, may reflect a compliance-oriented profile in which ethical norms are recognized but not consistently enacted, as suggested by studies showing that enhancements in moral judgment do not always translate into sustained moral implementation [31, 32]. The Technical-Priority & Fairness-Neglect profile suggests a fragmented form of ethical competence, where technical beneficence and non-maleficence are prioritized while justice-related considerations remain underdeveloped. This pattern echoes previous findings that justice is often the most difficult ethical principle for students to operationalize in clinical practice [6, 7, 33]. This profile therefore highlights a context-sensitive vulnerability in ethical enactment rather than an absence of ethical understanding. Consequently, there is a clear need to view ethical behavior as a multidimensional and context dependent phenomenon that is shaped by clinical environments.
To further interpret the observed heterogeneity in ethical behavior profiles, SCT provides an integrative explanatory framework [18]. SCT posits that ethical behavior emerges from the reciprocal interaction between personal factors, environmental influences, and behavioral enactment, rather than from any single determinant acting in isolation. Within this framework, variations in ethical enactment among nursing interns can be understood as the result of how individual moral resources, such as gender-related dispositions, professional identity, and moral courage, interact with clinical learning environments. This theoretical perspective provides a coherent foundation for the following discussion, which examines key personal and contextual factors associated with ethical behavior profile membership.
Gender emerged as a significant demographic factor associated with ethical behavior profile membership in this study. While neuroscience research suggests that females tend to exhibit higher levels of empathy and a greater capacity to understand others’ emotional states [34]. However, such differences are widely acknowledged to be shaped and moderated by socialization processes, professional role expectations, and clinical learning environments. Male nursing interns may encounter distinct challenges within a predominantly female profession, including fewer same-gender role models and differing expectations regarding professional identity formation [14, 16]. Such contextual factors may influence how ethical norms are interpreted, internalized, and enacted in clinical settings. From a SCT perspective, gender can thus be conceptualized as a contextualized personal factor that shapes how individuals respond to environmental cues and mobilize moral resources in ethically demanding situations. Educational programs should recognize these socio-cultural nuances and develop tailored strategies to support ethical competence across genders.
Professional passion was significantly associated with ethical behavior profiles in the present study. Interns with high passion had lower odds of being classified into the Moderate–Balanced profile compared to Consistent High-Scorers, which may indicate stronger engagement with and internalization of the nursing role. This finding is consistent with prior review suggesting that professional identity formation and role internalization are associated with commitment to ethical standards and sustained ethical engagement in practice [35]. From a social cognitive perspective, stronger professional identification may enhance self-regulatory capacities such as self-efficacy [18, 36], which may empower interns to uphold ethical principles even under real-world clinical pressures or hierarchical opposition. These findings suggest that supporting interns’ professional engagement and role internalization may be a practical leverage point for ethics education and supervision during clinical training.
This study further highlights moral courage as a key personal factor associated with ethical behavior profiles among nursing interns. Interns with lower moral courage were more likely to demonstrate only moderate ethical conduct in clinical practice. From the perspective of Rest’s Four-Component Model, moral courage can be understood as a critical aspect of moral character that enables individuals to translate ethical judgment and motivation into concrete action [6, 28]. Interns with lower moral courage may possess ethical sensitivity, yet experience difficulty sustaining ethical conduct when confronted with clinical dilemmas, hierarchical constraints, or concerns about personal consequences [17, 19]. Given that moral challenges are inherent to high-pressure healthcare environments, the capacity to act courageously in ethically complex situations becomes particularly salient during clinical training [19]. These findings suggest that nursing programs may benefit from moving beyond exclusively knowledge-based ethics education toward approaches that strengthen students’ moral courage and psychological readiness to act ethically in real clinical situations.
Beyond individual moral resources, the clinical environment emerged as a critical contextual condition shaping nursing interns’ ethical behavior. In particular, the local feedback culture may influence how interns interpret and respond to complaints during workplace learning [8, 9]. Experiences of patient complaints may function as salient stressors that disrupt ethical enactment during clinical training [37]. Such experiences may may trigger defensive or compliance-oriented coping strategies, particularly among interns with limited professional confidence or support [38]. Without structured guidance and reflective mentoring, interns may narrow their focus toward error avoidance, potentially at the expense of fairness-related and relational aspects of care. This interpretation aligns with developmental perspectives suggesting that early-career practitioners may temporarily constrict their ethical attention under perceived threat or evaluative pressure [20, 21, 31]. Notably, complaints can also be learning opportunities when supervisors provide psychologically safe, constructive feedback and guided reflection [39]. Our findings underscore the importance of fostering a supportive ethical climate in which clinical mentors not only teach technical skills but also actively guide interns in reflecting on and learning from challenging experiences such as patient complaints through structured debriefing and reflective supervision.
Implications for practice
The identification of distinct ethical behavior profiles among nursing interns highlights the necessity for a transition from generic training toward person centered ethics education tailored to specific behavioral patterns. For interns classified as Consistent High-Scorers, educational strategies may focus on fostering ethical leadership through participation in complex ethical case discussions or peer mentoring, thereby reinforcing professional identity and sustained ethical engagement. Interns within the Moderate–Balanced profile may benefit from targeted interventions aimed at strengthening moral courage, such as scenario-based simulations and case-based debates that provide safe opportunities to practice ethically challenging communication within hierarchical clinical settings. For those in the Technical-Priority & Fairness-Neglect profile, ethics education should place greater emphasis on humanistic care and distributive justice, using role-play to promote a more balanced integration of technical safety and fairness in care. In addition, given that patient complaints were strong predictors of suboptimal ethical behavior profiles, clinical mentors should implement structured feedback and reflective coaching to help interns process negative experiences constructively. Such support may prevent defensive, compliance-oriented responses and facilitate ethical development and professional resilience within workplace learning.
Limitations and future directions
This study has several limitations. First, it was conducted at a single medical center in one region of China, which may limit the generalizability of the findings to other settings or or cultural contexts. Due to its cross-sectional and self-reported nature, the study’s design limits the ability to infer causality and may be subject to social desirability bias. In addition, the findings are embedded within the specific socio-cultural and organizational context of the Chinese nursing system, which emphasizes collectivist values and hierarchical clinical structures. Despite these constraints, this study provides a meaningful snapshot of ethical socialization within a large-scale clinical environment. By utilizing a person-centered approach and validated instruments, our findings offer unique evidence from a collectivist professional perspective, contributing to a more inclusive global understanding of nursing ethics. Future studies should adopt multi-center, longitudinal, and mixed-method designs to validate these findings and to examine how targeted interventions influence the ethical development of nursing interns across diverse contexts.
Conclusion
This study used latent profile analysis to identify three distinct patterns of ethical behavior among nursing interns: Moderate-Balanced, Technical-Priority & Fairness-Neglect, and Consistent High-Scorer. While ethical conduct was generally moderate, there is significant diversity between profiles, showing that a uniform approach may not be effective for ethics education. Key predictors of profile membership included gender, professional passion, patient and mentor evaluations, and moral courage. These findings indicate that nursing education should move toward more person-centered approaches that strengthen professional identity and moral resilience through targeted educational strategies, such as simulation-based training and reflective mentoring. Establishing supportive clinical environments and structured feedback mechanisms is particularly important for helping interns interpret challenging experiences, including patient complaints, as opportunities for ethical development. Tailoring educational interventions to distinct ethical behavior profiles may ultimately support the cultivation of an ethically competent and patient-centered nursing workforce.
Acknowledgements
We would like to thank all nursing interns who voluntarily participated in this study.
Clinical trial number
Not applicable.
Abbreviations
- SCT
Social Cognitive Theory
- EBSN
Ethical Behavior Scale for Nurses
- NMCS
Nurses’ Moral Courage Scale
- LPA
Latent Profile Analysis
- AIC
Akaike Information Criterion
- BIC
Bayesian Information Criterion
Author’ contributions
Jia Qu (First Author): Writing – review & editing, Writing-original draft, Methodology, Conceptualization. Pu Lin : Methodology, Project Administration. Li Liu : Investigation, Formal Analysis. Min Min : Formal Analysis. Yayun Song(Corresponding Author): Supervision, Methodology, Conceptualization.
Funding
The study was funded by Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology (TJSZ2024076), Hubei Provincial Teaching Reform Research Project for Undergraduate Universities(2025453), and Education and Teaching Research Program of Hubei Polytechnic University(2025A02).
Data availability
The data that support the findings of this study are available from the corresponding author upon reasonable request.
Declarations
Ethics approval and consent to participate
The research project underwent ethical review and received approval from the Ethics Review Committee of Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology (Approval No.: TJ-IRB202410012). This study fully adheres to the ethical principles outlined in the Declaration of Helsinki. Prior to participation, all participants were provided with a clear and detailed explanation of the study’s objectives and procedures, ensuring that their involvement would not affect their professional relationships or standing within the organization. To prevent any potential coercion, invitations to participate were distributed through anonymous surveys rather than by direct supervisors or colleagues. Written informed consent was obtained online from all participants, who were explicitly informed that their participation was entirely voluntary, and they had the right to withdraw or decline participation at any time without any negative consequences. To protect participants’ privacy, responses were kept anonymous, and no personal identifiers were used in the presentation or analysis of the results. Confidentiality was strictly maintained throughout the study. Data were anonymized during both the collection and analysis phases, with responses linked to unique identifiers instead of participants’ names. All data were securely stored in a password-protected electronic database, accessible only to the research team. Data collection was carried out by a research assistant to ensure that supervisors and colleagues were unaware of which participants took part in the study, thereby further safeguarding participant confidentiality and preventing any undue influence.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
- 1.Beauchamp TL, Childress JF. Principles of biomedical ethics. 8th ed. New York: Oxford University Press; 2019. [Google Scholar]
- 2.International Council of Nurses. The ICN code of ethics for nurses. Geneva: ICN. 2021. Available from: https://www.icn.ch/sites/default/files/2023-06/ICN_Code-of-Ethics_EN_Web.pdf. Cited 2025 Sep 9.
- 3.American Nurses Association. Code of ethics for nurses. Silver Spring (MD): ANA; 2025. Available from: https://codeofethics.ana.org/home. Cited 2025 Sep 9.
- 4.State Council of the People’s Republic of China. Regulations on nurses (Decree No. 517). Beijing: State Council; 2008. Available from: https://www.gov.cn/gongbao/content/2008/content_912536.htm. Cited 2025 Sep 9.
- 5.Bordbar S, Mehralian G, Davarani FR, Yusefi AR. Exploring the relationship between facilitating factors and adherence to nursing ethical standards. BMC Nurs. 2025;24:5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Ha K, Oh Y. Assessing educational needs of nurses’ ethical competence based on the four components model of moral behavior: a cross-sectional study using the Borich needs assessment and locus for focus models. BMC Nurs. 2025;24:615. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Molaei Tavani F, Behshid M, Rahmani A, Mousavi S, Seif-Farshad M, Rahmani P. Relationships between ethical decision-making and professional behavior in Iranian nursing students. J Med Ethics Hist Med. 2022;15:4. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Lawrence C, Mhlaba T, Stewart KA, Moletsane R, Gaede B, Moshabela M. The hidden curricula of medical education: A scoping review. Acad Med. 2018;93(4):648–56. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Greenway K, Butt G, Walthall H. What is a theory-practice gap? An exploration of the concept. Nurse Educ Pract. 2019;34:1–6. [DOI] [PubMed] [Google Scholar]
- 10.Tang Y, Chen X, Liao Y, Zheng T, Xiao Y, You Y. Status and associations of transition shock among nursing students during clinical practice: a cross-sectional study. PLoS ONE. 2025;20(2):e0313524. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Xiong W, Zhu A. Psychological experience among internship nurses at different internship stages: A qualitative study. Nurs Open. 2023;10(1):328–36. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Halldorsdottir S, Bryngeirsdottir HS. Ethical competence in nursing: A theoretical definition. Nurs Ethics. 2025;32(7):2134–62. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Mousazadeh N, Rezapour M, Babaieasl F, Sharif-Nia H, Mivehchi S. Beyond the bedside: how moral sensitivity and self-efficacy shape person-centered care in nursing. J Nurs Manag. 2025;2025:2823773. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Hu J, Chen X, Khoshnood K, Luo E, Muramatsu T, Yang M. A survey of ethical sensitivity among nursing students and its influencing factors. Nurs Ethics. 2024;31(8):1467–80. [DOI] [PubMed] [Google Scholar]
- 15.Ward A, Charalambous J, Antoniou C, East L, Moroney T, Levett-Jones T. Planetary health and nursing: embedding values into standards, behaviours, and education. Nurse Educ Today. 2025;153:106806. [DOI] [PubMed] [Google Scholar]
- 16.Jasemi M, Goli R, Zabihi RE, Khalkhali H. Educating ethics codes by lecture or role-play; which one improves nursing students’ ethical sensitivity and ethical performance more? A quasi-experimental study. J Prof Nurs. 2022;40:122–9. [DOI] [PubMed] [Google Scholar]
- 17.Chen Q, Chen Q, Ma C, Zhang Y, Gou M, Yang W. Moral sensitivity, moral courage, and ethical behavior among clinical nurses. Nurs Ethics. 2025;32(2):665–77. [DOI] [PubMed] [Google Scholar]
- 18.Bandura A. Social cognitive theory: an agentic perspective. Annu Rev Psychol. 2001;52:1–26. [DOI] [PubMed] [Google Scholar]
- 19.Gibson E, Duke G, Alfred D. Exploring the relationships among moral distress, moral courage, and moral resilience in undergraduate nursing students. J Nurs Educ. 2020;59(7):392–5. [DOI] [PubMed] [Google Scholar]
- 20.Huang Z, Qiu X, Fu Y, Zhang A, Huang H, Liu J, Yan J, Yi Q. Clinical internship environment and caring behaviours among nursing students: A moderated mediation model. Nurs Ethics. 2024;31(8):1481–98. [DOI] [PubMed] [Google Scholar]
- 21.Ventovaara P, Sandeberg MA, Räsänen J, Pergert P. Ethical climate and moral distress in paediatric oncology nursing. Nurs Ethics. 2021;28(6):1061–72. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Wang M. Latent variable modeling and applications using Mplus. Beijing: Higher Education Press; 2014. (In Chinese). [Google Scholar]
- 23.Wang R, Yu H, Han X, Yang Y, Chen D, Niu Q, Liu Y, Zhou M, Zhu X, Zhang Y. Identifying the personal characteristics of decent work perception for nursing students in China using latent profile analysis. BMC Med Educ. 2024;24:315. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Kelley K, Maxwell SE. Sample size for multiple regression: obtaining regression coefficients that are accurate, not simply significant. Psychol Methods. 2003;8(3):305–21. [DOI] [PubMed] [Google Scholar]
- 25.Ode J. Developing an ethical behavior scale for nurses. J Jpn Nurs Ethics. 2014;6(1):3–11. [Google Scholar]
- 26.Ode J. Developing a revised edition of the nurses’ ethical behavior scale for nurses. J Jpn Nurs Ethics. 2019;11(1):13–9. [Google Scholar]
- 27.Chen Q, Chen Q, Ma C, Liu S, Ma C, Zhang Y, Gou M, et al. Validity and reliability testing of the Chinese version of the ethical behavior scale for nurses-revise. J Nurs Sci. 2023;38(23):65–8. (In Chinese). [Google Scholar]
- 28.Numminen O, Katajisto J, Leino-Kilpi H. Development and validation of nurses’ moral courage scale. Nurs Ethics. 2019;26(7–8):2438–55. [DOI] [PubMed] [Google Scholar]
- 29.Wang S, Wei L, Zhang Y, Liu T, Jiang W, Yang H, et al. The reliability and validity of the Chinese version nurses’ moral courage scale. J Nurs Sci. 2019;34(21):92–5. (In Chinese). [Google Scholar]
- 30.Li Z, Chen Q, Xu X, Zhang Y, Liu L, Dai Q, et al. Ethical behavior and its influencing factors among oncology nurses. J Nurs Sci. 2024;39(7):13–6. (In Chinese). [Google Scholar]
- 31.McDonald J, Graves J, Abrahams N, Thorneycroft R, Hegazi I. Moral judgement development during medical student clinical training. BMC Med Educ. 2021;21:140. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32.Andersson H, Svensson A, Frank C, Rantala A, Holmberg M, Bremer A. Ethics education to support ethical competence learning in healthcare: an integrative systematic review. BMC Med Ethics. 2022;23:29. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33.Muramatsu T, Nakamura M, Okada E, Katayama H, Ojima T. The development and validation of the ethical sensitivity questionnaire for nursing students. BMC Med Educ. 2019;19:215. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34.Wu X, Lu X, Zhang H, Bi Y, Gu R, Kong Y, Hu L. Sex difference in trait empathy is encoded in the human anterior Insula. Cereb Cortex. 2023;33(9):5055–65. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 35.Geoghan Marold SM, Strouse SM, Butcher D. Professional identity in nursing: a narrative review of the ISPIN definition and domains usage. SAGE Open Nurs. 2025;11:23779608251335240. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 36.Deng Y. The silver lining of perceived overqualification: examining the nexus between perceived overqualification, career self-efficacy and career commitment. Psychol Res Behav Manag. 2023;16:2681–94. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 37.Lorenc T, Khouja C, Harden M, Fulbright H, Thomas J. Defensive healthcare practice: systematic review of qualitative evidence. BMJ Open. 2024;14(7):e085673. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 38.Dong C, Altshuler L, Ban N, Wong LY, Mohammed FEA, Tang CT, Kachur E. Psychological safety in health professions education: insights and strategies from a global community of practice. Front Med. 2025;11:1508992. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 39.Thomas C, Gupta S. International medical students’ experiences of psychological safety in feedback episodes: A focused ethnographic study. BMC Med Educ. 2024;24:1101. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.