The Relationships Between Ethical Sensitivity, Ethical Decision-Making Ability, and Ethical Conflict Among ICU Nurses: A Structural Equation Model.

Ethical conflict in nursing is a common phenomenon in intensive care units (ICUs). Nurses' ethical sensitivity forms the basis for identifying ethical conflicts. Ethical decision-making abilities are closely related to ethical conflict. However, there are currently no reports on the pathways between ethical sensitivity, decision-making ability, and conflicts among ICU nurses. Based on the cognitive-behavioral theory, a structural equation model was developed to quantitatively analyze the relationships between ICU nurses' ethical sensitivity, decision-making ability, and conflicts. A cross-sectional survey was conducted involving ICU nurses from six general hospitals in China from May to July 2024, using the General Information Questionnaire, Ethical Conflict Nursing Questionnaire-Critical Care Version (ECNQ-CCV), Chinese Moral Sensitivity Questionnaire-Revised Version (MSQ-R-CV, including the dimensions of moral responsibility and strength and sense of moral burden), and Chinese version of judgment about nursing decision (JAND-CE). Descriptive analyses were conducted with SPSS 25.0, and a structural equation model (using Amos 26.0) was performed to identify path relationships between the variables. The constructed model demonstrated a strong overall fit, and there were significant correlations between ethical sensitivity, decision-making ability, and conflicts among Chinese ICU nurses ( < 0.05). The values of path coefficients showed that moral responsibility and strength have a positive association with JAND-CE ( = 0.263, < 0.05) and negative association with ECNQ-CCV ( = -0.246, < 0.05). Moreover, sense of moral burden has a negative association with JAND-CE ( = -0.353, < 0.05) and positive association with ECNQ-CCV ( = 0.232, < 0.05). Further, JAND-CE has a negative association with ECNQ-CCV ( = -0.183, < 0.05). This study conducted mediation analysis by examining the indirect path between moral responsibility and strength, sense of moral burden, and ECNQ-CCV via JAND-CE, whereby the beta coefficients of independent mediating and mediating-dependent variables were multiplied. The indirect path between moral responsibility and strength and ECNQ-CCV through JAND-CE was significant (i.e. indirect path (0.263 × (-0.183)) = -0.048, < 0.05, LL = -0.608, UL = -0.07), and the indirect path between sense of moral burden and ECNQ-CCV through JAND-CE was significant (indirect path ((-0.353) × (-0.183)) = 0.065, < 0.05, LL = 0.082, UL = 0.758) and did not contain a zero value between lower and upper boundaries. This study reveals the dual-path mechanism of moral responsibility and strength and sense of moral burden on ethical conflicts through structural equation modeling, emphasizing the mediating pivotal role of ethical decision-making ability. The research findings provide a theoretical basis for the refinement of moral capacity cultivation systems, while also warning of the potential negative impacts of moral burden. Nursing managers should dynamically evaluate ICU nurses' ethical sensitivity and decision-making abilities to provide a reference for implementing individualized ethical conflict intervention measures.