Factors Hindering the Translation of Ethical Knowledge into Clinical Practice among Undergraduate Nursing Interns: A Qualitative Study

Abstract

Background: Undergraduate nursing students typically master core ethical principles through classroom education, yet frequently struggle to translate this knowledge into consistent ethical practice during clinical internships. The specific points of breakdown in the ethical decision-making process remain underexplored in the Chinese clinical context. Objective: Guided by Rest’s Four-Component Model of moral behavior (moral sensitivity, moral judgment, moral motivation, and moral implementation), this study explored barriers to ethical practice among nursing interns and examined how interns negotiate the gap between formal ethical knowledge and clinical reality. Methods: A framework-guided descriptive qualitative study was conducted. Fifteen fourth-year undergraduate nursing students completing clinical rotations at a tertiary hospital in Xi’an, China, were recruited via purposive maximum-variation sampling. Semi-structured in-depth interviews, lasting 45–60 minutes each, were developed around Rest’s four-component framework. Data were analyzed using inductive thematic analysis, informed by Colaizzi’s seven-step method of data reduction, with the aid of NVivo 12 software. Rigor was established through dual independent coding, member checking with a subset of participants, peer debriefing, a comprehensive audit trail, and contrasting case analysis. Results: Four overarching themes and ten subthemes were identified, mapping onto Rest’s four components: (1) selective moral sensitivity—interns readily recognized overt ethical violations but often overlooked subtle ethical dimensions embedded in routine care; (2) distorted moral judgment—hierarchical authority and time pressure displaced principled ethical reasoning, with interns deferring to preceptors; (3) diminished moral motivation—self-protective concerns and rigid teacher–student power relations suppressed the intention to act ethically, though a small subset of interns did act under specific conditions; and (4) blocked moral implementation—perceived gaps in institutional support, heavy workloads, and inadequate practical communication skills prevented ethical intentions from being enacted. Conclusion: The theory–practice gap in nursing ethics manifests as cumulative challenges across all four components of the ethical decision-making chain. Findings suggest that nursing ethics education should shift from knowledge transmission toward situated decision-making skill training, and that clinical institutions should strengthen accessible ethical support systems.