The mediating roles of self-efficacy and professional identity in the association between internship environment and voice behavior among nursing interns: a multicenter cross-sectional study

In the high-stakes environment of modern healthcare, patient safety depends heavily on clear, unobstructed communication among medical professionals. Yet, for nursing interns stepping into real-world clinical settings for the first time, breaking the silence to report procedural errors, flag safety concerns, or propose workflow improvements remains a daunting challenge. A comprehensive new multicenter cross-sectional study published in Frontiers in Psychology sheds light on this critical issue, investigating how the clinical internship environment shapes nursing students’ willingness to speak up—a concept formally known as voice behavior—through the psychological mechanisms of self-efficacy and professional identity.

Conducted between January and February 2026 across three major tertiary teaching hospitals in Hunan Province, China, the research offers a deep dive into the psychological and environmental factors that either empower or silence the next generation of healthcare workers. As health systems worldwide grapple with persistent nursing shortages and mounting pressures on patient care quality, understanding what drives nursing interns to voice safety concerns has never been more urgent.

Background Context and the Global Nursing Shortage

The backdrop of this study is framed by an escalating global shortage of nursing professionals, placing immense pressure on healthcare delivery systems. To bridge this workforce gap, nursing interns serve as an essential reserve force, transitioning from academic lecture halls to fast-paced hospital wards where they participate directly in patient care under supervision.

However, clinical environments are historically hierarchical. Authority gradients, limited practical experience, and a lingering fear of negative evaluations by senior staff often create psychological barriers. These obstacles discourage junior personnel from questioning established practices or pointing out vulnerabilities. In healthcare, this silence can carry severe consequences. Scholars generally categorize voice behavior into two distinct dimensions: promotive voice, which involves proactive suggestions for organizational or operational improvement, and prohibitive voice, which centers on highlighting risks, clinical mistakes, or harmful practices. Both dimensions are vital for safeguarding patients and refining hospital workflows. When interns notice safety hazards but choose to remain silent, the margin for medical error widens, underscoring the necessity to identify what encourages them to speak out.

Study Design, Methodology, and Sample Characteristics

Led by a team of researchers including corresponding author Wei Cui from Central South University, the investigation adhered strictly to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. Using convenience sampling, the study targeted nursing interns actively undergoing clinical rotations at three tertiary hospitals in Hunan Province.

To determine an adequate sample size, researchers utilized G*Power software, calculating a minimum requirement of 227 participants based on a medium effect size, a significance level of 0.05, and high statistical power. Ultimately, the study distributed 520 questionnaires, yielding 498 valid, complete responses for a high response rate of 95.8%.

The demographic profile of the participants reflected typical nursing education cohorts: the mean age of the interns was 21.09 years, with a vast majority identifying as female (85.1%). Educational backgrounds varied, comprising vocational training students (46.2%), bachelor’s degree candidates (48.0%), and master’s degree candidates (5.8%). More than half of the participants (61.6%) had completed over six months of their internship duration. Notably, when assessing perceived internship stress, 56.8% reported moderate stress levels, while roughly 30% reported relatively high or very high stress.

Data collection relied on validated psychometric instruments. The Clinical Practice Environment Scale evaluated teaching methods, teacher quality, learning opportunities, interpersonal relationships, working atmosphere, and organizational support. Self-efficacy was measured using the General Self-Efficacy Scale, professional identity via a specialized nursing student questionnaire covering five core dimensions, and voice behavior through a dedicated scale capturing both promotive and prohibitive actions.

Key Findings: Environmental Support and Psychological Pathways

The empirical results revealed robust positive correlations across all core variables. Pearson correlation analyses demonstrated that a supportive internship environment was strongly correlated with higher overall voice behavior ($r = 0.553, p < 0.001$), enhanced self-efficacy ($r = 0.498, p < 0.001$), and a stronger professional identity ($r = 0.538, p < 0.001$). Furthermore, self-efficacy and professional identity were both heavily tied to the frequency of voice behaviors exhibited by the interns.

To dissect these associations further, the researchers applied Social Cognitive Theory (SCT) as a foundational framework, utilizing the PROCESS macro (Model 6) with 5,000 bootstrap resamples. After controlling for demographic variables, education, household registration, leadership experience, and perceived internship stress, the mediation analysis confirmed significant individual and combined indirect effects.

The statistical breakdown highlighted that the internship environment influences voice behavior through distinct psychological pathways:

• Self-Efficacy: Acting as a measure of perceived capability, self-efficacy accounted for a significant indirect effect, reflecting how supportive supervision and constructive feedback bolster an intern’s confidence to accept interpersonal risks and articulate ideas.
• Professional Identity: Serving as an internalized sense of professional responsibility and values, professional identity provided a motivational and ethical basis for speaking up in defense of patient safety.
• Combined Indirect Effects: The dual pathway involving both self-efficacy and professional identity demonstrated that confidence and professional commitment operate synergistically to empower proactive communication.

Interestingly, the data indicated that the total indirect effect played a more prominent role in prohibitive voice (accounting for 62.48% of the total effect descriptively) compared to promotive voice (49.47%). Because prohibitive voice involves confronting errors, risks, or rule violations, it is inherently more intimidating in hierarchical medical settings, requiring robust psychological resources and deep professional commitment from junior staff.

Implications for Clinical Education and Hospital Management

The implications of these findings extend far beyond academic theory, offering actionable insights for clinical educators, hospital administrators, and nursing mentors. In light of the data, healthcare institutions must move away from rigid, punitive hierarchies and actively cultivate psychologically safe environments.

Clinical educators are encouraged to implement structural changes that encourage open dialogue. These measures include establishing transparent, stigma-free reporting channels for patient safety concerns, providing regular mentorship, and ensuring that supervisors respond constructively to student feedback. Furthermore, nursing programs and hospital orientation modules should integrate training in assertive communication, conflict resolution, and patient safety advocacy. By intentionally fostering professional role modeling and reinforcing positive clinical environments, healthcare organizations can help nursing interns bridge the gap between noticing a safety hazard and having the confidence and professional backing to voice it.

Limitations and Future Research Directions

Despite its rigorous multicenter design and robust sample size, the study acknowledges several limitations. Because the research utilized a cross-sectional design, establishing definitive temporal ordering or causal relationships among the internship environment, psychological mediators, and voice behavior remains impossible. Additionally, reliance on self-reported questionnaires introduces the potential for common method bias, although statistical tests confirmed it did not invalidate the primary findings. Finally, while numerous demographic and professional covariates were controlled for, unmeasured variables such as specific organizational climates and departmental leadership styles may also influence intern behavior.

Future research would benefit from longitudinal study designs tracking nursing students across different phases of their education and into their transition as registered nurses, offering deeper insights into how voice behaviors evolve as clinical experience deepens.