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Khaghanizadeh et al. BMC Medical Ethics (2023) 24:58 https://doi.org/10.1186/s12910-023-00938-5

BMC Medical Ethics

*Correspondence: Amir Vahedian-Azimi [email protected]

Full list of author information is available at the end of the article

Abstract Background Ethical decision-making and behavior of nurses are major factors that can affect the quality of nursing care. Moral development of nurses to making better ethical decision-making is an essential element for managing the care process. The main aim of this study was to examine and comparison the effect of training in ethical decision- making through lectures and group discussions on nurses’ moral reasoning, moral distress and moral sensitivity.

Methods In this randomized clinical trial study with a pre- and post-test design, 66 nurses with moral reasoning scores lower than the average of the community were randomly assigned into three equal groups (n = 22) including two experimental groups and one control group. Ethical decision-making training to experimental groups was provided through the lectures and group discussions. While, the control group did not receive any training. Data were collected using sociodemographic questionnaire, the nursing dilemma test (NDT), the moral distress scale (MDS) and the moral sensitivity questionnaire (MSQ). Unadjusted and adjusted binary logistic regression analysis was reported using the odds ratio (OR) and 95% confidence intervals.

Results Adjusted regression analysis showed that the probability of increasing the nursing principle thinking (NPT) score through discussion training was significantly higher than lecture (OR: 13.078, 95% CI: 3.238–15.954, P = 0.008), as well as lecture (OR: 14.329, 95% CI: 16.171–2.005, P < 0.001) and discussion groups compared to the control group (OR: 18.01, 95% CI: 22.15–5.834, P < 0.001). The possibility of increasing moral sensitivity score through discussion training was significantly higher than lecture (OR: 10.874, 95%CI: 6.043–12.886, P = 0.005) and control group (OR: 13.077, 95%CI: 8.454–16.774, P = 0.002). Moreover, the moral distress score was significantly reduced only in the trained group compared to the control, and no significant difference was observed between the experimental groups; lecture group vs. control group (OR: 0.105, 95% CI: 0.015–0.717, P = 0.021) and discussion group vs. control group (OR: 0.089, 95% CI: 0.015–0.547, P = 0.009).

The effect and comparison of training in ethical decision-making through lectures and group discussions on moral reasoning, moral distress and moral sensitivity in nurses: a clinical randomized controlled trial Morteza Khaghanizadeh1, Aliakbar Koohi1, Abbas Ebadi1 and Amir Vahedian-Azimi2,3*

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Background Patient care is an important concept and in fact the art of the nursing profession and requires the personal, social, moral, and spiritual ability of the nurse to be able to pro- vide desirable and ethical care [1, 2]. In the patient care process, commitment and observance of ethical takes precedence over caring [3]. Ethical dimension of nursing care is an essential component in nursing practice [4, 5]. Advances in science and technology have made patient care more sophisticated, so nurses face difficult situations in patient care that require appropriate ethical decisions [6, 7]. The ethical decision-making process for nurses is a challenging process that can be influenced by several factors, including sociodemographic characteristics, abil- ity of moral reasoning, moral sensitivity, and moral dis- tress [8–10]. Ethical decision-making is a logical process which involves making the best moral decisions through systematic reasoning in a situation that brings about con- flicting choices [11, 12].

One of the components of the moral decision-making process is moral reasoning, which refers to the ability of an individual to make judgments and make correct and rational decisions in dealing with everyday ethical dilem- mas [13, 14]. Familiarity of nurses with ethical dilemmas during their professional activities makes them think about the consequences when making decisions, respect people and perform their professional duties by consid- ering principles such as honesty, confidentiality and fair- ness [15, 16]. Moral sensitivity in nurses makes them use ethics better and more effectively in caring for clients [8]. Moral sensitivity is a combination of one’s knowledge of dimensions ethics and includes responsibility, giving importance to the issues, tolerance, and tranquility [17, 18]. Moral distress is a common phenomenon in nursing practice that can cause conflict in dealing with patients and providing quality care. It can disrupt the process of achieving the goals of the care system, such as making the correct moral decisions in the face of daily dilemmas, and thus have an adverse effect on the pattern of commu- nity health [19, 20]. Therefore, understanding the effects of sociodemographic factors, abilities of moral reasoning, moral sensitivities and moral distress on nurses’ ethical behavior provides valuable data for policy makers, based on which they can design programs to improve nurses’

ethical performance. Since there is no complete and proven information about the impact of these factors on nurses’ moral performance, in this study, the relationship between moral reasoning, moral sensitivity and moral distress levels of the nurses and their sociodemographic characteristics was investigated.

In addition, moral development of nurses is an essen- tial element for managing the care process as qualified and efficient [21]. However, it seems that making ethical decision in the presence of daily moral dilemmas is very difficult [15, 22]. Thus, strategies are needed to improve nurses’ ethical decision-making to minimize the likeli- hood of these problems [23]. It seems that one of the ways to improve the level of ethical decision-making in nurses is training. So that it can increase the ability of moral rea- soning and moral sensitivity of nurses and reduce their moral distress. In this regard, some previous studies have reported that ethical decision-making programs through purely theoretical training such as lecture method are not entirely satisfactory [4, 24]. Accordingly, it seems that the active learning strategies are needed to improve the out- comes of nursing ethics education. Evidence showed that the strategies such as case-based learning (CBL) [15], simulation [25], exposure to challenging situations [26], and multimedia education can be more effective [27]. One of the active learning strategies is group discussions (GD) technique is often used as a qualitative approach to gain in-depth understanding of issues [28]. Accord- ing to our literature search, the impact of nursing ethics education through GD on ethical reasoning, distress, and sensitivity is still unclear as to whether GD can be more effective in improving these abilities than lecture method or not. In this study, the effect of training in ethical deci- sion-making through lectures and group discussions on nurses’ moral reasoning, moral distress and moral sensi- tivity was examined and compared.

Methods Trial design This randomized clinical trial study with a pre- and post- test design was conducted to examine and comparison the effect of training in ethical decision-making through lectures and group discussions on nurses’ moral rea- soning, moral distress and moral sensitivity. The study

Conclusions The results of this study indicate that ethical decision-making training is effective on empowerment of ethical reasoning. Whereas the group discussion was also effective on increasing the ethical sensitivity, it is recommended the training plan provided in this study to be held as workshop for all nurses in health and treatment centers and placed in curricular plan of nursing students.

Registration This randomized clinical trial was registered in Iranian Registry of Clinical Trials under code (IRCT2015122116163N5) in 02/07/2016.

Keywords Ethical decision-making, Moral reasoning, Moral distress, Moral sensitivity, Nurses

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protocol was reviewed and approved by the Ethics Com- mittee of Baqiyatallah University of Medical Sciences, Tehran, Iran, under code IR.BMSU.REC.1394.145, in accordance with the Declaration of Helsinki of the World Medical Association [29]. This randomized clinical trial study was registered in Iranian Registry of Clinical Tri- als under code (IRCT2015122116163N5) in 02/07/2016. Written informed consent was obtained from all partici- pants. This study was performed and reported in accor- dance with the recommendations of the Consolidated Standards of Reporting Trials (CONSORT) statement [30].

Setting and participants All nurses of Baqiyatallah Hospital in Tehran, Iran, were eligible to participate in the study if they met all the inclusion criteria. The study inclusion criteria for nurses included having bachelor’s or higher degrees in nursing, having at least 1 year of work experience in direct par- ticipation in patient care. Based on inclusion criteria, 270 nurses were selected by census method in 2015, and the levels of moral reasoning, moral distress, and moral sensitivity of these nurses were determined by ques- tionnaires. Out of 270 questionnaires which distributed among participants, 25 questionnaires were excluded due to incompleteness. Therefore, the final sample size was 245 nurses with 90.7% response rate. According to our findings, in 86 nurses the mean moral reasoning score was lower than the community average. Among 86 nurses, 66 nurses who willingness to participate in the study if they did not have a history of attending in work- shops or nursing ethic courses in the past, were selected by simple random sampling method and assigned into three groups (two experimental groups and one control group) using block randomization methods.

Sample size based on the study of Borhani et al. [31], and using Alt- man nomogram with the confidence coefficient of 95%, the confidence interval of 1.96, type II error of 10% (1.63) and 90% power, the sample size was initially set at 17 sub- jects in each group which was raised to 22 subjects in view of the possibility of a 10% sample loss.

Randomization The subjects were included in the study by simple ran- dom sampling method and divided into three equal groups (n = 22) including two experimental groups (received nursing ethics education through lectures and group discussions methods) and a control group (did not received any nursing ethics training) using block random- ization methods. To perform blocked randomization, the randomization code was generated by computer in per- muted blocks of 6. Block randomization was performed

using sealed envelope technique and computer-generated random numbers by Random Allocation Software © (RAS; Informer Technologies, Inc., Madrid, Spain).

Intervention Nursing ethics education lesson plan in both experimen- tal groups was conducted in a one-day workshop for 8 h in order to get acquainted with the basics and principles of ethical decision-making and to acquire ethical reason- ing skills. The details of training program implemented for the two intervention groups is available in Addi- tional File 1. Education program via lectures method was conducted as a one-day symposium and the answers to questions of each scenario and the solutions to the ethi- cal dilemmas presented in each scenario were provided by lecturer. Training for the group discussions was pre- sented as a one-day workshop as a discussion and by giv- ing predetermined scenarios, the participants were asked about ethical issues in the field of nursing. They made ethical decisions in the face of these issues and reason- ably defended their decision, and participants criticized each other’s decisions. In summarizing the discus- sion between the participants about each scenario, the researcher based on scientific principles approved or rejected the participants’ decisions and was taught how to make ethical decisions, so that nurses at the end of the workshop could formulate ethical issues with critical rea- soning and identify the correct moral decision.

The educational content for both experimental groups was the same. So, there was no risk of between-group information leakage. The educational content included teaching the basics and principles definitions of eth- ics, the importance of nurses’ awareness of ethics, the importance of ethics to nursing, the ethical principles of nursing practice (including independence, secrecy, and accountability), professional ethics, and the approaches to ethical decision-making, Kohlberg’s level of moral development and presenting ethical scenarios. To deter- mine the validity of the program syllabus, the opinions of faculty members and members of the hospital ethics committee were used.

Data collection and study instruments Data were collected using four questionnaires including sociodemographic questionnaire, Nursing Dilemma Test (NDT), Moral Distress Scale (MDS) and Moral Sensi- tivity Questionnaire (MSQ). To determine the levels of moral reasoning, moral distress, and moral sensitivity of these nurses, the questionnaires were completed once by the participants. However, to examine and compari- son the effect of training in ethical decision-making, the questionnaires were completed by the participants twice, pre- and post-intervention.

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Sociodemographic questionnaire; The sociodemo- graphic data questionnaire consisted of twelve questions about age (years), gender (male and female), marital sta- tus (married and single), work experience (years), work wards (general ward and intensive ward), position (head nurse, nurse, and in charge nurse), employment type (full time, part time and contract employees), shift work (fixed shift and rotation shift), overtime work (hours), aware- ness of code of ethics (completely, partly and never), awareness of Patients’ Rights (completely, partly and never) and attending to ethics course (yes and no).

Nursing Dilemma Test (NDT); The NDT was devel- oped by Patricia Crisham in 1981 at the University of Minnesota through studying 130 nurses [32]. The NDT contains six scenarios on ethical dilemmas in nursing care, which includes (a) newborn with anomalies; (b) forcing medication; (c) adults’ requests to die; (d) new nurse orientation; (e) medication errors and (f ) termi- nally ill adults. Each scenario consists of three sections; first section asks about the necessary action in case of a moral dilemma presented in the scenario and wants the answerer to mark one of the three options provided for each ethical dilemma, which the answer can be inter- preted in three ways: correct, incorrect and unanswered. Second section is based on the Kohlberg’s Moral Devel- opment Theory and in this part six statements are pre- sented which asked the participants are asked to choose the most important statement among these six and to put the statements in order of importance for themselves. Responses given in this part determined the scores of Nursing Principled thinking (NPT). NPT shows the importance attached to considering moral principles when making a moral decision in nursing. The low- est and highest NPT score from each scenario is 3 and 11. Thus, the range of total score for six scenarios is 18 to 66 and a higher score of NPT indicates a higher level of moral reasoning abilities. The third section assesses whether participants had previous experiences with a similar dilemma or not. A familiarity score between 6 and 17 shows that the participants are familiar with a similar dilemma, while a score falling within the 18–30 range reveals no familiarity with a similar dilemma. The Cronbach’s alpha coefficient for the Persian version of the NDT was reported 0.82 and 0.95 by Borhani et al. [33], and Zirak et al. [34], respectively.

Moral Distress Scale (MDS); The MDS was developed and validated by Atashzadeh et al. [35], in Iran, which assesses the severity of moral distress in ICU nurses. This tool contains 30 items that include three dimen- sions; inappropriate competencies and responsibilities (10 items), errors (11 items) and not respecting the eth- ics principles (9 items). The scoring system for this scale is based on four-point Likert scale (0 = none to 4 = very much). Each item received 0–4 points and the whole

instrument had a score between 0 and 120. The moral distress score is obtained from the average total points of the items. Similarly, the score of each dimension is obtained from the average total points of the items of the same dimension. The moral distress score obtained from the whole scale was grouped into four categories (0–1 = low, 1.01–2 = average, 2.01–3 = high, 3.01–4 = very high). Thus, the obtained score ranged from low to very high of which the higher score indicates the existence of more moral tension. The Cronbach’s alpha coeffi- cient for the total MDS score and each dimension that includes inappropriate competencies and responsibili- ties, errors and not respecting the ethics principles was reported 0.93, 0.93, 0.96, and 0.89 by Atashzadeh et al. [36], respectively.

Moral Sensitivity Questionnaire (MSQ); The MSQ was developed by Lutzen et al. [37], in Sweden and then was used in various countries, including Iran. This tool measures the ethical status of nurses when pro- viding clinical services. The first questionnaire had 30 items, which reduced to 25 items during the process. The questionnaire is comprised of six subscales: respect the patient’s autonomy (questions 1, 10, 12), knowl- edge of how to communicate with the patient (ques- tions 1, 2, 3, 4, 17), professional knowledge (questions 16, 24), experience of ethical problems and conflicts (questions 9, 11, 15), the application of moral concepts in moral decisions (questions 6, 8, 14, 18, 20) and integ- rity and benevolence (questions 5, 7, 19, 21, 22, 23, 25). It is scored based on five-point Likert scale (0 = no com- ment to 4 = totally agree). The overall score of this scale is between 0 and 100. The total scores between 0 and 50, 50–75 and 75–100 indicates low, moderate and high level of moral sensitivity, respectively. The reliability of the questionnaire in the US and in Korea was 0.76 and 0.78, respectively [38, 39]. In addition, the Cronbach’s alpha coefficient for the Persian version of the MSQ instrument was reported 0.80 and 0.81 by Izadi et al. [40], and Has- sanpoor et al. [41], respectively.

Statistical analysis Categorical variables were described as frequency rates and percentages, and continuous variables were described using mean ± standard deviation (SD) values. Inferential statistics such as independent t-test and one- way analysis of variance (ANOVA) and Bonferroni post hoc test were used to examine the association of NDT, MD and MS and their dimensions’ mean scores with sociodemographic variables. Chi-square (χ2) or Fisher’s exact tests were used for comparing sociodemographic characteristics as categorical proportions with three groups of study. One-way ANCOVA (analysis of covari- ance) with repeated measures (RMANOVA) was used to assess the time trend and group interaction effects

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on the mean scores of NDT, MD and MS pre-and post- intervention in the three study groups. Both unadjusted and adjusted (adjusting for based on age group, gender, marital status, work experience, wards, shift work and overtime) repeated measures ANOVA were assessed. Multiple Bonferroni post hoc test was used to explore differences between pairwise groups in means of ques- tionnaires scores. Univariate and multivariate binary logistic regression were used to evaluate the association of sociodemographic characteristic with the scores of moral reasoning, moral distress and moral sensitivity of 245 nurses. In addition, unadjusted and adjusted binary logistic regression analysis were used to assessed the association between three groups of study with the scores of moral reasoning, moral distress and moral sensitivity of 66 nurses after intervention. Associations in regression analysis were reported using the odds ratio (OR) and 95% confidence intervals. (CI) GraphPad Prism 9© (Graph- Pad Software Inc., La Jolla, CA) was used for forest plot of logistic regression analysis to show the association of parameters. All analyses were conducted using SPSS software (ver.21) (SPSS Inc. IL, Chicago, USA) and in all analyses, a two-tailed P-value of < 0.05 was considered significant.

Results Levels of moral reasoning, moral distress and moral sensitivity A total of 245 nurses have completed the all question- naires. Distribution the mean total scores of nurs- ing dilemma test, moral distress and moral sensitivity according to sociodemographic characteristics of 245 nurses are available in Additional File 2 Table S1. In nurs- ing dilemma test, the mean total score of nursing prin- cipled thinking (NPT) (section B) and familiarity (section C) of the nurses were 40.80 ± 6.71 and 13.55 ± 4.09, respectively. The level of moral reasoning of 39 (15.9%), 187 (76.3%) and 19 (7.8%) of the nurses was pre-conven- tional, conventional and post-conventional, respectively. The mean total NPT score among the single nurses was significantly higher than married nurses (43.13 ± 7.60 vs. 40.45 ± 6.52, P = 0.035). In terms of familiarity, the results showed that the majority of nurses were familiar with similar dilemmas (n = 192, 78.4%). No significant dif- ferences were observed between familiarity score and sociodemographic characteristics (P > 0.05).

The mean total score of moral distress in nurses was 60.66 ± 26.23, which was slightly higher than average (Additional File 2 Table S1). Additionally, the findings revealed mean score of MD in “inappropriate competen- cies and responsibilities” dimension was 18.29 ± 9.44, in “errors” dimension, was 23.12 ± 10.35 and in “not respect- ing the ethics principles” dimension was 19.25 ± 9.05 (Additional File 2 Table S2). There was no statistically

significant difference between the sociodemographic fac- tors and moral distress and its dimensions.

The mean score of total moral sensitivity in the nurses was 63.78 ± 10.47, which indicates the moderate level of moral sensitivity in them (Additional File 2 Table S1). No significance differences were observed between moral sensitivity and sociodemographic characteristics. Dis- tribution the scores of moral sensitivity’s dimensions according to sociodemographic characteristics are pre- sented in Additional File 2 Table S3. The findings revealed mean score of MS in “respect the patient’s autonomy” dimension was 9.73 ± 1.99, in “knowledge of how to com- municate with the patient” dimension, was 15.88 ± 3.76, in “professional knowledge” dimension was 3.65 ± 1.73, in “experience of ethical problems and conflicts” dimen- sion was 8.48 ± 1.96, in “the application of moral concepts in moral decisions” dimension was 11.62 ± 3.04 and in “integrity and benevolence” dimension was 15.81 ± 3.70. In “respect the patient’s autonomy” dimension was observed that female nurses’ score was significantly higher than male (10.08 ± 17.33 vs. 8.96 ± 2.29, P = 0.001), contract employee status nurses had higher score than part time nurses (10.30 ± 1.47 vs. 8.17 ± 2.91, P = 0.005) and nurses with lower overtime work (≤ 60 h) had higher score than the nurses with more than 60 h overtime work (10.03 ± 1.85 vs. 9.37 ± 2.10, P = 0.009). According to the “knowledge of how to communicate with the patient” dimension, female nurses’ score was significantly higher than male (16.45 ± 3.80 vs. 14.64 ± 3.41, P = 0.001), nurses with higher work experience (< 15 years) had higher score than the nurses with lower work experience (≤ 15 years) (16.43 ± 4.14 vs. 15.37 ± 3.31, P = 0.027), employee status of nurses had impact on the score of this dimension as contract employee nurses had higher score than the full time (16.89 ± 4.15 vs. 15.36 ± 3.37, P = 0.05) and part time nurses (16.89 ± 4.15 vs. 14.17 ± 3.43, P = 0.006), the score was higher in the nurses with lower overtime work than that higher overtime work (16.34 ± 4.03 vs. 15.34 ± 3.36, P = 0.038). The score of “professional knowledge” dimen- sion in married nurses was significantly higher than single nurses (3.74 ± 1.73 vs. 3.06 ± 1.62, P = 0.040) and nurses working in ICU than those working in general wards (3.97 ± 1.74 vs. 3.07 ± 1.67, P = 0.002). The score of experience of ethical problems and conflicts dimension in female nurses was significantly higher than the male nurses (8.71 ± 1.81 vs. 7.99 ± 2.20, P = 0.007). In addition, the significantly higher score in “the application of moral concepts in moral decisions” dimension was observed in nurses with fixed shiftwork than nurses with rotation shiftwork (12.01 ± 2.82 vs. 11.02 ± 3.26, P = 0.012).

Results from section A of NDT The data obtained from section A of each scenario of NDT are showed in Additional File 2 Table S4. According

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to the results, more than half of the nurses (65.3%) were in favor of resuscitation of a newborn with abnormali- ties, 24.9% supported administering medication against the will of the patient while, and 4.1% of them remained undecided. As for the third scenario, the majority of the nurses (93.5%) stated that they would provide respiratory support although a competent adult patient requested to die. Nearly one third of the nurses (33.9%) stated that time should be set aside for the orientation of new nurses, and 8.6% of them remaining undecided. A great majority of the nurses (90.6%) stated that medication

errors must be informed. The last scenario presented a dilemma about a terminally ill adults and fewer than half of the nurses (44.45%) thought that patients’ questions must be answered and 15.5% remained undecided.

Binary logistic regression findings Univariate and multivariate binary logistic regression analysis to evaluate the association of sociodemographic characteristic with NPT score (section B of NDT) are presented in Fig.  1A and B. In multivariate regression analysis, the NPT score was significantly increased by

Fig. 1 Forest plot of (A) univariate and (B) multivariate binary logistic regression analysis to show the association of sociodemographic characteristic with the section B (NP score ≤ 41 vs. >41) of the Nursing Dilemma Test

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single status (OR: 1.66, 95% CI: 1.289–3.506, P = 0.023), lower (≤ 15 years) work experience (OR: 2.297, 95%CI: 1.993–5.314, P = 0.042), working in general wards (OR: 1.677, 95%CI: 1.023–3.858, P = 0.045) and completely awareness of code of ethics than partly (OR: 2.757, 95%CI: 1.43–5.316, P = 0.002) and never (OR: 4.08, 95%CI: 1.68–9.909, P = 0.001) awareness. Furthermore, Univariate and multivariate binary logistic regression analysis to evaluate the association of sociodemographic characteristic with familiarity, MD and MS scores are available in Additional File 2 Table S5–S7. However, no significant association was observed between the factors and scores of familiarity, MD and MS.

Characteristics of nurses in the second phase of study (n = 66) The CONSORT flow diagram of study population in the second phase of study is presented in Fig. 2. Of the 245 nurses who participated in the first phase of the study, 66 nurses with NPT scores below the community aver- age, no history of attending the nursing ethics educa- tion, and willingness to participate were selected for the second phase. These 66 nurses randomly assigned into three equal groups (n = 22) including two experimental groups (lectures method and group discussions methods) and one control group. Mean age of the patients in the lecture group, group discussion, and control group were 37.32 ± 7.93, 40.05 ± 5.63, and 37.32 ± 6.41 years, respec- tively, with female predominance of 77.3%, 63.6%, and

Fig. 2 CONSORT flow diagram

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68.2%, respectively, in the three groups of study. Accord- ing to post hoc Tukey test, the mean age of almond group was significantly higher than the mean age of the patients in the lavender group (63.19 ± 9.07 vs. 56.92 ± 9.12, P = 0.016). Also, in terms of marital status, the signifi- cant statistically difference was observed between the three groups of study (P < 0.001). However, there was no statistically significant difference between the three groups regarding in the gender (P = 0.729) and qualifica- tion (P = 0.078) The results indicated that there was no significant difference between the three groups in terms of the demographic variables, including age (P = 0.555), gender (P = 0.605), marital status (P = 0.288), work expe- rience (P = 0.832), ward of working (P = 0.650), position (P = 0.528), employment types (P = 0.136), shift working (P = 0.299), overtime working (P = 0.785) and awareness of patients’ rights (P = 0.683) (Table 1). However, awareness of ethical code was significantly higher in the group dis- cussions than the other groups (P = 0.002).

Comparison of pre- and post-intervention scores Comparison of pre- and post-intervention scores of nursing dilemma, moral distress and moral sensitiv- ity between three groups are presented in Table  2. The

results showed no significant differences between the three groups in terms of their NPT (P = 0.838), familiarity (P = 0.640), moral distress (P = 0.931) and moral sensitivity (P = 0.159) scores in pre-intervention. At the beginning of the study, the mean NPT scores did not differ signifi- cantly between the three groups (P = 0.838), however, after the intervention, this mean score increased signifi- cantly in the both experimental groups compared to the control group (P < 0.001). Also, between the two experi- mental groups, the improved NPT score after the inter- vention in the discussion group was significantly higher than the lecture group (52.50 ± 2.44 vs. 44.64 ± 4.70, P < 0.001). However, the differences between the mean scores of nurses’ familiarity after the intervention in the three studied groups was not significant (P = 0.997). The mean score of the post-intervention moral sensitiv- ity in the discussion group was significantly higher than the lecture (76.50 ± 11.52 vs. 61.55 ± 11.57, P < 0.001) and control groups (76.50 ± 11.52 vs. 64.27 ± 9.45, P < 0.001). In terms of moral distress, the difference between the mean total scores and its dimensions after the interven- tion in the three studied groups was not significant, but in the dimension of “not respecting the ethics principles” in pre- and post-intervention, a significant decrease was

Table 1 Sociodemographic characteristics of the participants in three groups of study (n = 66) Sociodemographic characteristics Total

(n = 66) Lecture group (n = 22)

Discussion group (n = 22)

Control group (n = 22)

P-value

Gender Male 20 (30.3) 5 (22.7) 8 (36.4) 7 (31.8) 0.605

Female 46 (69.7) 17 (77.3) 14 (63.6) 15 (68.2)

Age (year) ≤ 40 42 (63.6) 15 (68.2) 12 (54.5) 15 (68.2) 0.555

> 40 24 (36.4) 7 (31.8) 10 (45.5) 7 (31.8)

Marital status Single 13 (19.7) 6 (27.3) 5 (22.7) 2 (9.1) 0.288

Married 53 (80.3) 16 (72.2) 17 (77.3) 20 (90.9)

Work experience ≤ 15 36 (54.5) 11 (50) 12 (54.5) 13 (59.1) 0.832

(year) > 15 30 (45.5) 11 (50) 10 (45.5) 9 (40.9)

Ward of General 29 (43.9) 11 (50) 10 (45.5) 8 (36.4) 0.650

working ICU 37 (56.1) 11 (50) 12 (54.5) 14 (63.6)

Position Head nurse 10 (15.2) 4 (18.2) 4 (18.2) 2 (9.1) 0.528

In charge nurse 19 (28.8) 6 (27.3) 4 (18.2) 9 (40.9)

Nurse 37 (56.1) 12 (54.5) 14 (63.6) 11 (50)

Employment Full time 39 (59.1) 11 (50) 11 (50) 17 (77.3) 0.136

types Part time 4 (6.1) 3 (13.6) 1 (4.5) 0

Contract employees 23 (34.8) 8 (36.4) 10 (45.5) 5 (22.7)

Shift working Fixed shift 40 (60.6) 16 (72.7) 13 (59.1) 11 (50) 0.299

Rotation shift 26 (39.4) 6 (27.3) 9 (40.9) 11 (50)

Overtime work ≤ 60 34 (51.5) 10 (45.5) 12 (54.5) 12 (54.5) 0.785

(hours) > 60 32 (48.5) 12 (54.5) 10 (45.5) 10 (45.5)

Awareness of Completely 12 (18.2) 4 (18.2) 8 (36.4) 0 0.002* Ethical code Partly 41 (62.1) 14 (63.6) 14 (63.6) 13 (59.1)

Never 13 (19.7) 4 (18.2) 0 9 (40.9)

Awareness of Completely 49 (74.2) 15 (68.2) 17 (77.3) 17 (77.3) 0.683

Patients’ Rights Partly 16 (24.2) 6 (27.3) 5 (22.7) 5 (22.7)

Never 1 (1.5) 1 (4.5) 0 0 *P < 0.05 considered as significant

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observed between the two intervention groups after intervention. These differences in the lecture and discus- sion groups were (21.91 ± 9.59 to 17.36 ± 7.75, P = 0.020) and (17.27 ± 8.54 to 12.59 ± 4.82, P = 0.017), respectively. In addition, in this dimension significantly differed was observed between the discussion group and control group (12.59 ± 4.82 vs. 20.09 ± 10.07, P = 0.007).

Findings of regression analysis between groups Unadjusted and adjusted binary logistic regression analy- sis to evaluate the association between three groups of study with the NPT score, familiarity score, moral dis- tress score and moral sensitivity score are presented in Figs.  3 and 4. Adjusted regression analysis showed that the probability of increasing the nursing prin- ciple thinking (NPT) score through discussion train- ing was significantly higher than lecture (OR: 13.078, 95% CI: 3.238–15.954, P = 0.008), as well as lecture (OR: 14.329, 95% CI: 16.171–2.005, P < 0.001) and discussion groups compared to the control group (OR: 18.01, 95% CI: 22.15–5.834, P < 0.001). The possibility of increas- ing moral sensitivity score through discussion training

was significantly higher than lecture (OR: 10.874, 95%CI: 6.043–12.886, P = 0.005) and control group (OR: 13.077, 95%CI: 8.454–16.774, P = 0.002). Moreover, the moral distress score was significantly reduced only in the trained group compared to the control, and no signifi- cant difference was observed between the experimental groups; lecture group vs. control group (OR: 0.105, 95% CI: 0.015–0.717, P = 0.021) and discussion group vs. con- trol group (OR: 0.089, 95% CI: 0.015–0.547, P = 0.009). Details of all regression analyzes are available in the Additional File 2 Table S8–S11.

Discussion The results of this study showed that the level of moral reasoning, moral sensitivity and moral distress in the nurses compared to previous studies and the level of average community, were low, medium and high, respec- tively. The results of the nurses’ responses to the ques- tions of part A of the NDT test showed that many of them are familiar with these problems, which is a confir- mation of the findings of part C of the NDT test. In this study, familiarity scores of the majority nurses indicated

Table 2 Comparison of pre- and post-intervention scores of nursing dilemma, moral distress and moral sensitivity between three groups Parameters Times Lecture

group (n = 22)

Discussioin group (n = 22)

Control group (n = 22)

P-value ***

P-value ****

Nursing dilemma test (NDT)

NP score Pre-intervention 36.09 ± 5.28 36.18 ± 3.72 35.45 ± 4.09 0.838 < 0.001* Post-intervention 44.64 ± 4.70 52.50 ± 2.44 35.36 ± 4.03 < 0.001* P-value** < 0.001* < 0.001* 0.936

Familiarity score Pre-intervention 14.91 ± 3.41 14.50 ± 3.76 13.82 ± 4.33 0.640 0.811

Post-intervention 13.68 ± 3.63 13.46 ± 3.67 13.73 ± 4.39 0.997

P-value* 0.203 0.445 0.943

Moral Sensitivity Questionnaire (MSQ)

Total moral sensitivity score Pre-intervention 60.36 ± 11.68 59.23 ± 11.43 65.55 ± 11.34 0.159 0.010* Post-intervention 61.55 ± 11.57 76.50 ± 11.52 64.27 ± 9.45 < 0.001* P-value* 0.742 < 0.001* 0.689

Moral Distress Scale (MDS)

Total Moral distress score Pre-intervention 60.23 ± 21.34 57.32 ± 26.93 58.09 ± 30.32 0.931 0.337

Post-intervention 53.41 ± 21.34 44.73 ± 17.24 61.32 ± 31.93 0.085

P-value* 0.176 0.104 0.754

Moral distress’s dimensions

Inappropriate competencies Pre-intervention 17.32 ± 7.18 17.27 ± 7.85 15.82 ± 10.90 0.814 0.651

and responsibilities Post-intervention 16.77 ± 7.86 14.68 ± 8.84 16.86 ± 11.11 0.684

P-value* 0.806 0.381 0.785

Errors Pre-intervention 23.05 ± 9.79 22.77 ± 12.30 23.09 ± 12.11 0.995 0.316

Post-intervention 18.82 ± 9.11 17.45 ± 6.78 24.36 ± 12.78 0.056

P-value* 0.059 0.117 0.739

Not respecting the ethics Pre-intervention 21.91 ± 9.59 17.27 ± 8.54 19.18 ± 9.45 0.252 0.175

principles Post-intervention 17.36 ± 7.75 12.59 ± 4.82 20.09 ± 10.07 0.009* P-value* 0.020* 0.017* 0.771

Data are presented as mean ± SD; * P < 0.05 considered as significant, ** Obtained from paired t-test (within-group differences); *** Obtained from unadjusted one- way ANCOVA (analysis of covariance) with repeated measures (RMANOVA) (between-group differences); **** Obtained from adjusted (based on age group, gender, marital status, work experience, wards, shift work and overtime) one-way ANCOVA (analysis of covariance) with repeated measures (between-group differences)

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that they were familiar with ethical dilemmas. Familiar- ity of the nurses with ethical dilemmas is considered to affect their decision making for ethical problems posi- tively [34, 42]. However, ethical decision-making of the nurses may be affected by the several factors such as poli- cies and expectations of the institutions where they work, feeling of mastery of the medical profession, stressful environment, patient complex conditions, and the com- munication with patients that instead of following the rules, they listen to their inner voice [43, 44].

The present study found that the mean NPT scores of nurses were slightly lower than the average level (40.80 ± 6.71). In previous studies by Zirak et al. [34], Borhani et al. [45], and Ham et al. [46], the NPT scores reported 46.67 ± 6.7, 42.16 ± 5.8 and 51.5 ± 7.9, respec- tively. These differences could be due to the attitudes and beliefs of nurses can be influenced by several fac- tors, including rules of workplace and regulations, level of education, cultural, social, political, religious, and clinical experiences of nursing [47]. According to mul- tivariate regression analysis, single status, less work

Fig. 3 Forest plot of unadjusted binary logistic regression analysis to evaluate the association between three groups of study with the (A) NPT score (≤ 50 vs. >50), (B) familiarity score (≤ 18 vs. >18), (C) moral distress score (≤ 58 vs. >58) and (D) moral sensitivity score (≤ 75 vs. >75)

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experience (≤ 15 years), work in the general wards, and awareness of the code of ethics were found to be associ- ated with a higher score of NPT. The results of second phase of study showed that the post-intervention mean score of the NPT scale was significantly higher in both experimental groups than the control group. The major- ity of participants (76.3%) were at the conventional level of moral reasoning, and according to Kohlberg’s theory, the basis of their moral reasoning is to adhere to the rules of the organization, to be in harmony with the commu- nity, and to show oneself well in the eyes of others. The

low number of nurses (7.8%) with post-conventional level of ethical reasoning can be due to the overempha- sis on the authorities to unreasonably follow the rules of the organization and also the complexity of ethical deci- sion-making in clinical settings, which reduces nurses to the customary level of Kohlberg’s moral development stages. Nurses try to have arguments in line with other colleagues that are approved by colleagues and the insti- tute [4, 5]. Therefore, after completing the training course with the main purpose of familiarizing nurses with the concepts of professional ethics, the principles of nursing

Fig. 4 Forest plot of adjusted binary logistic regression analysis to evaluate the association between three groups of study with the (A) NPT score (≤ 50 vs. >50), (B) familiarity score (≤ 18 vs. >18), (C) moral distress score (≤ 58 vs. >58) and (D) moral sensitivity score (≤ 75 vs. >75)

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ethics and ethical conflicts and challenges in clinical care and acquiring ethical decision-making skills, NPT scores were increase among learners.

In this study, total mean score of moral distress include “inappropriate competencies and responsibilities” and ‘‘errors’’ dimensions were high. However, moral dis- tress in ‘‘not respecting the ethics principles’’ dimension was moderate. The highest moral distress was related to ‘‘errors’’ dimension, which was consistence with a study by Atashzadeh-Shoorideh et al. [36]. No significant asso- ciation was found between moral distress levels of the nurses and their sociodemographic variables. The lack of connection between moral distress and sociodemo- graphic characteristics can mean that all nurses, regard- less of age, gender, work experience, ward of works, shift work, and etc., experience moral distress. According to evidence more than half of nurses experience moral dis- tress in their work environment [48, 49]. Provide educa- tion and training to reduce moral distress and its impact on nurses is very important. Although the results of the second phase of the study showed that the training did not have much effect in reducing the moral distress scores of the nurses and only dimension “not respecting the ethics principles” there was a significant reduction. Moral distress may be disrupting the moral decision- making process of achieving care system objectives and consequently have an adverse effect on the health pat- tern of the society. On the other, it can create mental and physical problems for nurses, which may influence on occupational satisfaction and their willingness to remain in the profession, and eventually the quality of care [35, 50]. It seems that training alone is not enough to reduce the two dimensions “inappropriate competences and responsibilities” and “error” of moral distress. Therefore, it is essential to create a safe and supportive environment for nurses to express their feelings and concerns without fear of punishment. Creating a culture of open communi- cation and collaboration between nurses and other mem- bers of the health care team. Morover, increasing rewards for nurses who manage moral distress, creating support systems for nurses dealing with moral distress, providing resources for nurses to make decisions, as well as recog- nizing and address systemic issues that may be contribut- ing to moral distress.

Current study showed that the majority of nurses have moderate moral sensitivity, which was consistent with some previous studies [17, 51]. Because nurses deal with serious situations in patient care that require ethical abil- ity to make appropriate decisions and actions, they need to be sensitive and familiar with ethical issues related to their profession. In this study, there was no significant relationship between sociodemographic characteristics with moral sensitivity, which is consistent with the study of Hassanpoor et al. [41]. Therefore, it can be concluded

that all nurses, regardless of individual and professional conditions, have moderate moral sensitivity, which should be identified as limiting factors of moral sensitiv- ity. Therefore, moderate moral sensitivity of nurses in this study can be due to the “patient-related”, “environmental” and “managerial”, the most important obstacle related to patients includes the patient’s lack of knowledge about the nurse’s job description and the most important envi- ronmental obstacle of the crowded ward [52]. The find- ings of this study showed that the moral sensitivity in nurses was improved with training in ethical decision- making program.

In line with previous research [53–55], the findings of this study showed that moral reasoning decreases with increasing nurses’ work experience. The reasons for this can be crowded work shifts, burnout, job dissatisfaction, stressful and diverse work environment that make nurses unmotivated by the challenges of clinical ethics. On the other hand, with increasing work experience, nurses ‘commitment to the institution increases and nurses may prefer organizational interests to patients’ rights [56]. The findings from this research confirmed that ethical behavior is more influenced by the ethics educational program rather than sociodemographic factors. The results also indicated that the group discussions-based ethics education be more effective in improving the abilities of moral reasoning and moral sensitivity than lecture method. In teaching via lecture method, a large amount of information is provided to nurses in a short period of time. Additionally, in this method, participants are mostly passive, and hence, not all of their problem- solving, decision-making and analytical abilities can be improved. Although the scores of nurses’ ethical reason- ing increased with this method compared to the control group, but it was significantly lower to compare with the group discussions. Therefore, it seems that in this method, nurses still have problems and low self-con- fidence for decision-making in difficult situations and knowledge use in practice. While the results showed that ethics education based on group discussions significantly improved nurses’ moral reasoning and moral sensitivity. The positive effects of group discussions can be attrib- uted to the active involvement of nurses in the process of learning, their group discussions on learning materials, and their exposure to realistic or simulated situations and cases [57].

Limitations The present study has some limitations such as the first phase of study was carried out as descriptive study in single-center hospital, and data was collected using self-reported questionnaires. There may be a possibil- ity of bias and exaggeration of scores. The time inter- val between the intervention and post-test outcome

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assessment was also short, and thus, the study provided no information about the long-term effects of education program on moral reasoning, sensitivity and distress. Ultimately, it should be considered that the impact of one session training on nurses through discussion was very high (Hedge’s g effect size), a possible reason for this extreme finding is that the study focused on training low performers. Therefore, the effects that were found would probably be significantly lower for nurses with lesser development needs. For these reasons, the generaliza- tion of the findings is limited and also the results should be interpreted with caution. Nevertheless, the findings of the study would be helpful for nurse educators and policy makers to develop continuous training in ethical deci- sion-making to improve nurses’ awareness and under- standing of the importance of moral decision-making process and improve the quality of care.

Conclusion According to the results, moral reasoning, moral sensi- tivity and moral distress in the nurses compared to previ- ous studies and the level of average community, were low, medium and high, respectively. In addition, single status, less work experience, work in the general wards, and awareness of the code of ethics were found to be asso- ciated with a higher ability to moral reasoning. While, there was no significant relationship between moral sen- sitivity and moral distress with any of the demographic characteristics of nurses. The findings of the random- ized clinical trial phase of this study indicate that train- ing ethical decision-making through group discussions is an effective strategy for improving moral reasoning and moral sensitivity in nurses, but has no effect on moral distress. Therefore, it can be said that all nurses at any level of sensitivity and moral reasoning experience moral stress that nursing managers should reduce the cause of stress. Therefore, it seems that the all nurses with any sociodemographic characteristics and also at any level of moral reasoning and moral sensitivity, experience moral distress that the policy makers should be find the strategy to reduce it.

Abbreviations NDT Nursing Dilemma Test MDS Moral Distress Scale MSQ Moral Sensitivity Questionnaire OR Odds Ratio GD Group Discussions

Supplementary Information The online version contains supplementary material available at https://doi. org/10.1186/s12910-023-00938-5.

Additional File 1: Educational program for the intervention group (lectures and group discussion).

Additional File 2: Table s1–Table s11.

Acknowledgements Thanks to guidance and advice from the “Clinical Research Development Unit of Baqiyatallah Hospital”.

Author contributions All authors contributed to this study; A. V-A and M. KH designed the study. Acquisition of data, analysis and interpretation by A. K and A. E. Drafting the article by A. V-A and M. KH. All authors edited and revised manuscript and approved final version of manuscript.

Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Data availability The data that support the findings of this study are available from the corresponding author upon reasonable request.

Declarations

Competing interests The authors declare no competing interests. Ethics approval and consent to participate. The present study was approved by the Ethics Committee of Baqiyatallah University of Medical Sciences, Tehran, Iran, under code IR.BMSU.REC.1394.145. This clinical trial study was registered in Iranian Registry of Clinical Trials under code (IRCT2015122116163N5) in 02/07/2016. Written informed consent was obtained from all participants. This study was performed and reported in accordance with the recommendations of the Consolidated Standards of Reporting Trials (CONSORT) statement and the Declaration of Helsinki of the World Medical Association. Consent for publication. Not applicable.

Author details 1Behavioral Sciences Research Center, Life Style Institute, Nursing Faculty, Baqiyatallah University of Medical Sciences, Tehran, Iran 2Trauma Research Center, Nursing Faculty, Baqiyatallah University of Medical Sciences, Tehran, Iran 3Trauma Research Center, Nursing Faculty, Baqiyatallah University of Medical Sciences, Sheykh bahayi Street, Vanak Square Tehran, TehranP.O. Box 19575-174, Iran

Received: 28 May 2022 / Accepted: 25 July 2023

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