Patient gratitude, moral agency and nurses' ethical action.

BackgroundNursing ethics is enacted through everyday clinical relationships as well as through formal standards. Perceived patient gratitude may function as a relational moral cue, but its association with nurses' ethically relevant workplace behaviour remains unclear.Research aimTo examine whether perceived patient gratitude was associated with nurses' workplace prosocial behaviour through moral efficacy and going beyond compliance.Research designA multicentre cross-sectional survey was conducted, and mediation analyses were performed using Hayes' PROCESS macro.Participants and research contextData were collected from 793 registered nurses working in hospitals in Henan, Hubei and Shaanxi provinces, China.Ethical considerationsEthical approval was obtained from the relevant institutional ethics committee. Participation was voluntary and anonymous, and electronic informed consent was obtained before questionnaire completion.FindingsPerceived patient gratitude was positively associated with workplace prosocial behaviour. Moral efficacy and going beyond compliance each independently mediated this association. A significant sequential indirect effect was also identified, in which perceived patient gratitude was associated with stronger moral efficacy, which was in turn associated with greater willingness to go beyond minimum professional expectations and, subsequently, higher workplace prosocial behaviour.ConclusionsPerceived patient gratitude may be associated with ethically relevant workplace conduct when relational recognition strengthens nurses' moral capability and professionally bounded ethical initiative. However, gratitude should not be regarded as a patient obligation, a condition of appropriate care or a substitute for organisational support. Longitudinal and relational research is needed to clarify these processes and their implications for equitable nursing practice.