Clinical Skills and Moral Sensitivity among Student Nurses during Patient Care: A Critical Integrative Review through the Lens of Nel Noddings’ Ethics of Care

Abstract

Undergraduate nursing curricula treat technical proficiency and ethical responsiveness as separate learning outcomes, assessed by different instruments and taught by different means, yet clinical placement confronts students with both simultaneously and within the same encounter. This review examines what is known about the relationship between clinical skills and moral sensitivity in pre-registration nursing students during direct patient care, and interprets that evidence through the relational care ethics of Nel Noddings, in which caring is completed only when it is received and acknowledged by the person cared for. Literature was identified through iterative topic-specific searching of Crossref Metadata Search, with record-level verification and abstract retrieval in Europe PMC and OpenAlex, covering 1 January 1995 to 5 June 2026, supplemented by conceptually foundational earlier works. Sources were appraised for design adequacy, instrument quality, contextual specificity and consistency with related evidence, and were synthesised thematically rather than sequentially. Four findings emerge. Direct empirical linkage between measured clinical competence and measured moral sensitivity rests on a very small number of single-site cross-sectional studies with modest explained variance, and cannot presently support causal interpretation. The dominant measurement instruments show unstable factor structures across translations, which limits cross-national comparison and weakens claims about developmental trajectory. Educational interventions raise moral sensitivity scores reliably in the short term but show decay within three months and little demonstrated transfer to observed clinical behaviour. Environmental conditions of placement, including ethical climate, mentor relationships and students’ own perceived standing, appear to determine whether recognised moral concerns are converted into action, which the Noddings framework anticipates by locating caring in a reciprocal relation rather than in an individual disposition. The literature is heavily concentrated in a small number of national contexts and relies almost entirely on self-report. Priorities include longitudinal designs anchored in observed care, instruments constructed for student populations, and dyadic measurement that captures the patient’s experience of being cared for.