Moral Sensitivity Shapes How New ICU Nurses Make Ethical Decisions, Study Finds

Intensive care units are among the most ethically demanding environments in modern medicine. Nurses working there routinely confront end-of-life decisions, conflicts with patients’ families, and situations where the right course of action is far from obvious. For nurses in the advanced beginner stage, those with roughly one to three years of clinical experience, these dilemmas arrive while their clinical competence is still developing. A new cross-sectional study from South Korea now offers one of the clearest pictures yet of what shapes ethical decision-making in this vulnerable professional group, and its findings point to moral sensitivity as the single most consistent factor.

The study, published in BMC Nursing by Mihwa Kim of Pusan National University Hospital and Jungmi Yun of Pusan National University, surveyed 125 advanced beginner nurses working in the intensive care units of two tertiary hospitals in South Korea. Participants had between 13 and 36 months of total clinical experience, a range that places them squarely in the advanced beginner stage as defined by Jang’s adaptation of Benner’s well-known novice-to-expert model. In that framework, advanced beginners have moved beyond rule-following novices but still lack the deep situational judgment that characterizes competent and expert practitioners, making them a particularly important group to study in high-stakes settings.

Data were collected in March and April 2025 through a structured online self-report questionnaire. The researchers measured four distinct constructs: moral sensitivity, assessed with the Korean Moral Sensitivity Questionnaire; role conflict, the tension nurses feel when competing expectations pull them in different directions; the perceived ethical climate of the hospital, measured with the Hospital Ethical Climate Survey; and ethical decision-making, which was captured in two separate forms. Participants rated both what they judged would be ideally appropriate in an ethical situation and what they believed would realistically occur in practice, using the Judgement about Nursing Decision instrument.

The results revealed a striking gap between the ideal and the real. On a five-point scale, the nurses’ mean score for ideal ethical decision-making was 3.69, while their mean score for realistic ethical decision-making was just 3.15. The difference of 0.54 points was highly statistically significant, with a 95 percent confidence interval of 0.46 to 0.61, a t-value of 13.69, and a p-value below 0.001. The effect size, expressed as Cohen’s d of 1.23, is large by conventional standards. In practical terms, these nurses clearly recognized what the ethically appropriate response would be, yet they simultaneously expected that the response actually enacted on the ward would fall short of that standard.

Moral sensitivity itself scored 4.89 on a seven-point scale, indicating a moderately high level of awareness of ethical issues among the participants. Role conflict averaged 3.71 on a five-point scale, and perceived ethical climate averaged 3.74. These baseline figures set the stage for the study’s central analytical question: which of these factors, if any, would predict the two forms of ethical decision-making once the researchers accounted for nurses’ general characteristics such as experience and unit type?

To answer that question, the team ran multiple linear regression models that included all general characteristics together with the three study variables. For ideal ethical decision-making, moral sensitivity emerged as a significant positive predictor, with an unstandardized coefficient of 0.18, a 95 percent confidence interval of 0.02 to 0.34, a standardized beta of 0.20, and a p-value of 0.029. Total clinical experience, experience on the current unit, and working in an emergency ICU were also associated with ideal decision-making. The full model explained a modest 14.7 percent of the variance after adjustment.

Realistic ethical decision-making told a somewhat different story. Here, moral sensitivity was again a significant predictor, and a stronger one, with an unstandardized coefficient of 0.26, a confidence interval of 0.11 to 0.42, a standardized beta of 0.30, and a p-value of 0.001. But the perceived ethical climate also mattered, contributing an unstandardized coefficient of 0.20, a confidence interval of 0.07 to 0.33, a standardized beta of 0.28, and a p-value of 0.003. This model explained 20.7 percent of the variance after adjustment, still modest but noticeably better than the ideal-decision model. Role conflict, despite its theoretical importance, was not significantly associated with either form of decision-making in the final models.

The distinction between the two outcome types carries real weight for how the findings should be interpreted. Ideal ethical decision-making reflects what a nurse believes ought to happen, a judgment rooted largely in personal moral reasoning. Realistic ethical decision-making reflects what the nurse expects will actually happen, a judgment shaped by the surrounding organizational reality. The fact that perceived ethical climate predicted only the realistic form suggests that the ward environment, with its norms, hierarchies, and support structures, exerts its influence precisely at the point where moral intention is translated into expected action. Nurses who perceived their hospital’s ethical climate more favorably expected a smaller gap between the ideal and the real.

The authors are careful about the limits of their design. As a cross-sectional study using convenience sampling at two tertiary hospitals, the work captures a single point in time and a specific population, so causal direction cannot be established and the findings may not generalize to all ICU settings or to nurses at other career stages. The explanatory power of both regression models was modest, meaning that many other factors beyond moral sensitivity and ethical climate almost certainly shape how these nurses reason through ethical problems. The researchers themselves note that these factors warrant further consideration in the development and evaluation of support strategies, and they call for longitudinal and intervention studies to test whether the associations hold over time and whether targeted programs can strengthen them.

Even with those caveats, the study offers a concrete signal for hospital administrators and nursing educators. If moral sensitivity is associated with both what new ICU nurses believe should be done and what they expect will be done, then educational interventions that sharpen ethical awareness could pay dividends across the board. And if the perceived ethical climate is tied to the realistic side of the equation, then improving the moral texture of the workplace itself, through leadership, open discussion of ethical cases, and visible institutional support, may be the lever that closes the gap between what nurses know is right and what they expect to see happen at the bedside. For a workforce navigating its first years in one of medicine’s most ethically charged arenas, that gap may be the most important metric of all.

Subject of Research: Ethical decision-making among advanced beginner nurses in intensive care units

Article Title: Moral sensitivity, role conflict, ethical climate, and ethical decision-making among advanced beginner nurses in intensive care units: a cross-sectional study

Article References: Kim, M., & Yun, J. (2026). Moral sensitivity, role conflict, ethical climate, and ethical decision-making among advanced beginner nurses in intensive care units: a cross-sectional study. BMC Nursing. https://doi.org/10.1186/s12912-026-05519-6

Image Credits: AI Generated

DOI: 10.1186/s12912-026-05519-6

Keywords: nursing ethics, intensive care units, moral sensitivity, ethical climate, role conflict, ethical decision-making, advanced beginner nurses, Benner's model, cross-sectional study, South Korea, end-of-life care, BMC Nursing