Psychological Capital and Spiritual Well-Being as Predictors of Moral Sensitivity in Nursing Students: A Cross-Sectional Study

Abstract

Introduction

Moral sensitivity is a core component of ethical competence in nursing. However, the role of personal psychological and existential resources particularly psychological capital and spiritual well-being in shaping this sensitivity remains underexplored among nursing students. This study aimed to examine the relationships between psychological capital, spiritual well-being, and moral sensitivity, and to identify their predictive value among nursing students.

Methods

A cross-sectional study was conducted in 2023 among 200 nursing students with census sampling. Validated scales were used to measure psychological capital (PCQ), spiritual well-being (SWBS), and moral sensitivity (MSQ). Hierarchical regression analysis was performed to assess the independent and combined effects of the predictors.

Results

Participants showed relatively high levels of psychological capital (M = 111.5, SD = 14.2) and moral sensitivity (M = 94.2, SD = 12.0), and moderately high spiritual well-being (M = 82.7, SD = 12.2). Strong positive correlations were found between all main variables (r = 0.51–0.61, p < 0.001). Hierarchical regression revealed that both psychological capital (β = 0.38, p < 0.001) and spiritual well-being (β = 0.31, p < 0.001) were significant independent predictors of moral sensitivity, collectively explaining 45% of its variance.

Conclusion

Psychological capital and spiritual well-being appear to be closely related to moral sensitivity in nursing students. This suggests that educational efforts focused on strengthening these inner resources could help foster ethical competence. Future interventional studies are needed to test this possibility.

Keywords

moral sensitivity psychological capital spiritual well-being nursing students cross-sectional studies

Introduction

Moral sensitivity refers to an individual’s ability to recognize their role and responsibilities in ethically challenging situations, detect moral violations, and anticipate their consequences for others.¹ It is a foundational component of ethical decision-making in nursing, enabling professionals to respond empathetically to vulnerable patients and uphold moral principles in clinical practice.^2,3 Nurses with higher moral sensitivity are more likely to demonstrate moral courage, maintain professional integrity, and provide patient-centered care.⁴ However, multiple studies have reported moderate levels of moral sensitivity among nursing students and practicing nurses,^5,6 highlighting the need for early educational interventions to strengthen this competency.

Spiritual well-being, a multidimensional construct encompassing religious and existential aspects, has been recognized as a key influence on moral sensitivity.⁷ Individuals with higher spiritual well-being tend to adopt a holistic perspective on life and demonstrate greater empathy, compassion, and respect for patient dignity.⁸ Among nursing students, higher levels of spiritual well-being are associated with enhanced moral sensitivity and improved quality of spiritual care.⁹ Therefore, cultivating spiritual awareness during nursing education is crucial for nurturing both personal development and the provision of compassionate, ethically grounded care.¹⁰

Similarly, psychological capital, a positive psychological resource comprising hope, efficacy, resilience, and optimism, has gained increasing attention in nursing education and practice.¹¹ Beyond its associations with mental health, academic engagement, and clinical performance,¹² psychological capital may also underpin moral sensitivity by fostering the inner strengths necessary for ethical awareness and action. Specifically, hope motivates individuals to pursue morally desirable outcomes despite challenges; self-efficacy enhances confidence in identifying and addressing ethical issues; resilience enables nurses to sustain moral awareness in stressful or ethically ambiguous situations; and optimism supports the belief that ethical conduct can lead to positive change.¹³ Supporting this perspective, Ren et al (2021) found that psychological capital is significantly associated with professional identity among Chinese nurses¹⁴ a construct closely linked to moral sensitivity, as a strong professional identity reflects internalized ethical values, responsibility toward patients, and moral attentiveness in clinical practice. Yet, these studies have largely treated the constructs separately, with limited attention to their potential interaction or the cultural factors that may moderate their relationships.

Despite the individual relevance of psychological capital and spiritual well-being to moral sensitivity, few studies have proposed an integrated perspective on how these resources interact. We propose that psychological capital, through hope, efficacy, resilience, and optimism, provides the agentic capacity to act on moral insights, while spiritual well-being offers the value-based foundation that guides ethical awareness. In the Iranian context, where nursing education is shaped by collectivist values, religiously informed ethics, and strong emphasis on interpersonal responsibility, this synergy may be especially relevant. Additionally, nursing students at Khoy University of Medical Sciences face significant academic and emotional demands with limited support systems, making personal and spiritual resources critical for sustaining moral sensitivity. Yet, no study has examined how these factors jointly operate in this setting. Understanding their interplay is essential for designing culturally appropriate interventions to strengthen ethical competence among nursing students.^15,16 Therefore, this study aimed to investigate the relationship between psychological capital, spiritual well-being, and moral sensitivity, and to determine their predictive value among nursing students at Khoy University of Medical Sciences in 2023.

Methodology

Study Design and Sampling

This descriptive-analytical, cross-sectional study was conducted from September to December 2023 at the School of Nursing, Khoy University of Medical Sciences, Iran. A census sampling method was used to recruit all eligible undergraduate nursing students in their third semester or higher who were currently enrolled in or had completed clinical training. Inclusion criteria were: (1) enrollment in the third semester or above, (2) active participation in clinical education, (3) willingness to participate, and (4) absence of diagnosed chronic physical or psychological conditions that could affect responses. This criterion ensured that all participants had completed the mandatory nursing ethics course (offered in semester 2 of the university curriculum), which covers ethical challenges and decision-making frameworks in clinical practice. Consequently, all 200 eligible students who met these criteria participated in the study. Exclusion criteria included incomplete questionnaire completion.

All 200 eligible nursing students participated, yielding a 100% response rate with no missing data. Given the small and fully accessible population, a formal sample size or power calculation was not performed; the study included the entire eligible cohort through a census approach.

Two trained nursing students, acting as research assistants, distributed the questionnaires after confirming eligibility. Participants completed the self-report instruments independently and returned them immediately to ensure confidentiality and minimize non-response bias.

Data Collection Tools

Validated, standardized instruments were used to measure the main constructs. All tools have been previously translated into Persian and demonstrated acceptable psychometric properties in Iranian populations.

1). Moral Sensitivity Questionnaire (Lützen, 1994)

The Moral Sensitivity Questionnaire (MSQ) developed by Lützen (1994).¹⁶Moral sensitivity was assessed using the Persian version of the MSQ. The Persian adaptation has been validated among Iranian nursed and nursing students. Abbaszade et al (2008),¹⁷ demonstrating acceptable content validity and internal consistency. It consists of 25 items across six subscales.

• Respect for Patient Autonomy (3 items)

• Awareness of Communication (5 items)

• Professional Knowledge (2 items)

• Experience of Ethical Conflicts (3 items)

• Application of Ethical Principles (5 items)

• Honesty and Benevolence (7 items)

Responses are scored on a 5-point Likert scale (0 = “No Opinion”, 1 = “Strongly Disagree”, 4 = “Strongly Agree”), with total scores ranging from 0 to 100. Higher scores indicate greater moral sensitivity. The Persian version was validated in Iran with a Cronbach’s alpha of 0.80, confirming acceptable internal consistency.¹⁸

2). Spiritual Well-Being Scale (Paloutzian & Ellison, 1983)

The Spiritual Well-Being Scale (SWBS) was used to measure spiritual well-being.¹⁹ In this study, the Persian version of SWBS was used to assess spiritual well-being of nursing students. It includes 20 items rated on a 6-point Likert scale (1 = “Strongly Disagree” to 6 = “Strongly Agree”), with total scores ranging from 20 to 120. The scale comprises two subscales: Religious Well-Being and Existential Well-Being. The Persian version was validated by Khormaee and Zare Bahramabadi (2011), showing acceptable to good internal consistency (Cronbach’s α = 0.86)²⁰ and confirming its suitability for use in Iranian contexts.

3). Psychological Capital Questionnaire (Luthans et al, 2007)

The Persian version of the Psychological Capital Questionnaire (PCQ-24) was used to assess psychological capital. It contains 2 4 items across four dimensions: hope, self-efficacy, resilience, and optimism. Items are scored on a 6-point Likert scale (1 = “Strongly Disagree” to 6 = “Strongly Agree”), with total scores ranging from 24 to 144. The Persian version has demonstrated strong reliability in Iranian military personnel, with a Cronbach’s alpha of 0.93.²¹

The full Persian versions of all questionnaires used in this study are provided as supplementary materials. These instruments have been previously validated in Iranian populations, and their psychometric properties are cited in the text.

4). Demographic Questionnaire

A researcher-developed demographic questionnaire collected information on age, gender, academic semester, marital status, residential status (native/non-native), and religious affiliation. All participants were native Persian speakers. “Non-native” denotes students originating from provinces other than West Azerbaijan (where Khoy is located), who had relocated to Khoy for their education.

Statistical Analysis

Data were analyzed using SPSS version 21. Descriptive statistics (means, standard deviations, frequencies) were used to summarize participant characteristics and main variables. Normality was assessed using the Kolmogorov-Smirnov test and Q-Q plots.

Pearson correlation coefficients were calculated to examine bivariate relationships between moral sensitivity, spiritual well-being, and psychological capital. Independent samples t-tests were used to compare means by gender and marital status. One-way ANOVA was applied to assess differences across academic semesters, with post-hoc Tukey tests for pairwise comparisons.

Hierarchical multiple regression analysis was conducted to determine the independent predictive value of psychological capital and spiritual well-being on moral sensitivity, after controlling for demographic variables. Multicollinearity was assessed using variance inflation factors (VIFs), and model assumptions (linearity, homoscedasticity, normality of residuals) were verified. A p-value < 0.05 was considered statistically significant.

Ethical Considerations

The study was approved by the Ethics Committee of Khoy University of Medical Sciences (Approval No: IR.KHOY.REC.1402.024 approval date: August 13, 2023). Written informed consent was obtained from all participants after a full explanation of the study’s purpose, procedures, confidentiality, and voluntary nature. Participation was entirely voluntary, and participants were informed of their right to withdraw at any time without consequence. All data were anonymized and stored securely.

This cross-sectional study was reported in accordance with the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) statement.²²

Results

The study included 200 participants with balanced gender distribution (50.5% male, 49.5% female). The sample was predominantly single (85%) and non-native (66.5%). Participants averaged 23.17 years (SD=3.10) and were in their 6th academic semester (SD=1.78), indicating a young, mid-program student population (Table 1).

Table 1.

The Characteristics of Study Population

Variables	n (%), mean ± SD	Median (Q1 - Q3)
Age (years)	23.17 ± 3.10	23 (21- 24)
Academic semester	5.82 ± 1.78	6 (4- 7)
3	38 (19.0)
4	17 (8.5)
5	14 (7.0)
6	48 (24.0)
7	40 (20.0)
8	43 (21.5)
Gender
Male	101 (50.5)
Female	99 (49.5)
Residential status
Native	67 (33.5)
Non-native	133 (66.5)
Marital status
Single	170 (85.0)
Married	30 (15.0)

Notes. Age and academic semester are presented as mean ± standard deviation.

Median (25th percentile - 75th percentile) shown for continuous variables.

Categorical variables presented as frequency (percentage).

Table 2 presents descriptive statistics and reliability coefficients for the main study variables. It reports means, standard deviations, medians, score ranges, and Cronbach’s alpha values for Psychological Capital, Spiritual Well-Being, and Moral Sensitivity scales along with their subscales. Participants showed relatively high scores in Psychological Capital (111.5±14.2) and Moral Sensitivity (94.2±12.0), with strong internal consistency (α=0.88 and α=0.86, respectively). Spiritual Well-Being scores were moderately high (82.7±12.2, α=0.77). While most subscales showed acceptable reliability, Resilience (α=0.56) and Ethical Conflicts (α=0.55) had slightly lower consistency, though still adequate for research purposes.

Table 2.

Descriptive Statistics and Reliability of Measured Variables (N = 200)

Variables	No. of items	Mean ± SD	Median (IQR)	Min-Max	Cronbach’s α
Psychological Capital	24	111.49 ± 14.24	113 (103-121)	59-144	0.881
Self-Efficacy	6	28.73 ± 4.44	29 (26-32)	13-36	0.790
Hope	6	28.37 ± 5.01	29 (26-31)	10-36	0.840
Resilience	6	28.00 ± 3.59	28 (26-30)	18-36	0.562
Optimism	6	26.39 ± 4.30	26 (23-30)	16-36	0.591
Spiritual Well-Being	20	82.74 ± 12.24	80 (74-91)	60-120	0.767
Religious Well-Being	10	41.99 ± 6.63	40.5 (37-46.8)	29-60	0.606
Existential Well-Being	10	40.75 ± 6.61	39 (36-46)	27-60	0.686
Moral Sensitivity	25	94.23 ± 11.98	93 (85-101)	75-125	0.855
Respect for Patient Autonomy	3	11.34 ± 2.09	11 (10-13)	7-15	0.627
Awareness of Communication	5	20.74 ± 2.73	21 (19-23)	13-25	0.676
Professional Knowledge	2	6.59 ± 1.85	6 (5-8)	3-10	0.681
Experience of Ethical Conflicts	3	11.69 ± 1.76	12 (10-13)	7-15	0.553
Application of Ethical Principles	5	18.92 ± 2.84	19 (17-21)	12-25	0.644
Honesty and Benevolence	7	24.96 ± 4.57	24 (21-29)	17-35	0.802

IQR (Interquartile Range).

The total scales showed good to excellent reliability (α = 0.77–0.88). The lower reliability of the Resilience and Experience of Ethical Conflicts subscales (α ∼ 0.55–0.56) is consistent with some prior validations [Luthans et al, 2007; Abbaszade et al, 2008]. Findings for these specific sub-dimensions should be interpreted with caution, as measurement error may attenuate their observed correlations.

Table 3 presents the correlation matrix among the study’s main variables. The correlation analysis revealed strong, positive relationships among all study variables. Psychological capital components showed moderate to strong inter-correlations (r=0.49-0.84, P<0.001), with the total score demonstrating particularly strong associations with moral sensitivity (r=0.61, P<0.001). Among spiritual well-being measures, religious and existential well-being were closely related (r=0.71, P<0.001). For moral sensitivity subscales, honesty-benevolence showed the strongest connection to the total score (r=0.88, P<0.001), while all subscales correlated well with each other (r=0.42-0.88, P<0.001). The only exception was a weak correlation between religious well-being and ethical conflicts (r=0.15).

Table 3.

Pearson Correlation Matrix for Study Variables (N = 200)

Variables	1	2	3	4	5	6	7	8	9	10	11	12	13	14
1. Self-Efficacy	1
2. Hope	0.63	1
3. Resilience	0.54	0.57	1
4. Optimism	0.59	0.49	0.57	1
5. Psychological Capital	0.84	0.84	0.79	0.80	1
6. Religious WB	0.30	0.30	0.42	0.48	0.45	1
7. Existential WB	0.36	0.26	0.41	0.54	0.47	0.71	1
8. Spiritual WB	0.36	0.30	0.45	0.55	0.50	0.92	0.92	1
9. Respect Autonomy	0.35	0.22	0.41	0.52	0.45	0.42	0.45	0.47	1
10. Comm. Awareness	0.37	0.37	0.30	0.27	0.40	0.20	0.23	0.23	0.35	1
11. Prof. Knowledge	0.36	0.22	0.38	0.48	0.43	0.44	0.46	0.48	0.58	0.19	1
12. Ethical Conflicts	0.26	0.30	0.29	0.25	0.34	0.15*	0.25	0.22	0.39	0.37	0.42	1
13. Ethical Decisions	0.45	0.38	0.40	0.53	0.54	0.44	0.41	0.46	0.55	0.39	0.49	0.42	1
14. Honesty-Benevolence	0.40	0.34	0.36	0.59	0.51	0.42	0.51	0.50	0.62	0.33	0.59	0.43	0.67	1
15. Moral Sensitivity	.0.50	0.42	0.47	0.62	0.61	0.47	0.53	0.54	0.77	0.59	0.70	0.63	0.82	0.88

* All correlations were significant at p < 0.01 (2-tailed), with the exception of the correlation between Religious Well-Being and Experience of Ethical Conflicts (r = 0.15, p < 0.05).

Table 4 presents comparisons of Psychological Capital, Spiritual Well-Being, and Moral Sensitivity across different demographic groups, along with their statistical significance levels.

Table 4.

Comparison of Psychological Capital, Spiritual Well-Being, and Moral Sensitivity Across Demographic Groups

		Psychological capital		Spiritual well-being		Moral sensitivity
Variable	Groups	Mean ± SD	Eta*, p-value	Mean ± SD	Eta, p-value	Mean ± SD	Eta, p-value
Gender	Male	111.30 ± 16.34	0.00,	83.00 ± 11.78	0.00,	93.62 ± 11.91	0.00,
Gender	Female	111.68 ± 11.81	0.85	82.46 ± 12.74	0.75	94.85 ± 12.08	0.47
Residential Status	Native	114.84 ± 12.55	0.03,	82.87 ± 12.16	0.00,	96.30 ± 11.12	0.01,
Residential Status	Non-native	109.80 ± 14.78	0.02	82.67 ± 12.32	0.91	93.19 ± 12.30	0.08
Marital Status	Single	110.56 ± 14.63	0.03,	82.81 ± 12.06	0.00,	93.94 ± 12.14	0.00,
Marital Status	Married	116.70 ± 10.57	0.03	82.30 ± 13.40	0.83	95.90 ± 11.08	0.40

*η² (Eta squared) is reported as the effect size measure. The reported η² values in this table indicate small effect sizes for the observed group differences.

Analysis revealed that married participants reported significantly higher Psychological Capital scores (Mean=116.70, SD=10.57) compared to single participants (Mean=110.56, SD=14.63), with this difference being statistically significant (p=0.029). Native students showed higher Moral Sensitivity scores (Mean = 96.30, SD = 11.12) than non-native students (Mean = 93.19, SD = 12.30), but this difference was not statistically significant (p = 0.083). No significant gender differences were found for any of the three constructs (p > 0.05).

The correlation analyses yielded additional insights. Psychological Capital showed small but statistically significant positive correlations with both age (r=0.19, p=0.008) and academic semester (r=0.17, p=0.015). Similarly, Moral Sensitivity was positively associated with academic progression (r=0.18, p=0.013). However, Spiritual Well-Being demonstrated no significant relationships with either age or semester (p>0.05).

Table 5 presents hierarchical regression analyses examining the predictive value of Psychological Capital and Spiritual Well-Being on Moral Sensitivity. The order of variable entry was theoretically determined. Separate models were first run for each main predictor (Model 1) to establish their individual associations with moral sensitivity. Subsequently, both psychological capital and spiritual well-being were entered simultaneously (Model 2) to assess their unique contributions while accounting for each other. Finally, demographic variables (age, marital status, residential status) were added (Model 3) to examine whether the relationships of the main predictors remained significant after adjusting for potential confounding background factors. This sequence prioritized testing our primary hypotheses concerning the independent roles of psychological resources. All models met key assumptions including normally distributed residuals, homoscedasticity, absence of multi-collinearity (VIFs < 1.5), and no autocorrelation (Durbin-Watson ≈1.5).

Table 5.

Hierarchical Regression Models Predicting Moral Sensitivity by Psychological Capital and Spiritual Well-Being

	Model 1		Model 2		Model 3
Predictors	β (95% CI)	p-value	β (95% CI)	p-value	β (95% CI)	p-value
Psychological Capital	0.51 (0.42, 0.61)	<0.001	0.38 (0.28, 0.48)	<0.001	0.38 (0.27, 0.48)	<0.001
Spiritual Well-Being	0.53 (0.42, 0.65)	<0.001	0.31 (0.19, 0.43)	<0.001	0.32 (0.20, 0.44)	<0.001

Model Specifications.

Model 1: separate regression models for Psychological Capital and Spiritual Well-Being.

Model 2: Psychological Capital + Spiritual Well-Being (R2=0.45, Adj. R2=0.44).

Model 3: Full adjusted model, adjusted for age, marital and Residential status (R2=0.45, Adj. R2=0.44).

Diagnostics: All VIFs < 1.5 (no multi-collinearity), Normally distributed residuals (Q-Q plots), Homoscedasticity confirmed (residual plots), Durbin-Watson ∼1.5 (no autocorrelation).

In initial separate models (Model 1), both Psychological Capital (β=0.51, 95% CI [0.42, 0.61], p<0.001) and Spiritual Well-Being (β=0.53, 95% CI [0.42, 0.65], p<0.001) showed strong individual predictive power for Moral Sensitivity. When combined (Model 2), both retained significant independent effects while explaining 45% of variance (Psychological Capital: β=0.38, p<0.001; Spiritual Well-Being: β=0.31, p<0.001). The final adjusted model (Model 3) demonstrated virtually identical coefficients (Psychological Capital: β=0.38, p<0.001; Spiritual Well-Being: β=0.32, p<0.001), indicating robust effects unaffected by demographic adjustments.

Discussion

The present study was conducted among 200 nursing students, representing a young and mid-academic cohort with balanced gender distribution. A notable proportion of participants were non-native students (66.5%), which may have implications for spiritual well-being, moral sensitivity, and psychological capital due to potential cultural, linguistic, and social adaptation challenges. This characteristic highlights the multicultural nature of the educational setting and calls for attention to culturally sensitive support systems in nursing education. The predominantly single status of participants is consistent with the typical demographic of undergraduate students in this age group and may reflect lower levels of familial responsibilities, potentially influencing components of psychological capital such as hope and optimism.

Participants in this study demonstrated relatively high levels of psychological capital (M = 111.5, SD = 14.2) and moral sensitivity (M = 94.2, SD = 12.0), along with moderately high spiritual well-being (M = 82.7, SD = 12.2). These findings are consistent with prior research indicating that nursing students generally maintain strong personal and existential resources during their education.^23,24 Notably, self-efficacy and hope scored higher than resilience and optimism, suggesting robust academic confidence but potentially lower capacity for emotional recovery—highlighting a need for resilience-building interventions. The relatively preserved moral sensitivity reflects students’ attentiveness to patient autonomy, ethical principles, and honest communication, which are essential in clinical practice. Furthermore, the moderate to high levels of spiritual well-being, particularly in existential well-being, may support ethical reasoning by fostering a sense of meaning and inner coherence. While most scales showed good internal consistency, the lower reliability of the resilience (α = 0.56) and ethical conflicts (α = 0.55) subscales warrants cautious interpretation of these specific domains, though they remain acceptable for research purposes.

A strong positive correlation was observed between psychological capital and moral sensitivity (r = 0.61, p < 0.001), indicating that higher scores on hope, self-efficacy, resilience, and optimism were associated with higher moral sensitivity scores. However, given the cross-sectional design of this study, causal inferences cannot be drawn, and the directionality of this relationship remains undetermined. This finding is consistent with recent evidence indicating that personal psychological resources enhance moral reasoning in healthcare students.²⁵ Similarly, the moderate to strong interrelationships among the components of spiritual well-being particularly the high correlation between religious and existential well-being (r = 0.71) support the holistic nature of spiritual health as a unifying construct. The link between spiritual well-being and moral sensitivity aligns with findings from Alquwez et al (2022), who reported that nursing students with higher spiritual well-being demonstrate greater moral sensitivity.⁶ Notably, moral sensitivity showed robust associations with both psychological capital and spiritual well-being, reinforcing the idea that moral sensitivity in nursing students is nurtured by a combination of inner strength and existential meaning. The particularly strong link between the honesty and benevolence subscale and overall moral sensitivity (r = 0.88) highlights the centrality of virtuous character traits in ethical decision-making. While most correlations were positive and significant, the weak association between religious well-being and experience of ethical conflicts (r = 0.15) may reflect that adherence to formal religious beliefs does not necessarily increase the frequency of ethical dilemmas, but rather how one copes with them. This distinction underscores the importance of focusing on existential and psychological resources, rather than doctrinal religiosity, in fostering ethical competence.

Significant differences were observed in psychological capital based on marital status, with married students reporting higher levels than their single counterparts (p = 0.029). This finding may reflect greater emotional stability, social support, and life experience among married individuals, which are known to enhance hope, resilience, and self-efficacy (core components of psychological capital). Although the difference in moral sensitivity between native and non-native students did not reach conventional significance (p = 0.083), the higher scores among native students suggest a potential influence of cultural familiarity and shared ethical norms in clinical education settings. The absence of gender differences in psychological capital, spiritual well-being, and moral sensitivity aligns with recent studies indicating that these personal and ethical resources develop independently of gender in nursing students.^6,26 Notably, psychological capital and moral sensitivity both showed positive associations with academic progression (r = 0.17, p = 0.015; r = 0.18, p = 0.013, respectively), indicating that higher academic levels were associated with higher scores on these constructs. Given the cross-sectional design, causal interpretations regarding clinical exposure or professional socialization cannot be established; however, this pattern is consistent with the hypothesis that accumulated clinical experience may contribute to ethical awareness and personal resilience. Similarly, the small but significant correlation between psychological capital and age (r = 0.19, p = 0.008) suggests that life experience may be linked to the development of psychological resources. In contrast, spiritual well-being remained stable across age and academic levels, indicating that it may be a more intrinsic or early-established dimension of well-being that is less influenced by educational progression.

Hierarchical regression analysis revealed that both psychological capital and spiritual well-being are significant independent predictors of moral sensitivity, collectively explaining 45% of its variance. In separate models, each construct demonstrated strong predictive power (β = 0.51 and β = 0.53, respectively, both p < 0.001), indicating their substantial individual contributions. When entered simultaneously, both variables retained significant effects, psychological capital (β = 0.38, p < 0.001) and spiritual well-being (β = 0.31, p < 0.001), suggesting unique and complementary roles in shaping moral sensitivity. The stability of these coefficients in the fully adjusted model, which included demographic variables, further confirms the robustness of these associations. These findings align with recent evidence highlighting the synergistic role of personal and existential resources in ethical decision-making among healthcare professionals.^27,28 This dual influence indicates that moral sensitivity is significantly associated with both psychological capital and spiritual well-being, reflecting their independent and complementary contributions. However, the cross-sectional design precludes inference regarding causal mechanisms or the nature of their interaction (e.g., additive vs. interactive effects).

This study has several strengths, including the use of well-validated instruments (PCQ, SWBS, and MSQ), a relatively large and gender-balanced sample, and robust statistical analyses, including hierarchical regression with diagnostic checks. However, limitations should be acknowledged: the cross-sectional design limits causal inference and precludes testing of integrated theoretical pathways or interaction mechanisms (e.g., additive versus interactive effects) between psychological capital and spiritual well-being in relation to moral sensitivity. The single-institution sample limits generalizability to nursing students in other institutions or cultural contexts, and self-report data may inflate correlations due to shared method variance and social desirability bias. Additionally, the lower reliability of the resilience (α = 0.56) and ethical conflicts (α = 0.55) subscales may have attenuated observed correlations with moral sensitivity, potentially underestimating their true associations. Despite these limitations, the findings have practical implications for nursing education, suggesting that nursing programs could integrate brief, practical activities such as 2–3 resilience workshops during clinical rotations, guided reflection on real ethical dilemmas, and short mindfulness exercises within existing ethics courses to nurture psychological and spiritual resources without adding significant burden to students’ schedules.

Conclusions

In conclusion, both psychological capital and spiritual well-being are significant and independent contributors to moral sensitivity among nursing students, collectively explaining 45% of its variance. These personal and existential resources show complementary associations with ethical awareness. Future research should adopt longitudinal or interventional designs and include diverse cultural settings to examine causal pathways and the transferability of these findings. Qualitative studies could also deepen understanding of how students integrate these dimensions in real-world ethical challenges.

Footnotes

Acknowledgment

The authors express their gratitude to the Research Deputy of the Khoy University of Medical Sciences and all the participants in the study.

ORCID iD

Leila Mokhtari

Ethical Considerations

Research Council and Ethics Committee in Khoy University of Medical Sciences had approved the study with ethical approval number (Approval No: IR.KHOY.REC.1402.024 approval date 13. 8. 2023). All participants complete and sign the written informed consent form. Anonymity throughout the research was followed to obtain privacy and confidentiality.

Author Contributions

Conceptualization: Leila Mokhtari, Fatemeh mehraji. Data curation: Leila Mokhtari, Fatemeh mehraji, Mohammad Zayer. Formal analysis: Mehrdad Karimi, Leila Mokhtari. Investigation: Leila Mokhtari. Methodology: Leila Mokhtari, Fatemeh mehraji, Mohammad Zayer. Project administration: Leila Mokhtari. Resources: Leila Mokhtari, Fatemeh mehraji. Software: Leila Mokhtari, Mehrdad Karimi. Supervision: Leila Mokhtari. Validation: Leila Mokhtari, Mehrdad Karimi. Visualization: Leila Mokhtari, Mehrdad Karimi.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research is derived from the research project approved by Department of Nursing, Khoy University of Medical Sciences and was supported by Khoy University of Medical Sciences, Vice Chancellor for Research (No: 401000025).

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

The data are available from the corresponding author on reasonable request.*

Declaration of AI Use

The authors used an artificial intelligence (AI) tool only to assist with the translation of the manuscript from Persian into English. The original manuscript, including all scientific content, data, analysis, interpretation, and intellectual contributions, was prepared entirely by the authors. No AI tool was used in the generation, modification, or analysis of research data, nor in the creation of tables or conceptual content.

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