Background <p>Advance care planning (ACP) can help align care with patients’ values and preferences, but its implementation in routine practice remains challenging. Nurses are well placed to support ACP, although their confidence in ACP-related communication may vary. This study aimed to identify latent profiles of ACP self-efficacy among clinical nurses in hospital settings in China, examine factors associated with profile membership, and explore whether attitudes towards death differed across profiles.</p> Methods <p>A cross-sectional survey was conducted from August to September 2025 among registered clinical nurses in nine hospitals in two provinces in northeastern China. Data from 531 nurses were analysed. ACP self-efficacy was measured using the Chinese version of the Advance Care Planning Self-Efficacy Scale, and attitudes towards death were assessed using the Death Attitude Profile–Revised. Latent profile analysis was used to identify ACP self-efficacy profiles. Factors associated with profile membership were examined using the R3STEP approach, and differences in attitudes towards death were tested using the BCH method.</p> Results <p>Three ACP self-efficacy profiles were identified: low (37.5%), moderate (49.7%), and high (12.8%). The profiles differed mainly in overall confidence rather than item-specific response patterns. Across profiles, nurses reported relatively lower confidence in discussing living will documentation and communicating bad news. Prior awareness of ACP was consistently associated with membership in higher-confidence profiles. Palliative care training was associated with lower odds of belonging to the low rather than the moderate profile, whereas resuscitation experience was associated with higher odds of belonging to the low rather than the moderate profile. Selected work-related factors, including professional title and department, were also associated with profile membership. Attitudes towards death did not differ significantly across profiles.</p> Conclusions <p>Clinical nurses in hospital settings showed heterogeneity in ACP self-efficacy. Profile membership appeared to be more closely linked to ACP-related exposure, training, and selected work-related factors than to general attitudes towards death. These findings support targeted strategies to strengthen nurses’ confidence in ACP communication, particularly through early ACP exposure, practical training in difficult communication tasks, and supportive clinical workflows.</p> Trial Registration <p>Not applicable.</p>