Emotional intelligence and clinical decision-making confidence in nurses: the chain mediating effect of creative self-efficacy and self-directed learning

Abstract

Background: Clinical decision-making competence underpins autonomous nursing practice. While external influences are documented, context-dependent psychological mechanisms linking emotional intelligence (EI) to clinical decision-making confidence (CDMC) remain unexplored. Using social cognitive theory, this cross-sectional study of 1,126 nurses from 12 Zhejiang tertiary hospitals examined EI’ s influence on CDMC via sequential mediation by creative self-efficacy (CSE) and self-directed learning (SDL), moderated by department stress and clinical experience. Methods: Nurses completed measures of EI (WLEIS), CDMC (CDMSCS), CSE, and SDL. Analyses used structural equation modeling (SEM) with bias-corrected bootstrapping and multi-group SEM with Bonferroni correction to test moderation by department type (high-stress: ICU/emergency/OR vs. non-high-stress) and experience (≤5 vs. >5 years). Results: The model showed excellent fit (χ2/df = 2.999, RMSEA = 0.030, CFI = 0.963, GFI = 0.934). EI predicted CDMC directly (27.16% of total effect) and indirectly via CSE (23.16%), SDL (25.26%), and sequential mediation (24.42%; 72.84% total indirect effect). Moderation revealed: In high-stress units (n = 159), the EI → CSE → CDMC path was stronger (β = 0.28, 95% CI [0.22, 0.35] vs. non-high-stress β = 0.21, 95% CI [0.17, 0.26]; Δβ = 0.07, p = 0.012). Conversely, EI → SDL → CDMC dominated in non-high-stress units (β = 0.27 vs. 0.20; Δβ = 0.07, p = 0.018), particularly pediatrics/gynecology. For nurses with ≤5 years’ experience (n = 254), sequential mediation (EI → CSE → SDL → CDMC; β = 0.31, 95% CI [0.25, 0.38]) was primary, with negligible direct effects (β = 0.08, p = 0.12). Nurses with >5 years’ experience (n = 872) showed strengthened direct EI → CDMC effects (β = 0.19, p = 0.003) and reduced SDL reliance (Δβ = 0.12, p = 0.007), suggesting experience compensates for psychological resource utilization. Conclusion: EI enhances CDMC through context-contingent pathways: CSE is pivotal in high-stress environments, SDL prevails in non-high-stress units (notably pediatrics/gynecology), and experiential knowledge supersedes mediation pathways with seniority. These findings challenge uniform decision-making models, urging healthcare systems to implement context/experience-specific strategies—such as stress-adapted EI training for critical care nurses and experiential integration for seniors—to optimize clinical decision-making across nursing settings.