Alexithymia and clinical communication competence in nursing interns in China with the mediating role of self-efficacy

Abstract

Effective communication is a critical professional competency for nursing interns, which needs to be systematically developed in clinical education. Alexithymia is a personality trait characterized by difficulties in identifying, describing, and understanding one’s own emotions. This cross-sectional study examined the mediating role of self-efficacy in the relationship between alexithymia and clinical communication competence among 216 nursing interns, with 208 valid responses (96.3% response rate). Using standardized measures (Toronto Alexithymia Scale, General Self-Efficacy Scale, Clinical Communication Competence Assessment Scale), results revealed elevated alexithymia levels (55.48 ± 10.31) alongside moderate self-efficacy (28.21 ± 4.64) and communication competence (84.67 ± 10.66). Spearman analysis demonstrated significant negative correlations between alexithymia and both self-efficacy (P < 0.05) and communication competence (P < 0.05), while self-efficacy was strongly and positively associated with all communication subdomains: relationship-building, active listening, problem identification, and affective validation (P < 0.01). Structural equation modeling identified self-efficacy as a partial mediator between externally oriented thinking (a core alexithymia component) and communication competencies, with mediation effects ranging from − 0.061 to − 0.099 (P < 0.01). These findings suggest that enhanced self-efficacy may mitigate alexithymia’s detrimental effects on communication skill development. The study provides empirical evidence for implementing dual-focused educational strategies targeting alexithymia reduction and self-efficacy enhancement in nursing curricula. Such interventions could optimize trainees’ clinical communication capacities while supporting psychological adaptation to healthcare environments, ultimately contributing to improved patient care outcomes and professional well-being.

Supplementary Information

The online version contains supplementary material available at 10.1038/s41598-026-44952-0.

Introduction

The practicum system for nursing interns in China is a very important part of nursing education. In China, nursing interns must complete a clinical nursing internship of at least eight months before they can register as nurses¹. This internship typically represents the first sustained, full-time clinical practice experience for nursing students, following the completion of their foundational theoretical coursework. The School of Nursing and the practicum unit are jointly responsible for this practicum process, which includes developing the student’s practicum program, arranging practicum rotations, monitoring the progress and quality of the practicum, and dealing with problems that arise during the practicum. It aims to develop students’ professional skills and clinical competence through internship training, thereby bridging the gap between theory and practice², and laying a solid foundation for their future careers.

By the end of their internship, nursing interns are expected to provide care to patients in a range of professional and practical settings in hospitals, communicating with patients and understanding and addressing their various needs³. However, due to a range of physical, psychological, social, and spiritual challenges⁴, satisfactory outcomes of patient care are not always guaranteed⁵. Nursing interns’ maladaptation to real clinical situations⁶ and the lack of a comprehensive clinical guidance and orientation program often result in “transition shock” and “disorientation,” negative experiences that influence their clinical performance⁷. These negative experiences lead to anxiety and decreased confidence in clinical practice, negatively affecting their overall clinical experience^8,9.

Communication is considered one of the essential competencies for clinical nurses, and the American Association of Colleges of Nursing states that patient safety may be compromised by ineffective communication between nurses and patients¹⁰. Therefore, nursing care should focus on effective communication with patients, timely understanding and observation of the patient’s reaction and psychological state, attention to the patient’s needs and discomfort, and timely guidance and assistance to improve the patient’s satisfaction with nursing care¹¹. Nursing interns are in a transitional phase between academic education and practical hospital experience. They may exhibit inadequate clinical communication skills due to maladaptation to the clinical environment, limited experience, and self-centeredness in clinical practice¹². This can lead to ineffective communication with patients, pose risks to patient safety, and hinder the interns’ professional growth. It is crucial to enhance the clinical communication skills of nursing interns during their internship.

However, nursing interns’ clinical communication abilities are influenced by elements like psychological conditions and the external environment. Alexithymia, referred to as the "inability to express emotions," is a psychological issue that impacts the communication abilities of nursing interns¹³. Alexithymia is a personality trait that is characterized by difficulties in expressing and understanding emotions¹⁴, which are manifested in the individual’s difficulties in identifying feelings (DIF), describing feelings (DDF), and externally oriented thinking (EOT). It is usually distributed as a normal personality trait in all people¹⁵; when the alexithymia system is disturbed, people often fall into emotions they cannot escape¹⁶. Alexithymia can also be a temporary state, the severity of which can vary at different levels of stress, anxiety, and depression¹⁷. The prevalence of alexithymia is 10% in healthy individuals and 26.9% in students of medical-related professions¹⁸, and it has also been considered that the prevalence of alexithymia in medical students is 49%¹⁹, suggesting that almost half of medical students suffer from alexithymia. Although there are differences between different studies, the prevalence of alexithymia among medical students is much higher than that of the general population, so the problem of alexithymia among medical students cannot be ignored and deserves to be explored in further detail. People with alexithymia often have trouble understanding and expressing their emotions²⁰, which makes it harder for them to understand others and makes them more likely to have communication problems²¹.

Self-efficacy, a key component of Social Cognitive Theory (SCT), refers to the beliefs that people have about what they are capable of or how sure they are that they can act²². Studies have shown that self-efficacy can enhance clinical communication competence²³. Individuals with higher self-efficacy feel confident in their abilities, and in clinical nursing, nursing interns with high self-efficacy tend to have greater self-confidence, higher motivation and initiative in their work, and greater cognitive ability to perceive the patient’s point of view, which may help them to better communicate with the patient and improve their clinical communication skills. However, at present, the research on nursing-related self-efficacy mostly focuses on students’ academic aspects by setting up various forms of courses to enhance self-efficacy^24–27. Research also concentrates on the assessment of self-efficacy in a specialty area, with fewer in-depth studies on self-efficacy and nursing interns’ clinical communication competence^28,29. Research has demonstrated a negative correlation between alexithymia and self-efficacy³⁰, meaning that individuals who struggle to identify and communicate their emotions are more likely to lack confidence in their abilities. This impaired emotional expression can undermine their self-assurance and effectiveness when dealing with difficulties.

To explore the correlation of clinical communication competence with alexithymia and self-efficacy among nursing interns, and examine the mediating effect of self-efficacy on the relationships between alexithymia and clinical communication competence by path analysis, the following mediating hypotheses were formulated in this study:

H1

Alexithymia is directly related to self-efficacy and clinical communication competence.

H2

The relationship between alexithymia and clinical communication competence is mediated by self-efficacy.

Methods

Study design and sample

This study adopted a cross-sectional design and included 216 nursing interns from five Grade A tertiary hospitals in China. These hospitals accepted interns from a variety of nursing education programs across the region. The inclusion criteria for participation were as follows: nursing interns enrolled in a school majoring in nursing or midwifery who understood the purpose and content of this study and volunteered to participate in this study. The exclusion criteria were nursing interns who could not complete the survey for various reasons, and those who completed the questionnaire in less than 1 min.

Procedural and ethical considerations

To determine the sample size, we followed the recommended practice of having 5–10 participants per variable for factor analysis ³¹. With 20 study variables and accounting for 10% of incorrect questionnaires, the necessary sample size falls between 112 and 223. The study was conducted in five tertiary grade A general hospitals using a convenience sampling method and was approved by the Institutional Review Board (IRB) of Zhejiang Chinese Medical University (Approval No: 202310206). Data collection was carried out in July 2024 by two trained researchers on-site. It is important to note that these researchers were not affiliated with the interns’ educational institutions and were not involved in their clinical assessments, thereby minimizing potential coercion and response bias. The study strictly adhered to the principles of informed consent and privacy protection. Prior to the survey, written informed consent was obtained from all participants. To ensure anonymity, questionnaires were administered in a confidential manner. Researchers remained available on-site to address procedural questions but did not observe participants’ specific responses. Upon completion, participants immediately deposited their questionnaires into a sealed collection box. This rigorous procedure, which ensured participant anonymity and convenience, is considered a key factor in achieving the high response rate of 96.3% (208 valid questionnaires collected out of 216 distributed).

Measures

All study instruments were administered in Chinese, which was the primary language of instruction and clinical caregiving in the participating institutions. This ensured full comprehension by all participants and eliminated potential language barriers as a confounding factor in their responses.

General information

A general information questionnaire was designed by the researchers to collect demographic data, including gender, education level, hometown, academic performance, and the number of clinical communication skills training sessions attended. The clinical communication skills training typically included role-playing, simulations, and lectures on patient interaction, delivered as part of the nursing curriculum or hospital orientation programs. The item “First Internship” was used to distinguish interns for whom this was their first 8-month clinical placement from those (e.g., students upgraded from college programs) who might have had prior internship experience during their previous education.

Alexithymia

Alexithymia was assessed using the Toronto Alexithymia Scale (TAS-20), a 20-item self-report scale developed by Bagby in 1994³². The TAS-20 is the copyrighted work of R. Michael Bagby, James D. A. Parker, and Graeme J. Taylor, and permission has been granted by the copyright holders for its use in this study and for publication of the findings by Springer Nature Limited in all formats. The Chinese version of the TAS-20 has been validated and used among Chinese populations ³³. This scale focuses on three main domains: difficulty identifying feelings (seven items: 1, 3, 6, 7, 9, 13, 14), difficulty describing feelings (five items: 2, 4, 11, 12, 17), and externally oriented thinking (eight items: 5, 8, 10, 15, 16, 18, 19, 20). A Likert 5-point scale was used, ranging from 1 (completely agree) to 5 (completely disagree). Entries numbered 4, 5, 10, 18, and 19 were reverse-scored. The total score ranged from 20 to 100 points. A score below 51 indicated non-alexithymia, 51–61 suggested possible alexithymia, and a score of 61 or higher indicated alexithymia. A higher total score corresponded to a more severe level of alexithymia. TAS-20 has been tested with good reliability and validity. Its Cronbach’s alpha coefficient is 0.80, Bartlett sphericity test p < 0.001, and Kaiser–Meyer–Olkin (KMO) value is 0.85^34,35.

Self-efficacy

The General Self-Efficacy Scale (GSES) was used, which was compiled by a German scholar, Schwarzer, and the Chinese version of the scale was revised by Zhang and Schwarzer³⁶, which mainly examines individuals’ general self-efficacy. The scale is unidimensional and has 10 items rated on a Likert 4-point scale, resulting in a total score ranging from 10 to 40, with higher scores indicating greater self-efficacy in the individual. The model fit test results of GSES fit well, and its Cronbach’s alpha coefficient was 0.87, suggesting satisfactory validity and reliability³⁷.

Clinical communication competence

The Clinical Communication Competence Assessment Scale for Nursing Interns, developed by Chinese scholar Fangyu Yang, was used, with a total of 28 entries containing six dimensions: establishing harmonious relationships, listening sensitively, recognizing patient problems, participating together, conveying effective information, and verifying feelings. A Likert 4-point scale was used, ranging from “1 (never used)” to “4 (often used),” with 7 entries (3, 17–22) reverse scored, and a total score range of 28 to 112, with higher scores indicating nursing interns’ clinical communication skills. The KMO value of the scale was 0.81, Bartlett’s sphericity test was P < 0.001, and the content validity was 0.84. The total Cronbach’s alpha of the scale was 0.84, and the Cronbach’s alpha of each dimension was 0.67–0.80³⁸.

Data analysis

Data were analyzed using SPSS 25.0 (IBM Corp., Armonk, NY, USA) and Amos 23.0 (IBM Corp.). SPSS 25.0 software was used for descriptive statistics and correlation analysis. The count data were described by frequency and percentage (gender, education, etc.), and the measurement data (alexithymia, self-efficacy, and clinical communication ability) were expressed as mean and standard deviation (x ± s). Statistical tests such as the t-test, one-way ANOVA, or rank-sum test were utilized for group comparisons. The correlation matrix between alexithymia, self-efficacy, and clinical communication competence was examined using Spearman correlation analysis. Multiple linear regressions were conducted to identify influencing factors. Amos 23.0 was used to construct the structural equation model. The bias-corrected nonparametric percentile Bootstrap method was employed to assess mediation effects by examining the significance of regression coefficients and whether the Bootstrap 95% confidence intervals included zero. The model fit was assessed using chi-square goodness of fit (x²/df), root mean square error of approximation (RMSEA), and comparative fit index (CFI). Confirmed acceptable fits: 2 < x²/df < 5, RMSEA ≤ 0.10, and CFI ≥ 0.80³⁹. An alpha level of 0.05 was set.

Results

General information about the survey respondents and results of the univariate analysis of factors

The majority of survey respondents were female (83.17%) and had an average age of 21.3 years. Out of the 208 nursing interns, 53.85% had prior experience as student leaders, who had served as class managers, such as monitors and community leaders. Regarding training in clinical communication skills, 26.92% had not received several sessions, 43.27% had attended 1–2 sessions, 21.16% had participated in 3–9 sessions, and 8.65% had received 10 or more sessions. The univariate analysis revealed that only student leadership experience and the number of clinical communication skills training sessions showed statistically significant associations with clinical communication competence subscales (P < 0.05). In contrast, other demographic factors, including “First Internship” (P > 0.05 for all subscales), were not significant. Table 1 displays the participants’ general information and the results of the univariate analysis of variables.

Table 1.

General information and results of univariate analysis of factors (N = 208).

Characteristic		n(%)	Establishing harmonious relationship		listening sensitively		recognizing patient problems		verifying feelings
			Z / H	P	Z / H	P	Z / H	P	Z / H	P
Gender	Male	35 (16.8)	Z = −1.49	0.137	Z = −1.61	0.108	Z = −1.16	0.248	Z = −1.72	0.085
	Female	173 (83.2)
Degree	Junior college	36 (17.3)	H = 1.02	0.599	H = 0.06	0.972	H = 0.36	0.834	H = 0.41	0.815
	Undergraduate	168 (80.8)
	Master	4 (1.9)
Place of student source	Countryside	97 (46.6)	H = 1.72	0.633	H = 1.16	0.762	H = 3.45	0.328	H = 0.19	0.978
	Township	32 (15.4)
	County	30 (14.4)
	City	49 (23.6)
First Internship	Yes	176 (84.6)	Z = 0.81	0.419	Z = 0.70	0.484	Z = 0.35	0.726	Z = 0.77	0.443
	No	32 (15.4)
Participation in student organizations	Yes	165 (79.3)	Z = 1.73	0.084	Z = 0.70	0.482	Z = 1.85	0.064	Z = 1.43	0.154
	No	43 (20.7)
Student leadership experience	Yes	112 (53.8)	Z = 3.85	< 0.001**	Z = 2.51	0.012*	Z = 2.77	0.006**	Z = 2.45	0.014*
	No	96 (46.2)
Academic ranking	Top 10%	21 (10.1)	H = 1.36	0.715	H = 1.74	0.627	H = 1.67	0.644	H = 1.66	0.645
	10–30%	57 (27.4)
	30–50%	67 (32.2)
	After 50%	63 (30.3)
Number of clinical communication skills training	0	56 (26.9)	H = 20.30	< 0.001**	H = 11.13	0.025*	H = 13.65	0.008**	H = 15.14	0.004**
	1–2	90 (43.3)
	3–9	44 (21.2)
	≥ 10	18 (8.7)

The alpha level was set at 0.05 for the test. *. p < 0.05, **. p < 0.01.

Alexithymia, self-efficacy, and clinical communication competence scores

Nursing interns scored an average of 55.48 (± 10.31) on alexithymia, 28.21 (± 4.64) on self-efficacy, and 84.67 (± 10.66) on clinical communication skills. Twenty-seven point four percent of the individuals had alexithymia scores equal to or greater than 61, whereas 42.3% fell within the 51–61 range.

Test of mediation hypothesis

Hypothesis 1.

Alexithymia is associated with self-efficacy and clinical communication skills.

As shown in Table 2, Spearman correlation analysis revealed specific relationships between the sub-dimensions. Externally oriented thinking (EOT) was negatively correlated with self-efficacy (r = − 0.168, p < 0.05). Regarding clinical communication competence, both establishing harmonious relationships and conveying effective information were significantly negatively correlated with all three dimensions of alexithymia (DIF, DDF, EOT; all p < 0.01). Recognizing patient problems and verifying feelings were negatively correlated specifically with EOT (r = − 0.222, p < 0.01; r = − 0.250, p < 0.01, respectively), but not with DIF or DDF (p > 0.05). Listening sensitively was negatively correlated with DDF and EOT (r = − 0.210, p < 0.01; r = − 0.275, p < 0.01), but not with DIF (p > 0.05). Participating together was negatively correlated with DIF and DDF (r = − 0.246, p < 0.01; r = − 0.147, p < 0.05), but its correlation with EOT was not significant (p > 0.05). In support of H1, these results indicate that alexithymia, particularly the EOT dimension, shows significant negative correlations with self-efficacy and multiple domains of clinical communication competence, though the specific pattern of associations varies across sub-dimensions.

Table 2.

Correlation analysis results of alexithymia, self-efficacy, and clinical communication competence (r, n = 208).

	Establishing harmonious relationships	Listening sensitively	Recognizing patient problems	Participating together	Conveying effective information	Verifying feelings	DIF	DDF	EOT	Self- efficacy
Establishing harmonious relationships	1.000
Listening sensitively	0.772**	1.000
Recognizing patient problems	0.710**	0.787**	1.000
Participating together	− 0.187**	− 0.205**	− 0.264**	1.000
Conveying effective information	0.237**	0.160*	0.126	0.419**	1.000
Verifying feelings	0.639**	0.628**	0.562**	− 0.284**	0.042	1.000
DIF	− 0.193**	− 0.116	− 0.094	− 0.246**	− 0.405**	0.005	1.000
DDF	− 0.243**	− 0.210**	− 0.135	− 0.147*	− 0.303**	− 0.111	0.792**	1.000
EOT	− 0.373**	− 0.275**	− 0.222**	− 0.106	− 0.351**	− 0.250**	0.417**	0.347**	1.000
Self-efficacy	0.362**	0.341**	0.285**	− 0.258	0.007	0.432**	0.010	− 0.016	− 0.168*	1.000

**. Correlation significant at the 0.01 level (two-tailed). *. Correlation significant at the 0.05 level (two-tailed).

Hypothesis 2.

The relationship between alexithymia and clinical communication competence was mediated by self-efficacy; the lower the level of alexithymia, the greater the clinical communication competence of practicing nursing interns.

The stepwise forward regression method was employed to include statistically relevant elements from univariate and correlation studies as independent variables in the regression equation for multifactorial analysis. The study found that the variables included in the models for establishing harmonious relationships and identifying patient problems were EOT, self-efficacy, experience as a student leader, and the frequency of training in nurse-patient communication skills. The variables included in the models for listening sensitively and verifying feelings were EOT, self-efficacy, and the frequency of training in nurse-patient communication skills. Control factors included the experience as a student leader and the amount of nurse-patient communication skills training. A structural equation model was developed using the results of the multifactorial analysis (Fig. 1.). Analysis of direct and mediating effects (Table 3) revealed that self-efficacy partially mediated the relationship between EOT and clinical communication competence in nursing interns. The mediating effect of establishing a harmonious relationship model accounted for 16.58% of the total effect, the listening sensitively model for 23.49%, the recognizing patient problems model for 25.42%, and the verifying feelings model for 34.62% of the total effect. These results support H2, indicating that self-efficacy partially mediates the relationship between EOT and clinical communication competence among nursing interns.

Fig. 1.

The mediating effect model of self-efficacy between externally oriented thinking and clinical communication competence.

Table 3.

Analysis of the mediating effect of self-efficacy between externally oriented thinking and clinical communication ability.

Parameter	Estimate	95%CI		P
		Lower	Upper
EOT → Establishing harmonious relationships	− 0.317	− 0.417	− 0.214	0.002
EOT → GSES → Establishing harmonious relationships	− 0.063	− 0.126	− 0.026	0.001
EOT → Listening sensitively	− 0.228	− 0.333	− 0.126	0.002
EOT → GSES → Listening sensitively	− 0.070	− 0.135	− 0.026	0.001
EOT → Recognizing patient problems	− 0.179	− 0.288	− 0.072	0.003
EOT → GSES → Recognizing patient problems	− 0.061	− 0.122	− 0.021	0.001
EOT → Verifying feelings	− 0.187	− 0.283	− 0.091	0.002
EOT → GSES → Verifying feelings	− 0.099	− 0.166	− 0.043	0.002

Test of mediation model fit with hypothesis

The model for establishing harmonious relationships and identifying patient problems demonstrated good fit (χ²/df = 2.518, RMSEA = 0.086), as did the model for listening sensitively and verifying feelings (χ²/df = 2.073, RMSEA = 0.072). The CFI for all four models were above 0.900, suggesting a good fit for the models.

Discussion

Communication is the direct or indirect transmission of information between two or more individuals using verbal and nonverbal cues such as speech units, eye contact, body language, gestures and facial expressions, and auditory modalities⁴⁰. As social creatures, efficient communication is critical for cognition, comprehension, and expression of human emotions¹³. Effective communication is particularly vital in the nursing profession. Nurses with good communication skills can effectively recognize and comprehend patients’ requirements, enabling them to provide timely and satisfactory care. According to a systematic review by Alberti et al.⁴¹, nursing interns require effective communication skills, the ability to express emotions, and the ability to distinguish between bodily senses and emotions. The current study found that the clinical communication competence scores of practicing nursing interns were 84.67 (± 10.66), with room for improvement. The alexithymia score was 55.48 (± 10.31), similar to previous studies¹³. Nursing interns with alexithymia have difficulty recognizing and expressing their emotions and thoughts, and difficulties encountered with emotional awareness lead to an inability to comprehend the underlying meanings of patients’ verbal and non-verbal expressions, making them prone to having problems communicating with the patients. The elevated alexithymia scores among nursing interns in this study can be interpreted from several perspectives. Firstly, from a cultural standpoint, cultural norms in China, influenced by philosophical traditions such as Confucianism and Taoism, emphasize emotional restraint and interpersonal harmony⁴². This cultural context may socialize individuals from an early age to prioritize emotional moderation over explicit expression, which could be a contributing factor to the higher levels of alexithymia observed in this sample compared to Western populations. Secondly, the developmental perspective is relevant. A longitudinal study by Parker et al.⁴³ suggested that the structure of adolescents’ alexithymia is a developmental phenomenon, the mean age of participants was 21.3 years, and emotional awareness and regulation continue to mature during early adulthood. Thirdly, the high-stakes, exam-oriented academic environment prevalent in many Chinese educational institutions may foster a focus on external achievement over internal emotional reflection, as evidenced by a cross-sectional study⁴⁴. Ongoing academic stress may be detrimental to a person’s mental health, resulting in symptoms such as anxiety and depression, according to a systematic review⁴⁵, and alexithymia may develop as a defense against stress-related unpleasant feelings, as theorized in a study by Zhang et al.⁴⁶. Lastly, from a neurocognitive perspective, individual differences in the connectivity between limbic and prefrontal regions have been linked to alexithymia⁴⁷, suggesting a potential biological underpinning that interacts with environmental factors.

Self-efficacy, as a mediator, has a negative correlation with alexithymia. Nursing interns with alexithymia may lack self-confidence and initiative in clinical communication due to low self-efficacy, resulting in insufficient clinical communication skills. In this study, nursing interns with higher self-efficacy reported stronger beliefs in their professional capabilities, while Mehralian et al. specifically found that such interns with high self-efficacy were more confident in interpersonal relationships and more proactive in communication, thereby enhancing their communicative competence²³. Hospitals should consider interns’ alexithymia when evaluating their clinical communication abilities. They should prioritize interns’ self-efficacy and provide training in professional skills, career development planning, and educational activities to strengthen their abilities and knowledge in nursing, ultimately enhancing their confidence in their practice. It is essential to enhance collaboration between hospitals and schools in teaching, provide more opportunities for clinical practice during school, implement bedside teaching, assign clinical teachers to oversee practice teaching of typical cases in core courses, and help nursing interns adjust to their roles early on in their clinical experience. This will boost their confidence before internships and improve their clinical communication skills by enhancing their self-efficacy.

The univariate analysis of this study revealed that student leader experience and training in nurse-patient communication skills (as supported by a systematic review⁴⁸, a randomized controlled trial protocol⁴⁹, and a quasi-experimental study⁵⁰) positively impacted the clinical communication skills of nursing interns. This could be attributed to the enhancement of students’ self-confidence, articulation, and communication skills through the experience of student leadership, potentially reducing the characteristics of alexithymia. Communication is an acquired skill required for the success of leaders and managers, as discussed in an integrative review⁵¹. Serving as a student leader inevitably requires communicating with teachers and other students to achieve certain goals or accomplish related tasks, which has positive implications for the improvement of their communication skills. Moreover, the completion of the corresponding student work will make them feel a certain sense of achievement, which will help enhance their self-confidence and help reduce the level of alexithymia so as to improve their communication skills. Therefore, the accumulation of student leadership experience can invariably improve a person’s communication ability. Studies have shown that academic success in students can improve interpersonal relationships and help prevent the development of emotional issues, ultimately reducing the likelihood of alexithymia¹³. Nursing interns should be given several practical chances to improve their expressive abilities through a variety of teaching and learning activities, including discussions, debriefings, and social practices. Students should utilize their professional knowledge to provide volunteer services, including health education and group activities in the community and nursing institutions, to enhance the communication skills of nursing interns. A systematic review of seven intervention trials by Kerr et al.⁵² showed that communication skills training can enhance nurse-patient interactions. This study found that nursing interns who underwent communication skills training exhibited improved clinical communication skills. A qualitative study by Friedrichsen et al. found that nurses prioritize task-oriented care in their clinical practice⁵³; however, Paulsen et al. acknowledged the significance of communication with patients, families, and caregivers in caregiving⁵⁴. Nurses also understand the necessity of receiving specialized training to improve their communication abilities⁵⁵. Schools and teaching hospitals should focus on creating nurse-patient communication courses and skills training that utilize role-playing and other methods. This will help nursing interns become proficient in verbal and nonverbal communication skills in various clinical scenarios, boosting their confidence in communication and improving their clinical communication abilities.

In structural equation modeling, the sub-dimension EOT of alexithymia had a detrimental impact on the clinical communication ability of nursing interns. EOT is a cognitive approach that emphasizes external details and events over an individual’s internal perceptions and emotions⁵⁶. In a systematic review⁵⁷, it was found that individuals with high levels of EOT may have theory of mind deficits that hinder their ability to comprehend the emotional states of others during social interactions. High EOT nursing interns may struggle to perceive their own and patients’ emotions accurately, hindering their ability to observe and interpret nonverbal cues during clinical interactions. This can impact the development of a positive nurse-patient relationship. Thus, it is important to monitor the mental well-being of nursing interns and implement interventions like psychological training to assist them in identifying and managing any negative psychological issues early on. A study by Fang et al.⁵⁸ indicates that enhancing mindfulness may serve as a preventive intervention to decrease alexithymia and suicide risk in Chinese students. Mindfulness, the awareness of one’s inner experience in the present moment, helps individuals recognize and articulate their emotions, serving as a foundation for emotional regulation⁵⁹. A randomized controlled trial tested approaches including autonomous mindfulness awareness and mindfulness breathing⁶⁰. These mindfulness techniques can be utilized to encourage nursing interns to focus on their inner selves and decrease the likelihood of experiencing alexithymia. Hospitals can also establish a mentorship training model where mentors’ guidance in work and life enhances the belonging of nurse interns, promotes emotional expression during internships, and reduces the likelihood of alexithymia⁶¹. Based on the integration of our study’s findings with the existing literature, a set of practical educational recommendations is provided in Supplementary Table S1.

Implications

This study demonstrated an interaction between nursing interns’ alexithymia, self-efficacy, and clinical communication competence. Further research is necessary to intervene with nursing interns in these three areas to further validate the associations and to find appropriate teaching methods and interventions to help nursing interns improve their psychological status and clinical communication competence.

Strengths and limitations

This study was limited by convenience sampling, and the questionnaires were distributed in the third or fourth month of the nursing interns’ clinical rotations. Therefore, for the 10-month internship cycle that needs to be completed, this study only investigated nursing interns who were relatively in the early stage of internship, which may affect the representativeness of the results. Future studies may include nursing interns in different stages of internship as the research subjects to conduct a large-sample longitudinal study, which will help to understand the status of alexithymia, self-efficacy, and the level of clinical communication competence among nursing interns in different stages of internship to help nursing educators make targeted interventions. Study strengths include robust and careful offline data collection, as well as rigorous data processing and analysis, to ensure the authenticity and reliability of the findings.

Conclusion

In summary, this study identified alexithymia as a prevalent issue among a sample of Chinese nursing interns. Our findings support H1, showing that alexithymia, particularly the EOT dimension, is negatively associated with self-efficacy and multiple domains of clinical communication competence. Furthermore, H2 was confirmed, indicating that self-efficacy partially mediates the relationship between alexithymia and clinical communication competence. These results suggest that interventions targeting both alexithymia reduction and self-efficacy enhancement could improve communication skills in this trainee population. However, the generalizability of these results is constrained by the study’s cross-sectional design and convenience sampling. Future longitudinal studies are needed to confirm these relationships and test the efficacy of proposed interventions.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contributions

Jiaying Yu and Lili Yang were involved in the design of the study, data acquisition, analysis and interpretation of data, drafting and revising the manuscript. Chengyu Zhu, Yuwen Ren, Mingna Fan, and Jiaying Yu collected the data, analyzed and interpreted it. Jiaying Yu wrote the draft of the manuscript and Lili Yang critically revised the manuscript. All authors have read and approved the final manuscript.

Funding

This research received funding: National Higher Education of Traditional Chinese Medicine ‘14th Five-Year Plan’ Education Research Project in 2023 (YB-23-08).

Data availability

The datasets used or analyzed during the current study are in Chinese and are available from the corresponding author on reasonable request but will require translation to English.

Declarations

Competing interests

The authors declare no competing interests.

Ethics approval and consent to participate

This study was approved by the Ethics Review Committee of the Institutional Review Board of the Institutional Review Board (IRB) of Zhejiang University of Chinese Medicine (NO: 202310206). Participation was voluntary, and anonymity was guaranteed. Informed consent was provided by all participants before participating in the survey. All methods were carried out following relevant guidelines and regulations.