Network analysis of interpersonal sensitivity and self-efficacy in nursing students

Interpersonal sensitivity, characterized by an increased awareness of social feedback, can contribute to stress, anxiety, and low self-efficacy in nursing students, leading to challenges in both clinical practice and personal development [1‐3]. In a nursing education environment, nursing students face many pressures, such as emotional pressures, end-of-life care stress, and interpersonal stress [4, 5]. High interpersonal sensitivity may exacerbate these stresses, which can have a negative impact on mental health and performance in school, life, and work [6]. However, previous research has found that self-efficacy can buffer these effects, enabling nursing students to cope with challenges more positively and effectively [7]. Self-efficacy is defined as an individual’s belief in his or her ability to complete tasks and successfully overcome challenges [8]. Nursing students possessing high self-efficacy are likely to effectively manage the stress related to demanding workloads, emotional exhaustion, and vulnerability to depression, which may ultimately develop better communication skills and interpersonal relationships [9]. Therefore, an in-depth exploration of the interactions and dynamic balance between interpersonal sensitivity and self-efficacy is important for nursing students’ mental health and social functioning and provides valuable insights for nursing education and interventions.

As the backbone of future nurses, nursing students’ mental health and interpersonal skills are crucial to the future of the nursing profession. Previous research has found that in the practice of nursing education, in addition to clinical skills and training, special attention should be paid to the enhancement of students’ interpersonal skills, as interpersonal communication is the core of nursing work [10]. Nurses need to maintain frequent and close interactions with patients, patients’ families, and the healthcare team. Developing positive interpersonal skills in nursing students helps to create a supportive and collaborative interpersonal environment that promotes personal growth and enhances their professional resilience [11]. In this context, Self-Determination Theory provides a valuable theoretical framework for nursing students to improve their interpersonal skills, emphasizing competence, relatedness, and autonomy as key psychological needs for improving communication skills, building supportive interpersonal relationships, and enhancing autonomous decision-making, which is essential for driving intrinsic motivation and well-being [12]. Specifically, among nursing students, competence refers to their skills in communicating and managing interpersonal relationships, enhancing self-confidence in interacting with patients and colleagues. Relatedness denotes the ability to build supportive relationships with peers and patients, which helps promote teamwork and trust. Autonomy emphasizes the ability to make social decisions based on personal values and self-perception, which helps to promote professional identity and self-confidence. Therefore, fostering nursing students’ interpersonal skills not only enhances their interpersonal relationships but also fulfills their need for social connection, thus promoting greater professional engagement.

However, nursing students often face unique mental health challenges in rigorous academic and clinical settings. Previous research has revealed significant associations between interpersonal sensitivity and anxiety, depression, and low self-esteem [13, 14].A study of 306 nursing students by Sun et al. found that higher interpersonal sensitivity exacerbated nursing students’ stress [15], leading to increased negative affect and the adoption of avoidant coping strategies. In contrast, self-efficacy was found to be effective in reducing stress and negative emotions. According to self-determination theory, self-efficacy fulfills an individual’s need for competence and thus enhances his or her intrinsic motivation, which helps the individual to show higher motivation and persistence in the face of challenges [12]. High self-efficacy enhances nursing students’ confidence in coping with challenges and stress management, with a significant positive association with psychological resilience, mental health, and academic performance [7, 16]. These findings highlighted the importance of self-efficacy in mitigating the negative effects of interpersonal sensitivity, suggesting that enhancing self-efficacy may help nursing students cope more effectively with the challenges associated with high interpersonal sensitivity, thereby improving their mental well-being.

Previous studies have recognized the importance of interpersonal sensitivity and self-efficacy as distinct psychological traits, yet they overlooked systematically exploring their interrelationships. While some previous studies have investigated the association between interpersonal sensitivity and self-efficacy [17, 18], these have primarily focused on general student populations, such as junior high school and college students. However, nursing students encounter unique stressors and interpersonal needs in their educational setting, necessitating a more comprehensive study of this specific group. In addition, most of these studies have used traditional association and regression analysis methods, which may not be able to fully capture the complex interactions and networked relationships between these two psychological traits. In contrast, network analysis can identify key nodes or central symptoms in a network, providing insight into the complex interrelationships between variables. This is particularly important for psychological studies, as analyzing the relationships between micro-symptoms and identifying key symptoms can help determine the most urgent targets for improvement, thereby enhancing the effectiveness of intervention programs. Therefore, adopting a network analysis approach to investigate the intrinsic link between interpersonal sensitivity and self-efficacy in nursing students will provide a fresh perspective in understanding the complex relationship between these psychological traits.

Employing network analysis introduces an innovative approach to examining the complex relationships between psychological symptoms and characteristics [19]. Network analysis reveals complex dynamics not captured by traditional methods by modeling these symptoms as interconnected nodes in a network. The method also introduces the concepts of central symptoms and bridge nodes, enabling researchers to identify central symptoms that play a key role in the network and bridge symptoms that connect different symptom clusters [20, 21]. The application of network analysis allows for an in-depth exploration of the interactions between interpersonal sensitivity and self-efficacy, providing new perspectives for a comprehensive understanding of the complex dynamics of nursing students in the area of mental health and contributing to the optimization of relevant interventions to enhance the overall psychological well-being of nursing students.

Therefore, this study aimed to use network analysis to gain insight into the intrinsic association between interpersonal sensitivity and self-efficacy among nursing students. By identifying core and bridge symptoms in the network, this study will reveal how these key variables interact with each other and inform the development of more targeted interventions. Understanding the complex relationship between interpersonal sensitivity and self-efficacy can help nursing educators guide nursing students to more effectively manage stress, improve interpersonal interactions, and enhance the overall well-being, so that they can cope more effectively with challenges in nursing practice.

To our knowledge, the study was the first to apply network analysis to examine the relationship between interpersonal sensitivity and self-efficacy in Chinese nursing students, offering a novel perspective for understanding the mechanisms underlying their association. Unlike previous studies that primarily explored the global relationship between total scores of interpersonal sensitivity and self-efficacy, our study explored their interactions and influence pathways from the localized perspective of the symptom nodes. The study identified “I feel happy when someone compliments me” (IPSM-CS9) as a central symptom, which may serve as a critical node for triggering and sustaining the interpersonal sensitivity and self-efficacy network. Additionally, “Faced with difficult tasks, confident that it can be accomplished” (NGSES1) and “Ability to successfully overcome many challenges” (NGSES2) were identified as bridge symptoms linking interpersonal sensitivity and self-efficacy. These findings highlighted the importance of targeted interventions focusing on these specific symptoms to address interpersonal sensitivity and improve self-efficacy among Chinese nursing students.

In this study, the strongest edge in nursing students’ interpersonal sensitivity and self-efficacy network was the connection between “I feel happy when someone compliments me” (IPSM-CS9) and “I can make other people feel happy” (IPSM-CS10), revealing the nursing students’ heightened sensitivity to praise and others’ happiness in social interactions. This finding aligns with a previous study on nursing students’ interpersonal sensitivity and loneliness, which suggested that nursing students’ emotional responses to social feedback (e.g., receiving praise and making others happy) are an important part of their interpersonal relationships [22]. This connection may be attributed to the following reasons. Nursing students need to develop good social skills and teamwork as part of their training to better fulfill their professional role of providing care and support [35]. Nursing students feel recognized when they receive compliments from others or bring happiness to others, which boosts their self-confidence and self-worth, which in turn motivates them to be more willing to interact with others and increases their self-efficacy [36, 37]. In addition to the influential edges within interpersonal sensitivity, several strong edges were observed within self-efficacy. The second strongest edge was between “Faced with difficult tasks, confident that it can be accomplished” (NGSES1) and “Ability to successfully overcome many challenges” (NGSES2). This finding reflected a strong connection between an individual’s confidence in his or her abilities and his or her successful experiences with challenges. This implied that past successes enhanced students’ confidence in future challenges. According to the self-determination theory, such confidence aligns with the psychological need for competence, which is crucial for fostering intrinsic motivation [12]. Nursing students’ confidence in their ability to cope with challenges and previous successes enhanced their sense of competence and fostered intrinsic motivation, enabling them to interpret the current situation positively and adopt positive action strategies, thus increasing their chances of successfully coping with challenges [38]. Based on our findings, nursing educators should provide positive feedback and psychological support and take specific measures to encourage students to maintain a positive mindset when facing challenges. This will help nursing students cope with career challenges more effectively and improve their mental health.

Across the network, “I feel happy when someone compliments me.” (IPSM-CS9) was the most central symptom, suggesting that it played an important role in the interpersonal sensitivity and self-efficacy network. Previous studies primarily emphasized improving interpersonal sensitivity holistically and often lacked specificity in identifying key targets for intervention [6, 23]. In contrast, the present study identified the central symptom of positive emotional responses to praise, providing a clear and actionable direction for designing targeted interventions. Nursing students often face high pressure and challenges in their studies and clinical practice [4, 39]. Positive feedback, such as appreciation and recognition, can enhance their sense of belonging and social support, thereby improving mental health status and maintaining stable interpersonal relationships [40, 41]. A study of nursing students found that praise training helped students develop positive coping styles, which may indirectly alleviate interpersonal sensitivities [42]. In addition, a randomized trial of 49 medical and nursing students showed that praise enhanced students’ cognitive and technical performance [43], suggesting that receiving recognition boosts students’ self-confidence and sense of self-worth, helping them to develop a positive self-image [37]. Therefore, nursing educators should incorporate positive feedback into their teaching strategies to recognize students’ efforts and achievements in academics and practice. In addition, positive thinking or resilience training can be introduced to help students accept praise gracefully and utilize it to enhance their self-esteem, thereby enhancing their stress management and interpersonal skills.

“If others knew the real me, they would not like me” (IPSM-CS2) was another central symptom in this study. This symptom reflects the vulnerability of the inner self by reflecting the individual’s negative evaluation of his or her true self, accompanied by a deep concern about rejection by others [44]. Nursing students are commonly concerned about potential social exclusion and lack of real understanding [45]. As previous studies have shown, undergraduate nursing students commonly experience skepticism about their abilities, often accompanied by negative emotions such as anxiety and low self-confidence [46, 47]. These negative emotions cause nursing students to exhibit excessive worry and defensive behaviors in their social interactions [48], exacerbating their interpersonal sensitivity and undermining their self-confidence and motivation [49]. Nursing students’ doubts about their abilities often trigger anxiety and withdrawal behaviors, which can diminish their positive engagement in both their studies and clinical placements [50]. In addition, the item “I worry about being criticized for things that I have said or done” (IPSM-CS4) showed a high node strength. This finding can be interpreted through Maslow’s hierarchy of needs, highlighting how esteem needs play a crucial role in understanding students’ concerns about criticism [51]. The demanding nature of the nursing profession necessitates that students deal with high standards and rigorous assessment in their learning and practice [52], which can lead to self-doubt and an excessive preoccupation with others’ evaluations [53]. This negative feedback threatens students’ self-esteem needs, prompting them to adopt negative coping, such as reducing social interactions, which can exacerbate social anxiety [54]. Particularly during the clinical placement phase, due to inadequate practical skills and the stress of adapting to new environments [55], nursing students experience negative evaluations that can lead to unmet self-esteem needs and doubt their own abilities, which can make them more inclined to adopt avoidant behaviors and reduce the opportunities to accumulate successful experiences, further weakening self-efficacy [56]. Therefore, nursing educators can apply the key symptoms identified in this study to more effectively address the effect of negative emotions on students’ mental health and career development. Providing targeted psychological support and counseling to help students reduce self-doubt, increase self-confidence, and improve their ability to cope with social and academic challenges, thereby enhancing their overall mental health.

Across the interpersonal sensitivity and self-efficacy network, two symptoms, “Faced with difficult tasks, confident that it can be accomplished” (NGSES1) and “Ability to successfully overcome many challenges” (NGSES2) were the strongest bridging symptoms, reflecting nursing students’ self-confidence and perceived competence in dealing with challenges. The importance of these two may stem from the central role of self-efficacy in psychological functioning, as it is a key factor in influencing an individual’s behavioral, motivational, and emotional responses [8]. Prior studies have suggested an interplay between interpersonal sensitivity and self-efficacy [17, 18], but they have not delved into how specific factors play critical roles in this relationship. However, the present study provided new perspectives for understanding the complex relationship between interpersonal sensitivity and self-efficacy by identifying key bridging symptoms. Nursing students often face negative emotions such as worry, helplessness, and anxiety in clinical settings and complex interpersonal relationships, which may erode their self-confidence and make them doubt their social skills and ability to cope with problems [13, 57], thus exacerbating interpersonal sensitivity. In contrast, nursing students with higher self-efficacy were more confident and were able to behave more positively in social interactions [58]. Therefore, this study highlighted the importance of enhancing self-efficacy in nursing education and psychological support. Nursing educators should incorporate elements of cognitive behavioral therapy into the curriculum to help students identify and overcome negative thinking and improve their ability to cope with challenges. At the same time, nursing students should be encouraged to actively participate in challenging tasks to enhance self-identity and self-confidence by gradually accumulating successful experiences, thereby increasing self-efficacy and emotion regulation and reducing interpersonal sensitivity.

Additionally, the network comparison test in this study found no significant difference in network structure invariance between genders, which may have been influenced by the unbalanced gender ratio in the sample. Therefore, future research should further explore the potential role of gender in relevant network characteristics through a more balanced sample design.

The study had several notable strengths, including using a large sample size and applying network analysis to visualize the relationship between interpersonal sensitivity and self-efficacy among nursing students. However, the present study also had several limitations. First, the structure of the interpersonal sensitivity and self-efficacy network constructed based on cross-sectional data could not reveal the causal relationships between symptoms and their dynamic changes. Therefore, future studies should prioritize longitudinal designs to explore dynamic network changes. Second, this study assessed nursing students’ interpersonal sensitivity and self-efficacy through self-report, which may be affected by subjectivity and recall bias. Future studies should consider using more objective methods (e.g., behavioral assessments and physiological indicators) or peer reports to provide a more comprehensive and accurate evaluation of interpersonal sensitivity and self-efficacy. Third, due to the unbalanced gender distribution of nursing students, most of the nursing students included in this study were female (79.2%), which may restrict the generalizability of the results. Future studies should incorporate a greater proportion of male nursing students or verify the applicability of this study’s findings in more diverse population. Finally, this study was conducted on undergraduate nursing students from only one Chinese university; therefore, it is recommended that future studies be conducted in different regional and cultural contexts to enhance the generalisability and applicability of the study.

This study identified the centrality symptoms (i.e., “I feel happy when someone compliments me”, “If others knew the real me, they would not like me”, and “I worry about being criticized for things that I have said or done”) and bridge symptoms (i.e., “Faced with difficult tasks, confident that it can be accomplished” and “Ability to successfully overcome many challenges”) in Chinese nursing students’ interpersonal sensitivity and self-efficacy networks. These findings provided new insights into nursing education and mental health support. Specifically, targeting central symptoms, nursing educators should provide students with positive feedback to enhance their sense of self-worth and incorporate self-awareness training to help them better build self-confidence. Based on the identified bridge symptoms, nursing educators should encourage students to engage in challenging tasks to gradually accumulate successful experiences. Additionally, implementing coping strategy workshops and stress management courses can strengthen students’ ability to handle pressure and overcome challenges effectively.