Nurses Who Follow Ethical Codes Report Greater Moral Comfort in the ICU

Intensive care units are among the most ethically charged environments in modern medicine. Every shift can bring decisions about withdrawing life-sustaining treatment, allocating scarce resources, or balancing a patient’s dignity against the demands of aggressive intervention. A new cross-sectional study from Iran suggests that the degree to which ICU nurses adhere to their professional ethical codes is strongly linked to a psychological state known as moral comfort, an inner sense of alignment between what a nurse believes is right and what they actually do at the bedside. The research, published in BMC Nursing by Ali Redaey and Maasoumeh Barkhordari-Sharifabad, offers quantitative evidence that ethical practice and moral well-being travel together in one of healthcare’s most demanding settings.

Moral comfort is a concept that has gained increasing attention in nursing ethics over the past two decades. It describes the positive end of a spectrum that runs from moral distress, the anguish felt when a clinician knows the ethically right course of action but is constrained from taking it, toward a state of psychological ease in which a nurse feels their actions are consistent with their moral values. For intensive care nurses, who confront end-of-life decisions and complex clinical judgments daily, moral comfort is not a luxury. Researchers consider it essential for sustaining mental health, preventing burnout, and maintaining the quality of care delivered to patients who are often unconscious and unable to advocate for themselves.

The study set out to test a specific hypothesis: that adherence to professional ethical standards in nursing care contributes to the development of moral comfort. Professional ethics in nursing is anchored in frameworks such as the International Council of Nurses’ Code of Ethics, which outlines responsibilities toward patients, colleagues, and society, including commitments to confidentiality, respect for human dignity, informed consent, and competent practice. The researchers reasoned that nurses who internalize and consistently apply these standards should experience fewer internal conflicts between their values and their actions, and therefore greater moral comfort.

To investigate this relationship, the team conducted a descriptive cross-sectional study in 2025 among nurses working in the intensive care units of two hospitals affiliated with Shahid Sadoughi University of Medical Sciences in Yazd, Iran. Using simple random sampling, they recruited a total of 165 ICU nurses. Each participant completed three instruments: a demographic information form capturing age, work experience, and other background variables; the Professional Ethics Adherence Questionnaire, which measures how consistently nurses report upholding ethical standards in their daily practice; and the Moral Comfort Questionnaire, a validated tool that quantifies the degree of moral comfort a nurse experiences. Data were analyzed with SPSS version 16 using descriptive statistics, Pearson correlation coefficients, independent t-tests, one-way ANOVA, and stepwise multiple linear regression.

The results revealed a striking pattern. The mean total score for moral comfort was 103.79 with a standard deviation of 14.72, while the mean score for professional ethics adherence was 143.86 with a standard deviation of 20.39. Most importantly, professional ethics adherence showed a significant positive correlation with moral comfort, with a Pearson correlation coefficient of r = .685 and a p-value below .001. In practical terms, nurses who reported stronger adherence to their ethical codes also reported substantially higher levels of moral comfort. A correlation of this magnitude, in behavioral and health research, is considered strong, indicating that the two constructs move together closely across the sample.

The analysis also uncovered demographic patterns worth noting. Age, clinical work experience, and ICU-specific work experience were each significantly and positively correlated with moral comfort. This suggests that seasoned nurses, who have had more time to develop coping strategies, clinical judgment, and confidence in navigating ethically fraught situations, tend to feel more morally at ease than their less experienced colleagues. However, the key question was whether ethics adherence would remain independently associated with moral comfort once these background factors were taken into account.

To answer that question, the researchers turned to hierarchical multiple linear regression, a statistical technique that enters variables into the model in stages, allowing investigators to see how much explanatory power each new variable adds beyond what earlier variables already account for. After adjusting for age, clinical experience, and ICU experience, professional ethics adherence remained independently and positively associated with moral comfort, with a standardized beta coefficient of .670 and a p-value below .001. The addition of professional ethics adherence to the model significantly increased the explained variance, contributing a change in R-squared of 0.366, with a change in F statistic of 113.660 across 1 and 160 degrees of freedom, again with p below .001. Taken together, the final model explained 48.5 percent of the variance in moral comfort among the studied nurses.

Those numbers deserve unpacking for readers less familiar with regression statistics. An R-squared of 0.485 means that nearly half of the variability in moral comfort from nurse to nurse can be statistically accounted for by the combination of demographic factors and ethical adherence measured in the study. The delta R-squared of 0.366 is particularly telling: it indicates that professional ethics adherence alone added more than a third of explanatory power beyond what age and experience provided. In other words, the association between ethical practice and moral comfort is not merely a byproduct of older, more experienced nurses being both more rule-abiding and more content. Even among peers of the same age and tenure, those who adhere more closely to professional ethical standards report markedly greater moral comfort.

The authors caution, as is appropriate for any cross-sectional design, that the study captures associations rather than proven causal direction. It is theoretically plausible that adhering to ethical codes fosters moral comfort, because consistent ethical behavior reduces the internal dissonance that fuels moral distress. It is also possible that nurses who feel morally comfortable find it easier to practice according to their ethical codes, or that unmeasured factors, such as supportive workplace culture, adequate staffing, or individual moral sensitivity, influence both variables simultaneously. Longitudinal and interventional studies would be needed to establish causality. Nevertheless, the strength and independence of the observed association make a compelling case that the two are meaningfully intertwined.

The practical implications reach well beyond the statistical tables. The authors suggest that ethics education, organizational support, and nurses’ participation in ethical decision-making may contribute to strengthening adherence to professional ethical standards, which in turn may be associated with greater moral comfort. For hospital administrators, this points toward concrete interventions: integrating ethics training into continuing education, creating forums where ICU nurses can voice and process ethical concerns, and involving bedside nurses directly in decisions about treatment goals and end-of-life care. For a profession grappling with global shortages, high burnout rates, and post-pandemic moral exhaustion, the message is clear. Protecting nurses’ moral well-being may begin not with wellness programs alone, but with building systems that make it easier for nurses to practice the ethics they already believe in.

Subject of Research: The relationship between professional ethics adherence and moral comfort among intensive care unit nurses

Article Title: Association of professional ethics adherence and moral comfort among intensive care unit nurses

Article References: Redaey, A., & Barkhordari-Sharifabad, M. (2026). Association of professional ethics adherence and moral comfort among intensive care unit nurses. BMC Nursing. https://doi.org/10.1186/s12912-026-05459-1

Image Credits: AI Generated

DOI: 10.1186/s12912-026-05459-1

Keywords: nursing ethics, moral comfort, moral distress, intensive care units, professional ethics adherence, ICU nurses, cross-sectional study, burnout, ethical decision-making, BMC Nursing, regression analysis, nurse well-being