The mediating roles of self-efficacy and professional identity in the association between internship environment and voice behavior among nursing interns: a multicenter cross-sectional study

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Aim To examine the association between the internship environment and voice behavior among nursing interns and to explore the statistical indirect effects involving self-efficacy and professional identity. Design A multicenter cross-sectional study. Methods From January to February 2026, 498 nursing interns from hospitals in Hunan Province, China, completed questionnaires on internship environment, self-efficacy, professional identity, and voice behavior. Descriptive statistics, Pearson correlation analysis, and regression analysis were conducted. PROCESS Model 6 with 5,000 bootstrap samples was used to estimate the individual and combined indirect effects involving self-efficacy and professional identity. Results Internship environment was positively correlated with voice behavior ( r = 0.553, p < 0.001), self-efficacy ( r = 0.498, p < 0.001), and professional identity ( r = 0.538, p < 0.001). After adjustment for demographic and internship-related characteristics, the 95% bootstrap confidence intervals for the individual indirect effects involving self-efficacy and professional identity and the combined indirect effect involving both variables did not include zero for overall, promotive, or prohibitive voice behavior. The descriptive ratios of the estimated total indirect effect to the estimated total effect were 55.98% for overall voice behavior, 49.47% for promotive voice, and 62.48% for prohibitive voice. Conclusion A more supportive internship environment was associated with higher levels of overall, promotive, and prohibitive voice behavior among nursing interns. Significant indirect effects involving self-efficacy and professional identity were also observed in these associations. Clinical educators should consider fostering psychologically safe and supportive internship environments in which nursing interns feel able to express suggestions and patient safety concerns.