The Effectiveness of a Moral Motivation Program in Promoting Moral Sensitivity among Practicing Nurses

The Effectiveness of a Moral Motivation Program in Promoting Moral Sensitivity among Practicing Nurses | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Effectiveness of a Moral Motivation Program in Promoting Moral Sensitivity among Practicing Nurses Reza Kazemiyan, Narges arsalani, farahnaz Mohammadi-Shahboulaghi, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7205406/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Moral sensitivity is critical for ethical nursing practice, particularly in rehabilitation settings where complex ethical dilemmas are common. This study evaluated the effect of a moral motivation program on the moral sensitivity of nurses working in rehabilitation wards. Methods : A quasi-experimental pretest-posttest study with a control group was conducted from May to October 2023 at Rofeidah Rehabilitation Hospital, Tehran, Iran. Twenty-seven nurses were purposively sampled and randomly allocated to an intervention (n=15) or control (n=12) group on the basis of ward assignments. The intervention group participated in a six-week moral motivation program, including two 2-hour in-person workshops and four weeks of virtual follow-up, with a focus on ethical principles and rehabilitation-specific scenarios. The control group received no intervention. Moral sensitivity was assessed via Lutzen’s Moral Sensitivity Questionnaire (MSQ) at baseline, post-intervention, and one-month follow-up. The Data were analyzed via repeated measures ANOVA. Results : Compared with the control group, the intervention group presented statistically significant statistically significant increases in moral sensitivity scores post-intervention (p<0.05), with sustained improvements at the one-month follow-up. No significant changes were observed in the control group. Conclusion : The moral motivation program effectively enhanced nurses’ moral sensitivity, with sustained effects over one month. These findings support the integration of context-specific ethical training into nursing education to improve ethical decision-making in rehabilitation care. Moral sensitivity moral motivation nursing ethics rehabilitation nursing quasi-experimental study Introduction Nurses, as the largest and most influential group of healthcare providers, play an unparalleled role in improving the quality of healthcare services( 1 , 2 ). Their professional performance and commitment directly impact the efficiency and effectiveness of the healthcare system, significantly enhancing patient outcomes( 3 ). However, nurses encounter numerous ethical challenges in their daily practice( 3 , 4 ). Studies indicate that approximately 11% of nurses face ethical dilemmas daily, and 36% encounter them periodically, requiring complex and sensitive decision-making( 5 , 6 ). These challenges highlight the critical need for adherence to professional ethical principles( 6 ). Ethical principles form the foundation of scientific nursing care by fostering effective communication, building trust with patients and their families, and delivering care on the bases of respect and empathy( 7 , 8 ). This is particularly significant in rehabilitation nursing, which focuses on caring for individuals with physical or mental disabilities and those with chronic illnesses( 9 , 10 ). Patients in rehabilitation settings are often more vulnerable due to their specific conditions, such as physical or mental impairments or lifestyle changes( 11 , 12 ). This vulnerability makes trust-based, deep relationships with nurses a critical factor in their recovery process( 11 ). However, prolonged nurse-patient interactions can lead to challenges, including reduced care quality, mutual distrust, feelings of helplessness, anger, frustration, and ultimately, burnout and professional dissatisfaction( 13 , 14 ). These issues highlight the importance of enhancing nurses’ ethical competencies and skills( 1 ). Moral sensitivity, a core component of professional competence, enables nurses to respond to patients’ physical, psychological, and emotional needs with patience, composure, and a deep sense of responsibility, providing dedicated and effective care( 15 ). Moral sensitivity relies not only on awareness of ethical principles but also on a profound understanding of patients’ needs, values, and human dignity( 16 ). Nevertheless, research suggests that mere awareness of ethical principles is insufficient to ensure ethical behavior; strong Moral motivation is also required( 17 , 18 ). Moral motivation is a process through which nurses prioritize ethical behavior and apply it in practice. This motivation can be cultivated through personal beliefs, targeted education, and enhanced ethical skills, serving as a key factor in fostering accountability and commitment to ethical conduct( 19 , 20 ). Hosseini et al. (2019) demonstrated that Moral motivation training significantly increased nurses’ Moral sensitivity. Their study, which focused on improving ethical decision-making through education, emphasized the need to expand such programs to other nurses nationwide( 21 ). However, the lack of similar studies in rehabilitation nursing, where ethical challenges are more complex due to patients’ unique characteristics, reveals a significant research gap( 22 , 23 ). Strengthening Moral sensitivity in this field could improve care quality and reduce ethical tensions( 16 ). Despite its importance, few studies have explored the impact of education on the development of nurses’ Moral sensitivity, particularly in rehabilitation settings. Researchers’ clinical experiences indicate greater ethical tensions in caring for patients with disabilities, often due to prolonged hospitalizations, mood changes, and complex patient needs. These conditions, coupled with a lack of comprehensive and cohesive research on ethics in rehabilitation-based nursing, highlight a notable research gap. Additionally, creating an ethical environment in rehabilitation hospitals, where ethical standards are upheld and reinforced, appears essential. Therefore, this study aims to investigate the impact of Moral motivation programs on the Moral sensitivity of nurses working in rehabilitation wards. Methods Study Design This quasi-experimental study employed a pretest-posttest design with a control group and follow-up to evaluate the effect of a moral motivation program on the moral sensitivity of nurses. The study was conducted from May to October 2023 at Rofeidah Rehabilitation Hospital in Tehran, Iran. Participants A purposive sampling method was used to recruit eligible nurses on the basis of the following inclusion criteria: ( 1 ) a bachelor’s degree or higher in nursing, ( 2 ) a minimum of one year of clinical experience in rehabilitation nursing, and ( 3 ) willingness to participate. Nurses were excluded if they: ( 1 ) failed to complete the intervention or follow-up, ( 2 ) were simultaneously enrolled in other ethics training programs, or ( 3 ) withdrew from the study. The required sample size was calculated using data from a previous study ( 21 ), with a significance level of 0.05, power of 80%, and a 10% estimated dropout rate. A total of 27 participants were recruited and randomly assigned to the intervention (n = 15) and control (n = 12) groups based on their ward assignments. Measurement Tool Moral sensitivity was assessed using the Moral Sensitivity Test (MST) developed by Lützén, Nordin, and Brolin (1994). This validated instrument consists of 25 items designed to measure nurses’ awareness of ethical dimensions in clinical decision-making, including moral responsibility, moral strength, and moral burden. The MST has demonstrated acceptable psychometric properties and has been widely used in nursing ethics research( 24 ). Notably, Ahansaz et al. (2024) employed the MST in their study on missed nursing care, confirming its relevance and applicability in diverse clinical settings( 25 ). Intervention The intervention group participated in a structured moral motivation program designed to enhance moral sensitivity among nurses in rehabilitation settings. The program was developed based on the Iranian Nursing Organization’s Code of Ethics, the Patient’s Bill of Rights, and established ethical principles in nursing, tailored to address the unique challenges of rehabilitation nursing. The intervention was delivered over six weeks and consisted of two in-person workshops followed by a four-week virtual follow-up phase. Written informed consent was obtained from all participants, who were informed of their right to withdraw at any time without consequences. Confidentiality was maintained through anonymized data handling, and no personal identifiers were recorded. The intervention posed no physical or psychological risks to participants. In-Person Workshops Two 2-hour workshops were conducted at Rofeidah Rehabilitation Hospital by the principal investigator, who is trained in nursing ethics. The workshops employed a combination of didactic and interactive methods to foster active learning and engagement. Workshops were scheduled during non-working hours to accommodate participants’ shifts, and virtual sessions were conducted using a secure platform compliant with data privacy regulations. Attendance was monitored, and participants who missed any workshop session or more than one virtual task were excluded from the analysis to ensure intervention fidelity. First Workshop This workshop focused on foundational ethical concepts, including the Iranian Nursing Organization’s Code of Ethics, professional responsibilities, and patient rights. The session began with a 45-minute lecture on ethical principles (e.g., autonomy, beneficence, non-maleficence, justice, confidentiality) and their application in rehabilitation nursing. This was followed by a 75-minute group discussion where participants analyzed real-life ethical scenarios specific to rehabilitation care, such as managing patient autonomy in cases of severe disability or addressing family dynamics in chronic illness care. The participants were encouraged to share personal experiences and propose ethically sound solutions, guided by the facilitator to ensure constructive dialogue( 26 , 27 ). Second Workshop Emphasized practical application through multimedia and role-playing. The session included a 30-minute presentation of ethical case studies, followed by the screening of three short educational videos (5–10 minutes each) depicting ethical dilemmas in rehabilitation nursing, such as handling patient refusal of treatment or addressing errors in care. These videos, sourced from validated educational materials, were selected to reflect realistic challenges faced by nurses. After each video, the participants engaged in a 20-minute role-playing exercise, placing themselves in the position of the decision-making nurse to propose and justify actions. A 40-minute group discussion followed, where participants critiqued the decisions made in the videos and role-plays, focusing on ethical reasoning and moral courage. The workshop concluded with a 10-minute summary of key takeaways, emphasizing strategies for applying ethical principles in clinical practice( 28 , 29 ). Virtual Follow-Up Phase Following the workshops, a four-week virtual follow-up was conducted via a secure online platform to reinforce learning and promote sustained engagement. Participants were divided into small groups (4–5 nurses) and assigned weekly tasks, including the following: Ethical Scenario Discussions Each week, participants received a new rehabilitation-specific ethical scenario (e.g., managing a patient with spinal cord injury refusing rehabilitation or addressing a colleague’s ethical lapse). The participants were required to post their proposed solutions and rationales on the platform, followed by asynchronous discussions moderated by the investigator. Each discussion required at least two responses per participant to encourage peer interaction and critical thinking. Video-Based Reflections Participants watched one additional educational video per week, similar to those used in the workshops, and submitted a brief written reflection (150–200 words) on the ethical issues depicted and potential solutions. The investigator provided individualized feedback to enhance understanding. Interactive Q&A Sessions Weekly 30-minute live virtual sessions were held to address questions, clarify ethical concepts, and discuss real-world applications of the training content. Control Group The control group received no intervention during the study period but continued their routine clinical duties. To ensure ethical fairness, the control group was offered access to the moral motivation program after the study’s completion. Data Collection Data were collected at three time points: baseline (pre-intervention), immediately post-intervention, and one-month post-intervention. Two instruments were used to collect demographic information and assess moral sensitivity. A researcher-designed questionnaire was used at baseline to collect participants' demographic and professional data, including age, sex, marital status, education, work experience, employment type, and shift pattern. Lützén’s 25-item Moral Sensitivity Questionnaire (MSQ) was used to assess nurses’ moral sensitivity in clinical decision-making, specifically their ability to recognize ethical dilemmas and understand the moral implications of their choices. The questionnaire includes six dimensions of moral sensitivity: respect for patient autonomy, awareness of communication methods with patients, level of professional knowledge, experience with ethical dilemmas and conflicts, application of ethical concepts in decision-making, and honesty and benevolence. Each item was rated on a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree), with total scores ranging from 0 to 100. Scores were categorized as low (0–50), moderate (51–75), or high (76–100) moral sensitivity( 30 ). The Persian version of the MSQ, validated in prior Iranian studies, demonstrated strong reliability (Cronbach’s alpha = 0.81)( 31 ). Completion took approximately 10–15 minutes. Statistical Analysis The data were analyzed using SPSS version 25. Normality was assessed using the Shapiro-Wilk test. Baseline comparability between groups was evaluated using independent t-tests for continuous variables (e.g., age, work experience) and chi-square tests for categorical variables (e.g., sex, marital status, education level). To examine the intervention’s effect on moral sensitivity, repeated measures analysis of variance (ANOVA) was used, with time (pre-intervention, post-intervention, one-month follow-up) as the within-subject factor and group (intervention vs. control) as the between-subject factor. Results No significant baseline differences were observed between the groups (Table 1 ). Table 1 Demographic Characteristics of Participants (n = 27) Variable Intervention Group (n = 15) Control Group (n = 12) p-value Gender (Female) 11 (73.3%) 11 (91.7%) 0.34 Mean Age (years) 33.4 ± 4.2 34.1 ± 3.9 0.37 Marital Status (Married) 8 (53.3%) 8 (66.7%) 0.69 Education (Master's) 8 (53.3%) 3 (25%) 0.78 Mean Work Experience (years) 9.6 ± 3.7 10.1 ± 4.1 0.86 Employment (Permanent) 6 (40%) 4 (33.3%) 0.93 Shift (Rotating) 10 (66.7) 5 (41.7%) 0.05 Table 2 shows that the intervention group demonstrated a significant improvement over time, whereas the control group experienced a slight decline. Between-group comparisons confirmed statistically significant differences after the intervention and at follow-up (p < 0.05). Table 2 Comparison of Moral Sensitivity Scores Within and Between Groups Over Time Group / Time Point Pre-Intervention (Mean ± SD) Immediately Post-Intervention (Mean ± SD) One Month Follow-up (Mean ± SD) Within-Group Test Result* Between-Group Test Result** Control 72.1 ± 1.44 70.5 ± 6.19 68.8 ± 7.15 0.02 < 0.001 Intervention 70.5 ± 4.56 78.5 ± 3.75 77.3 ± 5.27 0.007 ***Test Result 0.409 < 0.001 0.002 *Within-group differences analyzed using repeated-measures ANOVA. **Between-group differences analyzed using independent t-tests. ***Comparison between groups at each time point. Table 3 shows that the intervention group demonstrated significantly greater improvements in moral sensitivity after the training and at the one-month follow-up (p < 0.001). No significant difference was found between the groups in the change from immediately post-intervention to follow-up (p = 0.812). Table 3 Comparison of Changes in Nurses’ Moral Sensitivity Scores Between Groups Group / Time Interval Pre- vs. Immediately Post-Intervention (Mean ± SD) Pre- vs. 1-Month Follow-up (Mean ± SD) Immediately Post- vs. 1-Month Follow-up (Mean ± SD) Control 1.58 ± 2.31 ↓ 2.99 ± 3.25 ↓ 1.67 ± 1.87 ↓ Intervention 8.07 ± 3.91 ↑ 6.80 ± 7.14 ↑ 1.27 ± 5.48 ↓ Test Result (Between Groups) < 0.001 < 0.001 0.812 Discussion This study evaluated the effect of a moral motivation program on the moral sensitivity of nurses working in rehabilitation wards. The findings indicate that the intervention group demonstrated a statistically significant increase in moral sensitivity scores compared with the control group at both post-intervention and one-month follow-up assessments. These results suggest that moral motivation programs can effectively enhance nurses’ ability to recognize and respond to ethical dilemmas in clinical practice, particularly in the complex setting of rehabilitation nursing. The observed improvement in moral sensitivity aligns with previous studies that have explored the impact of ethics education on nursing practices. Hosseini et al. (2019) reported that targeted ethical training significantly improved moral sensitivity among Iranian nurses, emphasizing the importance of culturally relevant content( 21 ). Similarly, Similarly, Nasiriani et al. (2020) reported that virtual ethics education using narrative-based methods improved moral sensitivity among critical care nurses in Iran, using the same MSQ tool( 32 ). The current study’s use of rehabilitation-specific case scenarios and role-playing likely contributed to its effectiveness by fostering active engagement and practical application of ethical principles, such as beneficence and justice, which are critical in managing chronic care challenges. Namadi et al. (2018) further support these findings, demonstrating that, compared with lecture-based methods, case-based ethics education significantly improved moral sensitivity among nursing students highlighting the value of interactive approaches ( 33 ). In contrast, studies such as choe et al. (2020)( 31 ) and yeom et al. (2017)( 32 ), and Baykara et al. (2014)( 34 ) reported no significant improvements in moral sensitivity following lecture-based ethics seminars. These differences may be attributed to the lack of interactive elements, such as case discussions or role-playing, which were central to the current intervention. Choe et al.’s study, which was conducted among South Korean nurses, relied on didactic lectures, potentially limiting opportunities for practical application. Similarly, Yeom et al.’s focus on nursing students with limited clinical experience may explain their non-significant findings, as moral sensitivity may develop more robustly in practicing nurses exposed to real-world ethical dilemmas. Baykara et al. also reported non-significant gains in moral sensitivity among Turkish nurses, likely due to the absence of tailored, scenario-based content. The sustained improvement at the one-month follow-up highlights the efficacy of the virtual follow-up phase, which included asynchronous discussions and reflective exercises. This finding aligns with Rahmah et al. (2021), who emphasized the role of continuous learning in maintaining ethical competence( 35 ). The flexibility of the virtual component likely facilitated engagement among nurses with demanding schedules, a critical consideration in resource-constrained settings such as Iran, where in-person training opportunities are often limited. The program’s focus on rehabilitation nursing addresses unique ethical challenges, such as balancing patient autonomy with family expectations or navigating resource allocation for chronic care, enhancing its relevance and impact. These findings have significant implications for nursing education and practice. The incorporating moral motivation programs into continuing professional development could strengthen ethical decision-making, particularly in specialized fields like rehabilitation nursing. Despite these strengths, several limitations must be acknowledged. The small sample size and single-center design at Rofeidah Rehabilitation Hospital may limit the generalizability of the findings to other settings or nursing populations. Additionally, the one-month follow-up period, while sufficient to detect sustained effects, may not capture long-term changes in moral sensitivity, particularly as nurses encounter new ethical challenges over time. Abbreviations MSQ: Moral Sensitivity Questionnaire MST: Moral Sensitivity Test SPSS: Statistical Package for the Social Sciences ANOVA: Analysis of Variance SD: Standard Deviation IRB: Institutional Review Board RCT: Randomized Controlled Trial (if mentioned in references or background) USWR: University of Social Welfare and Rehabilitation Sciences Declarations Ethics approval and consent to participate This study was approved by the Ethics Committee of the University of Social Welfare and Rehabilitation Sciences (IR.USWR.REC.1402.087). Written informed consent was obtained from all participants, who were informed about the purpose of the study, confidentiality of responses, and their right to withdraw at any time without any consequences. This study was conducted in accordance with the Declaration of Helsinki. Consent for Publication: The authors confirm that this manuscript does not include any individual person’s data in any form. Therefore, consent for publication is not applicable. Availability of data and materials: The data collected and analysed during this study are fully presented within the published manuscript and its supplementary materials. No additional datasets were generated or deposited. Competing interests: The authors declare that they have no competing interests. Funding: Funding: None. Authors' contributions: R.K. conceptualized and designed the study, collected and analysed the data, and drafted the initial manuscript. N.A. contributed to the interpretation of findings, critically reviewed the manuscript for intellectual content, and approved the final version for submission. Both authors read and approved the final manuscript and agree to be accountable for all aspects of the work. Acknowledgment The authors would like to thank the staff of Rofeideh Rehabilitation Hospital, Tehran, Iran, for their kind cooperation and help in doing this research. Conclusion The moral motivation program significantly enhanced the moral sensitivity of nurses working in rehabilitation wards, with sustained improvements observed at the one-month follow-up. This study highlights the efficacy of structured, context-specific ethical training, combining in-person workshops and virtual follow-up, in fostering nurses’ ability to navigate ethical dilemmas in clinical practice. The findings highlight the potential of such programs to strengthen ethical competence in specialized nursing fields, particularly in resource-constrained settings. Integrating moral motivation training into continuing professional development could promote patient-centered care and ethical decision-making. Further research is needed to confirm these findings in larger, multi-center studies and to explore the long-term impacts on clinical outcomes. References Gaudine A, LeFort SM, Lamb M, Thorne L. Clinical ethical conflicts of nurses and physicians. 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09:40:42","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":714459,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7205406/v1/4e6abb5f-4048-4277-89a6-4b18d46c74b2.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Effectiveness of a Moral Motivation Program in Promoting Moral Sensitivity among Practicing Nurses","fulltext":[{"header":"Introduction","content":"\u003cp\u003eNurses, as the largest and most influential group of healthcare providers, play an unparalleled role in improving the quality of healthcare services(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Their professional performance and commitment directly impact the efficiency and effectiveness of the healthcare system, significantly enhancing patient outcomes(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). However, nurses encounter numerous ethical challenges in their daily practice(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Studies indicate that approximately 11% of nurses face ethical dilemmas daily, and 36% encounter them periodically, requiring complex and sensitive decision-making(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). These challenges highlight the critical need for adherence to professional ethical principles(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Ethical principles form the foundation of scientific nursing care by fostering effective communication, building trust with patients and their families, and delivering care on the bases of respect and empathy(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). This is particularly significant in rehabilitation nursing, which focuses on caring for individuals with physical or mental disabilities and those with chronic illnesses(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e\u003cp\u003ePatients in rehabilitation settings are often more vulnerable due to their specific conditions, such as physical or mental impairments or lifestyle changes(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). This vulnerability makes trust-based, deep relationships with nurses a critical factor in their recovery process(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). However, prolonged nurse-patient interactions can lead to challenges, including reduced care quality, mutual distrust, feelings of helplessness, anger, frustration, and ultimately, burnout and professional dissatisfaction(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). These issues highlight the importance of enhancing nurses\u0026rsquo; ethical competencies and skills(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eMoral sensitivity, a core component of professional competence, enables nurses to respond to patients\u0026rsquo; physical, psychological, and emotional needs with patience, composure, and a deep sense of responsibility, providing dedicated and effective care(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Moral sensitivity relies not only on awareness of ethical principles but also on a profound understanding of patients\u0026rsquo; needs, values, and human dignity(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eNevertheless, research suggests that mere awareness of ethical principles is insufficient to ensure ethical behavior; strong Moral motivation is also required(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Moral motivation is a process through which nurses prioritize ethical behavior and apply it in practice. This motivation can be cultivated through personal beliefs, targeted education, and enhanced ethical skills, serving as a key factor in fostering accountability and commitment to ethical conduct(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Hosseini et al. (2019) demonstrated that Moral motivation training significantly increased nurses\u0026rsquo; Moral sensitivity. Their study, which focused on improving ethical decision-making through education, emphasized the need to expand such programs to other nurses nationwide(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). However, the lack of similar studies in rehabilitation nursing, where ethical challenges are more complex due to patients\u0026rsquo; unique characteristics, reveals a significant research gap(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Strengthening Moral sensitivity in this field could improve care quality and reduce ethical tensions(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eDespite its importance, few studies have explored the impact of education on the development of nurses\u0026rsquo; Moral sensitivity, particularly in rehabilitation settings. Researchers\u0026rsquo; clinical experiences indicate greater ethical tensions in caring for patients with disabilities, often due to prolonged hospitalizations, mood changes, and complex patient needs. These conditions, coupled with a lack of comprehensive and cohesive research on ethics in rehabilitation-based nursing, highlight a notable research gap. Additionally, creating an ethical environment in rehabilitation hospitals, where ethical standards are upheld and reinforced, appears essential. Therefore, this study aims to investigate the impact of Moral motivation programs on the Moral sensitivity of nurses working in rehabilitation wards.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy Design\u003c/h2\u003e\u003cp\u003eThis quasi-experimental study employed a pretest-posttest design with a control group and follow-up to evaluate the effect of a moral motivation program on the moral sensitivity of nurses. The study was conducted from May to October 2023 at Rofeidah Rehabilitation Hospital in Tehran, Iran.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cp\u003eA purposive sampling method was used to recruit eligible nurses on the basis of the following inclusion criteria: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) a bachelor\u0026rsquo;s degree or higher in nursing, (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) a minimum of one year of clinical experience in rehabilitation nursing, and (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) willingness to participate. Nurses were excluded if they: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) failed to complete the intervention or follow-up, (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) were simultaneously enrolled in other ethics training programs, or (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) withdrew from the study. The required sample size was calculated using data from a previous study (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e), with a significance level of 0.05, power of 80%, and a 10% estimated dropout rate. A total of 27 participants were recruited and randomly assigned to the intervention (n\u0026thinsp;=\u0026thinsp;15) and control (n\u0026thinsp;=\u0026thinsp;12) groups based on their ward assignments.\u003c/p\u003e\n\u003ch3\u003eMeasurement Tool\u003c/h3\u003e\n\u003cp\u003eMoral sensitivity was assessed using the Moral Sensitivity Test (MST) developed by L\u0026uuml;tz\u0026eacute;n, Nordin, and Brolin (1994). This validated instrument consists of 25 items designed to measure nurses\u0026rsquo; awareness of ethical dimensions in clinical decision-making, including moral responsibility, moral strength, and moral burden. The MST has demonstrated acceptable psychometric properties and has been widely used in nursing ethics research(\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eNotably, Ahansaz et al. (2024) employed the MST in their study on missed nursing care, confirming its relevance and applicability in diverse clinical settings(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eIntervention\u003c/h3\u003e\n\u003cp\u003eThe intervention group participated in a structured moral motivation program designed to enhance moral sensitivity among nurses in rehabilitation settings. The program was developed based on the Iranian Nursing Organization\u0026rsquo;s Code of Ethics, the Patient\u0026rsquo;s Bill of Rights, and established ethical principles in nursing, tailored to address the unique challenges of rehabilitation nursing. The intervention was delivered over six weeks and consisted of two in-person workshops followed by a four-week virtual follow-up phase. Written informed consent was obtained from all participants, who were informed of their right to withdraw at any time without consequences. Confidentiality was maintained through anonymized data handling, and no personal identifiers were recorded. The intervention posed no physical or psychological risks to participants.\u003c/p\u003e\n\u003ch3\u003eIn-Person Workshops\u003c/h3\u003e\n\u003cp\u003eTwo 2-hour workshops were conducted at Rofeidah Rehabilitation Hospital by the principal investigator, who is trained in nursing ethics. The workshops employed a combination of didactic and interactive methods to foster active learning and engagement. Workshops were scheduled during non-working hours to accommodate participants\u0026rsquo; shifts, and virtual sessions were conducted using a secure platform compliant with data privacy regulations. Attendance was monitored, and participants who missed any workshop session or more than one virtual task were excluded from the analysis to ensure intervention fidelity.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eFirst Workshop\u003c/strong\u003e\u003cp\u003eThis workshop focused on foundational ethical concepts, including the Iranian Nursing Organization\u0026rsquo;s Code of Ethics, professional responsibilities, and patient rights. The session began with a 45-minute lecture on ethical principles (e.g., autonomy, beneficence, non-maleficence, justice, confidentiality) and their application in rehabilitation nursing. This was followed by a 75-minute group discussion where participants analyzed real-life ethical scenarios specific to rehabilitation care, such as managing patient autonomy in cases of severe disability or addressing family dynamics in chronic illness care. The participants were encouraged to share personal experiences and propose ethically sound solutions, guided by the facilitator to ensure constructive dialogue(\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eSecond Workshop\u003c/strong\u003e\u003cp\u003eEmphasized practical application through multimedia and role-playing. The session included a 30-minute presentation of ethical case studies, followed by the screening of three short educational videos (5\u0026ndash;10 minutes each) depicting ethical dilemmas in rehabilitation nursing, such as handling patient refusal of treatment or addressing errors in care. These videos, sourced from validated educational materials, were selected to reflect realistic challenges faced by nurses. After each video, the participants engaged in a 20-minute role-playing exercise, placing themselves in the position of the decision-making nurse to propose and justify actions. A 40-minute group discussion followed, where participants critiqued the decisions made in the videos and role-plays, focusing on ethical reasoning and moral courage. The workshop concluded with a 10-minute summary of key takeaways, emphasizing strategies for applying ethical principles in clinical practice(\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e).\u003c/p\u003e\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eVirtual Follow-Up Phase\u003c/h2\u003e\u003cp\u003eFollowing the workshops, a four-week virtual follow-up was conducted via a secure online platform to reinforce learning and promote sustained engagement. Participants were divided into small groups (4\u0026ndash;5 nurses) and assigned weekly tasks, including the following:\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eEthical Scenario Discussions\u003c/strong\u003e\u003cp\u003eEach week, participants received a new rehabilitation-specific ethical scenario (e.g., managing a patient with spinal cord injury refusing rehabilitation or addressing a colleague\u0026rsquo;s ethical lapse). The participants were required to post their proposed solutions and rationales on the platform, followed by asynchronous discussions moderated by the investigator. Each discussion required at least two responses per participant to encourage peer interaction and critical thinking.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eVideo-Based Reflections\u003c/strong\u003e\u003cp\u003eParticipants watched one additional educational video per week, similar to those used in the workshops, and submitted a brief written reflection (150\u0026ndash;200 words) on the ethical issues depicted and potential solutions. The investigator provided individualized feedback to enhance understanding.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eInteractive Q\u0026amp;A Sessions\u003c/strong\u003e\u003cp\u003eWeekly 30-minute live virtual sessions were held to address questions, clarify ethical concepts, and discuss real-world applications of the training content.\u003c/p\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eControl Group\u003c/h3\u003e\n\u003cp\u003eThe control group received no intervention during the study period but continued their routine clinical duties. To ensure ethical fairness, the control group was offered access to the moral motivation program after the study\u0026rsquo;s completion.\u003c/p\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003eData were collected at three time points: baseline (pre-intervention), immediately post-intervention, and one-month post-intervention. Two instruments were used to collect demographic information and assess moral sensitivity. A researcher-designed questionnaire was used at baseline to collect participants' demographic and professional data, including age, sex, marital status, education, work experience, employment type, and shift pattern.\u003c/p\u003e\u003cp\u003eL\u0026uuml;tz\u0026eacute;n\u0026rsquo;s 25-item Moral Sensitivity Questionnaire (MSQ) was used to assess nurses\u0026rsquo; moral sensitivity in clinical decision-making, specifically their ability to recognize ethical dilemmas and understand the moral implications of their choices. The questionnaire includes six dimensions of moral sensitivity: respect for patient autonomy, awareness of communication methods with patients, level of professional knowledge, experience with ethical dilemmas and conflicts, application of ethical concepts in decision-making, and honesty and benevolence. Each item was rated on a 5-point Likert scale (1\u0026thinsp;=\u0026thinsp;strongly disagree, 5\u0026thinsp;=\u0026thinsp;strongly agree), with total scores ranging from 0 to 100. Scores were categorized as low (0\u0026ndash;50), moderate (51\u0026ndash;75), or high (76\u0026ndash;100) moral sensitivity(\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). The Persian version of the MSQ, validated in prior Iranian studies, demonstrated strong reliability (Cronbach\u0026rsquo;s alpha\u0026thinsp;=\u0026thinsp;0.81)(\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Completion took approximately 10\u0026ndash;15 minutes.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eThe data were analyzed using SPSS version 25. Normality was assessed using the Shapiro-Wilk test. Baseline comparability between groups was evaluated using independent t-tests for continuous variables (e.g., age, work experience) and chi-square tests for categorical variables (e.g., sex, marital status, education level). To examine the intervention\u0026rsquo;s effect on moral sensitivity, repeated measures analysis of variance (ANOVA) was used, with time (pre-intervention, post-intervention, one-month follow-up) as the within-subject factor and group (intervention vs. control) as the between-subject factor.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eNo significant baseline differences were observed between the groups (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDemographic Characteristics of Participants (n\u0026thinsp;=\u0026thinsp;27)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIntervention Group (n\u0026thinsp;=\u0026thinsp;15)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eControl Group (n\u0026thinsp;=\u0026thinsp;12)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender (Female)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11 (73.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11 (91.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.34\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMean Age (years)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e33.4\u0026thinsp;\u0026plusmn;\u0026thinsp;4.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e34.1\u0026thinsp;\u0026plusmn;\u0026thinsp;3.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.37\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMarital Status (Married)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8 (53.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8 (66.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.69\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEducation (Master's)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8 (53.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (25%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.78\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMean Work Experience (years)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9.6\u0026thinsp;\u0026plusmn;\u0026thinsp;3.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10.1\u0026thinsp;\u0026plusmn;\u0026thinsp;4.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.86\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEmployment (Permanent)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (40%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (33.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.93\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eShift (Rotating)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10 (66.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (41.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.05\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows that the intervention group demonstrated a significant improvement over time, whereas the control group experienced a slight decline. Between-group comparisons confirmed statistically significant differences after the intervention and at follow-up (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison of Moral Sensitivity Scores Within and Between Groups Over Time\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGroup / Time Point\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePre-Intervention (Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eImmediately Post-Intervention (Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eOne Month Follow-up (Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eWithin-Group Test Result*\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eBetween-Group Test Result**\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eControl\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e72.1\u0026thinsp;\u0026plusmn;\u0026thinsp;1.44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e70.5\u0026thinsp;\u0026plusmn;\u0026thinsp;6.19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e68.8\u0026thinsp;\u0026plusmn;\u0026thinsp;7.15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIntervention\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e70.5\u0026thinsp;\u0026plusmn;\u0026thinsp;4.56\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e78.5\u0026thinsp;\u0026plusmn;\u0026thinsp;3.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e77.3\u0026thinsp;\u0026plusmn;\u0026thinsp;5.27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.007\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e***Test Result\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.409\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.002\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e*Within-group differences analyzed using repeated-measures ANOVA.\u003c/p\u003e\u003cp\u003e**Between-group differences analyzed using independent t-tests.\u003c/p\u003e\u003cp\u003e***Comparison between groups at each time point.\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows that the intervention group demonstrated significantly greater improvements in moral sensitivity after the training and at the one-month follow-up (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). No significant difference was found between the groups in the change from immediately post-intervention to follow-up (p\u0026thinsp;=\u0026thinsp;0.812).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison of Changes in Nurses\u0026rsquo; Moral Sensitivity Scores Between Groups\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGroup / Time Interval\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePre- vs. Immediately Post-Intervention (Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePre- vs. 1-Month Follow-up (Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eImmediately Post- vs. 1-Month Follow-up (Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eControl\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.58\u0026thinsp;\u0026plusmn;\u0026thinsp;2.31 \u0026darr;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.99\u0026thinsp;\u0026plusmn;\u0026thinsp;3.25 \u0026darr;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.67\u0026thinsp;\u0026plusmn;\u0026thinsp;1.87 \u0026darr;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIntervention\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8.07\u0026thinsp;\u0026plusmn;\u0026thinsp;3.91 \u0026uarr;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6.80\u0026thinsp;\u0026plusmn;\u0026thinsp;7.14 \u0026uarr;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.27\u0026thinsp;\u0026plusmn;\u0026thinsp;5.48 \u0026darr;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTest Result (Between Groups)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.812\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study evaluated the effect of a moral motivation program on the moral sensitivity of nurses working in rehabilitation wards. The findings indicate that the intervention group demonstrated a statistically significant increase in moral sensitivity scores compared with the control group at both post-intervention and one-month follow-up assessments. These results suggest that moral motivation programs can effectively enhance nurses\u0026rsquo; ability to recognize and respond to ethical dilemmas in clinical practice, particularly in the complex setting of rehabilitation nursing.\u003c/p\u003e\u003cp\u003eThe observed improvement in moral sensitivity aligns with previous studies that have explored the impact of ethics education on nursing practices. Hosseini et al. (2019) reported that targeted ethical training significantly improved moral sensitivity among Iranian nurses, emphasizing the importance of culturally relevant content(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Similarly, Similarly, Nasiriani et al. (2020) reported that virtual ethics education using narrative-based methods improved moral sensitivity among critical care nurses in Iran, using the same MSQ tool(\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). The current study\u0026rsquo;s use of rehabilitation-specific case scenarios and role-playing likely contributed to its effectiveness by fostering active engagement and practical application of ethical principles, such as beneficence and justice, which are critical in managing chronic care challenges. Namadi et al. (2018) further support these findings, demonstrating that, compared with lecture-based methods, case-based ethics education significantly improved moral sensitivity among nursing students highlighting the value of interactive approaches (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn contrast, studies such as choe et al. (2020)(\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e) and yeom et al. (2017)(\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e), and Baykara et al. (2014)(\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e) reported no significant improvements in moral sensitivity following lecture-based ethics seminars. These differences may be attributed to the lack of interactive elements, such as case discussions or role-playing, which were central to the current intervention. Choe et al.\u0026rsquo;s study, which was conducted among South Korean nurses, relied on didactic lectures, potentially limiting opportunities for practical application. Similarly, Yeom et al.\u0026rsquo;s focus on nursing students with limited clinical experience may explain their non-significant findings, as moral sensitivity may develop more robustly in practicing nurses exposed to real-world ethical dilemmas. Baykara et al. also reported non-significant gains in moral sensitivity among Turkish nurses, likely due to the absence of tailored, scenario-based content.\u003c/p\u003e\u003cp\u003eThe sustained improvement at the one-month follow-up highlights the efficacy of the virtual follow-up phase, which included asynchronous discussions and reflective exercises. This finding aligns with Rahmah et al. (2021), who emphasized the role of continuous learning in maintaining ethical competence(\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). The flexibility of the virtual component likely facilitated engagement among nurses with demanding schedules, a critical consideration in resource-constrained settings such as Iran, where in-person training opportunities are often limited. The program\u0026rsquo;s focus on rehabilitation nursing addresses unique ethical challenges, such as balancing patient autonomy with family expectations or navigating resource allocation for chronic care, enhancing its relevance and impact.\u003c/p\u003e\u003cp\u003eThese findings have significant implications for nursing education and practice. The incorporating moral motivation programs into continuing professional development could strengthen ethical decision-making, particularly in specialized fields like rehabilitation nursing. Despite these strengths, several limitations must be acknowledged. The small sample size and single-center design at Rofeidah Rehabilitation Hospital may limit the generalizability of the findings to other settings or nursing populations. Additionally, the one-month follow-up period, while sufficient to detect sustained effects, may not capture long-term changes in moral sensitivity, particularly as nurses encounter new ethical challenges over time.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eMSQ: Moral Sensitivity Questionnaire\u003c/p\u003e\n\u003cp\u003eMST: Moral Sensitivity Test \u003c/p\u003e\n\u003cp\u003eSPSS: Statistical Package for the Social Sciences\u003c/p\u003e\n\u003cp\u003eANOVA: Analysis of Variance\u003c/p\u003e\n\u003cp\u003eSD: Standard Deviation\u003c/p\u003e\n\u003cp\u003eIRB: Institutional Review Board \u003c/p\u003e\n\u003cp\u003eRCT: Randomized Controlled Trial (if mentioned in references or background) \u003c/p\u003e\n\u003cp\u003eUSWR: University of Social Welfare and Rehabilitation Sciences\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Ethics Committee of the University of Social Welfare and Rehabilitation Sciences (IR.USWR.REC.1402.087). Written informed consent was obtained from all participants, who were informed about the purpose of the study, confidentiality of responses, and their right to withdraw at any time without any consequences. This study was conducted in accordance with the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors confirm that this manuscript does not include any individual person’s data in any form. Therefore, consent for publication is not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data collected and analysed during this study are fully presented within the published manuscript and its supplementary materials. No additional datasets were generated or deposited.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFunding: None.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eR.K. conceptualized and designed the study, collected and analysed the data, and drafted the initial manuscript. N.A. contributed to the interpretation of findings, critically reviewed the manuscript for intellectual content, and approved the final version for submission. Both authors read and approved the final manuscript and agree to be accountable for all aspects of the work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank the staff of Rofeideh Rehabilitation Hospital, Tehran, Iran, for their kind cooperation and help in doing this research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe moral motivation program significantly enhanced the moral sensitivity of nurses working in rehabilitation wards, with sustained improvements observed at the one-month follow-up. This study highlights the efficacy of structured, context-specific ethical training, combining in-person workshops and virtual follow-up, in fostering nurses’ ability to navigate ethical dilemmas in clinical practice. The findings highlight the potential of such programs to strengthen ethical competence in specialized nursing fields, particularly in resource-constrained settings. Integrating moral motivation training into continuing professional development could promote patient-centered care and ethical decision-making. Further research is needed to confirm these findings in larger, multi-center studies and to explore the long-term impacts on clinical outcomes.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eGaudine A, LeFort SM, Lamb M, Thorne L. Clinical ethical conflicts of nurses and physicians. Nursing ethics. 2011;18(1):9\u0026ndash;19.\u003c/li\u003e\n\u003cli\u003eShahriari M, Baloochestani E. Applying professional values: the perspective of nurses of Isfahan hospitals. Journal of medical ethics and history of medicine. 2014;7.\u003c/li\u003e\n\u003cli\u003eHaahr A, Norlyk A, Martinsen B, Dreyer P. Nurses experiences of ethical dilemmas: A review. 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Iranian Journal of Medical Ethics and History of Medicine. 2018;11:231\u0026ndash;41.\u003c/li\u003e\n\u003cli\u003eUlrich C, O\u0026apos;Donnell P, Taylor C, Farrar A, Danis M, Grady C. Ethical climate, ethics stress, and the job satisfaction of nurses and social workers in the United States. Soc Sci Med. 2007;65(8):1708\u0026ndash;19.\u003c/li\u003e\n\u003cli\u003eJavidpour M, Ramezani-Badr F, Hamidi L, Amini K. Balancing ethics, burnout and job satisfaction: the challenges facing nurses in teaching hospitals. BMC Health Services Research. 2025;25(1):289.\u003c/li\u003e\n\u003cli\u003eHoseini M, Ebadi M, Farsi Z. The effect of ethical motivational program on nurses\u0026acirc; moral courage in Mashhad\u0026acirc; s military hospitals. Journal of Military Medicine. 2022;21(4):410\u0026ndash;7.\u003c/li\u003e\n\u003cli\u003eWerhane PH, de Colle S. Moral Motivation Across Ethical Theories: What Can We Learn for Designing Corporate Ethics Programs? 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J Public Health Res. 2021;11(2).\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Moral sensitivity, moral motivation, nursing ethics, rehabilitation nursing, quasi-experimental study","lastPublishedDoi":"10.21203/rs.3.rs-7205406/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7205406/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eMoral sensitivity is critical for ethical nursing practice, particularly in rehabilitation settings where complex ethical dilemmas are common. This study evaluated the effect of a moral motivation program on the moral sensitivity of nurses working in rehabilitation wards.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: A quasi-experimental pretest-posttest study with a control group was conducted from May to October 2023 at Rofeidah Rehabilitation Hospital, Tehran, Iran. Twenty-seven nurses were purposively sampled and randomly allocated to an intervention (n=15) or control (n=12) group on the basis of ward assignments. The intervention group participated in a six-week moral motivation program, including two 2-hour in-person workshops and four weeks of virtual follow-up, with a focus on ethical principles and rehabilitation-specific scenarios. The control group received no intervention. Moral sensitivity was assessed via Lutzen’s Moral Sensitivity Questionnaire (MSQ) at baseline, post-intervention, and one-month follow-up. The Data were analyzed via repeated measures ANOVA.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: Compared with the control group, the intervention group presented statistically significant statistically significant increases in moral sensitivity scores post-intervention (p\u0026lt;0.05), with sustained improvements at the one-month follow-up. No significant changes were observed in the control group.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e: The moral motivation program effectively enhanced nurses’ moral sensitivity, with sustained effects over one month. These findings support the integration of context-specific ethical training into nursing education to improve ethical decision-making in rehabilitation care.\u003c/p\u003e","manuscriptTitle":"The Effectiveness of a Moral Motivation Program in Promoting Moral Sensitivity among Practicing Nurses","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-15 08:34:46","doi":"10.21203/rs.3.rs-7205406/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"92a7e408-5d5e-4b5d-a0bf-742cc48b2760","owner":[],"postedDate":"December 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-01-09T09:40:15+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-15 08:34:46","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7205406","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7205406","identity":"rs-7205406","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}