Ethical decision-making confidence among nurse leaders: a mixed-methods study of determinants and ethical...

In today's complex healthcare environment, ethical decision-making confidence (EDMC) among nurse leaders plays a pivotal role in ensuring ethically sound nursing practice. While prior research has primarily emphasized ethical competence, empirical investigation of EDMC and its determinants among nurse leaders remains limited. This study aimed to assess the level of EDMC among nurse leaders in Guizhou Province and to identify its key influencing factors to inform targeted intervention strategies.

A sequential explanatory mixed-methods design was adopted. In the quantitative phase, 611 nurse leaders from secondary and tertiary hospitals in Guizhou Province were recruited through convenience sampling. Data were collected using the Ethical Decision-Making Confidence Scale (EDMC), the Chinese version of the Rushton Moral Resilience Scale (RMRs), and the Hospital Ethical Climate Survey (HECS). Univariate analyses and stepwise multiple linear regression were performed to identify independent predictors of EDMC. In the qualitative phase, purposive sampling and semi-structured interviews were conducted to further explain quantitative findings, and data were analyzed using Colaizzi's seven-step method.

Nurse leaders demonstrated overall moderate-to-high levels of EDMC, with nearly one-third reporting insufficient confidence. Moral resilience (β = 0.42, p < 0.001), hospital ethical climate (β = 0.35, p < 0.001), and professional title (β = 0.16, p = 0.021) were identified as significant predictors of EDMC. Qualitative analysis identified three interrelated domains influencing EDMC: individual factors (e.g., limited moral resilience and burnout), organizational factors (e.g., inadequate ethical climate and managerial support), and societal factors (e.g., resource constraints and public pressure).

EDMC among nurse leaders is shaped by the interaction of individual psychological resources, organizational environments, and societal influences. Although confidence levels were generally high, notable vulnerability persists in ethically complex contexts. Interventions aimed at strengthening moral resilience, improving ethical climate, and providing structured ethics training may enhance ethical decision-making confidence. By focusing on ethical decision-making confidence rather than competence alone, this study offers empirically grounded insights for leadership development and ethics education.