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International Journal of Nursing Sciences logoLink to International Journal of Nursing Sciences
. 2026 Feb 10;13(2):164–171. doi: 10.1016/j.ijnss.2026.02.005

Moderating effects of interprofessional collaboration on the relationship between moral sensitivity and job satisfaction among nursing assistants: A cross-sectional study

Takehiko Toyosato a,⁎, Anju Arakaki b, Kumiko Motonaga a, Chikako Maeshiro a, Michita Tokeshi a
PMCID: PMC13044358  PMID: 41937998

Abstract

Objectives

This study aimed to examine the moderating effect of interprofessional collaboration (IPC) on the association between moral sensitivity and job satisfaction among nursing assistants (NAs) in Japan.

Methods

A cross-sectional survey was conducted. We recruited 375 NAs using a convenient sampling method from 14 hospitals in Okinawa, Japan, from June to July 2024. Data were collected using a self-administered questionnaire including demographic and work-related variables, the 20-item short form of the Minnesota Satisfaction Questionnaire, the Japanese version of the Revised Moral Sensitivity Questionnaire, and the 24-item Revised Otsuka Interprofessional Work Competency Scale. Hierarchical multiple regression analysis and simple slope analysis were used to investigate moderating effects.

Results

The mean scores for job satisfaction and IPC were 59.50 ± 10.86 and 52.75 ± 15.08, respectively. The mean scores for moral responsibility, moral strength, and sense of moral burden were 7.38 ± 1.49, 11.43 ± 2.85, and 16.60 ± 3.42, respectively. Job satisfaction was positively correlated with IPC (r = 0.31, P < 0.001), moral strength (r = 0.40, P < 0.001), and sense of moral burden (r = 0.39, P < 0.001), but not with moral responsibility (r = 0.01, P > 0.05). Hierarchical multiple regression analysis revealed that moral strength (β = 0.25, P < 0.001) and sense of moral burden (β = 0.21, P = 0.003) significantly associated with job satisfaction. A significant interaction effect was observed between sense of moral burden and IPC (β = 0.13, P = 0.022). A simple slope analysis revealed that at high levels of IPC, sense of moral burden was positively associated with job satisfaction (P < 0.001).

Conclusions

A sense of moral burden may enhance job satisfaction when supported by strong IPC. Enhancing both moral sensitivity and IPC may improve job satisfaction among NAs and support patient-centered care in Japan’s rapidly aging society.

Keywords: Aging, Interprofessional collaboration, Job satisfaction, Nursing assistants, Moral sensitivity

What is known?

  • •

    Nursing assistants (NAs) play a crucial role in healthcare delivery but often experience low job satisfaction and high turnover.

  • •

    Moral sensitivity is associated with job satisfaction and well-being among nurses; however, evidence focusing on NAs is limited.

  • •

    Interprofessional collaboration (IPC) has been shown to enhance job satisfaction among healthcare professionals.

What is new?

  • •

    IPC moderated the relationship between sense of moral burden, typically experienced as work-related demands, and psychological strain, such that sense of moral burden was positively associated with job satisfaction when IPC was high.

  • •

    IPC has been identified as a key contextual factor that transforms moral demands into motivational resources, underscoring its importance for sustaining the NA workforce in aging societies.

1. Introduction

Globally, the population is aging rapidly. According to the United Nations [1], the number of people aged 60 years and above is projected to reach 1.4 billion by 2030. Among developed countries, Japan has experienced one of the most accelerated and pronounced demographic transitions. The proportion of older adults in Japan was 33.9 % in 2015 and is estimated to increase to 42.5 % by 2040 [1]. With the aging population, the need for physical care services will continue to grow, and the number of people who need care in hospitals, long-term care facilities, and home-based care settings is expected to peak by approximately 2040 [2]. However, accommodating this need presents a significant challenge due to workforce shortages in care services. Given the growing workforce gap, task shifting and task sharing with nursing assistants (NAs), who are non-licensed personnel, are becoming increasingly essential to support both medical and physical care services. Although NAs in Japan are not nationally certified and their scope of practice is not legally defined, they assist with activities of daily living, maintain ward environments, and perform clerical duties under the supervision of licensed nurses and physicians, in accordance with the Ministry of Health, Labour and Welfare (MHLW) guidelines [2]. The involvement of NAs has become crucial in mitigating registered nurses’ workload [3,4]. The turnover rates of NAs remain high, despite the increasing number of roles assigned to them, highlighting the significance of cultivating a work environment that fosters a sense of purpose and job satisfaction to sustain a stable workforce [5,6].

Several studies [7,8] have reported on factors that influence job satisfaction among NAs. For example, job satisfaction is positively influenced by emotional resources, health and lifestyle status, personal psychological resources, a work environment, organizational climate, financial rewards, and professional development. On the other hand, job satisfaction is negatively influenced by stress associated with challenging patient behaviors, such as shouting, threats, conflicts with staff, and maladaptive behavioral responses. These findings suggest that, beyond internal and organizational factors, relational and ethical dimensions, especially those emerging from interactions with patients, may also be critical determinants of job satisfaction. Therefore, NAs are expected to adhere to ethical standards consistent with professional nursing practice, considering their frequent presence in situations involving patient privacy and dignity, and, in some cases, greater access to sensitive information than nurses.

Moral sensitivity refers to the ability to identify moral issues, interpret situations in light of ethical values, and respond with appropriate ethical awareness and emotional engagement [9]. Despite the limited studies on moral sensitivity among NAs, its importance in nursing has been extensively examined [10]. For example, Jaafarpour and Khani [10] observed that job satisfaction is positively correlated with moral sensitivity, especially in dimensions such as interpersonal relationships, patient autonomy, and trust in ethical judgments. The finding highlights the significance of moral sensitivity in nursing practice and suggests its importance for NAs who frequently encounter ethical dilemmas. In contrast, NAs are expected to show a different pattern in the relationship between moral sensitivity and job satisfaction, given differences in responsibilities and roles. Unlike nurses, NAs typically lack the authority to act independently on moral concerns. They may therefore be more vulnerable to moral distress, defined as the psychological discomfort experienced when one is unable to act in accordance with one’s ethical judgment [11,12]. Repeated exposure to unresolved ethical challenges can lead to emotional exhaustion and reduced job satisfaction. Most previous studies examining the relationship between moral sensitivity and job satisfaction have focused on nurses [10,[13], [14], [15]], and research on NAs remains limited. Given their proximity to patients and involvement in ethically sensitive situations, it is essential to consider potentially distinct mechanisms linking moral sensitivity, distress, and job satisfaction among NAs.

To further elucidate the psychological mechanisms underlying this process, the Job Demands–Resources (JD-R) model provides a sound theoretical framework [16]. The JD-R model posits that job demands, defined as aspects of work that require sustained physical or psychological effort, are associated with strain and burnout. In contrast, job resources promote motivation, engagement, and personal growth. Importantly, specific demands can function as challenge demands when adequate resources are available, thereby fostering learning and professional fulfillment rather than distress. Within this framework, moral sensitivity among NAs can be conceptualized as a morally laden job demand. High moral sensitivity increases awareness of ethical issues related to patient dignity, autonomy, and well-being, which may intensify emotional and cognitive load. In contexts where NAs lack sufficient support or authority, this heightened awareness may manifest as moral burden and distress, negatively affecting job satisfaction. However, under supportive organizational conditions, moral sensitivity may serve as a constructive motivator, enhancing work meaning and professional identity. In this context, interprofessional collaboration (IPC) represents a critical job resource. IPC is defined as an active, ongoing partnership among professionals from diverse backgrounds who collaborate to provide patient-centered care [17]. A previous study has demonstrated that IPC buffers the negative association between emotional demands and intentions to leave among assistant nurses [18]. From the JD-R perspective, IPC may transform moral sensitivity from a potentially burdensome demand into a challenge by facilitating shared ethical responsibility, mutual support, and collective decision-making. Through collaborative discussions and team-based ethical reflection, NAs can validate their moral concerns and gain guidance from licensed professionals. Such processes can mitigate moral distress, enhance professional efficacy, and foster a sense of growth and fulfillment. Therefore, IPC is expected to moderate the relationship between moral sensitivity and job satisfaction by buffering its adverse effects and amplifying its motivational potential.

Based on this theoretical framework and the existing literature, the following hypotheses were formulated. Hypothesis 1: Moral sensitivity is positively associated with job satisfaction. Hypothesis 2: IPC moderates the association between moral sensitivity and job satisfaction. This study examined the relationship between moral sensitivity and job satisfaction among NAs in Japan and explored the moderating effect of IPC on this relationship.

2. Methods

2.1. Study design and participants

This study employed a cross-sectional design. This study adhered to the Strengthening of the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. NAs working at all designated advanced treatment hospitals (n = 1) and regional medical support hospitals (n = 13) in Okinawa Prefecture, Japan, were recruited. Of the 14 eligible hospitals, 11 hospitals agreed to participate (one advanced treatment hospital and 10 regional medical support hospitals). Participants were recruited between June and July 2024 using convenience sampling.

The inclusion criteria for this study were NAs who met the definition established by the Japan Nursing Association. No specific exclusion criteria were applied. NAs were defined in accordance with the definition established by the Japan Nursing Association [19] as individuals who do not hold national nursing qualifications but perform auxiliary nursing tasks under the supervision of licensed nurses. These tasks are not classified as “care for the sick or injured” or “medical treatment assistance” under Japanese law. This category includes individuals employed under titles such as NAs, nurse aides, or similar roles. NAs’ specific duties include, under the supervision of the head nurse and nursing staff, providing support for patients’ daily living activities (e.g., eating, hygiene, toileting, bathing, and mobility), maintaining the ward environment and making beds, as well as organizing nursing supplies and consumables within the ward, organizing and preparing documents and forms on behalf of nursing staff, and preparing medical records.

The sample size was calculated using G∗Power, version 3.1. The minimum sample size required for the multiple regression analysis was 116 for an effect size of 0.15 (medium), a significance level of 0.05, and a power of 0.90. Responses were received from 375 of the 507 eligible NAs employed at 11 hospitals that agreed to participate, yielding a response rate of 74.0 %. The sample size was sufficient for the statistical analysis.

2.2. Measures

2.2.1. Demographic and work-related variables

This study collected demographic and work-related variables, including sex, age, educational level, employment status, work experience, average working hours, and in-hospital ethics or IPC training programs.

2.2.2. Job satisfaction

The 20-item short form of the Minnesota Satisfaction Questionnaire [20] was used to assess job satisfaction. It measures two domains, namely intrinsic and extrinsic satisfaction. Intrinsic satisfaction refers to satisfaction derived from the work itself. It encompasses motivational aspects of work, including feelings of achievement, the use of one’s knowledge and skills, and task variety. In contrast, extrinsic satisfaction refers to satisfaction derived from external rewards and the work context and reflects environmental and organizational factors, including compensation, working conditions, and supervision. The Japanese version, translated and validated by Takahashi [21], uses a four-point Likert scale ranging from 1 (very dissatisfied) to 4 (very satisfied) and eliminates the neutral midpoint to reduce central tendency bias. Scores on this scale ranged from 20 to 80, with higher scores indicating greater job satisfaction. The study of the Japanese version of the Minnesota Satisfaction Questionnaire obtained a Cronbach’s α coefficient of 0.90 [21]. In our study, Cronbach’s α coefficient for this scale was 0.92.

2.2.3. Moral sensitivity

Moral sensitivity was measured using the Japanese version of the Revised Moral Sensitivity Questionnaire (J-MSQ), translated and validated by Maeda and Konishi [22], based on the original MSQ-R developed by Lützén et al. [23]. The J-MSQ consists of 9 items across 3 domains: moral responsibility (2 items), moral strength (3 items), and sense of moral burden (4 items). Each item is rated on a six-point Likert scale from 1 (completely disagree) to 6 (completely agree), yielding a possible total score range of 9 to 54. The internal consistency coefficients (Cronbach’s α coefficient) of the Japanese version scale were 0.14, 0.80, and 0.62 for moral responsibility, moral strength, and sense of moral burden, respectively. In this study, the internal consistency coefficients (Cronbach’s α coefficient) were 0.54, 0.82, and 0.75 for moral responsibility, moral strength, and sense of moral burden, respectively.

2.2.4. Interprofessional work competency

The 24-item Revised Otsuka Interprofessional Work Competency Scale, developed by Kunisawa et al. [24], was used to assess IPC. This scale evaluates the three core domains of collaboration: communication, teamwork, and mutual respect. Each item is rated on a four-point Likert scale from 1 (strongly disagree) to 4 (strongly agree). Scores on this scale ranged from 24 to 96, with higher scores indicating stronger IPC competencies. The Cronbach’s α coefficient was 0.96 in the original study [24] and 0.94 in this study.

2.3. Data collection

At each participating hospital, questionnaires were distributed by a designated staff member who was not directly involved in the participants’ supervision. All participants who provided informed consent were included in this study. Participants were invited to complete an anonymous self-administered questionnaire at their convenience and return it in a sealed opaque envelope to ensure anonymity. Completed questionnaires were sealed in opaque adhesive envelopes and collected at each hospital before being mailed.

2.4. Data analysis

Descriptive statistics were reported as frequencies and percentages for categorical variables, means and standard deviations for continuous variables that followed a normal distribution, and medians and interquartile ranges for continuous variables that did not meet the normality assumption. Normality of continuous variables was assessed using histograms, Q-Q plots, and by examining skewness and kurtosis, with absolute values ≤ 2 and kurtosis ≤4 [25]. To assess potential common method bias, Harmans single-factor test was conducted for each self-report scale by entering all items into an unrotated principal components analysis. Common method bias was evaluated by examining the proportion of variance explained by the first unrotated factor, with a threshold of 50 % used to indicate potential common method bias [26].

To examine demographic variables to be included as covariates and to determine the three subscales of the J-MSQ to be included as independent variables in the regression model and IPC as a moderator variable, analyses were performed using parametric tests (Student’s t-test, one-way analysis of variance, Tukey’s HSD test for post-hoc analysis, Pearson’s correlation coefficient) or nonparametric tests (Spearman’s rank correlation coefficient). Hierarchical multiple regression analysis was conducted to assess the moderating effect of IPC on the relationship between moral sensitivity and job satisfaction. Job satisfaction was the dependent variable in all models. The demographic and work-related variables that were significantly associated with job satisfaction were included as control variables. Model 1 included variables that were significantly associated with job satisfaction. Model 2 included moral sensitivity as an independent variable. Model 3 included multidisciplinary collaboration. Model 4 included the interaction term between moral sensitivity and IPC to test the moderating effects. All continuous variables were mean-centered to reduce multicollinearity. Variance inflation factors (VIFs) ≥ 2 were used as the threshold to identify multicollinearity, in accordance with previous guidelines [27]. To probe for significant interaction effects, simple slope analyses were conducted using the interactions package by plotting the slopes at approximately one standard deviation above and below the moderator variable. Additionally, the Johnson–Neyman technique was applied to determine the specific range of the moderator where the effect of moral sensitivity on job satisfaction was statistically significant [28]. All analyses were conducted using SPSS Statistics (version 29.0; IBM Corp., Armonk, NY, USA) and the PROCESS macro (v4.2). Statistical significance was set at P < 0.05.

2.5. Ethical considerations

The study protocol was approved by the Ethics Committee of the University of the Ryukyus (Approval No. 24-2288-00-00-00‬). The NAs participated voluntarily and were provided with comprehensive information regarding the study’s objectives, methods, and right to withdraw at any stage of the study without negative consequences. Only personal data was used in this study. Written informed consent was obtained from all the participants.

3. Results

3.1. Characteristics of the study participants

A total of 375 NAs participated in this study, with a response rate of 74.0 %. Of them, 321 (89.9 %) were female, and the largest proportion was in their fifties (n = 112, 31.5 %). Regarding educational background, the majority of the participants (n = 192, 54.4 %) were high school graduates. Regarding employment status, most were temporary staff (n = 142, 42.8 %), and 311 participants (89.4 %) had undergone in-hospital training. Appendix A presents the additional demographic and clinical characteristics.

3.2. Differences in job satisfaction according to demographic characteristics

As shown in Appendix A, job satisfaction differed significantly with age (F = 6.30, P < 0.001). Post-hoc analysis revealed that NAs in their teens to twenties had significantly higher job satisfaction scores (65.85 ± 11.13) than those in their thirties (55.86 ± 12.07), forties (60.26 ± 10.00), fifties (57.93 ± 9.91), or sixties (58.04 ± 10.21). No statistically significant differences in job satisfaction were found across different demographic characteristics. Based on these results, age was selected as a covariate in the subsequent hierarchical multiple regression analysis.

3.3. Mean scores and correlations among moral sensitivity, interprofessional collaboration, and job satisfaction

Appendix B presents the scores and Pearson’s correlation coefficients among moral sensitivity, IPC, and job satisfaction. The average job satisfaction score was 59.50 ± 10.86, indicating that participants were somewhat satisfied with their jobs. The average IPC score was 52.75 ± 15.08, indicating a moderate perception of IPC. The average scores for moral sensitivity (moral responsibility, moral strength, and sense of moral burden) were 7.38 ± 1.49, 11.43 ± 2.85, and 16.60 ± 3.42, respectively, indicating moderate levels of moral responsibility and moral strength, with a relatively high sense of moral burden. Correlation analysis revealed that job satisfaction was significantly and positively correlated with IPC (r = 0.31, P < 0.001), moral strength (r = 0.40, P < 0.001), and sense of moral burden (r = 0.39, P < 0.001). However, no significant correlation was observed between job satisfaction and moral responsibility (r = 0.01, P > 0.05). Based on these results, IPC was selected as a moderating variable, and moral strength and sense of moral burden were chosen as independent variables for the subsequent hierarchical multiple regression analysis.

3.4. Moderating effect of interprofessional collaboration on the relationship between moral strength and job satisfaction

The results of Harman’s single-factor test showed that the first unrotated factor accounted for 42.2 %, 44.4 %, and 47.1 % of the total variance for the Minnesota Satisfaction Questionnaire, the Revised Otsuka Interprofessional Work Competency Scale, and the J-MSQ, respectively. In all cases, the variance explained by the first factor did not exceed the 50 % threshold, suggesting no significant common method bias.

Table 1 presents a hierarchical regression analysis exploring the moderating effect of IPC on the relationship between moral strength and job satisfaction. Model 1, which included age and sense of moral burden as control variables, accounted for 18.0 % of the variance in job satisfaction (F = 27.16, P < 0.001). Younger age (β = −0.20, P < 0.001) and a higher sense of moral burden (β = 0.36, P < 0.001) were associated with higher job satisfaction among NAs. Model 2 added moral strength as an independent variable and explained 22.0 % of the variance, an increase of 4.0 % over Model 1 (F = 23.18, P < 0.001). Moral strength was a significant influencing factor of job satisfaction (β = 0.25, P < 0.001). Model 3, which introduced IPC as a moderating variable, accounted for 25.0 % of the variance, with a 3.0 % increase (F = 20.72, P < 0.001). IPC was a significant influencing factor (β = 0.19, P < 0.001). In Model 4, the interaction term between moral strength and IPC was included to examine IPC’s moderating effect on the relationship between moral strength and job satisfaction. Although moral strength (β = 0.18, P = 0.012) and IPC (β = 0.19, P = 0.002) remained significant influencing factors, the interaction term was not significant (β = 0.01, P = 0.924). The inclusion of the interaction did not increase the explained variance (ΔR2 = 0, P = 0.924), and the overall model remained significant (R2 = 25.0 %, F = 16.51, P < 0.001), indicating that IPC does not moderate the relationship between moral strength and job satisfaction. The VIFs range from 1.02 to 1.72, indicating no evidence of multicollinearity.

Table 1.

Moderating effect of interprofessional collaboration on the relationship between moral strength and job satisfaction.

Variables Model 1
 Model 2
 Model 3
 Model 4
B SE β P B SE β P B SE β P B SE β P
Constant 64.33 1.56 <0.001 64.37 1.52 <0.001 63.83 1.51 <0.001 63.82 1.51 <0.001
Age (years) −1.56 0.45 −0.20 <0.001 −1.57 0.44 −0.20 <0.001 −1.44 0.44 −0.18 0.001 −1.44 0.44 −0.18 0.001
Sense of moral burden 1.14 0.18 0.36 <0.001 0.66 0.22 0.21 0.003 0.65 0.22 0.21 0.003 0.65 0.22 0.21 0.003
Moral strength – – – – 0.93 0.26 0.25 <0.001 0.68 0.27 0.18 0.011 0.68 0.27 0.18 0.012
Interprofessional collaboration – – – – – – – – 0.14 0.04 0.19 0.001 0.14 0.04 0.19 0.002
Moral strength × Interprofessional collaboration – – – – – – – – – – – – 0 0.01 0.01 0.924
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Note: Hierarchical multiple regression analysis was conducted. All continuous variables were mean-centered prior to analysis. R2 = coefficient of determination. ΔR2 = change in R2. Model 1: F = 27.16 (P < 0.001), R = 0.42, R2 = 0.18, ΔR2 = 0.18 (P < 0.001). Model 2: F = 23.18 (P < 0.001), R = 0.47, R2 = 0.22, ΔR2 = 0.04 (P < 0.001). Model 3: F = 20.72 (P < 0.001), R = 0.50, R2 = 0.25, ΔR2 = 0.03 (P = 0.001). Model 4: F = 16.51 (P < 0.001), R = 0.50, R2 = 0.25, ΔR2 = 0 (P = 0.924).

3.5. Moderating effect of interprofessional collaboration on the relationship between sense of moral burden and job satisfaction

Table 2 presents a hierarchical regression analysis exploring the moderating effect of IPC on the relationship between sense of moral burden and job satisfaction. Model 1, which included age and moral strength as control variables, explained 19.0 % of the variance in job satisfaction (F = 29.35, P < 0.001). Younger age (β = −0.21, P < 0.001) and higher moral strength (β = 0.38, P < 0.001) were associated with higher job satisfaction. Model 2 added a sense of moral burden as an independent variable and explained 22.0 % of the variance, an increase of 3.0 % over Model 1 (F = 23.18, P < 0.001). Sense of moral burden was a significant influencing factor of job satisfaction (β = 0.21, P = 0.003). With the inclusion of IPC as a moderating variable, Model 3 explains 25.0 % of the variance in job satisfaction, with a 3.0 % increase (F = 20.72, P < 0.001). IPC emerged as a significant influencing factor (β = 0.19, P = 0.001). In Model 4, the interaction between sense of moral burden and IPC was statistically substantial (β = 0.13, P = 0.022). This model explains 27.0 % of the variance in job satisfaction, representing a 2.0 % increase over Model 3 (F = 17.93, P < 0.001), indicating that IPC moderates the relationship between sense of moral burden and job satisfaction among NAs. The VIFs range from 1.02 to 1.72, indicating no evidence of multicollinearity.

Table 2.

Moderating effect of interprofessional collaboration on the relationship between sense of moral burden and job satisfaction.

Variables Model 1
 Model 2
 Model 3
 Model 4
B SE β P B SE β P B SE β P B SE β P
Constant 64.59 1.55 <0.001 64.37 1.52 <0.001 63.83 1.51 <0.001 63.64 1.49 <0.001
Age (years) −1.63 0.45 −0.21 <0.001 −1.57 0.44 −0.20 <0.001 −1.44 0.44 −0.18 0.001 −1.47 0.43 −0.19 <0.001
Moral strength 1.40 0.21 0.38 <0.001 0.93 0.26 0.25 <0.001 0.68 0.27 0.18 0.011 0.60 0.27 0.16 0.025
Sense of moral burden – – – – 0.66 0.22 0.21 0.003 0.65 0.22 0.21 0.003 0.67 0.22 0.21 0.002
Interprofessional collaboration – – – – – – – – 0.14 0.04 0.19 0.001 0.13 0.04 0.19 0.002
Sense of moral burden × Interprofessional collaboration – – – – – – – – – – – – 0.02 0.01 0.13 0.022
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Note: Hierarchical multiple regression analysis was conducted. All continuous variables were mean-centered prior to analysis. R2 = coefficient of determination; ΔR2 = change in R2. Model 1: F = 29.35 (P < 0.001), R = 0.44, R2 = 0.19, ΔR2 = 0.19 (P < 0.001). Model 2: F = 23.18 (P < 0.001), R = 0.47, R2 = 0.22, ΔR2 = 0.03 (P = 0.003). Model 3: F = 20.72 (P < 0.001), R = 0.50, R2 = 0.25, ΔR2 = 0.03 (P = 0.001). Model 4: F = 17.93 (P < 0.001), R = 0.52, R2 = 0.27, ΔR2 = 0.02 (P = 0.022).

3.6. Simple slope analysis of the interaction between sense of moral burden and interprofessional collaboration on job satisfaction

Fig. 1 illustrates the result of a simple slope analysis examining the interaction between sense of moral burden and IPC on job satisfaction. Job satisfaction is on the vertical axis, and understanding of moral burden is shown on the horizontal axis at low (1 SD below the mean) and high (1 SD above the mean) levels. The figure also presents low (1 SD below the mean) and high (1 SD above the mean) levels of the IPC. A simple slope analysis revealed that, at high levels of IPC, the sense of moral burden was positively associated with job satisfaction (P < 0.001); however, this association was not statistically significant at low levels of IPC (P = 0.180), indicating that IPC moderates the relationship between sense of moral burden and job satisfaction.

Fig. 1.

Fig. 1

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Moderating effect of IPC on the relationship between the sense of moral burden and job satisfaction.

Note: IPC = interprofessional collaboration.

4. Discussion

To the best of our knowledge, this is the first study to examine the moderating effect of the IPC on the relationship between moral sensitivity and job satisfaction among NAs. Our analysis indicates that a sense of moral burden, often considered negative [29], may function as a constructive force when encountered in supportive teams. This study contributes to the limited body of literature on ethical competencies in NAs, particularly in Japan, where an aging population creates an urgent demand for a stable, ethically competent care workforce. Given the relatively low internal consistency of the “moral responsibility” subscale, this dimension was not included in the substantive interpretation of the results, and the discussion focuses primarily on moral strength and a sense of moral burden, which demonstrated adequate reliability.

4.1. Positive association between moral strength and job satisfaction among nursing assistants

In this study, moral strength was positively associated with job satisfaction among NAs. The result suggests partial support for Hypothesis 1. Moral strength is the ability to uphold ethical actions based on patient perspectives rather than self-protection. It includes the courage to address ethically challenging situations and recognize patients’ emotions and needs [23]. Within the JD-R framework, this dimension can be conceptualized as a personal resource that enables NAs to cope effectively with ethically demanding situations. Although no previous studies have examined these associations among NAs, the present finding is consistent with prior research, demonstrating that nurses who perceive themselves as utilizing these abilities in care experiences report enhanced confidence in the ethical appropriateness of their actions, thereby reinforcing their sense of professional efficacy and job satisfaction [30]. Healthcare professionals with greater moral strength provide more patient-centered care, enhance trust among colleagues, and foster a more positive work environment [31]. These factors are closely associated with professional identity formation and higher self-esteem [32], which, in turn, further increases job satisfaction [33,34]. Moreover, NAs occupy a unique position and engage in daily close-contact care, enabling them to detect subtle changes in patients’ conditions and build strong relationships with them. Abrahamson et al. [31] highlighted that NAs considered communication with patients a vital aspect of care. Similarly, Bellury et al. [35] reported that NAs viewed themselves as providers of comprehensive care, emphasizing emotional support and active listening. These findings suggest that NAs may derive meaning and a sense of accomplishment from their ethical engagement with patients by drawing on their ability to recognize patients’ emotions and needs—a key component of moral strength—which in turn may enhance job satisfaction.

4.2. Moderating effect of interprofessional collaboration on the relationship between sense of moral burden and job satisfaction among nursing assistants

A sense of moral burden was positively associated with job satisfaction only among NAs with high IPC. The results indicate that a sense of moral burden, typically perceived as a negative psychological demand [36,37], promoted job satisfaction among NAs in highly collaborative interprofessional environments, thereby partially supporting both Hypothesis 1 and Hypothesis 2. In the Japanese healthcare context, collectivist cultural norms, often conceptualized as “wa” (harmony), emphasize interpersonal harmony, team cohesion, and respect for hierarchical relationships [38]. Within this cultural framework, NAs’ open expression of ethical concerns may be constrained to preserve relational harmony. When the IPC is strong, and NAs’ ethical awareness is acknowledged and shared by nurses and physicians, the moral burden becomes a challenge that demands, serving as a source of motivation and professional meaning. These findings are consistent with previous studies among general and psychiatric nurses that reported positive associations between a sense of moral burden and perceptions of meaningful work [39] and empathy [32]. Rather than indicating moral distress per se, moral burden in this context may reflect ethical awareness and readiness to engage in morally complex situations, thereby reinforcing NAs’ sense of contribution to patient-centered care [12]. This interpretation aligns with Maeda and Konishi’s [22] conceptualization of moral burden as an awareness triggered by ethically charged situations, as well as with the Japanese translation of the construct, which emphasizes “moral awareness” rather than burden.

IPC emerged as a critical job resource that shapes how NAs experience and respond to moral demands. When nurses or physicians acknowledge and address the ethical concerns raised by NAs, they enhance NAs’ motivation and provide professional validation and core job resources. Positive feedback and acknowledgment from colleagues can reinforce their sense of efficacy, appreciation, and purpose, which are known to increase job satisfaction [40,41]. Conversely, ethical issues may remain unresolved in environments with weak collaboration, thereby placing NAs in morally distressing situations that erode job satisfaction and contribute to burnout. Therefore, interventions should aim to create conditions under which existing moral burdens can be constructively addressed, primarily by strengthening IPC. These findings suggest that IPC not only buffers the negative effects of moral demands but also facilitates the transformation of moral burdens into challenge demands that promote growth and fulfillment.

4.3. Need for ethics education for nursing assistants

The total moral sensitivity score among NAs in this study was 35.4 (SD = 6.1), which is notably lower than those reported for Japanese general ward nurses (37.7 ± 5.0), psychiatric nurses (39.0 ± 5.1) [39], emergency nurses (38.2 ± 6.1) [42], and nurses working abroad [43]. This disparity may reflect differences in educational backgrounds, professional training, and perceived professional roles. Nonetheless, patients and their families expect all caregivers to maintain a high level of ethical conduct regardless of licensure. Considering their direct access to patients’ private information, they must possess sufficient moral sensitivity. Ethics education can be viewed as an organizational investment that strengthens personal and professional resources, enabling NAs to manage moral demands better. However, the current standard curriculum for NAs in Japan allocates only 20 min of approximately 680 min of lecture-based training to ethics [19]. The limited focus on ethics education indicates the need for greater attention to it. The previous studies have shown that targeted educational interventions, such as ethics workshops, moral decision-making programs, and virtual narrative ethics sessions, can significantly improve moral sensitivity and reduce moral distress among nurses [[44], [45], [46]]. Seminar-style ethics education has been ineffective, highlighting the need for experiential and interactive learning methods. Additionally, in the Japanese healthcare context, which emphasizes team cohesion and respect for hierarchical relationships [38]. Efforts to strengthen IPC are particularly essential. An integrative review by Campbell et al. [47] identified several interventions that successfully enhanced team communication and increased job satisfaction. These include regular interdisciplinary team meetings, shared care plans, and communication tools designed to facilitate real-time information exchanges. Implementing such strategies could maximize the positive effects of moral sensitivity on job satisfaction.

5. Limitations

This study has some limitations. First, the cross-sectional design makes it impossible to reveal causal inferences. Second, the data were collected using self-report questionnaires, which may have introduced social desirability or recall bias. Third, the participants included NAs working in designated advanced treatment hospitals and regional medical support hospitals in Japan; therefore, the findings may not be generalizable to other populations or healthcare settings. Fourth, although the effective response rate of 74.0 % is acceptable for survey research in this field, it falls below the commonly cited benchmark of 80 %, raising the possibility of non-response bias. It is possible that NAs with lower job satisfaction or higher moral distress were less likely to participate, leading to an overestimation of job satisfaction or an underestimation of ethical strain. Accordingly, caution is warranted when generalizing the findings. In addition, the internal consistency of the “moral responsibility” subscale of the J-MSQ was relatively low (Cronbach’s α coefficient = 0.54), indicating limited reliability of this construct in the present sample. Therefore, findings related to this subscale should be interpreted with caution, and no substantive conclusions were drawn based on the “moral responsibility” scores. Accordingly, the interpretation of the results focused primarily on the “moral strength” and “sense of moral burden” subscales, which demonstrated adequate internal consistency. Future studies should consider longitudinal and qualitative approaches to better understand the nuanced experiences of moral burden and collaboration among unlicensed care workers.

6. Conclusions

This study demonstrated that moral sensitivity, particularly moral strength and a sense of moral burden, is significantly associated with job satisfaction among NAs and that IPC plays a critical moderating role. These findings suggested that moral burden, often regarded as a psychological strain, can function as a constructive motivator when embedded within supportive, collaborative team environments. Interpreted within the cultural and organizational context of Japanese healthcare, these findings indicate that when IPC is strong, shared responsibility and mutual recognition enhance the positive influence of moral sensitivity on job satisfaction. Accordingly, improving job satisfaction among NAs requires not only individual-level ethics education but also organizational efforts to foster inclusive and collaborative practices. Strategies, such as interdisciplinary ethics reflection and the explicit inclusion of NAs in team communication, may help transform moral demands into professional resources and support a sustainable and ethically competent care workforce in Japan’s aging society.

Data availability statement

The datasets generated during and/or analyzed during the current study are not publicly available due to ethical restrictions and the inclusion of sensitive personal information, but are available from the corresponding author upon reasonable request.

CRediT authorship contribution statement

Takehiko Toyosato: Conceptualization, Methodology, Validation, Formal analysis, Investigation, Data curation, Writing – original draft, Writing – review & editing, Project administration. Anju Arakaki: Conceptualization, Methodology, Validation, Formal analysis, Investigation, Resources, Data curation, Writing – review & editing. Kumiko Motonaga: Conceptualization, Methodology, Validation, Formal analysis, Investigation, Resources, Writing – review & editing. Chikako Maeshiro: Conceptualization, Methodology, Validation, Formal analysis, Writing – review & editing. Michita Tokeshi: Conceptualization, Methodology, Validation, Formal analysis, Funding acquisition, Writing – review & editing.

Funding

This study was funded by a Grant-in-Aid for Scientific Research (JP23K09881) from the Japan Society for the Promotion of Science KAKENHI.

Declaration of competing interest

The authors have declared no conflict of interest.

Acknowledgments

We would like to thank all nursing assistants who voluntarily participated in the study.

Footnotes

Peer review under responsibility of Chinese Nursing Association.

Appendices

Supplementary data to this article can be found online at https://doi.org/10.1016/j.ijnss.2026.02.005.

Appendices. Supplementary data

The following is the Supplementary data to this article:

Multimedia component 1
mmc1.docx (22.9KB, docx)
Multimedia component 2
mmc2.docx (13.1KB, docx)

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Multimedia component 1
mmc1.docx (22.9KB, docx)
Multimedia component 2
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Data Availability Statement

The datasets generated during and/or analyzed during the current study are not publicly available due to ethical restrictions and the inclusion of sensitive personal information, but are available from the corresponding author upon reasonable request.

Articles from International Journal of Nursing Sciences are provided here courtesy of Chinese Nursing Association

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