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

Intensive care units (ICUs) expose nurses to frequent ethical decision-making situations, including end-of-life care and conflicts with families. Advanced beginner nurses face these situations while their clinical competence is still developing, yet little is known about the factors associated with their ethical decision-making. This study identified factors associated with ethical decision-making among advanced beginner ICU nurses. This cross-sectional study included 125 nurses with 13–36 months of total clinical experience working in ICUs of two tertiary hospitals in South Korea, recruited by convenience sampling. The advanced beginner stage was defined according to Jang’s adaptation of Benner’s model. Data were collected through a structured online self-report questionnaire in March–April 2025. Data were analysed using descriptive statistics, t-test, paired t-test, one-way ANOVA with Scheffé post-hoc tests, Pearson’s correlation coefficients, and multiple linear regression including all general characteristics and the three study variables. Mean scores were 4.89 ± 0.48 out of 7 for moral sensitivity, 3.71 ± 0.58 out of 5 for role conflict, 3.74 ± 0.60 out of 5 for ethical climate, 3.69 ± 0.43 out of 5 for ideal ethical decision-making, and 3.15 ± 0.42 out of 5 for realistic ethical decision-making. Ideal scores were significantly higher than realistic scores (mean difference = 0.54, 95% CI [0.46, 0.61]; t = 13.69, p < .001; Cohen’s d = 1.23). Ideal ethical decision-making was associated with moral sensitivity (B = 0.18, 95% CI [0.02, 0.34], β = 0.20, p = .029), total and current-unit experience, and emergency ICU work (adjusted R² = 0.147). Realistic ethical decision-making was associated with moral sensitivity (B = 0.26, 95% CI [0.11, 0.42], β = 0.30, p = .001) and perceived ethical climate (B = 0.20, 95% CI [0.07, 0.33], β = 0.28, p = .003) (adjusted R² = 0.207). Moral sensitivity was associated with both ideal and realistic ethical decision-making, and perceived ethical climate with realistic ethical decision-making, within models of modest explanatory power. The lower realistic scores indicate a difference between what participants judged to be ideally appropriate and what they judged would realistically occur. These factors warrant further consideration in the development and evaluation of support strategies, and longitudinal and intervention studies are needed. Not applicable.