Profiles of moral sensitivity and their associated factors in nursing students: A latent profile analysis

Abstract

Aim

This study was conducted to identify group profiles in moral sensitivity among Chinese nursing students and examine the factors associated with moral sensitivity subgroups.

Background

Moral sensitivity is a precondition for ethical decision making. Developing this sensitivity equips nursing students with the skills to identify and respond appropriately to ethical dilemmas, which are essential as they prepare to enter clinical settings. As integral members of the future nursing workforce, nursing students must be well prepared to navigate the ethical challenges they face.

Design

This study used a cross-sectional design.

Methods

Using convenience sampling, 716 nursing undergraduates from three universities in Jiangxi Province participated in this study. Participants completed online assessments of personality traits, empathy, professional nursing values and moral sensitivity. Latent profile analysis was used to identify moral sensitivity profiles and multinomial logistic regression was used to explore factors influencing distinct moral sensitivity profiles in nursing undergraduates.

Results

Results identified three profiles: “moral idealists” (9.7 %; high moral strength, moral burden; low moral responsibility), “moral undertakers” (32.0 %; moderate moral strength, moral burden; high moral responsibility), “moral skeptics” (58.3 %; low moral strength, moral burden and moral responsibility). Multinomial logistic regression analysis showed that grade level, only child status, agreeableness, conscientiousness, emotional stability, empathy and professional nursing values were associated with different profiles of moral sensitivity in nursing students.

Conclusion

Most undergraduate nursing students were placed in the moral skeptics group; thus, educational institutions should pay special attention to nursing students with low levels of moral sensitivity. Particular attention and additional support should be given to nursing students who are only children, in their lower academic years, exhibit neurotic traits and possess lower levels of agreeableness and conscientiousness. Educational activities and programs that prioritize empathy and professional nursing values may present a viable approach to fostering moral sensitivity among nursing students.

1 Introduction

The swift advancement of medical technology, the growing complexity of patient care needs and the shortage of nursing human resources bring the heightened intricacy and challenges of ethical dilemmas within nursing practice ( ^{Peirce et al., 2020}). In particular, when public health emergencies occur suddenly, such as the COVID-19 outbreak, nurses are exposed to a more complex medical environment and face more ethical challenges ( ^{Morley et al., 2020}). This necessitates a solid foundation in professional knowledge and skills and an unprecedented emphasis on moral sensitivity and ethical decision-making abilities ( ^{Chen et al., 2021}). Moral sensitivity, also known as moral awareness or ethical sensitivity, is defined as the ability to recognize ethical issues, the vulnerability of patients, the impact of ethical issues and the consequences of ethical decisions ( ^{Lee and Kim, 2020; Lützén et al., 2006}). According to Lützen et al. ( ^{Lützén et al., 2006}), moral sensitivity comprises three dimensions: moral burden, moral strength and moral responsibility. Moral burden arises from conflicts between moral values or from an awareness of responsibilities and obligations but lacks the necessary resources and authority to act accordingly. Moral strength is demonstrated by adopting a moral stance during conflict scenarios and demonstrating resilience and perseverance. Moral responsibility refers to a sense of duty in accordance with moral principles.

Moral sensitivity is widely recognized as a critical moral competency in nursing and a core factor in ethical decision-making ( ^{Huang et al., 2016}). Specifically, strong moral sensitivity can boost nurses’ confidence in making ethical decisions, handling moral dilemmas and understanding their professional obligations ( ^{Kim and Park, 2019}), thereby enhancing their ability to address ethical dilemmas, mitigate moral stress and reduce the risk of job burnout. Moreover, studies have shown that moral sensitivity is essential for protecting patients’ lives and rights, enhancing the quality of nursing care, mitigating conflicts in healthcare settings and fostering positive nurse-patient relationships ( ^{Amiri et al., 2019; Huang et al., 2016; Lee et al., 2020}). Similarly, moral sensitivity can influence a patient’s well-being ( ^{Suazo et al., 2020}). Moral sensitivity is critical for nurses.

As a vital supplementary component of the nursing workforce, nursing students should be prepared to navigate ethical issues before entering clinical settings where ethical conflicts commonly occur ( ^{Lee et al., 2020}). Research has shown that negative experiences resulting from moral distress in clinical practice can hinder the retention of newly graduated nurses in the profession ( ^{Escolar-Chua, 2018}). Conversely, cultivating moral sensitivity among nursing students positively and directly influences their ethical conduct and behavior when facing moral dilemmas ( ^{Comrie, 2012}). Nursing students are currently at a crucial stage of cultivating moral character and increased attention should be paid to cultivating moral sensitivity among nursing students ( ^{Yeom et al., 2017}). Thus, exploring nursing students’ moral sensitivity and its influencing factors is imperative for developing effective strategies to foster heightened moral awareness among nursing professionals.

Several factors influence moral sensitivity, including demographic characteristics (e.g., age and gender), external environment and internal psychological factors ( ^{Ergin et al., 2022; Pang et al., 2024; Tuvesson and Lützén, 2017}). Increasing attention has been paid to psychological indices that affect moral sensitivity, particularly positive psychological variables, as most variables may be modifiable and manageable through interventions. Among these, positive personality traits, particularly those characterized by prosocial inclinations, significantly impact individual moral judgment by influencing behavioral patterns in social interactions ( ^{Smillie et al., 2021, Suazo et al., 2020}). This influence prompts them to adhere to specific moral norms when confronted with ethical dilemmas ( ^{Borhani et al., 2013; Tao et al., 2020}). In addition, different personality traits may influence moral decision-making. For instance, agreeableness may be linked to moral sensitivity and identity, while conscientiousness may predict moral identity and courage ( ^{Abbasi-Asl and Hashemi, 2019}). Empathy, defined as the ability to understand and share the feelings of others by imagining oneself in their situation and expressing emotions, is closely linked to moral sensitivity ( ^{Di Lorenzo et al., 2019}). Studies have shown that empathy can directly increase moral sensitivity in nurses ( ^{Kim et al., 2022; Rezapour-Mirsaleh et al., 2022}). Professional nursing values also play a crucial role in influencing moral sensitivity ( ^{Chen et al., 2021}). These values encompass the structured beliefs and attitudes held towards the nursing profession and responsibilities associated with nursing practice ( ^{Poorchangizi et al., 2019}). Studies have demonstrated that nursing students’ moral sensitivity positively influences their ethical behavior, as evidenced by their ability to integrate professional values and ethical codes to navigate ethical dilemmas effectively through moral judgment and reasoning ( ^{Kim and Park, 2019}).

Most research on moral sensitivity has concentrated on examining its general level and influencing factors using variable-centered methods (e.g., regression analysis) ( ^{Amiri et al., 2019; Chen et al., 2021; Comrie, 2012; Ergin et al., 2022; Escolar-Chua, 2018; Lee and Kim, 2020}), which overlook the individual heterogeneity of moral sensitivity among nursing students. Latent Profile Analysis (LPA), a person-centered approach, can delve deeply into data and classify individuals from a heterogeneous population into homogeneous subgroups ( ^{Liu et al., 2023}). LPA not only enables a more precise understanding of the underlying categorical structure of moral sensitivity in nursing undergraduates, but also helps identify students who need intervention and areas requiring targeted interventions ( ^{Spurk et al., 2020}). Furthermore, LPA has been used in research on many psychological attributes, such as examining empathic competence profiles in nursing interns ( ^{Wang et al., 2024}). Therefore, applying LPA allows identification of previously unobserved moral sensitivity subgroups and thus better understanding of their latent characteristics.

However, no study has attempted to identify distinct categories of nursing students’ moral sensitivity using LPA. Moreover, despite several studies examining the psychological factors influencing the moral sensitivity of nursing students, research exploring variations across specific latent profiles remains scarce. The present study seeks to fill this gap by employing a latent profile model to distinguish patterns of nursing students’ moral sensitivity and delve into the effects of sociodemographic factors (e.g., sex) and intrinsic psychological factors (i.e., personality traits, empathy and professional nursing values) on these distinct profiles. These findings are expected to provide valuable insights for developing tailored and effective support strategies, ultimately fostering moral sensitivity in nursing students.

2 Methods
2.1 Design

This is a cross-sectional study based on an online survey, which focused on undergraduate nursing students from three medical universities in Jiangxi Province, China.

2.2 Participants and procedures

From March 2024 to May 2024, a cross-sectional study was conducted using convenience sampling at three medical universities in Jiangxi Province, China. All participants were nursing undergraduates with full-time undergraduate enrolment, aged ≥ 18 years old and who consented to participate in this study. Students were excluded if they requested to withdraw from the study. The sample size of this study was calculated based on the requirements for Latent Profile Analysis (LPA), which typically requires a minimum of 500 participants to ensure robust model estimation and ensure sufficient statistical power detect meaningful latent classes ( ^{Nylund et al., 2007}). Considering a potential non-response rate of 20 %, we set a target sample size of 600 participants.

Data collection involved an anonymous online self-reported questionnaire, designed to take approximately 8–10 minutes to complete. Before starting the study, an online recruitment poster was shared via class-specific WeChat groups. The poster included a brief introduction to the study purpose, procedures and a link to the questionnaire. On clicking the link, participants were first directed to an informed consent page, where detailed information about the study background, participation process and confidentiality assurances was provided. Participants could proceed to the questionnaire only after agreeing to participate in the study. To minimize the risk of participant fatigue, we included progress indicators in the survey to allow participants to pause or navigate through the questionnaire at their own pace. Besides, the survey was designed to ensure no sensitive personal information was collected. Each IP address could access the questionnaire only once to avoid duplicate enrolment. The online survey remained open until the target number of students was reached. In total, 725 students were enrolled and after excluding incomplete, similar, or invalid data, 716 valid responses were obtained (response rate: 98.76 %).

2.3 Ethical consideration

Ethical approval for this study was obtained from the Gannan Medical University Institutional Review Board (2023630). Participants were informed about the study purpose, procedure and an explanation of what was expected of them before providing informed consent. And they were assured of voluntary involvement, anonymity and the confidentiality of their data.

2.4 Measures
2.4.1 Socio-demographic characteristics of participants

Guided by previous studies ( ^{Bilgiç, 2022, Comrie, 2012, Tuvesson and Lützén, 2017}), a set of socio-demographic variables was incorporated into the personal information form, which included age, gender, grade, monthly living expenses, location of the home, whether the only child, student cadre experience (serving as a student cadre or not), the first choice of major in the college entrance examination (nursing specialty or not) and relatives engaged in medically related employment (have or not).

2.4.2 Ten-item personality inventory, Chinese version (TIPI)

The TIPI is a self-reported instrument designed to measure personality traits ( ^{Gosling et al., 2003}). It includes 10 items rated on a 7-point scale (1 =strongly disagree, 7 =strongly agree) with five dimensions: extraversion, agreeableness, conscientiousness, emotional stability/neuroticism and openness. Sample statement: “I see myself as extraverted (enthusiastic).” Each dimension is represented by two items, with higher scores indicating higher levels of personality traits. The Chinese version has demonstrated adequate reliability and validity ( ^{Shi et al., 2022}). In this study, the Cronbach’s alpha was 0.745 for the TIPI.

2.4.3 Moral sensitivity questionnaire for nursing students (MSQ-ST)

The MSQ-ST is designed to measure moral sensitivity among nursing students ( ^{Takizawa et al., 2021}). It has 11 items to evaluate three domains, including four items to evaluate moral strength, five to evaluate moral burden and two to evaluate moral responsibility. A sample item is “I believe that I have an excellent ability to notice when patients are not receiving adequate care.” All items were rated on a 6-point scale (1 = completely disagree, 6 = completely agree). Moral strength and burden were calculated by adding the corresponding items and moral responsibility was reverse scored. The total scores summed the moral strength, moral burden and inverted moral responsibility scores, with a higher score suggesting a greater sense of moral sensitivity. The Chinese version of the MSQ-ST has demonstrated good reliability and validity ( ^{Hanjing et al., 2023}). Cronbach’s alphas were 0.74, 0.87, 0.79 and 0.70 for the MSQ-ST scale, moral strength, moral burden and moral responsibility, respectively.

2.4.4 Nursing professional values scale (NPVS)

The NPVS was used to assess the nursing students’ professional values ( ^{Weis and Schank, 2000; Chen, 2007}). It includes four dimensions: caregiving (ten items); activism (eight items); accountability, freedom and safety (five items); and trust (three items). Responses indicated the level of professional nursing values on a 5-point Likert scale ranging from 1 (not important) to 5 (most important). Total scores range from 26 to 130, with higher scores indicating higher professional nursing values. The Chinese version of the NPVS has demonstrated sound reliability and validity ( ^{Chen, 2007}). Cronbach’s alpha coefficient for the NPVS was 0.980 in the current study.

2.4.5 Jefferson scale of empathy (JSE)

The JSE was used to measure the empathetic ability of participants in patient care ( ^{Hojat et al., 2002; L, 2009}). It includes 20 items and three subscales: perspective-taking (10 items), compassionate care (8 items) and standing in patients’ shoes (2 items). Each item was measured on a seven-point scale (1 = strongly disagree, 7 = strongly agree), with 10 items scored in both the forward and reverse directions, resulting in a total score ranging from 20 to 140. Higher scores indicated higher levels of empathy. The Chinese version of the JSE has been reported to be reliable ( ^{L, 2009}). In this study, the total scale yielded a Cronbach’s alpha of 0.880.

2.5 Data analysis

R software (4.4.0 version) was used to conduct LPA and identify moral sensitivity subgroups based on the Z-scores of the three MSQ-ST dimensions. We measured the comparative model fit using the following conventional indices: the Akaike information criterion (AIC), Bayesian information criterion (BIC), Lo-Mendell-Rubin adjusted likelihood ratio test (LMRT), bootstrapped likelihood ratio test (BLRT) and entropy. Lower AIC, BIC and ABIC values indicated a better model fit. The LMRT and BLRT compared model fit improvements between two neighboring models and a significant value indicated that the k-class model was significantly better than the k-1-class model ( ^{Burnham and anderson, 2004}). Entropy values of 0.8 or higher indicated high classification accuracy ( ^{Spurk et al., 2020}). After determining the potential profiles, we used analysis of variance (ANOVA) and the Bonferroni test to test differences among the identified profiles. Partial eta squared (η2) was computed to obtain an effect size index. Differences in demographic and psychological variables were analyzed using chi-square and ANOVA tests for these profiles. Multinomial logistic regression analysis was performed to examine the association between moral sensitivity profiles and the independent variables. SPSS (version 26.0) was used for all analyses.

3 Results
3.1 Descriptive statistics and correlations

A total of 716 nursing undergraduates (85.6 % were females and 14.4 % were males) were included in the study, with a mean age of 20.19 (SD 1.53; range 17–26 years). Nearly half were first-year students (43.6 %) and 69.2 % had monthly living expenses of ≤ 1500 Chinese yuan; Over half of students resided in rural areas (63.8 %) and 90.6 % were not-only children. 71.4 % of them didn’t hold any student positions and 54.7 % o reported their first choice of major in the college entrance examination was a nursing specialty. Additionally, 24.4 % presented that they had relatives engaged in medical employment. For the three MSQ-ST subscales, the mean scores of moral strength, moral burden and moral responsibility were 17.89 (SD 2.06), 21.22 (SD 2.65) and 7.17 (SD 2.19), respectively. Furthermore, the mean scores of the three subscales were 4.47 (SD 0.51), 4.25 (SD 0.53) and 3.59 (SD 1.10), respectively. The mean score of extraversion, agreeableness, conscientiousness, emotional stability and openness were 8.22 (SD 2.00), 10.02 (SD 1.61), 9.29 (SD 1.77), 8.32 (SD 2.22) and 9.00 (SD 1.65), respectively. The mean scores for professional nursing values and empathy were 95.22 (SD 16.38) and 97.27 (SD 12.36), respectively.

3.2 Latent profile analysis for QoL

We estimated the model with 1–4 latent profiles and the model fit statistics are presented in ^{Table 1}. As the number of latent profiles increased, the AIC and BIC gradually decreased, whereas the LMRT and BLRT yielded statistically significant results when comparing models with k and k-1 classes. The 3-class model exhibited significant P-values of the LMRT and BLRT when compared with the 2-class model, thereby leading to the rejection of the latter. Although the 4-class model significantly outperforms the 3-class model, it unveiled a subgroup comprising nearly 5 % of the sample, suggesting that categorizing individuals into four or more profiles would not yield a representative classification. Moreover, the 3-class model had the highest entropy compare with the other profiles; thus, it was chosen for the final analysis.

^{Table 3} and ^{Fig. 1} show the Z-scores of the three subscales for the three classes. ANOVA and Bonferroni post-hoc tests revealed differences in the MSQ-ST subscale scores across all three profiles ( P < 0.001). Class 1, with 70 nursing students (9.7 %), was characterized by the highest scores for moral strength and burden but the lowest scores for moral responsibility and was named the “moral idealists” subgroup. Class 2 (n = 229, 32.0 %) was characterized by the highest moral responsibility, moderate moral strength and burden and was consequently named the “moral undertakers” subgroup. Class 3, with 417 participants (58.3 %), was characterized by low moral strength, moral burden and moral responsibility and was labeled as the “moral skeptic” subgroup.

3.3 Comparison of socio-demographic and other variables in each latent profile

^{Tables 1 and 3} summarize the results of the ANOVA in analyzing possible differences in sociodemographic and psychological variables (moral sensitivity, Big Five personality traits, moral empathy, professional nursing values) by the three profiles. Among these variables, age, grade level, being an only child status, agreeableness, conscientiousness, emotional stability, empathy and professional nursing values exhibited statistically significant differences among the three profiles (all P < 0.05). Additionally, no significant differences existed with respect to gender, monthly living expenses, location of home, student cadre experience, first choice of major, relatives engaged in medical employment, extraversion, or openness among the three classes (all P > 0.05).

3.4 Association of the three profiles with socio-demographic, personality, professional nursing values and empathy

We used multinomial logistic regression to analyze how moral sensitivity profiles were linked to sociodemographic and psychological factors. Class 3 (“moral skeptic” group) was considered as the baseline comparison reference profile. Only variables significantly linked to moral sensitivity in the univariate analysis were included in the regression. Therefore, grade level (fourth year as the reference), being an only child (“not being an only child” as the reference), age, agreeableness, conscientiousness, emotional stability, professional nursing values and empathy were considered as independent variables in the multinomial logistic regression analysis.

The results of the logistic regression analyses were shown in ^{Fig. 2}, compared with Class 3 (“moral skeptic” group), students who were only children (OR=2.641[1.077, 6.476]) and possessing higher level of professional nursing values (OR=1.071[1.049, 1.094]) and empathy (OR=1.034[1.009, 1.060]) were associated with the increased likelihood of belonging to Class 1 (“moral idealists” group). And nursing undergraduates with higher levels of emotional stability (OR=0.360[0.302, 0.430]) and conscientiousness (OR=0.481[0.223, 0.794]) were more likely to belong to the “low moral sensitivity” profile.

Additionally, Class 2 (“moral undertakers” group) was compared with Class 3 (“moral skeptic” group, reference). Specifically, students who were only children were more inclined to be in the “moral skeptic” group (OR=0.391[0.107, 0.560]); and those in their third year of academic study exhibited higher odds of belonging to the “moral skeptic” group compare with fourth-year students (OR=0.195[0.082, 0.460]). Nursing students who demonstrated higher levels of agreeableness (OR=1.763[1.235, 1.917]), conscientiousness (OR=2.696[2.228, 3.262]), professional nursing values (OR=1.016[1.000, 1.032]) and empathy (OR=1.041[1.019, 1.065]) and lower level of emotional stability (OR=0.697[0.598, 0.811]) were more likely to belong to the “moral undertakers” group.

4 Discussion

The current study is the first to identify the heterogeneity of moral sensitivity using LPA via the MSQ-ST in nursing students and to further examine the psychological variables and demographic data associated with moral sensitivity profiles. We identify three distinct profiles: moral idealists “moral idealists,” “moral undertakers,” and “moral skeptic” and “moral skeptics”. Furthermore, moral sensitivity profile traits were associated with demographic and psychological indicators (i.e., grade, being an only child, agreeableness, conscientiousness, emotional stability, empathy and professional nursing values). These findings may contribute to the development of tailored interventions to improve moral sensitivity in nursing students.

The “moral idealists” profile (7.9 %) exhibited the highest level of moral strength and burden and lowest moral responsibility. This suggests that while some students may possess the capability to act morally, they may not consistently exhibit a corresponding sense of accountability in their actions or adhere strictly to ethical standards, yielding a highlighted moral burden and raising concerns. The “moral undertakers” profile (22.0 %) presented the middle levels of moral strength and burden, the highest levels of moral responsibility. Students in this group demonstrated proficiency in promptly recognizing potential ethical conflicts and dilemmas, as well as possessing a heightened sense of moral awareness and responsibility, which facilitated their ability to navigate ethical decision-making processes effectively. However, acknowledging that they bear significant moral burdens is important. The largest profile was “moral skeptic” subgroup, accounting for 58.3 % of nursing students, they exhibited lowest levels of moral strength and burden and second lowest level of moral responsibility. Thus, they should prioritize moral education. These findings suggest that nursing students’ perceptions of moral sensitivity vary and exhibit individual differences. Our results are inconsistent with those of one study on variable-centered research on moral sensitivity in nurses, which showed the existence of three distinct moral sensitivity profiles (i.e., low, moderate and high moral sensitivity) ( ^{Zhang et al., 2020}). This discrepancy could be mainly attributed to sample and measurement differences.

In our study, compared with third-year nursing students (reference group: moral skeptic), fourth-year nursing students were more likely to belong to the “moral undertakers” subgroup. This aligns with previous research showing that senior nursing students tend to demonstrate higher levels of moral sensitivity than their junior counterparts ( ^{Park et al., 2012}). This may be attributed to the limited exposure of nursing students in lower grades to ethical dilemmas compare with their senior counterparts, who are more likely to encounter ethical conflicts in clinical settings and possess more related professional practice and experience. Thus, nursing educators should augment ethics instruction and offer increased clinical practice opportunities to students in the earlier stages of their education ( ^{Dehghani, 2020; Escolar-Chua, 2018}). Moreover, compared with not-only children (reference group: moral skeptic), the only children had a higher likelihood of belonging to the “moral idealists,” not “moral undertakers” subgroups. This can be related to only child characteristics; that is, students who lack siblings may exhibit self-centeredness, heightened self-awareness and challenges in understanding others’ perspectives and emotions ( ^{Karos et al., 2007}), potentially affecting their moral discernment and sense of accountability in nursing. While they may feel a heightened sense of moral awareness owing to familial or personal expectations, excessive nurturing can hinder their development of independence and responsibility. Therefore, greater emphasis should be placed on enhancing the moral sensitivity of only children to improve their ethical development.

In terms of personality traits, compare with low levels of conscientiousness and agreeableness (reference group: moral skeptic), students with higher levels of agreeableness are more likely to be classified into the “moral undertakers” group, higher levels of conscientiousness can be classified into the “moral undertakers” group, not “moral idealists” group. Furthermore, nursing students with higher levels of emotional stability were associated with an increased likelihood of belonging to the “moral skeptics” group. Specifically, conscientious individuals may demonstrate characteristics such as strong determination, reliability, persistence and adherence to rules and ethical standards. Studies have shown that conscientiousness is a significant predictor of moral responsibility ( ^{Cleary and Lees, 2019}), moral courage ( ^{Pakizekho and Barkhordari-Sharifabad, 2022}) and job performance ( ^{Alan and Baykal, 2018}) among nurses. Conscientious nurses typically exhibit heightened self-control and a strong sense of duty to act as the patients’ advocates, actively recognizing ethical complexities, evaluating potential outcomes and assuming accountability ( ^{Cleary and Lees, 2019}). Conversely, individuals with low conscientiousness may avoid responsibility and prioritize individual interests over collective interests, leading to hesitation and avoidance in ethical situations. This mindset categorizes nursing students within a group characterized by high moral awareness but low accountability, wherein they acknowledge ethical issues yet fail to take proactive measures due to a lack of responsibility. Agreeableness involves altruism, concern, sympathy, trust and a willingness to cooperate with others, contributing to heightened moral sensitivity ( ^{Abbasi-Asl and Hashemi, 2019}). Research has indicated that nurses exhibiting elevated levels of conscientiousness and agreeableness are more inclined to display enhanced personal accountability and moral awareness, leading to a reduced incidence of missed nursing care ( ^{Drach-Zahavy and Srulovici, 2019}). Emotional stability or neuroticism is often linked to an individual’s emotional state, stress management and sensitivity to external influences ( ^{Bolger and Schilling, 1991}). Students with high neuroticism exhibit increased concern about the outcomes of their actions because of heightened emotional sensitivity, thus demonstrating an elevated sense of moral burden. Hence, when developing moral sensitivity in students with neurotic traits, considering their emotional states and implementing strategies to alleviate their moral burdens is crucial.

Most saliently, nursing students with lower empathy and professional nursing values are more likely to belong to the “moral skeptic” subgroup. Empathy is essential for high-quality nursing care. Studies have shown that high empathy allows nurses to deeply understand patients’ emotions and needs, advocate for patients’ rights and engage in rational and ethical decision-making ( ^{Ter Heide, 2020}). This finding was confirmed among the nursing students ( ^{Liu et al., 2023; Türkmen et al., 2023}), indicating that empathic competence is beneficial and significant in enhancing moral sensitivity. Empathy also enables nursing students to understand patients’ suffering and situations, thereby enhancing their clinical interpersonal connections and communication ( ^{Bilgiç, 2022}). Consequently, actively cultivating the empathy levels of nursing students is recommended to promote their moral sensitivity. Additionally, nurses with strong professional values typically exhibited heightened moral sensitivity, which is supported by previous studies ( ^{Chen et al., 2021; Kim et al., 2015}). Haghighat et al. discovered a significantly positive association between nursing students’ moral competence and professional identity ( ^{Haghighat et al., 2020}). Other studies have demonstrated that nursing students experiencing difficulties establishing a professional identity may demonstrate unfavorable professional values and competence, resulting in a propensity to disregard clinical ethical considerations and engage in irrational decision-making ( ^{Chen et al., 2021; Dehghani, 2020}). A possible explanation may be that nursing students with a strong sense of professional values tend to hold themselves to higher professional obligations and moral standards, thereby fostering a heightened inclination to actively deliver care and support to patients and safeguard their rights ( ^{Johnson, 2021; Lee et al., 2017; Ranjbar et al., 2017}). Our findings suggest that cultivating professional nursing values is crucial for nurturing students’ intrinsic motivation and aptitude for nursing profession, enhancing their ethical awareness and promoting the advancement of the nursing profession.

Research has reported that moral sensitivity, empathy and professional nursing values are teachable and learnable ( ^{Kaya and Dalgiç, 2021, Kim and Park, 2019, Levett-Jones et al., 2019}). However, the development of these qualities is a continuous and long-term process that begins during nursing education and continues throughout professional practice ( ^{Engbers, 2020, Kantek et al., 2017, Kim and Park，2019}). The educational process plays a foundational role, serving as the starting point for cultivating ethical awareness and moral sensitivity ( ^{Yeom et al.，2017, Kim and Park, 2019}). Our study suggests that a structured educational program focusing on empathy and professional nursing values may serve as an effective approach to promoting moral sensitivity in nursing students. Various interventions integrating theoretical learning and practical experiences have been attempted and confirmed to be effective in improving empathy. These include communication skills training, reflective practices, patient experience simulations, nurse role-play simulations, confluent educational strategies and listening to patients’ voices ( ^{Engbers, 2020}). Moreover, recent systematic reviews indicate that immersive and experiential simulation-based interventions are the most effective in fostering empathy ( ^{Levett-Jones et al., 2019}). Importantly, elevated empathy in nursing students has been shown to correlate with stronger professional values. Clinical practice, where students demonstrate empathy in real patient interactions, further provides opportunities to shape and reinforce professional values through experiential learning ( ^{Su et al., 2020}). The integration of empathy and professional nursing values into education holds significant potential for cultivating moral sensitivity. However, the development of these attributes is also influenced by cultural background, personal experiences, supportive institutional policies and mentorship from role models. Understanding and addressing these multifaceted influences, rather than an isolated intervention, can better prepare students to navigate ethical challenges in healthcare settings.

5 Limitations

This study had several limitations. First, the relatively limited sample size included only three undergraduate medical colleges in Jiangxi Province, which may weaken the representativeness and generalizability of the findings. Future research should increase the sample size and include various regions to offer a more comprehensive understanding of moral sensitivity among undergraduate nursing students. Second, while robust quantitative statistical methods were used to examine the proposed relationships, the cross-sectional nature of the study prevented confirmation of causation. Longitudinal research should be conducted to further explore the associations derived from the results of this study. Third, the data collection method in this study predominantly used self-reporting by nursing students, potentially leading to social desirability bias. Finally, this study focused exclusively on sociodemographic factors, personality traits, empathy and professional nursing values as determinants. Future research should consider broader variables to comprehensively analyze the factors influencing the moral sensitivity of nursing students. Despite these limitations, our study showed the benefits of using LPA to identify moral sensitivity profiles and examine the role of psychological indicators in influencing moral sensitivity among nursing students. These results provide guidance for the formulation of targeted interventions for different moral sensitivity subgroups.

6 Conclusions

This study used LPA to identify three categories of moral sensitivity among nursing students, illuminating the varied characteristics within these groups and filling a gap in the existing literature. The moral sensitivity of undergraduate nursing students varies based on sociodemographic characteristics and personality traits, with professional nursing values and empathy emerging as significant predictors of moral sensitivity in this population. These results offer a new perspective for developing tailored intervention initiatives aimed at enhancing the moral sensitivity of nursing students.

Funding

This work was supported by the humanities and social sciences of Jiangxi Higher Education Institutions Project [grant numbers 22Y1716].

Author Statement

All the authors have approved the manuscript and agree with submission to your esteemed journal. There are no conflicts of interest to declare. All the authors have read and approved the final version of the manuscript.

CRediT authorship contribution statement

Wen Chao: Writing – review & editing, Writing – original draft, Investigation, Data curation, Conceptualization. Huang Wen: Writing – original draft, Investigation, Formal analysis, Data curation. Sun Yingyin: Investigation, Formal analysis, Data curation. Luo Qing: Methodology, Investigation, Formal analysis, Data curation. Liu Chunqin: Methodology, Investigation, Formal analysis, Data curation. Xiao Jiajian: Investigation, Data curation. Yin Ling: Writing – review & editing, Writing – original draft, Supervision, Project administration, Methodology, Conceptualization.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgments

We sincerely appreciate all the participants who completed the questionnaires and enabled this study.

Table 1

Participants’ sociodemographic characteristics in different profile types (N = 716).

Variables M (SD) or n (%)	Class 1 n (%) 70 (9.7)	Class 2 n (%) 229 (32.0)	Class 3 n (%) 417 (58.3)	Total n (%) 716 (100)	F/χ 2	P
Age (years)	20.41 (1.51)	19.91 (1.47)	20.22 (1.54)	20.19 (1.53)	4.378	0.013
Gender
Male	26 (25.2)	23 (22.3)	54 (52.4)	103 (14.4)	2.584	0.275
Female	115 (18.8)	135 (22.0)	363 (59.2)	613 (85.6)
Grade
Fist-year	46 (14.7)	83 (26.6)	183 (58.7)	312 (43.6)	26.221	< 0.001
Second-year	35 (24.3)	33 (2.9)	76 (25.6)	144 (20.1)
Third-year	39 (24.4)	15 (9.4)	106 (66.3)	160 (22.3)
Fourth-year	21 (21.0)	27 (27.0)	52 (52.0)	100 (14.0)
Location of home
City/Town	25 (20.1)	63 (24.3)	144 (55.6)	259 (36.2)	1.454	0.483
Rural	89 (19.5)	95 (20.8)	273 (59.7)	457 (63.8)
Monthly living expenses (CNY)
≤1500	89 (18.0)	109 (22.0)	297 (60.0)	495 (69.2)	6.677	0.154
1501–1900	40 (21.6)	40 (21.6)	105 (56.8)	185 (25.8)
≥ 2000	12 (33.3)	9 (25.0)	15 (41.7)	36 (5.0)
Only child
Yes	20 (29.9)	17 (25.4)	30 (44.8)	67 (9.4)	6.540	0.038
No	121 (18.6)	141 (21.7)	387 (59.6)	649 (90.6)
Student cadre experience
Yes	46 (22.4)	45 (22.0)	114 (55.6)	205 (28.6)	1.443	0.486
No	95 (18.6)	113 (22.1)	303 (59.3)	511 (71.4)
First choice of major
Nursing specialty	65 (20.1)	78 (24.1)	181 (55.9)	324 (45.3)	1.695	0.429
Others	76 (19.4)	80 (20.4)	236 (60.2)	392 (54.7)
Relatives engaged in medical employments
Have	40 (22.9)	40 (22.9)	95 (54.2)	175 (24.4)	1.865	0.394
None	101 (18.7)	118 (21.8)	322 (59.5)	541 (75.6)

Table 2

Model fit indices for the compared latent profiles (n = 716).

Model	AIC	BIC	LMRT P-value	BLRT P-value	Entropy	Category probability
						1	2	3	4
1-class	4335.22	4362.66	NA	NA	NA	NA
2-class	3919.02	3964.75	< 0.001	0.01	0.82	0.245	0.755
3-class	3591.99	3656.02	< 0.001	0.01	0.90	0.097	0.320	0.583
4-class	3556.29	3638.62	< 0.001	0.01	0.89	0.229	0.185	0.535	0.051

Table 3

Analysis of variance of each scale between three latent classes.

Variables	Class 1 (n = 70)	Class 2 (n = 229)	Class 3 (n = 417)	P	Partial η2	Bonferroni post-hoc test
	M (SD)	M (SD)	M (SD)
MSQ-ST subscales:
Moral strength	20.55 (1.58) a	17.99 (1.48) b	16.95 (1.52) c	< 0.001	0.452	a>b>c
Moral burden	24.87 (1.90) a	21.76 (1.79) b	19.79 (1.72) c	< 0.001	0.553	a>b>c
Moral responsibility	5.16 (1.54) a	10.61 (1.05) b	6.55 (0.84) c	< 0.001	0.765	a<c<b
TIPT subscales:
Extraversion	8.33 (2.24) a	8.18 (2.18) b	8.19 (1.85) c	0.764	0.001	/
Agreeableness	10.33 (1.88) a	10.16 (1.58) b	9.69 (1.50) c	0.020	0.234	a>b>c
Conscientiousness	8.30 (2.00) a	10.51 (1.29) b	8.95 (1.65) c	< 0.001	0.421	a<c<b
Emotional stability	6.18 (2.76) a	8.57 (1.67) b	8.98 (1.72) c	< 0.001	0.564	a<b<c
Openness	9.15 (1.89) a	9.06 (1.70) b	8.92 (1.54) c	0.311	0.003	/
Empathy	103.06 (13.36) a	99.77 (13.17) b	94.36 (10.72) c	< 0.001	0.750	a>b>c
Professional nursing values	106.83 (14.37) a	96.39 (17.02) b	90.85 (14.73) c	< 0.001	0.642	a>b>c