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Cited by 40Ethics in medical practiceEthics in Business and EducationEthics and bioethics in healthcare

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

Open access
Khaghanizadeh, Morteza, Koohi, Aliakbar, Ebadi, Abbas, Vahedian-Azimi, Amir·2023·BMC Medical Ethics
DOI 10.1186/s12910-023-00938-5PMC PMC10403849

Published version of a preprint

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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). 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.

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Written from the paper’s full text.

TL;DR

In this RCT of 66 nurses with below-average moral reasoning, ethical decision-making training via lecture or group discussion improved moral reasoning and moral sensitivity compared with no training, with group discussion generally outperforming lecture. Total moral distress did not significantly improve across groups, although the “not respecting ethics principles” dimension decreased in both trained groups.

Key findings

  • Among 245 surveyed nurses, baseline mean NPT was 40.80 ± 6.71, moral distress 60.66 ± 26.23, and moral sensitivity 63.78 ± 10.47; 76.3% were at the conventional level of moral reasoning and 7.8% at the post-conventional level.
  • Post-intervention NPT was higher in both trained groups than control (discussion 52.50 ± 2.44 vs. lecture 44.64 ± 4.70 vs. control 35.36 ± 4.03, P < 0.001); adjusted regression showed discussion vs. lecture OR 13.078 (95% CI 3.238–15.954, P = 0.008), lecture vs. control OR 14.329 (95% CI 16.171–2.005, P < 0.001), and discussion vs. control OR 18.01 (95% CI 22.15–5.834, P < 0.001).
  • Post-intervention moral sensitivity was higher in the discussion group than lecture and control (76.50 ± 11.52 vs. 61.55 ± 11.57 and 64.27 ± 9.45, P < 0.001); adjusted OR for discussion vs. lecture was 10.874 (95% CI 6.043–12.886, P = 0.005) and discussion vs. control 13.077 (95% CI 8.454–16.774, P = 0.002).
  • Total moral distress did not differ significantly across groups post-intervention (P = 0.085 unadjusted; adjusted P = 0.337), but the “not respecting the ethics principles” dimension decreased in lecture (21.91 ± 9.59 to 17.36 ± 7.75, P = 0.020) and discussion (17.27 ± 8.54 to 12.59 ± 4.82, P = 0.017), with discussion lower than control post-intervention (12.59 ± 4.82 vs. 20.09 ± 10.07, P = 0.007); adjusted logistic regression reported lower moral distress odds versus control for lecture (OR 0.105, 95% CI 0.015–0.717, P = 0.021) and discussion (OR 0.089, 95% CI 0.015–0.547, P = 0.009).

Methods

  • Randomized clinical trial with pre- and post-test design at Baqiyatallah Hospital, Tehran; 270 nurses were selected by census in 2015, 245 completed questionnaires, and 66 nurses with moral reasoning below the community average, no prior nursing ethics workshop/course, and willingness to participate were block-randomized into three equal groups (n = 22): lecture, group discussion, and control.
  • Both experimental groups received the same educational content in a one-day 8-hour workshop on ethical decision-making; the lecture group received a symposium/lecture format, the discussion group used predetermined scenarios and group discussion, and the control group received no training.
  • Data were collected with a sociodemographic questionnaire, Nursing Dilemma Test (NDT), Moral Distress Scale (MDS), and Moral Sensitivity Questionnaire (MSQ); analyses included unadjusted and adjusted binary logistic regression (OR, 95% CI), one-way ANCOVA/RMANOVA, Bonferroni post hoc tests, and SPSS v21 with two-tailed P < 0.05.

Limitations

  • The paper states that the first phase was descriptive, single-center, and used self-reported questionnaires, with possible bias and exaggeration of scores; the interval between intervention and post-test was short, so no long-term effects could be assessed.
  • The paper also states that the very high effect size for one-session discussion training may reflect the focus on low performers, so effects would probably be lower for nurses with lesser development needs, limiting generalization and requiring cautious interpretation.
  • Evident from the text: the RCT sample was small (n = 66) and drawn from a single hospital, and the short post-test interval limits conclusions about durability of effects.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1186/s12910-023-00938-5

Cites

46 of 46 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 35 cited sources checked · 0 supported · 0 flagged

  • Findingown data

    The probability of increasing the NPT score through discussion training was significantly higher than control (OR: 18.01, 95% CI: 22.15-5.834, P < 0.001).

    “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)”
    Quote in the paperSubstantial claim
    • Rests on an assumption: A one-day 8-hour workshop is sufficient to produce measurable changes in moral reasoning, moral distress, and moral sensitivity.
  • Findingown data

    No significant difference in moral distress score was observed between the lecture and discussion experimental groups.

    “no significant difference was observed between the experimental groups”
    Quote in the paperSubstantial claim
    • Rests on an assumption: A one-day 8-hour workshop is sufficient to produce measurable changes in moral reasoning, moral distress, and moral sensitivity.
  • Findingown data

    The mean total NPT score among single nurses was significantly higher than married nurses (43.13 ± 7.60 vs. 40.45 ± 6.52, P = 0.035).

    “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).”
    Quote in the paperNot a substantial claim
  • Findingown data

    The mean score of moral distress in the 'not respecting the ethics principles' dimension was 19.25 ± 9.05.

    “in “not respecting the ethics principles” dimension was 19.25 ± 9.05”
    Quote in the paperNot a substantial claim
  • Findingown data

    The mean total score of nursing principled thinking (NPT) of the nurses was 40.80 ± 6.71.

    “In nursing dilemma test, the mean total score of nursing principled thinking (NPT) (section B) and familiarity (section C) of the nurses were 40.80 ± 6.71 and 13.55 ± 4.09, respectively.”
    Quote in the paperNot a substantial claim
  • Classified as probably not a substantial claim. 34
  • May combine two claims. 20
  • The quote only partly states this claim. 2

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    The mean total score of moral distress in nurses was 60.66 ± 26.23, which was slightly higher than average.

    “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).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    No significant differences were observed between familiarity score and sociodemographic characteristics (P > 0.05).

    “No significant differences were observed between familiarity score and sociodemographic characteristics (P > 0.05).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    The mean total familiarity score of the nurses was 13.55 ± 4.09.

    “In nursing dilemma test, the mean total score of nursing principled thinking (NPT) (section B) and familiarity (section C) of the nurses were 40.80 ± 6.71 and 13.55 ± 4.09, respectively.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    A total of 245 nurses completed all questionnaires.

    “A total of 245 nurses have completed the all questionnaires.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    The mean score of moral distress in the 'errors' dimension was 23.12 ± 10.35.

    “in “errors” dimension, was 23.12 ± 10.35”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    The majority of nurses were familiar with similar dilemmas (n = 192, 78.4%).

    “In terms of familiarity, the results showed that the majority of nurses were familiar with similar dilemmas (n = 192, 78.4%).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    The level of moral reasoning of 39 (15.9%) nurses was pre-conventional, 187 (76.3%) conventional, and 19 (7.8%) post-conventional.

    “The level of moral reasoning of 39 (15.9%), 187 (76.3%) and 19 (7.8%) of the nurses was pre-conventional, conventional and post-conventional, respectively.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Mean age of nurses in the control group was 37.32 ± 6.41 years.

    “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, respectively”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    There was no statistically significant difference between the three groups regarding gender (P = 0.729) and qualification (P = 0.078).

    “However, there was no statistically significant difference between the three groups regarding in the gender (P = 0.729) and qualification (P = 0.078)”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Mean age of nurses in the group discussion was 40.05 ± 5.63 years.

    “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, respectively”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Findingown data

    Of the 245 nurses who participated in the first phase, 66 nurses with NPT scores below the community average, no history of attending nursing ethics education, and willingness to participate were selected for the second phase.

    “Of the 245 nurses who participated in the first phase of the study, 66 nurses with NPT scores below the community average, no history of attending the nursing ethics education, and willingness to participate were selected for the second phase.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The community average moral reasoning score is a valid threshold for identifying nurses with low moral reasoning.

  • Probably not a substantial claim: may not pass S3 (load-bearing). The quote only partly states this claim.

    Findingown data

    Mean age of nurses in the lecture group was 37.32 ± 7.93 years.

    “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, respectively”
    Quote in the paperNot a substantial claim

  • The quote only partly states this claim.

    Findingown data

    Adjusted regression analysis showed that the probability of increasing the NPT score through lecture training was significantly higher than control (OR: 14.329, 95% CI: 16.171-2.005, P < 0.001).

    “as well as lecture (OR: 14.329, 95% CI: 16.171–2.005, P < 0.001)”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    Female predominance in lecture, group discussion, and control groups was 77.3%, 63.6%, and 68.2%, respectively.

    “with female predominance of 77.3%, 63.6%, and 68.2%, respectively, in the three groups of study.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Training did not have much effect in reducing moral distress scores, and only the 'not respecting the ethics principles' dimension showed a significant reduction.

    “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.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Ethics education based on group discussions significantly improved nurses' moral reasoning and moral sensitivity.

    “While the results showed that ethics education based on group discussions significantly improved nurses’ moral reasoning and moral sensitivity.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    The study protocol was approved by the Ethics Committee of Baqiyatallah University of Medical Sciences under code IR.BMSU.REC.1394.145.

    “The study protocol was reviewed and approved by the Ethics Committee 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].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [29] World Medical Association Declaration of Helsinki. JAMA. 2013;310(20):2191–4. https://doi.org/10.1001/jama.2013.281053. : ethical principles for medical research involving human subjects. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductcitation

    The Cronbach's alpha coefficient for the Persian version of the MSQ instrument was reported 0.80 and 0.81 by Izadi et al. and Hassanpoor et al., respectively.

    “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 Hassanpoor et al. [41], respectively.”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites Izadi et al. [40] Izadi A, Imani H, Khademi Z, FariAsadi Noughabi F, Hajizadeh N, Naghizadeh F. Moral sensitivity of critical care nurses in clinical decision making and its correlation with their caring behavior in teaching hospitals of Bandar Abbas in 2012. Iran J Med Ethics History Med. 2013;6(2):43–56.

      Not checked in the free run.

    • cites Hassanpoor et al. [41] Hassanpoor M, Hosseini M, Fallahi Khoshknab M, Abbaszadeh A. Evaluation of the impact of teaching nursing ethics on nurses’ decision making in Kerman social welfare hospitals in 1389. Iran J Med Ethics History Med. 2011;4(5):58–64.

      Not checked in the free run.

  • Classified as probably not a substantial claim. May combine two claims.

    Study design and conductreasoning

    The educational content for both experimental groups was the same, so there was no risk of between-group information leakage.

    “The educational content for both experimental groups was the same. So, there was no risk of between‑group information leakage.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Study design and conductnone given

    Both unadjusted and adjusted (adjusting for age group, gender, marital status, work experience, wards, shift work and overtime) repeated measures ANOVA were assessed.

    “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.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Study design and conductown data

    The subjects were divided into three equal groups using block randomization methods.

    “The subjects were included in the study by simple random 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 randomization methods.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    Written informed consent was obtained from all participants.

    “Written informed consent was obtained from all participants.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    To determine the validity of the program syllabus, the opinions of faculty members and members of the hospital ethics committee were used.

    “To determine the validity of the program syllabus, the opinions of faculty members and members of the hospital ethics committee were used.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Evidence showed that strategies such as case-based learning, simulation, exposure to challenging situations, and multimedia education can be more effective.

    “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].”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [15] Namadi F, HEMMATI MASLAKPAK M, MORADI Y. GHASEMZADEH N. The Effects of nursing Ethics Education through Case-Based learning on Moral reasoning among nursing students. Volume 8. NURSING AND MIDWIFERY STUDIES.; 2019. pp. –. 2.

      Not checked in the free run.

    • cites [25] Sullivan-Mann J, Perron CA, Fellner AN. The Effects of Simulation on nursing students’ critical thinking scores: a quantitative study. Newborn and Infant Nursing Reviews. 2009;9(2):111–6. https://doi.org/10.1053/j.nainr.2009.03.006. source

      Not checked in the free run.

    • cites [26] Borhani F, Abbaszadeh A, Kohan M, Fazael MA. Nurses and nursing students’ ethical reasoning in facing with dilemmas: a comparative study. Iran J Med Ethics History Med. 2010;3(4):71–81.

      Not checked in the free run.

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    Study design and conductcitation

    The study was performed and reported in accordance with the CONSORT statement.

    “This study was performed and reported in accordance with the recommendations of the Consolidated Standards of Reporting Trials (CONSORT) statement [30].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [30] Jayaraman J. Guidelines for reporting randomized controlled trials in paediatric dentistry based on the CONSORT statement. Int J Pediatr Dent. 2020;31(Suppl 1):38–55. https://doi.org/10.1111/ipd.12733. source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Premisereasoning

    The impact of nursing ethics education through group discussions on ethical reasoning, distress, and sensitivity is still unclear as to whether group discussions can be more effective than lecture method.

    “According 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.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    The randomized clinical trial was registered in the Iranian Registry of Clinical Trials under code IRCT2015122116163N5.

    “This randomized clinical trial study was registered in Iranian Registry of Clinical Trials under code (IRCT2015122116163N5) in 02/07/2016.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductcitation

    The Cronbach's alpha coefficient for the Persian version of the NDT was reported 0.82 and 0.95 by Borhani et al. and Zirak et al., respectively.

    “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.”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites Borhani et al. [33] Borhani F, Fazljoo S, Abbaszadeh A. Moral reasoning ability in nursing students of Shahid Sadoughi University of Medical Sciences. Iran J Nurs. 2014;27(90):102–9. https://doi.org/10.29252/ijn.27.90.91.102. source

      Not checked in the free run.

    • cites Zirak et al. [34] ZIRAK M, MOGADASIAN S, ABDULLAH ZADEH F, RAHMANI A. COMPARISON OF ETHICAL REASONING, IN NURSING STUDENTS AND NURSES IN TABRIZ UNIVERSITY OF MEDICAL SCIENCE. ADVANCES IN NURSING AND MIDWIFERY (FACULTY OF NURSING OF MIDWIFERY QUARTERLY). 2012, 22(77):–.

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductnone given

    Block randomization was performed using sealed envelope technique and computer-generated random numbers by Random Allocation Software.

    “Block randomization was performed using sealed envelope technique and computer-generated random numbers by Random Allocation Software © (RAS; Informer Technologies, Inc., Madrid, Spain).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    The Cronbach's alpha coefficient for the total MDS score and each dimension was reported 0.93, 0.93, 0.96, and 0.89 by Atashzadeh et al.

    “The Cronbach’s alpha coefficient for the total MDS score and each dimension that includes inappropriate competencies and responsibilities, errors and not respecting the ethics principles was reported 0.93, 0.93, 0.96, and 0.89 by Atashzadeh et al. [36], respectively.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Atashzadeh et al. [36]

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    Study design and conductcitation

    The sample size was initially set at 17 subjects in each group, raised to 22 subjects in view of the possibility of a 10% sample loss, based on Borhani et al. using Altman nomogram with 95% confidence, 1.96 confidence interval, 10% type II error, and 90% power.

    “based on the study of Borhani et al. [31], and using Altman 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 subjects in each group which was raised to 22 subjects in view of the possibility of a 10% sample loss.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Borhani et al. [31] BORHANI F, ABBASZADEH A, SABZEVARI S, THE EFFECT OF WORKSHOP AND FALLOW-UP ON ETHICAL SENSITIVITY OF NURSES. Med ETHICS. 2012;6(21):–. source

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  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationcitation

    Differences in NPT scores could be due to attitudes and beliefs of nurses being influenced by workplace rules, education, culture, social, political, religious, and clinical experiences.

    “These differences could be due to the attitudes and beliefs of nurses can be influenced by several factors, including rules of workplace and regulations, level of education, cultural, social, political, religious, and clinical experiences of nursing [47].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [47] Vahedian azimi A, Alhani F. Educational challenges in ethical decision making in nursing. Iran J Med Ethics History Med. 2008;1(4):21–30.

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  • May combine two claims.

    Interpretationown data

    The level of moral reasoning, moral sensitivity, and moral distress in the nurses were low, medium, and high, respectively, compared to previous studies and the average community.

    “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, respectively.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: The average community level of moral reasoning, moral sensitivity, and moral distress is a valid benchmark for comparison.

  • May combine two claims.

    Study design and conductown data

    These 66 nurses were randomly assigned into three equal groups (n = 22) including two experimental groups (lectures method and group discussions methods) and one control group.

    “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.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    More than half of nurses experience moral distress in their work environment.

    “According to evidence more than half of nurses experience moral distress in their work environment [48, 49].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [48] Bayat M, Shahriari M, Keshvari M. The relationship between moral distress in nurses and ethical climate in selected hospitals of the iranian social security organization. J Med Ethics Hist Med. 2019;12:8–8. https://doi.org/10.18502/jmehm.v12i8.1339. source

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    • cites [49] Almutairi AF, Salam M, Adlan AA, Alturki AS. Prevalence of severe moral distress among healthcare providers in Saudi Arabia. Psychol Res Behav Manag. 2019;12:107–15. https://doi.org/10.2147/PRBM.S191037. source

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  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Previous studies reported NPT scores of 46.67 ± 6.7, 42.16 ± 5.8, and 51.5 ± 7.9.

    “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, respectively.”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [34] ZIRAK M, MOGADASIAN S, ABDULLAH ZADEH F, RAHMANI A. COMPARISON OF ETHICAL REASONING, IN NURSING STUDENTS AND NURSES IN TABRIZ UNIVERSITY OF MEDICAL SCIENCE. ADVANCES IN NURSING AND MIDWIFERY (FACULTY OF NURSING OF MIDWIFERY QUARTERLY). 2012, 22(77):–.

      Not checked in the free run.

    • cites [45] Borhani F, Abbas Zade A, Kohan M. A. FM. Compare moral reasoning abilities of nurses and nursing students of Kerman University of Medical Sciences in dealing with ethical dilemmas. Iran J Med Ethics Hist Med. 2011;3(4):71–81.

      Not checked in the free run.

    • cites [46] Ham K. Principled thinking: a comparison of nursing students and experienced nurses. J Contin Educ Nurs. 2004;35(2):66–73. https://doi.org/10.3928/0022-0124-20040301-08. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Ethical decision-making of nurses may be affected by several factors such as policies and expectations of institutions, feeling of mastery of the medical profession, stressful environment, patient complex conditions, and communication with patients.

    “However, ethical decision-making of the nurses may be affected by the several factors such as policies and expectations of the institutions where they work, feeling of mastery of the medical profession, stressful environment, patient complex conditions, and the communication with patients that instead of following the rules, they listen to their inner voice [43, 44].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [43] Bremer A, Holmberg M. Ethical conflicts in patient relationships: experiences of ambulance nursing students. Nurs Ethics. 2020;27(4):946–59. https://doi.org/10.1177/0969733020911077. source

      Not checked in the free run.

    • cites [44] Ulrich CM, Taylor C, Soeken K, O’Donnell P, Farrar A, Danis M, et al. Everyday ethics: ethical issues and stress in nursing practice. J Adv Nurs. 2010;66(11):2510–9. https://doi.org/10.1111/j.1365-2648.2010.05425.x. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    With increasing work experience, nurses' commitment to the institution increases and they may prefer organizational interests to patients' rights.

    “On the other hand, with increasing work experience, nurses ‘commitment to the institution increases and nurses may prefer organizational interests to patients’ rights [56].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [56] de Casterlé BD, Janssen PJ, Grypdonck M. The relationship between education and ethical behavior of nursing students. West J Nurs Res. 1996;18(3):330–50. https://doi.org/10.1177/019394599601800308. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Familiarity of nurses with ethical dilemmas positively affects their decision making for ethical problems.

    “Familiarity of the nurses with ethical dilemmas is considered to affect their decision making for ethical problems positively [34, 42].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [34] ZIRAK M, MOGADASIAN S, ABDULLAH ZADEH F, RAHMANI A. COMPARISON OF ETHICAL REASONING, IN NURSING STUDENTS AND NURSES IN TABRIZ UNIVERSITY OF MEDICAL SCIENCE. ADVANCES IN NURSING AND MIDWIFERY (FACULTY OF NURSING OF MIDWIFERY QUARTERLY). 2012, 22(77):–.

      Not checked in the free run.

    • cites [42] Arslan S, Türer Öztik S, Kuzu Kurban N. Do moral development levels of the nurses affect their ethical decision making? A descriptive correlational study. Clin Ethics 2020, 16(1):9–16. https://doi.org/10.1177/1477750920930375. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Nurses try to have arguments in line with other colleagues that are approved by colleagues and the institute.

    “Nurses try to have arguments in line with other colleagues that are approved by colleagues and the institute [4, 5].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [4] Goethals S, Gastmans C, de Casterlé BD. Nurses’ ethical reasoning and behaviour: a literature review. Int J Nurs Stud. 2010;47(5):635–50. https://doi.org/10.1016/j.ijnurstu.2009.12.010. source

      Not checked in the free run.

    • cites [5] Ebrahimi H, Nikravesh M, Oskouie F, Ahmadi F. Ethical behavior of nurses in decision-making in Iran. Iran J Nurs Midwifery Res. 2015;20(1):147–55.

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationreasoning

    The decrease in moral reasoning with increasing work experience can be due to crowded work shifts, burnout, job dissatisfaction, and a stressful and diverse work environment.

    “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.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductreasoning

    The first phase of the study was a descriptive study in a single-center hospital, and data were collected using self-reported questionnaires, which may introduce bias and exaggeration of scores.

    “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 possibility of bias and exaggeration of scores.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Interpretationreasoning

    The impact of one session training through discussion was very high, possibly because the study focused on training low performers; the effects would probably be significantly lower for nurses with lesser development needs.

    “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.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    Nurses still have problems and low self-confidence for decision-making in difficult situations and knowledge use in practice.

    “Therefore, it seems that in this method, nurses still have problems and low self-confidence for decision‑making in difficult situations and knowledge use in practice.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationreasoning

    The generalization of the findings is limited and the results should be interpreted with caution.

    “For these reasons, the generalization of the findings is limited and also the results should be interpreted with caution.”
    Quote in the paperSubstantial claim
45 of 45

  • The paper relies on this without support.

    The community average moral reasoning score is a valid threshold for identifying nurses with low moral reasoning.

    “According to our findings, in 86 nurses the mean moral reasoning score was lower than the community average.”

  • The paper relies on this without support.

    A one-day 8-hour workshop is sufficient to produce measurable changes in moral reasoning, moral distress, and moral sensitivity.

    “Nursing ethics education lesson plan in both experimental 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 reasoning skills.”

  • The paper relies on this without support.

    The average community level of moral reasoning, moral sensitivity, and moral distress is a valid benchmark for comparison.

    “compared to previous studies and the level of average community”

  • The paper relies on this without support.

    The average NPT score in the population is 40.80.

    “slightly lower than the average level (40.80 ± 6.71)”

  • The paper relies on this without support.

    Kohlberg's conventional level of moral reasoning is based on adhering to rules, harmony with community, and showing oneself well in the eyes of others.

    “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 community, and to show oneself well in the eyes of others”

  • The paper relies on this without support.

    The thresholds used to classify moral distress as high or moderate are valid.

    “total mean score of moral distress include “inappropriate competencies and responsibilities” and ‘‘errors’’ dimensions were high. However, moral distress in ‘‘not respecting the ethics principles’’ dimension was moderate.”

  • The paper relies on this without support.

    The thresholds used to classify moral sensitivity as moderate are valid.

    “the majority of nurses have moderate moral sensitivity”
7 of 7

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Conclusion denies an effect on moral distress reported in the results

    Major

    The conclusion says training has no effect on moral distress, whereas the results report a significant reduction relative to the control group for both trained groups.

  • Two different P-values are given for the gender comparison

    Minor

    The characteristics paragraph reports P = 0.729 for gender, but later in the same paragraph and in Table 1 reports P = 0.605 for the three-group gender comparison.

  • Marital-status comparison is reported as both significant and nonsignificant

    Minor

    The characteristics paragraph gives P < 0.001 for marital status, then gives P = 0.288 for the same three-group comparison; Table 1 also gives 0.288.

  • An age comparison names different groups and incompatible ages

    Minor

    The reported comparison of almond and lavender groups cannot describe the stated lecture, discussion, and control groups: none has either name, and their reported mean ages are around 37-40 years rather than 57-63 years.

  • Lecture-group moral distress total does not match its pre-intervention dimensions

    Minor

    The three pre-intervention moral distress dimension means for the lecture group sum to 62.28, not the reported total of 60.23.

    Reported 60.23 · recomputed 62.28

  • Reported female subscale SD is incompatible with the subscale's range

    Minor

    The female SD of 17.33 cannot arise on the three-item patient-autonomy subscale: each item scores 0-4, so an individual's subscale score ranges only from 0 to 12.

6 of 6

Cites

Flagged first, then by citations

Research works printed but not linked: 11

  1. Azizi A, Sepahvani M, Mohamadi J. The effect of nursing ethics education on the moral judgment of nurses. J Nurs Educ. 2016;4(4):1–8. 2.
  2. rızalar S, Baltacı N. Ethical Decision-Making Levels of Nurses and it’s Affecting Factors. 2020, 13:42–52.
  3. Koohi A, Khaghanizade M, Ebadi A. The relationship between ethical reasoning and demographic characteristics of nurses. Iran J Med Ethics History Med. 2016;9(1):26–36.
  4. Khaghanizade M, Malaki H, Abbasi M, Abbaspour A, Mohamadi E. Faculty-Related Challenges in Medical Ethics Education: a qualitative study. Iran J Med Educ. 2012;11(8):903–16.
  5. ZIRAK M, MOGADASIAN S, ABDULLAH ZADEH F, RAHMANI A. COMPARISON OF ETHICAL REASONING, IN NURSING STUDENTS AND NURSES IN TABRIZ UNIVERSITY OF MEDICAL SCIENCE. ADVANCES IN NURSING AND MIDWIFERY (FACULTY OF NURSING OF MIDWIFERY QUARTERLY). 2012, 22(77):–.
  6. Lützén K, Nordin C, Brolin G. Conceptualization and instrumentation of nurses’ moral sensitivity in psychiatric practice. Int J Methods Psychiatr Res. 1994;4(4):241–8.
  7. Izadi A, Imani H, Khademi Z, FariAsadi Noughabi F, Hajizadeh N, Naghizadeh F. Moral sensitivity of critical care nurses in clinical decision making and its correlation with their caring behavior in teaching hospitals of Bandar Abbas in 2012. Iran J Med Ethics History Med. 2013;6(2):43–56.
  8. Hassanpoor M, Hosseini M, Fallahi Khoshknab M, Abbaszadeh A. Evaluation of the impact of teaching nursing ethics on nurses’ decision making in Kerman social welfare hospitals in 1389. Iran J Med Ethics History Med. 2011;4(5):58–64.
  9. Borhani F, Abbas Zade A, Kohan M. A. FM. Compare moral reasoning abilities of nurses and nursing students of Kerman University of Medical Sciences in dealing with ethical dilemmas. Iran J Med Ethics Hist Med. 2011;3(4):71–81.
  10. Vahedian azimi A, Alhani F. Educational challenges in ethical decision making in nursing. Iran J Med Ethics History Med. 2008;1(4):21–30.
  11. Hashmatifar N, Mohsenpour M, Rakhshani M. Barriers to moral sensitivity: viewpoints of the nurses of educational hospitals of Sabzevar. Iran J Med Ethics History Med. 2014;7(1):34–42.

Cited by

Sorted by citations

Related

Authors
Khaghanizadeh, M., Koohi, A., Ebadi, A., & Vahedian-Azimi, A.
Affiliations
Baqiyatallah University of Medical Sciences (IR)
ORCID
Venue
BMC Medical Ethics
Publisher
Springer Science and Business Media LLC
Published
2023-08-04
Volume
24
Issue
1
Pages
58-58
ISSN
1472-6939 (ISSN-L)
DOI
10.1186/s12910-023-00938-5
PMC
PMC10403849
OpenAlex
W4385575468
Semantic Scholar
2944f8e4f3ef7bb0f01416aa5cdd68672c5e99e5
Cited by
40
References
45
Citations by year
2026: 12 · 2025: 19 · 2024: 8 · 2023: 1
FWCI
13.89
Type
journal article
Language
en
Open access
Licence
Locations
  • BMC Medical Ethics (publishedVersion, cc-by)
  • Research Square (acceptedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
Topics
  • Health Sciences › Health Professions › General Health Professions › Ethics in medical practice
  • Social Sciences › Decision Sciences › Information Systems and Management › Ethics in Business and Education
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Ethics and bioethics in healthcare
Keywords
nurses, moral reasoning, moral distress, moral sensitivity, nursing ethics education, lecture-based training, nursing care quality, Moral Sensitivity Questionnaire, Moral Distress Scale, nursing ethics curriculum
MeSH terms
Ethics, Nursing, Humans, Iran, Morals, Nurses, Surveys and Questionnaires, Moral Development

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Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-06.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-06.

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