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. 2026 Apr 1;27:94. doi: 10.1186/s12910-026-01441-3

Evaluation of “nursing ethics-professional teaching” integrated ward-round in practicing nursing students: a practical study

Yuying Tang 1,#, Yuqin Yang 1,#, Li Zhang 2,#, Yuwei Yang 3,✉, Guirong Li 1,✉
PMCID: PMC13169596  PMID: 41923061

Abstract

Background

Competence in ethical decision making and moral sensitivity are becoming increasingly important in nursing education. While teaching reforms have been conducted in nursing ethics, these reforms often fail to drive the adequate development of students’ critical thinking and ethical decision-making skills. To address this gap, in this study, a “nursing ethics–professional teaching” program is constructed on the basis of Rest’s ethical decision-making model, and its effects on enhancing the ethical decision-making ability and sensitivity of nursing interns are explored.

Methods

Limited by the prespecified monthly departmental rotation schedule and the need to avoid intergroup contamination, this nonrandomized controlled study used an imbalanced design to divide all 99 undergraduate nursing interns into an intervention group (n = 24) and a control group (n = 75). They received six months of “nursing ethics–professional teaching” training, in which ward rounds and routine ward-round teaching, respectively, were integrated. An investigation was conducted before and after the intervention, in which the Moral Sensitivity Questionnaire (MSQ) and the Judgments Regarding Nursing Decisions (JAND) were used to analyze the differences in the development and the correlation of the ethical sensitivity and decision-making ability between the two groups.

Results

After the intervention, both the MSQ and JAND scores were significantly higher for the intervention group than they were for the control group (t = 7.371 and 6.377, respectively; both P < 0.001). Subgroup comparisons conducted before and after the intervention revealed unexpected decreases in MSQ scores in the control group (t = 3.784, P < 0.01), which contrasted sharply with the significant increase that was revealed in MSQ scores in the intervention group (t=-5.925, P < 0.001) and those in the JAND scores across both groups (t=-23.115 and − 24.092, both P < 0.001). Both the intervention method and its interaction with the intervention duration significantly affected the MSQ (F = 25.642, P < 0.01) and JAND (F = 8.910, P < 0.01) scores. Overall, the total and dimensional MSQ and JAND scores were negatively correlated before the intervention (r=-0.300 to -0.237; all P < 0.05) but showed no correlation after the intervention.

Conclusion

The model-based integrated “nursing ethics–professional teaching” ward-round shows promising effects on intern nurses’ moral sensitivity and ethical decision-making—unlike conventional clinical internships, which enhance only the latter.

Trial registration

Not applicable.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12910-026-01441-3.

Keywords: Clinical practice, Nursing education, Nursing ethics, Ethical sensitivity, Ethical decision-making

Introduction

Ethical decision making abilities enable clinical nurses to analyze, evaluate, and select solutions that meet cultural and moral standards, thereby directly affecting patient safety and well-being while protecting patient rights [1–2]. Ethical sensitivity is considered to be the origin of moral competence [3]; however, this factor is often insufficient among clinical nurses. The pertinent issues include a disconnect between ethical theory and clinical practice, limited practical training in independent ethical judgment, and significant stress in the face of real-life dilemmas [4–5]. Although nursing ethics education is crucial, its current curricula often lack depth and integration with clinical training [6]. The adoption of innovative approaches such as scenario-based learning [7], debates [8], and teaching simulations [7, 9] have partially improved upon the limitations of traditional theoretical instruction, which frequently remain in classroom settings, or lack a systematic framework that connects ethical cognition with clinical behavior.

To address this gap, we developed and evaluated an integrated “nursing ethics–professional teaching” ward-round intervention. The originality and structure of this intervention are explicitly derived from Rest’s Ethical Decision-Making Model [10], in which ethical action is conceptualized as a sequence of four interrelated psychological processes: moral awareness, moral judgment, moral motivation and moral behavior. We systematically translated these theoretical components into a structured clinical teaching scheme comprising four corresponding modules: (1) teaching objectives aimed at cultivating moral awareness, judgment, and motivation; (2) lesson plans designed to trigger awareness through case selection; (3) implementation focused on the practice of moral judgment and behavior in bedside assessment and guided discussion; and (4) evaluation for assessing the level of growth across all of the components. This structured operationalization of Rest’s model constitutes the core added value of our intervention, as it provides a replicable clinically embedded framework that systematically fosters ethical competence within the workflow of clinical practice.

Therefore, this study is aimed at evaluating the effects of this model-based, structured ward-round intervention on enhancing the ethical sensitivity and ethical decision-making ability of nursing interns during clinical placements.

Background

Considering the disorganization between nursing ethics theory and clinical practice, both the content and teaching methods of nursing programs deserve continued exploration [11]. Clinical internships, in which students directly encounter patients and complex situations, present a critical yet underutilized opportunity for ethics education. The predominant teaching method during internships is the clinical teaching of ward rounds, in which theoretical knowledge is traditionally combined with skills training [12]. While they are effective for developing clinical competency [13, 14], conventional rounds often neglect systematic ethical deliberation.

Ethics-focused ward rounds have been shown to promote ethical reasoning [15, 16]. Building on this, we developed the “nursing ethics–professional teaching” integrated ward-round, which is explicitly structured through the Rest’s ethical decision-making model. This model conceptualizes ethical action as a sequence of four interrelated psychological processes: moral awareness, moral judgment, moral motivation, and moral behavior. Moral awareness is a prerequisite for the understanding of professional responsibility [17] and the provision of ethical care [18]. Moral judgment involves discerning the correct course of action [19], whereas moral motivation and behavior deal with the commitment to and execution of that judgment. Previous studies have successfully applied Rest’s model to enhance ethical cognition [20] or assess ethical competence [17], thereby confirming its utility as a framework for ethics education.

Our study extends this application by developing a fully operationalized clinical teaching scheme on the basis of the model’s components. The scheme details how each stage of a clinical ward round—from preparatory case selection to bedside implementation and postround evaluation—can be designed to target the specific components of ethical decision-making (Supplementary Table 1). This approach ensures that ethics learning is not an abstract add-on but is rather intrinsically woven into the clinical learning process, thereby addressing the need for teaching strategies that are both theoretically grounded and fully integrated into real-world clinical scenarios. By doing so, this study is aimed at equipping nursing interns with a structured process for ethical perception, reasoning, and action.

Methods

Design

This was a nonrandomized controlled teaching study that was approved by the ethics committee of Mianyang Central Hospital (Approval Number: S20220367-01). All the participants provided written informed consent. In accordance with the pertinent definitions in China’s “Measures for the Administration of Investigator-Initiated Clinical Research in Medical Institutions” and “Measures for the Ethical Review of Life Science and Medical Research Involving Human Subjects”, nursing ethics education studies are not classified as clinical trials that require registration. Consequently, this study did not secure a registration number from a clinical trial registration platform.

Origin of the teaching scheme

In this study, a “nursing ethics–professional teaching” integrated ward-round is developed on the basis of Rest’s model of ethical decision-making. According to this model, the program comprises four first-level indicators (teaching objectives, preparation, implementation, and evaluation), 12 s-level indicators, and 36 third-level indicators (for details, refer to Supplementary Table 1). Its core features include (1) the authenticity of ethical scenarios, for which real clinical cases involving ethical conflicts are selected; (2) the teaching of operability, which requires clear definitions of teaching content and instructor standards across all stages of the program; and (3) the capacity for multidimensional evaluation involving the integration of baseline assessments, reflective process evaluations, and terminal behavioral assessments. As an embedded pedagogical intervention, such evaluations seamlessly integrate ethics education into routine ward-round teaching on the basis of Rest’s model. An operational logic diagram of the four components of Rest’s model is shown in Fig. 1.

Fig. 1.

Fig. 1

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Illustration of how rest’s four components are operationalized

Study setting and sampling

Full-time undergraduate nursing interns who were residents at a tertiary general hospital in Mianyang city between September 2023 and March 2024 were included in the study. The inclusion criteria entailed (1) full-time undergraduate degree internship nursing interns; (2) a September 2023–March 2024 6-month engagement in the hospital internship program; and (3) full attendance in the monthly rountine ward-round teaching or “nursing ethics–professional teaching” integrated ward-round training intervention. The exclusion criteria entailed (1) a continuous absence for more than 1 month during the internship due to illness or personal leave and (2) withdrawal from the internship for various reasons. General information about all the nursing interns was collected, including their age, sex, race, single-child status, residence, and class. At the beginning of the study, the nursing interns had already commenced their departmental rotations in June in accordance with the internship rotation schedule, and the rotation plan was redesigned to meet the research needs while avoiding intergroup contamination, which would inevitably prevent a considerable number of nursing students from completing their full internship program. Therefore, on the basis of the established internship rotation schedule, we selected nursing interns who would only rotate through six departments during their subsequent internship, which ensured that there was no contamination between this group and those who rotated through other departments. Under such circumstances, we were constrained to adopt a nonrandomized controlled study design. Finally, the nursing interns who were rotating through six departments (neurosurgery, oncology, gastroenterology, orthopedics, respiratory medicine, and cardiology) were selected as the intervention group (n = 24), and the nursing interns who were rotating through the remaining 17 departments were selected as the control group (n = 75). The control group adopted a routine ward-round teaching that involved nursing interns’ case reports, their superior faculty members’ inquiries about the condition, bedside checkups, case discussions and analyses, and the faculty members’ comments and summaries on a monthly basis. The intervention group participated in “nursing ethics–professional teaching”, which was integrated into the ward round based on the control group on a monthly basis. The enrollment and training of the nursing interns during the study period are shown in Supplementary Fig. 1.

Intervention measures

The “nursing ethics–professional teaching” integrated ward-round was designed to systematically strengthen the ethical competence of nursing students, which encompasses ethical awareness, judgment, moral motivation, and ethical behavior, through structured, clinically grounded, and contextually rich teaching activities. The core components of the intervention are outlined below:

Under the joint organization and preparation of professional and ethics teachers, the “nursing ethics–professional teaching” integrated ward-round, which lasts for 2 class hours (approximately 1.5 to 2 h), is conducted once a month. During each ward round, emphasis is place on the integration of the teaching of ethical sensitivity into the case presentation and bedside examination sections and that of the teaching of ethical decision-making and actions into the discussion and summary sections of the curriculum. The teaching method involves students thinking, summarizing and presenting, which is followed by comments and summaries provided by the ethics teacher.

Quality control

Prior to its formal implementation, this study was approved and supported by the Teaching and Research Office of the Nursing Department by the establishment of an Ethics Teaching and Research Section. This section consisted of three full-time teachers who each had at least five years of experience in medical ethics teaching and research, a master’s degree or above, and an intermediate or higher professional title. All the teachers had completed hospital ethics training, passed the relevant assessments, obtained ethics certificates at the provincial or municipal and above levels, and possessed extensive teaching and clinical experience.

To control for research interference, the intervention-group nursing students were instructed not to disclose specific teaching plans to the control group during training prior to their joining the integrated “nursing ethics–professional teaching” rounds. Uniform terminology was used for field data collection. All the participants were undergraduate nursing students from the same cohort, and they had similar distributions in regard to their educational backgrounds, sexes, and ages. Both groups received standardized training, and, to minimize confounding effects, no cross-rotation was allowed between the two groups throughout the 6-month clinical rotation.

Instruments

The ethical sensitivity and ethical decision-making skills of practicing nurse practitioners were assessed before and after their 6-month clinical placements.

Moral sensitivity was assessed using the Chinese version of the Moral Sensitivity Questionnaire (MSQ), which was originally developed in 2001, revised in 2006 [21], and translated into Chinese in 2016 [22]. The questionnaire covered two dimensions (moral responsibility and moral strength, sense of moral burden), for a total of nine items. Each item was scored on a 6-point Likert scale (1 = completely disagree, 6 = completely agree), with a total score of 9–54. Higher scores indicated greater ethical sensitivity. The Cronbach’s alpha for this scale was 0.82.

Competency in ethical decision-making was assessed using the Judgments Regarding Nursing Decisions (JAND) questionnaire, which was developed by Ketefian on the basis of the American Academy of Nursing’s Code of Nursing Ethics and then revised in 2007 [23]. The questionnaire covers six ethical narratives covering 48 different items to be evaluated under two scenarios (ideal and real conditions) for determining scores in the ethical choice and ethical action dimensions. Each item was scored separately for the ethical choice and ethical action dimensions on a 5-point Likert scale, with each dimension having a total score of 48–240. The nursing ethical decision-making competence score is calculated via the sum of the scores for the ethical choice and ethical action dimensions. Higher scores indicated greater ethical decision-making competence. The Cronbach’s alpha of this questionnaire covering ethical choice, ethical action, and ethical decision-making competence ranged from 0.66 to 0.73.

Data analysis

Statistical analysis was performed using SPSS 25.0, and MedCalc 20.1 was used for statistical analysis. Normal or approximately normal distributions are described by the mean ± standard deviation, and two independent samples t tests, paired t tests, repeated measures analysis of variance (ANOVA), Pearson’s correlation, and partial correlation were used for statistical inference. The test level α was 0.05.

Results

Comparison of the general information between groups

There were no significant differences (P > 0.05) between the two groups in terms of age, sex, ethnicity, whether they were single children, place of residence, whether they had served as class officers, ethical sensitivity, or ethical decision-making ability (Table 1).

Table 1.

Comparison of the general data between the two groups

Item Intervention group (n = 24) Control group (n = 75) t/χ2 P
Age 21.17 ± 0.87 20.92 ± 0.87 1.214 0.228
Sex 1.067 0.302
 Male 6(25.00%) 10(13.33%)
 Female 18(75.00%) 65(86.67%)
Race 0.517 0.472
 Ethnic Han 23(95.83%) 66(88.00%)
 Minority 1(4.17%) 9(12.00%)
Single child
 Yes 7(29.17%) 24(32.00%) 0.000 0.994
 No 17(70.83%) 51(68.00%)
Habitation 0.964 0.326
 Countryside 12(50.00%) 27(36.00%)
 City 12(50.00%) 48(64.00%)
Class cadre 0.000 1.000
 Yes 12(50.00%) 37(49.33%)
 No 12(50.00%) 38(50.67%)
Department category 0.000 1.000
 Internal medicine 4(66.67%) 10(58.82%)
 Surgery 2(33.33%) 7(41.18%)
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Pre- and post-comparison of the MSQ, JAND and dimension scores between the two groups

Before the intervention, there was no statistically significant difference in the MSQ or JAND scores or the scores for each dimension between the intervention and control groups (P > 0.05). After the intervention, the MSQ and JAND scores and all dimension scores for the intervention group were significantly greater than those for the control group (P < 0.05). (Table 2)

Table 2.

Pre- and post-intervention comparisons of the MSQ, JAND, and their dimension scores between the two groups

Group Item Intervention group Control group t P
Preintervention MSQ 37.00 ± 5.01 39.33 ± 7.48 -1.427 0.157

Moral responsibility and

strength

 21.79 ± 4.13 23.15 ± 4.41 -1.329 0.187
Sense of moral burden 15.21 ± 2.40 16.19 ± 3.82 -1.180 0.241
JAND 178.46 ± 17.43 174.93 ± 29.11 0.720 0.474
Ethical choice 86.88 ± 10.11 84.95 ± 16.63 0.684 0.496
Ethical action 91.58 ± 9.12 89.99 ± 13.52 0.657 0.514
Postintervention MSQ 45.63 ± 5.07 33.49 ± 11.08 7.371 < 0.001

Moral responsibility and

strength

 26.96 ± 2.63 19.32 ± 6.98 7.891 < 0.001
Sense of moral burden 18.67 ± 3.44 14.17 ± 4.71 4.311 < 0.001
JAND 292.00 ± 15.14 266.15 ± 17.90 6.377 < 0.001
Ethical choice 151.63 ± 8.90 137.44 ± 10.60 5.915 < 0.001
Ethical action 140.38 ± 9.72 128.71 ± 9.32 5.285 < 0.001
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 There were no significant differences in the MSQ, JAND, or their dimensional scores before the intervention, but there was a significant difference after the intervention

JAND the Judgments Regarding Nursing Decisions Questionnaire, MSQ the Chinese version of the Moral Sensitivity Questionnaire

Group differences in MSQ and JAND total and dimensional scores

The MSQ and JAND scores and all the dimension scores improved significantly in the intervention group postintervention (P < 0.001). In the control group, the JAND scores and the scores for all dimensions were higher after the intervention than they were before the intervention (P < 0.001), whereas the MSQ scores and the scores for all dimensions were lower after the intervention than they were before the intervention (P < 0.01). See Fig. 2.

Fig. 2.

Fig. 2

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Pre- and postintervention comparison of the MSQ, JAND and dimension scores between the intervention and control groups. Note: (a) Scores of the intervention group pre- and postintervention; (b) scores of the control group pre- and postintervention. JAND, the Judgments Regarding Nursing Decisions Questionnaire; MSQ, the Chinese version of the Moral Sensitivity Questionnaire. JAND and its dimension scores increased in both the intervention and control groups, whereas MSQ and its dimension scores increased only in the intervention group and decreased in the control group. *, P < 0.01; **, P < 0.001

Group changes in MSQ and JAND total and dimensional scores

After adjusting for the basic information of nursing interns (including age, gender, ethnicity, whether they are an only child, place of residence, whether they serve as class cadre, and department category), repeated measures ANOVA showed that intervention duration had no significant effect on MSQ, moral sense of responsibility and power, or moral burden (Partial eta-squared = 0.003–0.005; F = 0.764–1.539; all P > 0.05), but there was a significant interaction between intervention method and intervention duration (Partial eta-squared = 0.08–0.117; F = 14.635–22.837; all P < 0.01).However, for JAND, ethical choice, and ethical action, significant effects were detected for the intervention method (Partial eta-squared = 0.062–0.074; F = 11.676 ~ 16.429; all P < 0.01), the intervention duration (Partial eta-squared = 0.743–0.794; F = 439.664–701.258; all P < 0.01), and their interaction (Partial eta-squared = 0.037–0.044; F = 6.553–8.356; all P < 0.01) (Fig. 3).

Fig. 3.

Fig. 3

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Pre- and postintervention comparisons of repeated-measures ANOVA for the MSQ, JAND and dimension scores. Note: (a) MSQ overall score; (b) moral responsibility and strength dimension score; (c) moral burden dimension score; (d) JAND overall score; (e) ethical choice dimension score; (f) ethical action dimension score. JAND, the Judgments Regarding Nursing Decisions Questionnaire; MSQ, the Chinese version of the Moral Sensitivity Questionnaire. For MSQ and its dimension scores, the intervention duration had no significant effect (P > 0.05), but the intervention method and its interaction with the intervention duration had a substantial effect (P < 0.01). For JAND and its dimension scores, the intervention method, intervention duration, and their interaction all showed significant effects (P < 0.01)

Pre- and post-intervention correlation between the MSQ and JAND total and dimension scores

Under the theoretical assumption that nursing students’ inherent ethical sensitivity may influence their ethical decision-making processes, we exploratorily investigated the correlation between MSQ and JAND scores at pre- and post-intervention. There was a negative correlation between the preintervention JAND scores and its dimensions and between the MSQ scores and its dimensions (r=-0.300 to -0.237, P < 0.05) (Fig. 4A). However, after the intervention, the JAND scores and its dimensions unexpectedly did not correlate with the MSQ scores and its dimensions (P > 0.05) (Fig. 4B).

Fig. 4.

Fig. 4

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Pre- and post-correlation analysis results between the MSQ and JAND dimensions before and after the intervention. Note: All P values are adjusted via the Bonferroni method. A Preintervention; B postintervention. JAND, the Judgments Regarding Nursing Decisions Questionnaire; MSQ, the Chinese version of the Moral Sensitivity Questionnaire. Overall, the total and dimensional MSQ and JAND scores were negatively correlated before the intervention (P < 0.05) but showed no correlation after the intervention (P > 0.05)

Secondary correlation analyses: exploratory item-level findings

A list of the MSQ items and details for S1-S9 are provided in Supplementary Table 2. Given the unexpected reversal in MSQ scores between two groups and inconsistent MSQ–JAND correlations before versus after intervention, we further exploratorily examined how the 9 MSQ ethical sensitivity items correlate to ethical decision-making, to identify group differences in these items. Spearman correlation analysis revealed that preintervention JAND and its ethical choice dimension scores correlated negatively only with S2, S7, S8, and S9 (r=-0.324 to -0.228, P < 0.05); the ethical action dimension correlated negatively only with S2, S3, S4, S7, and S9(r=-0.274 to -0.204, P < 0.05) (Supplementary Fig. 2A). After the intervention, no significant correlations emerged between JAND (total or dimensions) and 9 item scores of MSQ (P > 0.05) (Supplementary Fig. 2B). Further partial correlation analysis verified an independently negative correlation of S2 with preintervention JAND, ethical choice dimension, and ethical action dimension (rpart=-0.315, -0.354, -0.274; std.beta=-0.586, -0.649, and-0.274; all P < 0.05), as well as an independently positive correlation of S1 with ethical choice dimension (rpart=0.265, std.beta = 0.484, P < 0.05) and S5 with ethical action dimension (rpart=0.216. std.beta = 0.314, P < 0.05). After the intervention, JAND was independently negatively correlated with S8 (rpart=-0.235, std.beta=-0.331, P < 0.05) and independently positively correlated with S9 (rpart=0.227, std.beta = 0.32, P < 0.05). Ethical choice was independently positively correlated with S9 only (rpart=0.275, std.beta = 0.396, P < 0.05), and ethical action was not correlated with all of the MSQ items (P > 0.05) (Supplementary Table 3).

However, within the control group, JAND, ethical choice, and ethical action were independently negatively correlated with S2 and S9 (rpart=-0.428~-0.172, std.beta=-0.428~-0.222, P < 0.05), whereas within the intervention group, JAND was independently positively correlated with S2 and S4 (rpart=0.309 ~ 0.518, std.beta = 0.267 ~ 0.498, P < 0.05), ethical choice was independently positively correlated with S4 and S7 (rpart=0.330 ~ 0.506, std.beta = 0.396 ~ 0.506, P < 0.05), and ethical action was independently positively correlated with S2 (rpart=0.505, std.beta = 0.505, P < 0.05) (Supplementary Table 4).

Discussion

The integration of the Rest model with the “nursing ethics–professional teaching” ward-round effectively improves ethical sensitivity and ethical decision-making among nursing interns

To ensure the reliability of our findings, we observed and compared the baseline situations of the two groups of nursing interns in terms of their learning experience, ethical decision-making ability, and ethical sensitivity before the intervention. The results revealed no significant differences in the preintervention indicators between the two groups. The results showed that the integrated ward round shows promising effects on the ethical sensitivity and ethical decision-making ability of nursing interns. Following the intervention, the MSQ and JAND scores of the intervention group were significantly greater than those of the control group, which suggested the effectiveness of the teaching model in improving the ethical competence of nursing interns. These findings are consistent with the theoretical framework of Rest’s Ethical Decision-Making Model, which states that nursing interns can identify and resolve ethical issues more effectively in clinical settings through systematic training in ethical awareness, judgment, intent, and behavior.

Compared with traditional methods of teaching ethics (e.g., lecture-based teaching or case discussion), this study innovatively combines ethics teaching with the clinical ward round, emphasizing a “case-led, student-oriented” teaching concept that achieves a closed-loop learning process of “theory-practice-reflection”. This model not only enhances the clinical translation of ethical theories but also cultivates critical thinking and ethical judgment, thereby realizing the teaching objectives of “identifying ethical issues, analyzing their background and influencing factors, and applying ethical principles to determine optimal solutions”. This approach has been corroborated by the research of Morrill et al. [20] and Lee et al. [24].

Routine clinical practice shows promising effects on nursing decision-making ability but not on ethical sensitivity

This study reveals that while routine clinical placements helped to improve nursing interns’ decision-making skills, they played a limited role in promoting ethical sensitivity and may even trigger a decline in ethical sensitivity. Specifically, the MSQ scores of the control group in the postintervention period were significantly lower than those in the preintervention period, which stands in contrast to the findings of Chen et al. [25]. Chen et al. reported that the ethical sensitivity of nursing interns increases with the increasing duration of clinical placement. However, data from the control group suggest that without enhanced ethical education, nursing interns may tend to place a greater focus on technical nursing practices during routine clinical rotations while neglecting the identification and management of ethical issues. The decline in MSQ scores that can be seen in the control group is an expected outcome of the interaction of multiple factors in clinical settings. During the initial stage of clinical training, interns’ ethical enthusiasm may wane as a result of the influence of clinical realities and workload pressures, leading to cognitive resources becoming concentrated on technical tasks and the space for ethical reflection becoming constricted [26]. Moreover, as novice learners in hospitals, interns frequently remain silent with regard to clinical ethical issues. This is because they are afraid of challenging authority, worried about negative evaluations, or concerned about the impact on their training performance [27]. Moreover, long-standing unresolved ethical dilemmas can readily induce occupational burnout and empathy fatigue, which in turn further erodes ethical sensitivity [28]. Therefore, the active integration of ethical education during ward rounds is essential for countering negative environmental impacts and safeguarding and nurturing the ethical awareness of nursing interns.

Interaction between “nursing ethics–professional teaching” integrated ward rounds and routine placements

Validated by repeated-measures ANOVA, the results of this study reveal a nonsignificant main effect of clinical practice on ethical sensitivity; however, the “nursing ethics–professional teaching” integrated ward-round based on Rest’s model showed a significant main effect on ethical sensitivity, with a significant interaction effect detected between this model and the 6-month clinical internship period. These results suggest that although a purely clinical practicum helps improve nursing interns’ decision-making ability, nursing interns’ ethical sensitivity may decline in the absence of systematic ethical education. By introducing an ethics teaching study based on Rest’s model, nursing interns were not only contribute to improve their ethical sensitivity but were also contribute to apply ethical principles more effectively in clinical practice. These findings are consistent with those of Kaşıkçı M et al. [29], who reported that integrating ethics education into clinical placements significantly enhances the ethical competence of nursing interns. The “nursing ethics–professional teaching” integrated ward-round that was designed in this study compensates for the shortcomings of ethics education in the traditional clerkship model by integrating ethics education with clinical practice and providing a more comprehensive and integrated learning environment for nursing interns.

Exploratory findings

Despite these findings, which are in line with our expectations, certain unexpected results were observed in this study. First, there was no significant correlation between the JAND scale score and its dimension scores or between the MSQ score and its dimension scores after the practicum, which contrasted with the negative correlation that was observed prior to the practicum. These results may indicate that the relationship between nursing interns’ ethical decision-making ability and level of ethical sensitivity changed after “nursing ethics–professional teaching” was integrated into the ward-round. The significant positive correlation between postintervention ethical choices and S9 (“Compliance with rules and regulations helps me understand what is good or bad for patients”) highlights the crucial role of clinical practice guidelines and hospital regulations that have been established by national laws in enhancing the ethical competencies of nursing interns. Second, the preintervention S2 items (“My ability to perceive patients’ needs is always helpful in my work”) were negatively correlated with JAND, ethical choices, and ethical behavior, which was particularly evident in the control group and may be a result of bias within the control group. This might reflect nursing interns’ lack of awareness regarding ethical issues at the beginning of their internship, which leads them to have a greater reliance on intuition than on ethical principles in the face of ethical issues. However, after the ethics teaching intervention, the nursing interns in the intervention group showed a significant improvement in this area, indicating that the “nursing ethics–professional teaching” integrated ward-round might contribute to enhanced the competences of the nursing interns to perceive patients’ needs.

However, these exploratory findings warrant cautious interpretation, as no comparable studies have been reported to date. Overall, the principal findings of this study align closely with those of prior interventions in ethics education. Specifically, the “nursing ethics–professional teaching” integrated ward-round significantly enhanced nursing students’ ethical sensitivity and ethical decision-making capacity. Repeated-measures ANOVA further confirmed both the significant effect of this intervention method and its interaction with intervention duration.

Limitations

Despite the positive outcomes of this study, several limitations remain. First, to accommodate the established internship rotation schedule and avoid intergroup contamination, a nonrandomized controlled design was required, which resulted in a significant imbalance in sample sizes between the intervention and control groups, which is an issue that could introduce the risk of selection bias. It is reported that nursing ethical decision-making is influenced by nurse-related (e.g., professional identity perception and exposure to ethically complex cases), patient-related (e.g., patient acuity and clinical condition changes), team-related (e.g., supervision style and teamwork collaboration ability), and contextual factors (e.g., ethical climate and workload intensity) [30]. Elevated pressure across any of the aforementioned dimensions may adversely affect the quality of ethical decision-making. Fortunately, there was no disparity in the internal medicine/surgery distribution and the baseline data of the nursing interns of the two groups, which might alleviate the impact of different clinical environments to a certain degree. However, elevated workloads and diminished professional identity are independently associated with reductions in MSQ and JAND scores [31, 32]. In contrast, robust clinical supervision, exposure to ethically complex cases, dynamic shifts in patients’ clinical conditions, and engagement within a multifaceted ethical climate correlate positively with higher MSQ and JAND scores [33, 34]. Thus, these influencing factors across different departments necessitate further rigorous investigation to address potential risks. Second, the limited student enrollment led to a small sample size, and the lack of an a priori power analysis may reduce statistical power, particularly for the subgroup analyses that specifically target the intervention group. These secondary and item-level findings are exploratory and use for hypothesis-generating, thus their interpretations should be substantially restrained. Therefore, future studies should expand the sample size and adopt a randomized controlled design to achieve balanced intergroup sample numbers to further validate the findings of this study. Third, the 6-month intervention cycle of the “nursing ethics–professional teaching” integrated ward-round program only demonstrated preliminary effects, and its long-term efficacy requires further validation. Finally, this study was conducted exclusively at a tertiary Grade A hospital; future research should be conducted across hospitals of different levels to verify the generalizability of this teaching approach. Moreover, although the moderate reliability of the JAND scale is acceptable in social science research, lower Cronbach’s alpha values may attenuate observed associations and increase measurement error, thereby influencing interpretation and compromising conclusion credibility. Therefore, a more robust ethical competence assessment scale is needed.

Implications for nursing education

The results of the present study have important practical implications for nursing education. First, the “nursing ethics–professional teaching” integrated ward-round, which is based on Rest’s model, provides a new teaching mode for nursing education that may contribute to enhanced nursing interns’ ethical sensitivity and decision-making ability. Second, the results of this study suggest that although routine clinical placements can improve nursing interns’ decision-making ability, the absence of systematic ethical education may decrease nursing interns’ ethical sensitivity. This study innovatively integrates ethical education into clinical teaching processes, demonstrating that the incorporation of ethical awareness into ward-round instruction enhances the ethical sensitivity of nursing interns. This pedagogical innovation contributes to the sustained advancement of ethical education. Furthermore, the findings of this study indicate that nursing educators should prioritize ethical education during clinical internships, particularly at the beginning of clinical experience. Educators should assist nursing interns in the development of strong ethical awareness through systematic ethics instruction. Future research should also investigate ways to integrate ethics education into other clinical skills training programs to cultivate well-rounded nursing professionals.

However, owing to the imbalance in research design, the low reliability of the scale, and the complexity of the ethical atmosphere and context, the aforementioned suggestions for integrating regular courses should be considered conditionally. Further research should be carried out using stronger designs to validate them, such as multi-center studies, cluster randomization, or stepped wedge methods.

Conclusion

Compared with conventional clinical internships, the integrated “nursing ethics–professional teaching” ward-round based on Rest’s model is associated with improvements on intern nurses’ moral sensitivity and ethical decision-making. This stands in contrast to conventional clinical internships, which enhance only the latter. By combining ethics education with clinical practice, this study provides a novel method of teaching nursing ethics and provides an important reference for future nursing education reform.

Supplementary Information

Supplementary Material 1. (45.9KB, docx)
12910_2026_1441_MOESM2_ESM.docx (1.4MB, docx)

Supplementary Material 2: Figure 1. Enrollment and training process of nursing interns during the study period. Supplementary Figure 2. Pre- and post-correlation analysis results between the JAND dimensions and MSQ items before and after the intervention. Note: All P values are adjusted via the Bonferroni method. A) Preintervention; B) postintervention. JAND, the Judgments Regarding Nursing Decisions Questionnaire; MSQ, the Chinese version of the Moral Sensitivity Questionnaire. The total and dimensional JAND scores were negatively correlated to S2, S7 to S9 before the intervention (P<0.05), and ethical action dimension were also negatively correlated to S3 and S4 (P<0.05). However, there were no correlations after the intervention (P>0.05).

Acknowledgements

We sincerely thank every author for their collaborative efforts in this work.

Clinical trial number

Not applicable.

Authors' contributions

Yuying Tang: Conceptualization; data curation; formal analysis; writing of the original draftYuqin Yang: Investigation; methodology; writing: reviewing and editingLi Zhang: Investigation; writing: reviewing and editing; softwareYuwei Yang: Project administration; resources; softwareGuirong Li: Funding acquisition; supervision; validation; visualization; roles/writing of the original draft; and writing: reviewing and editing.

Funding

This research was financially supported by the Education and Teaching Reform Research Projects of Chengdu Medical College [Approval No.: JG2022064].

Data availability

All the data generated or analyzed during this study are included in this published article [and its supplementary information files].

Declarations

Ethics approval and consent to participate

This study complies with the requirements of the Declaration of Helsinki. This study was reviewed and approved by the Ethics Committee of a tertiary general hospital in Mianyang city, China (Ethics Review Approval Number: S20220367-01). All the participants provided written informed consent.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Supplementary Fig. 2

Pre- and post-correlation analysis results between the JAND dimensions and MSQ items before and after the intervention.

Footnotes

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Yuying Tang, Yuqin Yang and Li Zhang contributed equally to this work.

Contributor Information

Yuwei Yang, Email: yyw318@vip.163.com, Email: yyw318@sc-mch.cn.

Guirong Li, Email: 384895848@qq.com.

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Associated Data

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

Supplementary Materials

Supplementary Material 1. (45.9KB, docx)
12910_2026_1441_MOESM2_ESM.docx (1.4MB, docx)

Supplementary Material 2: Figure 1. Enrollment and training process of nursing interns during the study period. Supplementary Figure 2. Pre- and post-correlation analysis results between the JAND dimensions and MSQ items before and after the intervention. Note: All P values are adjusted via the Bonferroni method. A) Preintervention; B) postintervention. JAND, the Judgments Regarding Nursing Decisions Questionnaire; MSQ, the Chinese version of the Moral Sensitivity Questionnaire. The total and dimensional JAND scores were negatively correlated to S2, S7 to S9 before the intervention (P<0.05), and ethical action dimension were also negatively correlated to S3 and S4 (P<0.05). However, there were no correlations after the intervention (P>0.05).

Data Availability Statement

All the data generated or analyzed during this study are included in this published article [and its supplementary information files].

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