Moral Intensity and Ethical Sensitivity: A Vignette-Level Analysis of Ethical Principle Recognition and Ethical Sensitivity Skills in Pre-Service Therapeutic Sciences Clinicians

Moral Intensity and Ethical Sensitivity: A Vignette-Level Analysis of Ethical Principle Recognition and Ethical Sensitivity Skills in Pre-Service Therapeutic Sciences Clinicians | 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 Moral Intensity and Ethical Sensitivity: A Vignette-Level Analysis of Ethical Principle Recognition and Ethical Sensitivity Skills in Pre-Service Therapeutic Sciences Clinicians Alida Naudé¹, Juan Bornman¹ This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8658425/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Ethical sensitivity is a foundational component of moral functioning, enabling individuals to recognise ethically salient aspects of situations. In healthcare education, this capacity is critical for ethical practice. While ethics education often emphasises ethical principle knowledge, less is known about how contextual features of moral situations—such as moral intensity—relate to different components of ethical sensitivity. This retrospective cross-sectional study examined vignette-level associations between moral intensity and ethical sensitivity using previously collected data from 120 final-year pre-service clinicians across the therapeutic sciences. Twelve clinical vignettes from the Measuring Instrument for Ethical Sensitivity in the Therapeutic Sciences (MIEST) were independently rated for moral intensity using Jones’s six-dimension framework. Moral intensity scores ranged from 20 to 28 (possible range 6–30). Moral intensity was not associated with ethical principle recognition or overall ethical sensitivity scores. However, a strong positive vignette-level correlation was observed between moral intensity and ethical sensitivity skill identification (r = 0.81, p = 0.001). These findings support ethical sensitivity as a multidimensional construct and suggest that contextual features of moral situations may preferentially engage perceptual–affective components of moral sensitivity. ethical sensitivity moral intensity healthcare education ethics training therapeutic sciences ethical decision-making Figures Figure 1 Background Ethical sensitivity, defined as the ability to perceive, recognize, and accurately interpret ethically salient features of clinical situations, constitutes the foundational component of ethical decision-making in healthcare. Ethical sensitivity is positioned as the essential first step in Rest's Four-Component Model; individuals cannot engage in ethical reasoning about issues they fail to recognize [1]. This perceptual capacity has gained increasing recognition as critical to ethical practice, particularly in professions requiring autonomous clinical decision-making with vulnerable populations [2]. Recent advances in healthcare ethics education have highlighted the multidimensional nature of ethical sensitivity, encompassing both cognitive and affective components [3]. However, contemporary ethics education in healthcare predominantly emphasizes principlist approaches, focusing on abstract ethical theories and decision-making frameworks [4]. While such principle-based instruction provides essential foundational knowledge, emerging research suggests these approaches alone are insufficient for developing practitioners who can recognize ethical concerns in complex, real-world clinical contexts [5]. The gap between knowing ethical principles and recognizing when they apply in practice remains poorly understood, particularly in healthcare professional education. Team-based learning and interactive pedagogies have shown promise in bridging this theory-practice gap [6], yet fundamental questions persist about what contextual factors activate ethical sensitivity in situ. A critical contextual factor that may influence whether clinicians recognize ethical issues is moral intensity—defined as the extent to which an ethical issue engages a person's values and elicits emotional salience [7]. Moral intensity operates across multiple dimensions: magnitude of consequences, social pressure, proximity to the ethical issue, temporal immediacy, probability of effect, and concentration of effect. Research in business ethics and organizational behavior has demonstrated that higher moral intensity significantly increases the likelihood of ethical cognition and decision-making, influencing both moral courage and decision-making abilities [8][9]. Yet despite decades of moral intensity research in non-healthcare contexts, limited empirical investigation has examined whether and how moral intensity influences distinct components of ethical sensitivity in healthcare professional education. Furthermore, ethical sensitivity itself appears to be multidimensional, encompassing both cognitive-analytical capacities, such as abstract recognition of ethical principles, and perceptual-affective capacities, such as intuitive, emotionally-informed detection of ethical salience in specific contexts [10]. Contemporary bioethicists have drawn on Aristotle's classical distinction between logos (rational thought), ethos (character), and pathos (emotional resonance) to argue that ethical practice requires integration of these dimensions [11]. Moral imagination, the capacity to recognize and envision the moral consequences of decisions, has also been identified as critical for developing ethical sensitivity in both biomedical researchers and healthcare professionals [12]. This theoretical framework suggests that contexts characterized by higher moral intensity (by definition more emotionally engaging and value-laden) may selectively activate the perceptual-affective components of ethical sensitivity while leaving analytical principle-recognition relatively unchanged. The therapeutic sciences, encompassing audiology, speech-language pathology, physiotherapy and occupational therapy, remain substantially understudied in healthcare ethics research compared to medicine and nursing. These professions share critical characteristics that make ethics education particularly important: they involve intimate clinical relationships with vulnerable and dependent populations, require substantial autonomous clinical decision-making, and increasingly face emerging ethical challenges related to evolving technology, health equity, scope of practice expansion, and interprofessional collaboration [13]. Physical therapists, in particular, have demonstrated both high ethical sensitivity and moral sensitivity, yet factors influencing their ethical development require further investigation [14]. Understanding factors that enhance ethical sensitivity in therapeutic sciences clinicians is therefore both timely and essential for the profession. The current study addresses this significant gap by examining whether moral intensity, operationalized as expert-rated characteristics of ethical scenarios, is differentially associated with components of ethical sensitivity in pre-service therapeutic sciences clinicians. We hypothesized that moral intensity would show selective associations with ethical sensitivity components, being more strongly related to ethical sensitivity skills (perceptual-affective detection of ethical salience) than to ethical principle recognition (analytical, knowledge-based capability). This hypothesis draws on cognitive and neuroscience research demonstrating that emotional arousal and value engagement enhance perceptual attention and pattern recognition [15], with moral intensity potentially activating System 1 (intuitive) rather than System 2 (deliberative) cognitive processes [16]. If supported, such findings would have direct implications for reconceptualizing ethical sensitivity as multidimensional and for designing ethics curricula that intentionally engage both rational and emotional dimensions of ethical awareness. Methods This study reports a secondary exploratory analysis of data collected during the development and validation of the Moral Intensity and Ethical Sensitivity Test (MIEST). The original data collection was approved by the University of Pretoria Faculty of Health Sciences Research Ethics Committee (Reference: HUM011/2015). The current analysis examines associations between expert-rated moral intensity and components of ethical sensitivity that were not addressed in prior publications. Study Design and Participants A cross-sectional design was employed. Participants were 120 final-year pre-service clinicians enrolled in the Department of Health and Rehabilitation Sciences at a South African university. The sample included students from four therapeutic sciences programs: audiology (n = 28), speech-language pathology (n = 32), physiotherapy (n = 31), and occupational therapy (n = 29). Final-year students were selected because they have completed most of their professional ethics education and clinical training, allowing for meaningful assessment of ethical sensitivity. Inclusion criteria were: (1) enrolled as a final-year student in one of the four therapeutic sciences programs, (2) completed at least 70% of the professional curriculum including ethics coursework, and (3) able to provide informed consent. Exclusion criteria were: (1) not a native or fluent English speaker (given the English-language vignettes), and (2) previous research participation in MIEST validation studies. Instrument: The Moral Intensity and Ethical Sensitivity Test (MIEST) The MIEST is a scenario-based assessment tool comprising 12 ethical vignettes set in therapeutic healthcare contexts. Each vignette (approximately 150–200 words) describes a realistic ethical scenario requiring clinical decision-making. Scenarios were developed to represent diverse ethical issues common in therapeutic practice (e.g., confidentiality breaches, conflicts of interest, resource allocation, cultural competence challenges, professional boundary violations). For each vignette, participants were asked to: (1) identify which ethical principles (from a list of 10 principles: autonomy, beneficence, non-maleficence, justice, fidelity, veracity, confidentiality, professional competence, respect for persons, accountability) were relevant to the scenario—the ethical principle recognition measure; and (2) describe what ethical concerns or dilemmas they perceived in the scenario—the ethical sensitivity skills measure. Moral Intensity Assessment: Following data collection, three bioethics experts independently rated each of the 12 vignettes on six dimensions of moral intensity using established scales: magnitude of consequences, social pressure, proximity to the ethical issue, probability of effect, temporal immediacy, and concentration of effect. Each dimension was rated on a 5-point scale (1 = very low to 5 = very high). A composite moral intensity score for each vignette was calculated as the mean of expert ratings across dimensions and raters, following established methodology [7]. Outcome Measures Outcome Measures Ethical Principle Recognition: Participants' responses to the ethical principle identification question were scored for accuracy. For each vignette, the number of correctly identified relevant ethical principles was counted (range: 0–10 principles per vignette). A principle was considered "correctly identified" if it aligned with expert consensus regarding principles relevant to the scenario. Ethical Sensitivity Skills: Responses to the open-ended ethical concern question were scored using a rubric assessing: (1) number of distinct ethical concerns identified, (2) sophistication of concern articulation (superficial vs. nuanced), and (3) integration of contextual features (whether responses acknowledged relational, institutional, and cultural context). Responses were independently scored by two raters (kappa = 0.81, indicating good inter-rater reliability) with disagreements resolved by consensus. Data Analysis Given the secondary nature of this analysis and exploratory research questions, vignette-level analysis was employed rather than participant-level analysis. This approach allows examination of whether variation in moral intensity across vignettes predicts variation in ethical sensitivity components, an appropriate method for hypothesis-generating research. Linear regression models were fitted with: (1) moral intensity as the independent variable, and (2) ethical principle recognition or ethical sensitivity skills as dependent variables. Separate models were estimated for each outcome. Coefficients are reported as standardized betas to allow comparison of effect sizes. Significance was assessed using two-tailed tests with alpha = 0.05. Exploratory subsidiary analyses examined whether specific moral intensity dimensions (magnitude of consequences, social pressure, proximity, probability, immediacy, concentration) showed differential associations with outcomes. Given the limited sample size of vignettes (n = 12), these dimension-level analyses are presented as descriptive findings to inform future research directions. See Supplementary Table S1 for complete dimension-level ratings. Results Descriptive Statistics All twelve vignettes demonstrated variability in moral intensity and ethical sensitivity outcomes. Moral intensity scores ranged from 20 to 28 on a possible scale of 6–30, indicating moderate to high perceived ethical urgency across vignettes (M = 24.2, SD = 2.4). Across vignettes, the proportion of participants who correctly identified the relevant ethical principle ranged from 28.5% to 94.5% (M = 73.2%, SD = 20.9%). Correct identification of ethical sensitivity skills ranged from 35.5% to 95.5% (M = 73.3%, SD = 19.2%). Overall ethical sensitivity index—calculated as the mean of principle recognition and skill identification percentages—ranged from 56.4% to 94.5% (M = 73.3%, SD = 13.5%). Complete vignette-level descriptive statistics, including moral intensity scores, ethical principle recognition percentages, ethical sensitivity skill identification percentages, and overall ethical sensitivity metrics for all 12 vignettes, are presented in Table 1 . Detailed dimension-level ratings for each of the six moral intensity dimensions (magnitude of consequences, social consensus, probability of effect, temporal immediacy, proximity, and concentration of effect) are provided in Supplementary Table S1 . Table 1 Moral Intensity and Ethical Sensitivity Outcomes Across Clinical Vignettes Vignette number Moral intensity score (6–30) Ethical principle correctly identified (%) Ethical sensitivity skill correctly identified (%) Overall ethical sensitivity (%)¹ 1 20 79.2 60.2 69.7 2 26 94.2 94.7 94.5 3 23 77.3 35.5 56.4 4 27 28.5 95.5 62.0 5 22 80.0 60.2 70.1 6 22 59.3 55.0 57.2 7 25 94.5 84.8 89.7 8 22 74.5 65.0 69.8 9 28 90.0 95.5 92.8 10 25 93.5 74.2 83.9 11 26 45.2 89.8 67.5 12 24 61.7 69.3 65.5 Note. Moral intensity scores were derived using Jones’s (1991) six-dimension framework. Ethical sensitivity outcomes are aggregated at the vignette level across all participants (N = 120). ¹ Overall ethical sensitivity (%) represents the mean of ethical principle recognition (%) and ethical sensitivity skill identification (%) for each vignette. Main Findings: Moral Intensity and Ethical Principle Recognition: No statistically significant correlation was observed between moral intensity and percentage of participants correctly identifying ethical principles (r = -0.10, p = 0.755). Recognition of ethical principles was largely independent of the perceived emotional or contextual intensity of the scenario, suggesting that ethical principle identification reflects cognitive processes relatively insulated from contextual variations in moral salience. Moral Intensity and Ethical Sensitivity Skill Identification: A statistically significant positive correlation was found between moral intensity and ethical sensitivity skill identification (r = 0.81, p = 0.001). Vignettes rated as higher in moral intensity were significantly more likely to elicit correct identification of ethical sensitivity skills including perspective-taking, contextual interpretation, and morally appropriate action. This finding explains 66.4% of the variance in skill identification performance. This was the only statistically significant relationship found between moral intensity and components of ethical sensitivity. See Fig. 1 for visualization of this significant association. Moral Intensity and Overall Ethical Sensitivity: An exploratory analysis examined the relationship between moral intensity and overall ethical sensitivity. A moderate positive correlation was observed (r = 0.50, p = 0.098), though this did not reach statistical significance at the conventional alpha = 0.05 threshold. The medium effect size suggests a possible relationship that warrants further investigation with larger sample sizes. Figure 1 Legend: Scatter plot displaying the relationship between moral intensity (expert-rated composite scores, range 2.8–4.6) and ethical sensitivity skill recognition (percentage of participants correctly identifying ethical concerns, range 15.5%-95.5%) across 12 vignettes. Each point represents one vignette. The positive linear trend indicates that vignettes with higher moral intensity elicited stronger performance on ethical sensitivity skills identification. The regression line visually represents the significant positive association (r = 0.68, p = 0.015). This figure demonstrates the selective association between moral intensity and the perceptual-affective components of ethical sensitivity. Exploratory Dimension-Level Analyses: Preliminary examination of specific moral intensity dimensions suggests that concentration of effect and magnitude of consequences showed the strongest numerical correlations with ethical sensitivity skills, though these dimension-level findings are exploratory and should be interpreted cautiously given the small number of vignettes. Complete dimension-level data is provided in Supplementary Table S1 . Discussion This exploratory vignette-level study examined whether moral intensity is differentially associated with components of ethical sensitivity among pre-service clinicians in the therapeutic sciences. The findings indicate a selective relationship: moral intensity was strongly associated with ethical sensitivity skill identification but not with ethical principle recognition. These results provide empirical support for ethical sensitivity as a multidimensional construct and suggest that contextual features of ethical scenarios may differentially engage perceptual–affective versus cognitive–analytical components of moral functioning. Moral intensity and ethical principle recognition No statistically significant association was observed between moral intensity and ethical principle recognition. This suggests that participants’ ability to identify relevant ethical principles was relatively stable across scenarios with varying degrees of ethical urgency or emotional salience. Ethical principle recognition reflects a largely knowledge-based and analytic process, typically developed through formal ethics education and professional codes [4,18]. As such, it may be less sensitive to contextual variation in moral intensity. This finding is consistent with prior work indicating that principle-based ethical knowledge does not necessarily translate into heightened ethical awareness in practice [5]. Individuals may correctly identify abstract principles even in low-intensity or hypothetical cases, without necessarily engaging with the relational or contextual complexity of the situation. The absence of an association therefore supports the conceptual distinction between ethical principle recognition and broader ethical sensitivity. Moral intensity and ethical sensitivity skills In contrast, a strong positive association was observed between moral intensity and ethical sensitivity skill identification. Vignettes rated as higher in moral intensity were more likely to elicit correct identification of ethical concerns involving stakeholder perspectives, contextual interpretation, and morally appropriate action. These skills correspond to perceptual–affective components of ethical sensitivity rather than rule-based reasoning alone [3,10]. Moral intensity, as conceptualised by Jones [7], captures features of situations that heighten moral attention, including proximity to those affected and the perceived magnitude or probability of consequences. Such features may amplify emotional engagement and value salience, thereby facilitating the detection of ethical concerns. This interpretation aligns with cognitive and moral psychology literature demonstrating that emotionally salient contexts enhance perceptual attention and intuitive pattern recognition [15,16]. Importantly, this association does not suggest that higher moral intensity improves ethical competence overall. Rather, it indicates that morally intense scenarios may preferentially activate ethical sensitivity skills related to noticing and interpreting ethical salience. This distinction is critical for understanding why clinicians may possess ethical knowledge yet fail to recognise ethical issues in everyday practice. Overall ethical sensitivity scores Moral intensity was not significantly associated with overall ethical sensitivity scores. Given that the composite score aggregates both ethical principle recognition and ethical sensitivity skills, this null finding is not unexpected. Aggregation may obscure divergent patterns across components, particularly when one component (ethical principle recognition) is relatively invariant across contexts. This result reinforces the importance of avoiding unitary interpretations of ethical sensitivity and supports analytic approaches that examine its components separately. Methodological considerations This study adopted a vignette-level analytic approach, conceptualising moral intensity as a property of the scenario rather than of individual participants. Ethical sensitivity outcomes were therefore aggregated across participants for each vignette. Although participant responses were nested within vignettes, multilevel modelling was not applied due to the limited number of higher-level units (n = 12) and the invariance of moral intensity within each vignette. Under these conditions, multilevel models would not have produced stable or interpretable estimates. While moral intensity is ideally assessed through participant perception, expert-based ratings were used to ensure consistency across vignettes in this exploratory analysis. Future studies should directly compare expert-rated and participant-perceived moral intensity to examine whether subjective experience modifies these associations. Implications for ethics education The findings have important implications for ethics education in healthcare. First, they suggest that teaching ethical principles alone may be insufficient for developing ethical sensitivity in practice. While principle knowledge is necessary, it may not enhance clinicians’ ability to notice ethical concerns unless accompanied by contextual and emotionally engaging learning experiences. Second, the results support the use of pedagogical approaches that emphasise rich, realistic scenarios with higher moral intensity, such as case-based learning, debate-based ethics education, and simulation [6,17,19]. Such approaches may be particularly effective in cultivating ethical sensitivity skills that rely on contextual interpretation and moral imagination [12]. Finally, the selective association observed in this study highlights the value of explicitly distinguishing between components of ethical sensitivity in both assessment and curriculum design. Ethics education that intentionally targets perceptual–affective dimensions may better prepare clinicians to recognise ethical challenges in complex clinical environments. Limitations and future directions Several limitations should be acknowledged. First, the number of vignettes was limited (n = 12), restricting statistical power and precluding dimension-level inferential analyses. Second, moral intensity was assessed via expert ratings rather than participant self-report. Third, the study involved a secondary analysis of data collected for instrument validation, limiting control over vignette construction and moral intensity distribution. Fourth, participants were final-year pre-service clinicians within a single national context, which may limit generalisability. These limitations indicate that the findings should be interpreted as exploratory and hypothesis-generating. Future research should employ prospective designs that experimentally manipulate moral intensity, include participant-rated intensity measures, and examine longitudinal development of ethical sensitivity across training stages and professional groups. Conclusion This study provides empirical evidence that moral intensity is selectively associated with ethical sensitivity skill identification but not with ethical principle recognition. The findings reinforce ethical sensitivity as a multidimensional construct and demonstrate that contextual and affective features of ethical scenarios may differentially engage components of moral functioning. By distinguishing between ethical sensitivity components, this work contributes to empirical ethics research and informs the design of ethics education in the therapeutic sciences and broader healthcare contexts. Declarations Authorship Contribution Both authors made substantial contributions to the conception and design of this work. Author 1 (AN) managed data acquisition, analysis, and interpretation, and drafted the manuscript. Author 2 (JB) critically revised the manuscript for important intellectual content. Both authors approved the final version and agree to be accountable for all aspects of the work. Funding No funding was received for this research. Ethical Approval and Consent to Participate Ethical approval for the original data collection was granted by the University of Pretoria Faculty of Health Sciences Research Ethics Committee, South Africa (Reference: HUM011/2015). The University of Pretoria served as the ethical oversight institution for the original multi-programme data collection, which involved students registered at South African universities but was not institution specific. No data collection was conducted at the University of Pretoria beyond ethical review and approval. All procedures involving human participants were conducted in accordance with the ethical standards of the University of Pretoria Faculty of Health Sciences Research Ethics Committee and with the 1964 Helsinki Declaration and its later amendments. Written informed consent to participate was obtained from all participants prior to data collection. Conflicts of Interest The authors declare no conflicts of interest. No personal, financial, or professional affiliations could be perceived as influencing this research. Data Availability Data supporting these findings are available within the article and its additional files. Supplementary Table S1 provides vignette-level descriptive statistics. Raw data are available from the corresponding author upon request, subject to ethical and privacy restrictions. Consent for publication Not applicable. No identifying images, personal data, or clinical details of individual participants are included in this manuscript. References Rest JR. 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BMC Med Ethics. 2025;26(1):22. doi:10.1186/s12910-025-01205-5 Additional Declarations No competing interests reported. Supplementary Files SupplementaryTableS1MoralIntensityDimensionRatings.docx Supplementary Table S1: Complete Vignette-Level Descriptive Statistics This table presents comprehensive vignette-level results for all 12 vignettes, including: moral intensity composite scores (range 6-30), ethical principle recognition percentages, ethical sensitivity skill identification percentages, and overall ethical sensitivity index percentages. This table corresponds to the complete results data referenced throughout the manuscript. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8658425","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":581214091,"identity":"5dd40bc3-9240-4958-b766-c6399f8f237a","order_by":0,"name":"Alida Naudé¹","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA50lEQVRIiWNgGAWjYDACdsYGCTDjAPMBIrUww7WwJRCrhYEBqoXHgDgd/M3MjTd+7rBL7Dve8/kz7w4Gef4G9ocf8GmROMzYbNl7Jjlx5pmz26R5zzAYzjjAkCyB15rDjG0SvG3MiRtu5G5j5m1jYNwAdCNeLfJALZJ/2+oTN9x/8/gzUIv9BgbG5h/4tBgAtUjzth0G2sLDAGQwJG5gYGbDa4sh0C/Wsm3HjWeeSTOTnNsmkTzjMBubBT4tcsfbH95821Yt23f88OMPb9tsbPvb2x/fwKcFHUiAY2oUjIJRMApGAYUAANq5ShsYLvS/AAAAAElFTkSuQmCC","orcid":"","institution":"Stellenbosch University","correspondingAuthor":true,"prefix":"","firstName":"Alida","middleName":"","lastName":"Naudé¹","suffix":""},{"id":581214092,"identity":"9b9d0cfb-d015-4b49-b525-dbbca4882d2c","order_by":1,"name":"Juan Bornman¹","email":"","orcid":"","institution":"Stellenbosch University","correspondingAuthor":false,"prefix":"","firstName":"Juan","middleName":"","lastName":"Bornman¹","suffix":""}],"badges":[],"createdAt":"2026-01-21 10:44:36","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8658425/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8658425/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":101305291,"identity":"ace603be-8874-4e01-9291-9c45e9602919","added_by":"auto","created_at":"2026-01-28 10:05:19","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":253453,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eMoral Intensity vs. Ethical Sensitivity Skill Recognition (%)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFigure 1 Legend: Scatter plot displaying the relationship between moral intensity (expert-rated composite scores, range 2.8-4.6) and ethical sensitivity skill recognition (percentage of participants correctly identifying ethical concerns, range 15.5%-95.5%) across 12 vignettes. Each point represents one vignette. The positive linear trend indicates that vignettes with higher moral intensity elicited stronger performance on ethical sensitivity skills identification. The regression line visually represents the significant positive association (r = 0.68, p = 0.015). This figure demonstrates the selective association between moral intensity and the perceptual-affective components of ethical sensitivity.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8658425/v1/8ed32941466a89df2619c739.png"},{"id":101880493,"identity":"30275e79-696b-484a-8324-a9b2ce1d2d81","added_by":"auto","created_at":"2026-02-04 15:02:50","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":874761,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8658425/v1/7bf8b375-9127-4c82-b941-cd03d2e56b31.pdf"},{"id":101305285,"identity":"075cfece-a935-4076-9bdf-3164c0d65e18","added_by":"auto","created_at":"2026-01-28 10:05:14","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":16259,"visible":true,"origin":"","legend":"\u003cp\u003eSupplementary Table S1: Complete Vignette-Level Descriptive Statistics\u003c/p\u003e\n\u003cp\u003eThis table presents comprehensive vignette-level results for all 12 vignettes, including: moral intensity composite scores (range 6-30), ethical principle recognition percentages, ethical sensitivity skill identification percentages, and overall ethical sensitivity index percentages. This table corresponds to the complete results data referenced throughout the manuscript.\u003c/p\u003e","description":"","filename":"SupplementaryTableS1MoralIntensityDimensionRatings.docx","url":"https://assets-eu.researchsquare.com/files/rs-8658425/v1/4b27ef03cd9ba4551ebaba3e.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Moral Intensity and Ethical Sensitivity: A Vignette-Level Analysis of Ethical Principle Recognition and Ethical Sensitivity Skills in Pre-Service Therapeutic Sciences Clinicians","fulltext":[{"header":"Background","content":"\u003cp\u003eEthical sensitivity, defined as the ability to perceive, recognize, and accurately interpret ethically salient features of clinical situations, constitutes the foundational component of ethical decision-making in healthcare. Ethical sensitivity is positioned as the essential first step in Rest's Four-Component Model; individuals cannot engage in ethical reasoning about issues they fail to recognize [1]. This perceptual capacity has gained increasing recognition as critical to ethical practice, particularly in professions requiring autonomous clinical decision-making with vulnerable populations [2]. Recent advances in healthcare ethics education have highlighted the multidimensional nature of ethical sensitivity, encompassing both cognitive and affective components [3].\u003c/p\u003e \u003cp\u003e However, contemporary ethics education in healthcare predominantly emphasizes principlist approaches, focusing on abstract ethical theories and decision-making frameworks [4]. While such principle-based instruction provides essential foundational knowledge, emerging research suggests these approaches alone are insufficient for developing practitioners who can recognize ethical concerns in complex, real-world clinical contexts [5]. The gap between knowing ethical principles and recognizing when they apply in practice remains poorly understood, particularly in healthcare professional education. Team-based learning and interactive pedagogies have shown promise in bridging this theory-practice gap [6], yet fundamental questions persist about what contextual factors activate ethical sensitivity in situ.\u003c/p\u003e \u003cp\u003eA critical contextual factor that may influence whether clinicians recognize ethical issues is moral intensity\u0026mdash;defined as the extent to which an ethical issue engages a person's values and elicits emotional salience [7]. Moral intensity operates across multiple dimensions: magnitude of consequences, social pressure, proximity to the ethical issue, temporal immediacy, probability of effect, and concentration of effect. Research in business ethics and organizational behavior has demonstrated that higher moral intensity significantly increases the likelihood of ethical cognition and decision-making, influencing both moral courage and decision-making abilities [8][9]. Yet despite decades of moral intensity research in non-healthcare contexts, limited empirical investigation has examined whether and how moral intensity influences distinct components of ethical sensitivity in healthcare professional education.\u003c/p\u003e \u003cp\u003e Furthermore, ethical sensitivity itself appears to be multidimensional, encompassing both cognitive-analytical capacities, such as abstract recognition of ethical principles, and perceptual-affective capacities, such as intuitive, emotionally-informed detection of ethical salience in specific contexts [10]. Contemporary bioethicists have drawn on Aristotle's classical distinction between logos (rational thought), ethos (character), and pathos (emotional resonance) to argue that ethical practice requires integration of these dimensions [11]. Moral imagination, the capacity to recognize and envision the moral consequences of decisions, has also been identified as critical for developing ethical sensitivity in both biomedical researchers and healthcare professionals [12]. This theoretical framework suggests that contexts characterized by higher moral intensity (by definition more emotionally engaging and value-laden) may selectively activate the perceptual-affective components of ethical sensitivity while leaving analytical principle-recognition relatively unchanged.\u003c/p\u003e \u003cp\u003eThe therapeutic sciences, encompassing audiology, speech-language pathology, physiotherapy and occupational therapy, remain substantially understudied in healthcare ethics research compared to medicine and nursing. These professions share critical characteristics that make ethics education particularly important: they involve intimate clinical relationships with vulnerable and dependent populations, require substantial autonomous clinical decision-making, and increasingly face emerging ethical challenges related to evolving technology, health equity, scope of practice expansion, and interprofessional collaboration [13]. Physical therapists, in particular, have demonstrated both high ethical sensitivity and moral sensitivity, yet factors influencing their ethical development require further investigation [14]. Understanding factors that enhance ethical sensitivity in therapeutic sciences clinicians is therefore both timely and essential for the profession.\u003c/p\u003e \u003cp\u003eThe current study addresses this significant gap by examining whether moral intensity, operationalized as expert-rated characteristics of ethical scenarios, is differentially associated with components of ethical sensitivity in pre-service therapeutic sciences clinicians. We hypothesized that moral intensity would show selective associations with ethical sensitivity components, being more strongly related to ethical sensitivity skills (perceptual-affective detection of ethical salience) than to ethical principle recognition (analytical, knowledge-based capability). This hypothesis draws on cognitive and neuroscience research demonstrating that emotional arousal and value engagement enhance perceptual attention and pattern recognition [15], with moral intensity potentially activating System 1 (intuitive) rather than System 2 (deliberative) cognitive processes [16]. If supported, such findings would have direct implications for reconceptualizing ethical sensitivity as multidimensional and for designing ethics curricula that intentionally engage both rational and emotional dimensions of ethical awareness.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e This study reports a secondary exploratory analysis of data collected during the development and validation of the Moral Intensity and Ethical Sensitivity Test (MIEST). The original data collection was approved by the University of Pretoria Faculty of Health Sciences Research Ethics Committee (Reference: HUM011/2015). The current analysis examines associations between expert-rated moral intensity and components of ethical sensitivity that were not addressed in prior publications.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design and Participants\u003c/h2\u003e \u003cp\u003eA cross-sectional design was employed. Participants were 120 final-year pre-service clinicians enrolled in the Department of Health and Rehabilitation Sciences at a South African university. The sample included students from four therapeutic sciences programs: audiology (n\u0026thinsp;=\u0026thinsp;28), speech-language pathology (n\u0026thinsp;=\u0026thinsp;32), physiotherapy (n\u0026thinsp;=\u0026thinsp;31), and occupational therapy (n\u0026thinsp;=\u0026thinsp;29). Final-year students were selected because they have completed most of their professional ethics education and clinical training, allowing for meaningful assessment of ethical sensitivity.\u003c/p\u003e \u003cp\u003eInclusion criteria were: (1) enrolled as a final-year student in one of the four therapeutic sciences programs, (2) completed at least 70% of the professional curriculum including ethics coursework, and (3) able to provide informed consent. Exclusion criteria were: (1) not a native or fluent English speaker (given the English-language vignettes), and (2) previous research participation in MIEST validation studies.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eInstrument: The Moral Intensity and Ethical Sensitivity Test (MIEST)\u003c/h3\u003e\n\u003cp\u003eThe MIEST is a scenario-based assessment tool comprising 12 ethical vignettes set in therapeutic healthcare contexts. Each vignette (approximately 150\u0026ndash;200 words) describes a realistic ethical scenario requiring clinical decision-making. Scenarios were developed to represent diverse ethical issues common in therapeutic practice (e.g., confidentiality breaches, conflicts of interest, resource allocation, cultural competence challenges, professional boundary violations).\u003c/p\u003e \u003cp\u003e For each vignette, participants were asked to: (1) identify which ethical principles (from a list of 10 principles: autonomy, beneficence, non-maleficence, justice, fidelity, veracity, confidentiality, professional competence, respect for persons, accountability) were relevant to the scenario\u0026mdash;the ethical principle recognition measure; and (2) describe what ethical concerns or dilemmas they perceived in the scenario\u0026mdash;the ethical sensitivity skills measure.\u003c/p\u003e \u003cp\u003eMoral Intensity Assessment: Following data collection, three bioethics experts independently rated each of the 12 vignettes on six dimensions of moral intensity using established scales: magnitude of consequences, social pressure, proximity to the ethical issue, probability of effect, temporal immediacy, and concentration of effect. Each dimension was rated on a 5-point scale (1\u0026thinsp;=\u0026thinsp;very low to 5\u0026thinsp;=\u0026thinsp;very high). A composite moral intensity score for each vignette was calculated as the mean of expert ratings across dimensions and raters, following established methodology [7].\u003c/p\u003e\n\u003ch3\u003eOutcome Measures\u003c/h3\u003e\n\u003cdiv class=\"Heading\"\u003eOutcome Measures\u003c/div\u003e \u003cp\u003e Ethical Principle Recognition: Participants' responses to the ethical principle identification question were scored for accuracy. For each vignette, the number of correctly identified relevant ethical principles was counted (range: 0\u0026ndash;10 principles per vignette). A principle was considered \"correctly identified\" if it aligned with expert consensus regarding principles relevant to the scenario.\u003c/p\u003e \u003cp\u003eEthical Sensitivity Skills: Responses to the open-ended ethical concern question were scored using a rubric assessing: (1) number of distinct ethical concerns identified, (2) sophistication of concern articulation (superficial vs. nuanced), and (3) integration of contextual features (whether responses acknowledged relational, institutional, and cultural context). Responses were independently scored by two raters (kappa\u0026thinsp;=\u0026thinsp;0.81, indicating good inter-rater reliability) with disagreements resolved by consensus.\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eGiven the secondary nature of this analysis and exploratory research questions, vignette-level analysis was employed rather than participant-level analysis. This approach allows examination of whether variation in moral intensity across vignettes predicts variation in ethical sensitivity components, an appropriate method for hypothesis-generating research.\u003c/p\u003e \u003cp\u003e Linear regression models were fitted with: (1) moral intensity as the independent variable, and (2) ethical principle recognition or ethical sensitivity skills as dependent variables. Separate models were estimated for each outcome. Coefficients are reported as standardized betas to allow comparison of effect sizes. Significance was assessed using two-tailed tests with alpha\u0026thinsp;=\u0026thinsp;0.05.\u003c/p\u003e \u003cp\u003eExploratory subsidiary analyses examined whether specific moral intensity dimensions (magnitude of consequences, social pressure, proximity, probability, immediacy, concentration) showed differential associations with outcomes. Given the limited sample size of vignettes (n\u0026thinsp;=\u0026thinsp;12), these dimension-level analyses are presented as descriptive findings to inform future research directions. See Supplementary Table \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e for complete dimension-level ratings.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eDescriptive Statistics\u003c/h2\u003e \u003cp\u003eAll twelve vignettes demonstrated variability in moral intensity and ethical sensitivity outcomes. Moral intensity scores ranged from 20 to 28 on a possible scale of 6\u0026ndash;30, indicating moderate to high perceived ethical urgency across vignettes (M\u0026thinsp;=\u0026thinsp;24.2, SD\u0026thinsp;=\u0026thinsp;2.4).\u003c/p\u003e \u003cp\u003e Across vignettes, the proportion of participants who correctly identified the relevant ethical principle ranged from 28.5% to 94.5% (M\u0026thinsp;=\u0026thinsp;73.2%, SD\u0026thinsp;=\u0026thinsp;20.9%). Correct identification of ethical sensitivity skills ranged from 35.5% to 95.5% (M\u0026thinsp;=\u0026thinsp;73.3%, SD\u0026thinsp;=\u0026thinsp;19.2%). Overall ethical sensitivity index\u0026mdash;calculated as the mean of principle recognition and skill identification percentages\u0026mdash;ranged from 56.4% to 94.5% (M\u0026thinsp;=\u0026thinsp;73.3%, SD\u0026thinsp;=\u0026thinsp;13.5%).\u003c/p\u003e \u003cp\u003eComplete vignette-level descriptive statistics, including moral intensity scores, ethical principle recognition percentages, ethical sensitivity skill identification percentages, and overall ethical sensitivity metrics for all 12 vignettes, are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Detailed dimension-level ratings for each of the six moral intensity dimensions (magnitude of consequences, social consensus, probability of effect, temporal immediacy, proximity, and concentration of effect) are provided in Supplementary Table \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\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\u003e\u003cem\u003eMoral Intensity and Ethical Sensitivity Outcomes Across Clinical Vignettes\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVignette number\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMoral intensity score (6\u0026ndash;30)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEthical principle correctly identified (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEthical sensitivity skill correctly identified (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOverall ethical sensitivity (%)\u0026sup1;\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e79.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e60.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e69.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e94.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e94.7\u003c/p\u003e \u003c/td\u003e \u003ctd 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colname=\"c4\"\u003e \u003cp\u003e95.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e62.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e80.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e60.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e70.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e59.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e55.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e57.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e94.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e84.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e89.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e74.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e65.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e69.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e90.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e95.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e92.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e93.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e74.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e83.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e45.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e89.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e67.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e61.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e69.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e65.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cem\u003eNote.\u003c/em\u003e Moral intensity scores were derived using Jones\u0026rsquo;s (1991) six-dimension framework. Ethical sensitivity outcomes are aggregated at the vignette level across all participants (N\u0026thinsp;=\u0026thinsp;120).\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u0026sup1; Overall ethical sensitivity (%) represents the mean of ethical principle recognition (%) and ethical sensitivity skill identification (%) for each vignette.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eMain Findings:\u003c/h3\u003e\n\u003cp\u003e Moral Intensity and Ethical Principle Recognition: No statistically significant correlation was observed between moral intensity and percentage of participants correctly identifying ethical principles (r = -0.10, p\u0026thinsp;=\u0026thinsp;0.755). Recognition of ethical principles was largely independent of the perceived emotional or contextual intensity of the scenario, suggesting that ethical principle identification reflects cognitive processes relatively insulated from contextual variations in moral salience.\u003c/p\u003e \u003cp\u003eMoral Intensity and Ethical Sensitivity Skill Identification: A statistically significant positive correlation was found between moral intensity and ethical sensitivity skill identification (r\u0026thinsp;=\u0026thinsp;0.81, p\u0026thinsp;=\u0026thinsp;0.001). Vignettes rated as higher in moral intensity were significantly more likely to elicit correct identification of ethical sensitivity skills including perspective-taking,\u003c/p\u003e \u003cp\u003econtextual interpretation, and morally appropriate action. This finding explains 66.4% of the variance in skill identification performance. This was the only statistically significant relationship found between moral intensity and components of ethical sensitivity. See Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e for visualization of this significant association.\u003c/p\u003e \u003cp\u003e Moral Intensity and Overall Ethical Sensitivity: An exploratory analysis examined the relationship between moral intensity and overall ethical sensitivity. A moderate positive correlation was observed (r\u0026thinsp;=\u0026thinsp;0.50, p\u0026thinsp;=\u0026thinsp;0.098), though this did not reach statistical significance at the conventional alpha\u0026thinsp;=\u0026thinsp;0.05 threshold. The medium effect size suggests a possible relationship that warrants further investigation with larger sample sizes.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e Legend: Scatter plot displaying the relationship between moral intensity (expert-rated composite scores, range 2.8\u0026ndash;4.6) and ethical sensitivity skill recognition (percentage of participants correctly identifying ethical concerns, range 15.5%-95.5%) across 12 vignettes. Each point represents one vignette. The positive linear trend indicates that vignettes with higher moral intensity elicited stronger performance on ethical sensitivity skills identification. The regression line visually represents the significant positive association (r\u0026thinsp;=\u0026thinsp;0.68, p\u0026thinsp;=\u0026thinsp;0.015). This figure demonstrates the selective association between moral intensity and the perceptual-affective components of ethical sensitivity.\u003c/p\u003e\n\u003ch3\u003eExploratory Dimension-Level Analyses:\u003c/h3\u003e\n\u003cp\u003ePreliminary examination of specific moral intensity dimensions suggests that concentration of effect and magnitude of consequences showed the strongest numerical correlations with ethical sensitivity skills, though these dimension-level findings are exploratory and should be interpreted cautiously given the small number of vignettes. Complete dimension-level data is provided in Supplementary Table \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis exploratory vignette-level study examined whether moral intensity is differentially associated with components of ethical sensitivity among pre-service clinicians in the therapeutic sciences. The findings indicate a selective relationship: moral intensity was strongly associated with ethical sensitivity skill identification but not with ethical principle recognition. These results provide empirical support for ethical sensitivity as a multidimensional construct and suggest that contextual features of ethical scenarios may differentially engage perceptual\u0026ndash;affective versus cognitive\u0026ndash;analytical components of moral functioning.\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eMoral intensity and ethical principle recognition\u003c/h2\u003e \u003cp\u003e No statistically significant association was observed between moral intensity and ethical principle recognition. This suggests that participants\u0026rsquo; ability to identify relevant ethical principles was relatively stable across scenarios with varying degrees of ethical urgency or emotional salience. Ethical principle recognition reflects a largely knowledge-based and analytic process, typically developed through formal ethics education and professional codes [4,18]. As such, it may be less sensitive to contextual variation in moral intensity.\u003c/p\u003e \u003cp\u003e This finding is consistent with prior work indicating that principle-based ethical knowledge does not necessarily translate into heightened ethical awareness in practice [5]. Individuals may correctly identify abstract principles even in low-intensity or hypothetical cases, without necessarily engaging with the relational or contextual complexity of the situation. The absence of an association therefore supports the conceptual distinction between ethical principle recognition and broader ethical sensitivity.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eMoral intensity and ethical sensitivity skills\u003c/h2\u003e \u003cp\u003eIn contrast, a strong positive association was observed between moral intensity and ethical sensitivity skill identification. Vignettes rated as higher in moral intensity were more likely to elicit correct identification of ethical concerns involving stakeholder perspectives, contextual interpretation, and morally appropriate action. These skills correspond to perceptual\u0026ndash;affective components of ethical sensitivity rather than rule-based reasoning alone [3,10].\u003c/p\u003e \u003cp\u003eMoral intensity, as conceptualised by Jones [7], captures features of situations that heighten moral attention, including proximity to those affected and the perceived magnitude or probability of consequences. Such features may amplify emotional engagement and value salience, thereby facilitating the detection of ethical concerns. This interpretation aligns with cognitive and moral psychology literature demonstrating that emotionally salient contexts enhance perceptual attention and intuitive pattern recognition [15,16].\u003c/p\u003e \u003cp\u003eImportantly, this association does not suggest that higher moral intensity improves ethical competence overall. Rather, it indicates that morally intense scenarios may preferentially activate ethical sensitivity skills related to noticing and interpreting ethical salience. This distinction is critical for understanding why clinicians may possess ethical knowledge yet fail to recognise ethical issues in everyday practice.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eOverall ethical sensitivity scores\u003c/h2\u003e \u003cp\u003eMoral intensity was not significantly associated with overall ethical sensitivity scores. Given that the composite score aggregates both ethical principle recognition and ethical sensitivity skills, this null finding is not unexpected. Aggregation may obscure divergent patterns across components, particularly when one component (ethical principle recognition) is relatively invariant across contexts. This result reinforces the importance of avoiding unitary interpretations of ethical sensitivity and supports analytic approaches that examine its components separately.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eMethodological considerations\u003c/h2\u003e \u003cp\u003eThis study adopted a vignette-level analytic approach, conceptualising moral intensity as a property of the scenario rather than of individual participants. Ethical sensitivity outcomes were therefore aggregated across participants for each vignette. Although participant responses were nested within vignettes, multilevel modelling was not applied due to the limited number of higher-level units (n\u0026thinsp;=\u0026thinsp;12) and the invariance of moral intensity within each vignette. Under these conditions, multilevel models would not have produced stable or interpretable estimates.\u003c/p\u003e \u003cp\u003eWhile moral intensity is ideally assessed through participant perception, expert-based ratings were used to ensure consistency across vignettes in this exploratory analysis. Future studies should directly compare expert-rated and participant-perceived moral intensity to examine whether subjective experience modifies these associations.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eImplications for ethics education\u003c/h2\u003e \u003cp\u003eThe findings have important implications for ethics education in healthcare. First, they suggest that teaching ethical principles alone may be insufficient for developing ethical sensitivity in practice. While principle knowledge is necessary, it may not enhance clinicians\u0026rsquo; ability to notice ethical concerns unless accompanied by contextual and emotionally engaging learning experiences.\u003c/p\u003e \u003cp\u003eSecond, the results support the use of pedagogical approaches that emphasise rich, realistic scenarios with higher moral intensity, such as case-based learning, debate-based ethics education, and simulation [6,17,19]. Such approaches may be particularly effective in cultivating ethical sensitivity skills that rely on contextual interpretation and moral imagination [12].\u003c/p\u003e \u003cp\u003eFinally, the selective association observed in this study highlights the value of explicitly distinguishing between components of ethical sensitivity in both assessment and curriculum design. Ethics education that intentionally targets perceptual\u0026ndash;affective dimensions may better prepare clinicians to recognise ethical challenges in complex clinical environments.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eLimitations and future directions\u003c/h2\u003e \u003cp\u003eSeveral limitations should be acknowledged. First, the number of vignettes was limited (n\u0026thinsp;=\u0026thinsp;12), restricting statistical power and precluding dimension-level inferential analyses. Second, moral intensity was assessed via expert ratings rather than participant self-report. Third, the study involved a secondary analysis of data collected for instrument validation, limiting control over vignette construction and moral intensity distribution. Fourth, participants were final-year pre-service clinicians within a single national context, which may limit generalisability.\u003c/p\u003e \u003cp\u003eThese limitations indicate that the findings should be interpreted as exploratory and hypothesis-generating. Future research should employ prospective designs that experimentally manipulate moral intensity, include participant-rated intensity measures, and examine longitudinal development of ethical sensitivity across training stages and professional groups.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003e This study provides empirical evidence that moral intensity is selectively associated with ethical sensitivity skill identification but not with ethical principle recognition. The findings reinforce ethical sensitivity as a multidimensional construct and demonstrate that contextual and affective features of ethical scenarios may differentially engage components of moral functioning. By distinguishing between ethical sensitivity components, this work contributes to empirical ethics research and informs the design of ethics education in the therapeutic sciences and broader healthcare contexts.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthorship Contribution\u003c/h2\u003e\n\u003cp\u003eBoth authors made substantial contributions to the conception and design of this work. Author 1 (AN) managed data acquisition, analysis, and interpretation, and drafted the manuscript. Author 2 (JB) critically revised the manuscript for important intellectual content. Both authors approved the final version and agree to be accountable for all aspects of the work.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eNo funding was received for this research.\u003c/p\u003e\n\u003ch2\u003eEthical Approval and Consent to Participate\u003c/h2\u003e\n\u003cp\u003eEthical approval for the original data collection was granted by the University of Pretoria Faculty of Health Sciences Research Ethics Committee, South Africa (Reference: HUM011/2015). The University of Pretoria served as the ethical oversight institution for the original multi-programme data collection, which involved students registered at South African universities but was not institution specific. No data collection was conducted at the University of Pretoria beyond ethical review and approval.\u003c/p\u003e\n\u003cp\u003eAll procedures involving human participants were conducted in accordance with the ethical standards of the University of Pretoria Faculty of Health Sciences Research Ethics Committee and with the 1964 Helsinki Declaration and its later amendments.\u003c/p\u003e\n\u003cp\u003eWritten informed consent to participate was obtained from all participants prior to data collection.\u003c/p\u003e\n\u003ch2\u003eConflicts of Interest\u003c/h2\u003e\n\u003cp\u003eThe authors declare no conflicts of interest. No personal, financial, or professional affiliations could be perceived as influencing this research.\u003c/p\u003e\n\u003ch2\u003eData Availability\u003c/h2\u003e\n\u003cp\u003eData supporting these findings are available within the article and its additional files. Supplementary Table S1 provides vignette-level descriptive statistics. Raw data are available from the corresponding author upon request, subject to ethical and privacy restrictions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable. No identifying images, personal data, or clinical details of individual participants are included in this manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eRest JR. Moral development: Advances in research and theory. New York: Praeger Publishers; 1986.\u003c/li\u003e\n\u003cli\u003eAndersson H, Svensson A, Frank C, Rantala A, Holmberg M, Bremer A. Ethics education to support ethical competence learning in healthcare: an integrative systematic review. BMC Med Ethics. 2022;23(1):19. doi:10.1186/s12910-022-00766-z \u003c/li\u003e\n\u003cli\u003eHa K, Oh Y. Assessing educational needs of nurses ethical competence based on the four components model of moral behaviour: a cross-sectional study using the Borich needs assessment and locus for focus models. BMC Nurs. 2025;24(1):145. doi:10.1186/s12912-025-03269-5\u003c/li\u003e\n\u003cli\u003eBaliga M, Marakala V, Madathil LP, George T, D\u0026apos;Souza RF, Palatty P. Ethical and moral principles for oncology healthcare workers: A brief report from a Bioethics consortium emphasizing on need for education. J Educ Health Promot. 2024;13(1):120. doi:10.4103/jehp.jehp_1048_23\u003c/li\u003e\n\u003cli\u003eJunges JR, Schaefer R, Abreu MCM. Moral sensitivity and the ethical formation of medical students. Rev Bras Educ Med. 2025;49(4):e030. doi:10.1590/1981-5271v49.4-2025-0030.ing\u003c/li\u003e\n\u003cli\u003eAlizadeh M, Bahrami S, Saeedi Z, Khaninezhad L. Outcomes of team based learning in teaching medical ethics: a systematic review. BMC Med Ethics. 2025;26(1):3. doi:10.1186/s12910-025-01329-8\u003c/li\u003e\n\u003cli\u003eJones TM. Ethical decision making by individuals in organizations: an issue-contingent model. Acad Manage Rev. 1991;16(2):366-395. doi:10.5465/amr.1991.4278958\u003c/li\u003e\n\u003cli\u003eEl Zalabany M, Khedr W. The role of moral courage and moral intensity in influencing ethical intention to decision making. Manag Soc Responsib. 2025;1(3):155-175. doi:10.1108/msar-10-2024-0155\u003c/li\u003e\n\u003cli\u003eHe Q, Huang C, Feng Z, Shen H. The relationships between ethical sensitivity, ethical decision-making ability, and ethical conflict among ICU nurses: a structural equation model. J Nurs Manag. 2025;33(4):e17756. doi:10.1155/jonm/7756343\u003c/li\u003e\n\u003cli\u003eIbrahim E, Ibrahim R. The nexus of emotional intelligence, empathy, and moral sensitivity: enhancing ethical nursing practices in clinical settings. J Nurs Manag. 2025;2025:9571408. doi:10.1155/jonm/9571408\u003c/li\u003e\n\u003cli\u003eErbay H. Narrative medicine in ethics education: from theory to practice. J Med Humanit. 2025;18(9):e19658. doi:10.18502/jmehm.v18i9.19658\u003c/li\u003e\n\u003cli\u003eGerrits EM, Assen L, Noordegraaf-Eelens L, Bredenoord A, van Mil MHW. Moral imagination as an instrument for ethics education for biomedical researchers. J Acad Ethics. 2023;21(3):171-191. doi:10.1007/s40889-023-00171-z\u003c/li\u003e\n\u003cli\u003eMoreno-Segura N, Fuentes-Aparicio L, Fajardo S, Querol-Giner F, Atef H, Sillero-Sillero A, et al. Physical therapists\u0026apos; ethical and moral sensitivity: a STROBE-compliant cross-sectional study with a special focus on gender differences. Healthcare. 2023;11(3):333. doi:10.3390/healthcare11030333\u003c/li\u003e\n\u003cli\u003eValle PH. Moral and ethical responsibilities among nurses in geriatric healthcare decision-making: a phenomenological study. Int J Res Soc Serv Inform. 2025;12(8):0151. doi:10.51244/ijrsi.2025.120800151\u003c/li\u003e\n\u003cli\u003eKahneman D. Thinking, fast and slow. New York: Farrar, Straus and Giroux; 2011.\u003c/li\u003e\n\u003cli\u003eEvans JSBT. Dual-process theories of reasoning: prospects and challenges. In: Over DE, editor. Evolution and the psychology of thinking: the debate. Hove: Psychology Press; 2003. p. 27-46.\u003c/li\u003e\n\u003cli\u003eHeydari Sharifabad H, Heydari S, Ranjbar S, Nasiriani K. The effect of debate-based nursing ethics education on the moral sensitivity and judgment of nursing students. BMC Nurs. 2025;24(1):546. doi:10.1186/s12912-025-03795-2\u003c/li\u003e\n\u003cli\u003eAbuadas M, Albikawi Z, Rayani AM. The impact of an AI-focused ethics education program on nursing students ethical awareness, moral sensitivity, attitudes, and generative AI adoption intention: a quasi-experimental study. 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Am J Crit Care. 2021;30(3):e59. doi:10.4037/ajcc2021359\u003c/li\u003e\n\u003cli\u003eNovick G. Is there a bias against telephone interviews in qualitative research? Res Nurs Health. 2008;31(4):391-398. doi:10.1002/nur.20259\u003c/li\u003e\n\u003cli\u003eMollaei M, Metanat F, Javazm AR, Motie M. Exploring the foundations and influences of nurses\u0026apos; moral courage: a scoping review. BMC Med Ethics. 2025;26(1):22. doi:10.1186/s12910-025-01205-5\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"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":"bmc-medical-ethics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meth","sideBox":"Learn more about [BMC Medical Ethics](http://bmcmedethics.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meth/default.aspx","title":"BMC Medical Ethics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"ethical sensitivity, moral intensity, healthcare education, ethics training, therapeutic sciences, ethical decision-making","lastPublishedDoi":"10.21203/rs.3.rs-8658425/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8658425/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eEthical sensitivity is a foundational component of moral functioning, enabling individuals to recognise ethically salient aspects of situations. In healthcare education, this capacity is critical for ethical practice. While ethics education often emphasises ethical principle knowledge, less is known about how contextual features of moral situations\u0026mdash;such as moral intensity\u0026mdash;relate to different components of ethical sensitivity. This retrospective cross-sectional study examined vignette-level associations between moral intensity and ethical sensitivity using previously collected data from 120 final-year pre-service clinicians across the therapeutic sciences. Twelve clinical vignettes from the Measuring Instrument for Ethical Sensitivity in the Therapeutic Sciences (MIEST) were independently rated for moral intensity using Jones\u0026rsquo;s six-dimension framework. Moral intensity scores ranged from 20 to 28 (possible range 6\u0026ndash;30). Moral intensity was not associated with ethical principle recognition or overall ethical sensitivity scores. However, a strong positive vignette-level correlation was observed between moral intensity and ethical sensitivity skill identification (r\u0026thinsp;=\u0026thinsp;0.81, p\u0026thinsp;=\u0026thinsp;0.001). These findings support ethical sensitivity as a multidimensional construct and suggest that contextual features of moral situations may preferentially engage perceptual\u0026ndash;affective components of moral sensitivity.\u003c/p\u003e","manuscriptTitle":"Moral Intensity and Ethical Sensitivity: A Vignette-Level Analysis of Ethical Principle Recognition and Ethical Sensitivity Skills in Pre-Service Therapeutic Sciences Clinicians","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-28 10:03:11","doi":"10.21203/rs.3.rs-8658425/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-23T05:20:43+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-21T10:28:17+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-28T14:58:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"158910839055097165880688766730466326210","date":"2026-03-04T05:48:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"25253990328949721623239261430426082446","date":"2026-01-29T01:57:14+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-27T01:55:30+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-27T01:53:38+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-23T10:16:36+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-23T06:18:49+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Ethics","date":"2026-01-23T06:08:54+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-ethics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meth","sideBox":"Learn more about [BMC Medical Ethics](http://bmcmedethics.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meth/default.aspx","title":"BMC Medical Ethics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7069b50a-ca2a-4f30-8536-eec008ba88bd","owner":[],"postedDate":"January 28th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-07T08:53:28+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-28 10:03:11","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8658425","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8658425","identity":"rs-8658425","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}