Abstract
BACKGROUND: Certain populations face challenges in accessing online health information, leading to the emergence of Proxy Online Health Information Seeking (Proxy OHIS). Due to their close contact with patients and medical knowledge, nursing interns frequently encounter requests from patients to perform Proxy OHIS, which presents various ethical challenges. Currently, no research specifically focuses on nursing interns within the context of their Proxy OHIS activities. AIM: This study aims to explore the ethical decision-making processes of nursing interns when engaging in Proxy OHIS for patients during their clinical practice and to analyze the associated ethical challenges, thereby contributing to improved ethical decision-making among nursing students. METHODS: This qualitative study was guided by a constructivist paradigm. Rest's Four-Component Model of ethical decision-making served as the theoretical framework for examining the decision-making process. Participants were recruited via purposive sampling from a tertiary Grade A hospital in Zibo between August and September 2025. Individual semi-structured interviews were conducted with eligible participants until data saturation was achieved. The study involved nursing interns at multiple educational levels (diploma, bachelor's, and postgraduate) from eight different universities. Data were transcribed verbatim and analyzed using Graneheim and Lundman's conventional qualitative content analysis approach with NVivo 14.0 software. RESULTS: A total of 18 nursing interns participated. Content analysis identified four primary categories: "Identifying ethical issues and risks", "Formulating appropriate ethical judgments", "Balancing multiple ethical motivations" and "Implementing prudent behavioral strategies". CONCLUSION: Guided by Rest's Four-Component Model, this study revealed that nursing interns encounter a range of ethical challenges throughout their decision-making process when performing Proxy OHIS for patients. These challenges span the entire process, from initial issue recognition to the implementation of final actions. To address these challenges effectively, interventions should focus on two key areas: ethics and online health information seeking. In the future, nursing education stakeholders can build a comprehensive ethical support system, including establishing structured supervision protocols for handling Proxy OHIS requests.