Introduction
Scientific and technological advancements, the shifting disease spectrum, an aging population, and nursing shortages have transformed and complicated the clinical nursing environment. These changes have placed nurses in a dilemma, often due to role ambiguity, moral conflicts, and value discrepancies [1]. Routine nursing activities, which frequently involve repetitive tasks, sometimes give rise to ethical challenges. These challenges can result in contradictory scenarios, such as conflicts related to professional autonomy, patient care disputes, misuse of technologies, prolonging life in terminal situations, and disrespect for patient dignity in daily practice [2, 3].
Addressing an ethical problem requires first understanding it. Moral sensitivity is a personal attribute and a fundamental prerequisite for a nurse’s ability to recognize, interpret, and respond appropriately to ethical issues affecting patients. It also involves understanding the potential impact of their actions on patient well-being [4]. Moral sensitivity is defined as the ability to discern the moral significance of a particular situation and respond accordingly [5]. In clinical settings, moral sensitivity is essential for providing high-quality, holistic care, addressing ethical challenges, and avoiding unintended or unethical outcomes [6]. It enables nurse to grasp a patient’s vulnerability while appreciating the ethical implications of decision-making in a clinical situation [7]. Moral sensitivity heightens awareness of ethical issues within the workplace, allowing nurses to identify patient needs and deliver care in line with the ethical standards of the nursing profession [8, 9]. Moreover, it enhances attention to ethical considerations, improves ethical decision-making, and equips nurses with problem-solving skills during ethical dilemmas [10].
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The components of ethical sensitivity in nursing work can be understood in three areas: ethical awareness, benevolent motivation, and self-motivated ethical perception [11]. In ethical awareness, the nurse must be aware of the ethical principles (ethical codes) of their profession and the possible ethical conflicts that occur in the healthcare environment, and in those cases, act according to these principles. Ethical awareness is, therefore, the first step in the process of ethical decision-making and recognizing the ethical consequences of nursing practices [12]. Through ethics education, nurses can improve their professional knowledge and provide a suitable physical, social, and psychological environment for patients [13]. In contrast, poor ethical awareness impairs sound decision-making and leads to neglect of the ethical aspects of care [14]. Benevolent motivation refers to the desire to do what is beneficial and right for the patient. Finally, spontaneous ethical perception reflects the nurse’s ability to recognize ethical situations that could affect the patient [11]. Ethical sensitivity empowers nurses to care for their patients effectively, helping them understand ethical dilemmas and make ethical decisions in their professional environment [15]. Various studies investigating the moral sensitivity of nurses in Iran have reported different results. Given the diversity of findings, it is not possible to make healthcare decisions based on these individual studies; therefore, a synthesis of these studies is needed to understand the current situation. Accordingly, in this study, the moral sensitivity of Iranian nurses has been systematically examined through a comprehensive review of the literature. This study aims to integrate the findings of previous research to provide a clearer understanding of the moral sensitivity levels among Iranian nurses, identify key influencing factors, and highlight potential gaps in ethical practice.
Methods
This systematic review and meta-analysis were conducted in accordance with the PRISMA guidelines (Supplementary Table 1). The study was approved by Shahid Beheshti University of Medical Sciences, Iran, and its protocol has been registered in PROSPERO (CRD42024628940).
Search strategy
The national databases, including the Scientific Information Database and MagIran, as well as the international databases PubMed, Web of Science (ISI), EMBASE, and Scopus, were searched for eligible articles published between 2000 and September 2024. The search was conducted using the keywords “moral sensitivity”, “ethical sensitivity”, “nursing staff”, “nursing personnel”, “registered nurse”, “Iran” and “Islamic Republic of Iran.” The Farsi equivalent of these keywords was also used to search national databases. The reference lists of selected articles were also reviewed to ensure that no studies were missed.
Inclusion and exclusion criteria
All observational studies published between 2000 and 2024 that met the following inclusion criteria were included in the analysis: publication in Farsi or English, conducted on nurses, and reporting a raw score of ethical sensitivity. Interventional studies, qualitative studies, review articles, letters to the editor, replication studies, and studies conducted on other treatment groups were excluded from the analysis.
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Data extraction
Initially, the articles retrieved from the databases were imported into EndNote version 20, and duplicates were identified and removed. Two independent researchers (RGG and FD) then performed a preliminary screening of the articles by reviewing their titles and abstracts. Following this, the full texts of the articles deemed eligible were selected for further evaluation. These full-text articles were independently assessed by the same two researchers (RGG and FD) for eligibility based on predefined inclusion criteria. Key information, including the first author, year of publication, sample size, study location, and the instrument used to measure moral sensitivity, was systematically extracted by both authors. In case of any discrepancies or disagreements during the data extraction process, the researchers consulted with the corresponding author (LS) to reach a consensus. This collaborative approach ensured the accuracy and consistency of the extracted data.
Quality assessment
To evaluate the methodological quality of the included studies, the Joanna Briggs Institute (JBI) critical appraisal tool was applied. This tool comprises eight items assessing key methodological aspects, including the clarity of inclusion criteria, detailed description of the sample and setting, validity and reliability of the measurement tools, adherence to standard measurement criteria, identification and management of confounding factors, validity of outcome assessments, and appropriateness of the statistical analyses employed. Each item was rated as “yes” (score of 1), “no” (score of 0), “unclear” (score of 0), or “not applicable” (score of 0). The total scores ranged from 0 to 8, with higher scores signifying superior methodological quality [16].
Outcome and conversion of raw score to standard score
The outcome variable in this study was the raw score of moral sensitivity. Since different questionnaires with varying numbers of items and scoring systems were used to measure this variable, the raw scores were converted into standardized scores to enable comparisons across different studies. Raw scores of ethical sensitivity, reported as means and standard deviations in the studies, were converted into standardized scores on a scale of 0 to 100. For this purpose, the minimum and maximum possible scores of the measurement instrument used in each study were identified and recorded along with the reported raw scores. The standardized score was calculated as follows: the minimum possible score was subtracted from the raw score, and the result was divided by the range (i.e., the difference between the maximum and minimum possible scores). The outcome was then multiplied by 100 to scale it from 0 to 100. A higher standardized score indicates a higher level of ethical sensitivity.
Statistical analysis
The extracted data were analyzed using STATA software, version 17. Heterogeneity across the studies was assessed through the I² index and Cochran’s Q statistic. I² values of 25%, 50%, and 75% were interpreted as low, moderate, and high heterogeneity, respectively. For studies with high heterogeneity, a random-effects model was employed, while a fixed-effects model was used in cases of low or moderate heterogeneity. Results were presented as pooled standardized scores with 95% confidence intervals, accompanied by a forest plot. Publication bias and the potential impact of small-study effects were evaluated graphically using a funnel plot and statistically with Egger’s test, which is particularly sensitive to asymmetries in funnel plots indicative of publication bias. Additionally, the Trim-and-Fill method was applied to adjust for potential publication bias by estimating and imputing missing studies, providing a more balanced estimate of the true effect size. Subgroup analyses were conducted based on study location, language, and sample size (≤ 200 versus > 200) to identify potential variations in moral sensitivity attributable to factors such as instrument type or regional differences. Furthermore, meta-regression analysis was performed to explore the influence of mean participant age, sample size, and year of publication on the pooled standardized moral sensitivity score.
Results
In the initial search, 262 articles were retrieved from international databases and 301 articles from national databases. After removing duplicates (n = 284), the titles and abstracts of the remaining articles were reviewed. At this stage, 214 unrelated studies were excluded, and the full texts of 86 articles were reviewed. Thirteen studies were further excluded from the analysis due to missing essential details, such as questionnaire scoring information (required for calculating the standardized score) (Fig. 1).
Fig. 1
Screening and selection process of included articles
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A total of 52 studies, including 11,621 participants (an average of 223 participants per study), were included in the final analysis. The studies, published between 2012 and 2024, consisted of 24 articles in Farsi and 28 in English. The highest number of publications was recorded in 2022 (n = 9). The sample sizes ranged from 60 to 524 participants, with 28 studies featuring more than 200 participants. Most studies were conducted in Tehran (n = 9). The age of nurses in these studies varied from 28.5 to 39.4 years. The standardized moral sensitivity scores ranged from 45.3 to 97% (Table 1).
Table 1
Characteristics of studies included in the meta-analysis
First author | Year | Sample size | Location | Age | Quality | Tools | Standard score |
|---|---|---|---|---|---|---|---|
Khorani [17] | 2024 | 250 | Qazvin | 32.62 | 8 | L-MSQ, 25 item | 63.9 |
Fouladi [18] | 2024 | 345 | Ardabil | 32.19 | 8 | L-MSQ, 25 item | 70.8 |
Ahansaz [19] | 2024 | 210 | Urmia | 30.95 | 8 | L-MSQ, 30 item | 66.2 |
Nobahar [20] | 2023 | 200 | Semnan | 32.7 | 8 | L-MSQ, 25 item | 64.2 |
Momennasab [21] | 2023 | 298 | Shiraz | 30.69 | 8 | MSQ, 28 item | 63.1 |
Lotfi-Bejestani [22] | 2023 | 500 | Different regions | 37.59 | 8 | MS scale, 25 items | 59.8 |
Nasiriani [23] | 2023 | 140 | Yazd | 33.73 | 7 | L-MSQ, 25 item | 64 |
Zeynali [24] | 2023 | 336 | Ilam | 32.6 | 8 | L-MSQ, 25 item | 65.6 |
Darzi-Ramandi [10] | 2023 | 211 | Hamadan | 33.63 | 8 | L-MSQ, 30 item | 45.3 |
Sedghi Goyaghaj [9] | 2022 | 160 | Tehran | 34.96 | 8 | MS scale − 25 items | 80.5 |
Rezapour-Mirsaleh [25] | 2022 | 162 | Yazd | 33.7 | 8 | MS, 9 item | 71.4 |
Nazari [26] | 2022 | 445 | Tehran | 39.41 | 8 | L-MSQ, 25 item | 52.3 |
NikJoo [27] | 2022 | 161 | Golestan | 34.85 | 8 | L-MSQ, 25 item | 66 |
Taghavi [28] | 2022 | 208 | Bojnourd | - | 8 | L-MSQ, 25 item | 92 |
Mohammadi [29] | 2022 | 524 | Fars | 33.89 | 8 | L-MSQ, 25 item | 93.4 |
Moayedi [30] | 2022 | 288 | Kerman | - | 8 | L-MSQ, 25 item | 67.3 |
Mangeli [31] | 2022 | 135 | Kerman | 36.2 | 8 | L-MSQ, 30 item | 64 |
Hajibabaee [32] | 2022 | 406 | different regions of Iran | 37.66 | 8 | L-MSQ, 25 item | 62.1 |
Zahednezhad [33] | 2021 | 181 | Tehran | 30.9 | 8 | L-MSQ, 25 item | 70.8 |
Sepehrirad [34] | 2021 | 132 | Ardabil | 33.99 | 8 | L-MSQ, 25 item | 81.4 |
Mohammadi [35] | 2021 | 337 | Hamadan | 31.82 | 8 | L-MSQ, 25 item | 62.8 |
Kobrai Abkenar [36] | 2021 | 180 | Guilan | 33.98 | 8 | L-MSQ, 25 item | 60.9 |
Khodaveisi [37] | 2021 | 405 | different regions of Iran | 39.04 | 8 | MSQ, 28 item | 89.6 |
Afrasiabifar [38] | 2021 | 250 | Yasuj | 32.6 | 8 | L-MSQ, 25 item | 59.5 |
Khalighi [39] | 2020 | 110 | Ilam and Kermanshah | - | 8 | L-MSQ, 25 item | 59.2 |
Nikbakht Nasrabadi [40] | 2020 | 300 | Tehran | 35.0 | 8 | L-MSQ, 25 item | 97 |
Hoseini [41] | 2020 | 100 | Sabzevar | 30.63 | 8 | L-MSQ, 25 item | 89.7 |
Dehghani [42] | 2020 | 112 | Amol | 33.667 | 8 | L-MSQ, 25 item | 65.8 |
Sharifi [43] | 2020 | 350 | Kashan | 32.36 | 7 | L-MSQ, 25 item | 68.1 |
Dalvand [44] | 2019 | 200 | Khorramabad | 32.21 | 8 | L-MSQ, 25 item | 58.9 |
Mostafavian [45] | 2019 | 123 | Mashhad | 35.02 | 7 | L-MSQ, 25 item | 62.41 |
Mostafavian [45] | 2019 | 82 | Mashhad | 20.88 | 7 | L-MSQ, 25 item | 61.34 |
Amiri [46] | 2019 | 198 | Tabriz | 31.19 | 8 | MSQ, 28 item | 64.6 |
Tazakori [47] | 2018 | 144 | Ardabil | - | 8 | L-MSQ, 25 item | 87 |
Maghami [48] | 2018 | 361 | Shiraz | 28.9 | 8 | L-MSQ, 25 item | 69.8 |
Azadehjo [49] | 2018 | 200 | Qazvin | 36.17 | 8 | H- MSQ, 25 item | 53.2 |
Sadeghi [13] | 2018 | 190 | Alborz | 31.35 | 8 | L-MSQ, 25 item | 69.5 |
Khosravani [50] | 2018 | 60 | Arak | - | 8 | H- MSQ, 25 item | 70.6 |
Rahnama [51] | 2017 | 204 | Tehran | 34.0 | 8 | L-MSQ, 25 item | 69.7 |
Mahdiyoun [52] | 2017 | 260 | Tehran | 32.7 | 8 | L-MSQ, 30 item | 72.5 |
Mohammadi [53] | 2017 | 257 | Birjand | 35.0 | 8 | H-MMSQ, 25 item | 77.5 |
Borhani [54] | 2017 | 153 | Tehran | 32.9 | 8 | L-MSQ, 25 item | 68.6 |
Mikaeili [55] | 2016 | 250 | Ardebil | - | 8 | L-MSQ, 25 item | 78.1 |
Karimi Noghondar [56] | 2016 | 110 | Mashhad | 35.4 | 7 | L-MSQ, 25 item | 83.3 |
Mousavi [57] | 2015 | 77 | Tehran | 32.37 | 7 | L-MSQ, 25 item | 63.5 |
Farasatkish [58] | 2015 | 181 | Tehran | 30.9 | 8 | L-MSQ, 25 item | 70.8 |
Mahdaviseresht [59] | 2015 | 260 | Tabriz | 35.89 | 8 | L-MSQ, 25 item | 61 |
Sadrollahi [60] | 2015 | 288 | Golestan | 31.2 | 8 | L-MSQ, 25 item | 63.5 |
Baloochi Beydokhti [61] | 2014 | 170 | Gonabad | 28.53 | 8 | L-MSQ, 30 item | 71.8 |
Baghaei [62] | 2014 | 200 | Urmia | 32.0 | 7 | L-MSQ, 25 item | 61.1 |
EIzadi [63] | 2013 | 97 | Bandar Abbas | 33.11 | 8 | L-MSQ, 25 item | 70.2 |
Jaafarpour [64] | 2012 | 120 | Ilam | 34.0 | 8 | MSQ, 27 item | 52.7 |
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The standard moral sensitivity score was 69% (95% CI: 66–72, I2 = 94.03%) (Fig. 2). No significant difference in moral sensitivity scores was found between articles published in Farsi and English (70.2% with 95% CI: 65.8–74.7 vs. 68% with 95% CI: 63.8–72.2, p = 0.475) or between studies with sample sizes greater or less than 200 participants (70% with 95% CI: 66.3–73.6 vs. 68.3% with 95% CI: 63.7–73, p = 0.589). Regional analysis revealed that the highest and lowest ethical sensitivity scores were observed in region 5 (Sistan and Balouchestan, Khorasan, Yazd, and Kerman provinces) (73.6% with 95% CI: 67–80.1) and region 4 (Hamadan, Kermanshah, Khuzestan, Markazi, Lorestan, and Ilam provinces) (59.1% with 95% CI: 51.9–66.3), respectively. However, moral sensitivity scores did not significantly differ across regions 1 to 5 (p = 0.052) (Table 2).
Fig. 2
Forest plot of standardized moral sensitivity scores among Iranian nurses. In this forest plot, each study is represented by a blue square, the size of which reflects the relative weight of the study in the meta-analysis. Horizontal lines extending from each square depict the 95% confidence intervals for the study’s standardized score. The green diamond at the bottom of the plot represents the pooled effect size, with its width corresponding to the 95% confidence interval for the meta-analysis
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Table 2
Standard score of moral sensitivity after subgroup analysis
Subgroup | Number of studies | Standard Score (95% CI) | I2 | Q | P | |
|---|---|---|---|---|---|---|
Region | Region 1 | 16 | 68.4 (63.2–73.6) | 92.83% | 659.71 | 0.001 |
Region 2 | 6 | 70.9 (61.2–80.6) | 96.16% | 272.03 | 0.001 | |
Region 3 | 9 | 70.2 (63.8–76.7) | 90.35% | 82.18 | 0.001 | |
Region 4 | 6 | 59.1 (51.9–66.3) | 84.89% | 29.96 | 0.001 | |
Region 5 | 11 | 73.6 (67–80.1) | 91.39% | 139.20 | 0.001 | |
Language | Farsi | 24 | 70.2 (65.8–74.7) | 717.74 | 93.47% | 0.001 |
English | 28 | 68.0 (63.8–72.2) | 834.19 | 94.10% | 0.001 | |
Sample size | Less than 200 | 24 | 70.0 (66.3–73.6) | 152.08 | 82.94% | 0.001 |
More than 200 | 28 | 68.3 (63.7–73.0) | 1404.95 | 96.70% | 0.001 | |
Meta-regression analysis indicated no significant association between the moral sensitivity score and the year of publication (p = 0.982), sample size (p = 0.671), or the mean age of nurses (p = 0.947). However, publication bias was found to be significant (p = 0.001). The Trim-and-Fill analysis shows that after adjusting for publication bias, the estimated mean increased from 0.693 to 0.726. This suggests that publication bias led to an underestimation of the true effect, and the corrected value is slightly higher. However, since the confidence intervals of the observed and adjusted estimates largely overlap, the overall impact of publication bias on the study’s results appears to be noticeable but not substantial (Fig. 3).
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Fig. 3
The results of meta-regression (A, B, and C), and publication bias (D). In Figure D, the blue dots (Observed studies) represent the actual studies included in the meta-analysis. The orange dots (Imputed studies) are studies estimated by the Trim-and-Fill method that may be missing from the meta-analysis. The gray lines (Pseudo 95% CI) indicate the 95% confidence interval. In the absence of bias, the studies are expected to be evenly distributed within these lines. The red line represents the adjusted overall effect estimate
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Discussion
In the present study, which aimed to systematically review and meta-analyze ethical sensitivity among Iranian nurses. The findings revealed that the mean standardized ethical sensitivity score for nurses was 69%, indicating a moderate level. A review of the literature found no meta-analytic studies conducted on this topic in other countries.
However, studies conducted in Turkey on various nursing groups reported a standardized level of ethical sensitivity among Turkish nurses that was similar to the findings of the present study [65, 66]. The study by Chen et al. (2024) reported a mean moral sensitivity score of 40.84, which, when converted to a standardized score, equaled 70.75% and fell within an average range [67]. The observed differences can be attributed to cultural variations, hospital and national policies, and the measurement tools used for assessing ethical sensitivity in these countries.
From our perspective, the moderate level of ethical sensitivity among Iranian nurses can be explained by factors such as high workloads, a shortage of human resources, inadequate equipment, and extended working hours—factors that contribute to burnout and reduced focus on ethical values. Hashmatifar et al. (2014) highlighted that a shortage of human resources, intensive work shifts, and overcrowded wards are the primary barriers to ethical sensitivity among nurses [68]. Furthermore, Iranian nurses frequently report limited organizational support when confronted with ethical challenges, which can undermine their confidence in ethical decision-making. In contrast, in settings with stronger organizational support, nurses are better equipped to address ethical issues effectively. The findings of Cerit et al. (2019) highlight that the organizational ethical climate is a significant determinant of nurses’ ethical sensitivity. Thus, fostering an appropriate ethical climate in hospitals can enhance the ethical sensitivity of nurses [69].
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To enhance the ethical sensitivity of Iranian nurses, efforts should focus on strengthening professional ethics education, improving working conditions, providing organizational support, and fostering cultural awareness in the workplace. These initiatives can promote ethical care and enhance the quality of healthcare services. The study findings indicated that the language of publication did not significantly affect the results of ethical sensitivity. In other words, the language of publication likely plays a minimal role in altering the interpretation or reporting of ethical sensitivity. This could be attributed to the similarity in the raw data from both groups of nurses, driven by comparable working and cultural conditions, the use of similar measurement instruments, consistent research methods, and a shared understanding of ethical concepts among the nurses studied. Another finding of the study was that the sample size did not significantly affect the results of ethical sensitivity. This may be attributed to the use of standardized measurement instruments, a balanced distribution of demographic characteristics such as work experience and work environment within the samples, or the inherently stable nature of ethical concepts among nurses. The study results revealed that the highest level of ethical sensitivity was recorded in Region 5, while the lowest was in Region 4; however, no statistically significant difference was found.
Cultural, social, and work environment factors may have contributed to these differences. It appears that Region 5, with better working and cultural conditions, may have provided a more conducive environment for the development of ethical sensitivity among nurses. Conversely, work pressures and resource limitations in Region 4 may have influenced the results. Mangeli et al. (2022) state that favorable working environment conditions for nurses are associated with higher moral sensitivity [31]. Cultural and social factors also significantly influence the ethical sensitivity of nurses. Education in ethics and cultural knowledge plays a crucial role in enhancing ethical sensitivity among nurses [70, 71]. These findings highlight the importance of developing comprehensive educational programs and fostering supportive organizational environments to promote the ethical sensitivity of nurses in diverse cultural contexts.
Another finding of the present study was that the moral sensitivity score of nurses remained relatively unchanged from 2000 to 2024. This finding could be attributed to factors such as the lack of significant changes in the educational system and policies regarding nursing ethics courses, cultural stability, and persistently unfavorable working conditions in nursing, including high workloads and staff shortages. Huang et al. (2016) report that insufficient training on ethical issues is a key factor contributing to decreased ethical sensitivity among nurses [72]. Findings from other studies suggest that ethical sensitivity in nurses improves with better working conditions and targeted educational workshops focused on clinical ethical issues [31, 73]. This highlights the significance of planned and targeted interventions to enhance ethical sensitivity in nurses. Moreover, revisiting educational policies and designing professional development programs on nursing ethics appear essential.
In the present study, no significant relationship was found between nurses’ average age and their moral sensitivity. Similarly, Zeynali et al. (2023) reported that some individual characteristics of nurses, including average age, were not significantly associated with moral sensitivity [24]. However, other studies have indicated that an increase in nurses’ age may positively influence their moral sensitivity [70, 74]. Given these conflicting findings, it appears that the relationship between age and moral sensitivity in nurses is complex and multifaceted. Factors such as job burnout, work environment, and professional experience may contribute to this relationship. Future research is needed to examine the combined impact of age and work experience on moral sensitivity more comprehensively.
In this study, publication bias was significant, which could lead to an underestimation of the true effect. To adjust for this bias, the Trim-and-Fill method was used to estimate the number of potentially missing studies and correct the overall effect. After applying this adjustment, the estimated cumulative standard score increased from 0.693 to 0.726, suggesting that publication bias had resulted in a slight underestimation of the true effect. However, the substantial overlap between the confidence intervals of the observed and adjusted estimates indicates that its overall impact on the study’s conclusions was limited. One possible reason for publication bias in this study is the lack of a comprehensive database for gray literature in Iran. Dissertations and unpublished research reports are not systematically archived, which may contribute to missing studies. Additionally, many local studies are published in Persian and may not be indexed in international databases, limiting access to unpublished studies with non-significant results. Furthermore, factors such as preference for significant findings among researchers and reviewers and journal policies favoring positive results may further contribute to publication bias. Despite these challenges, the use of the Trim-and-Fill method helped correct for this bias, and confidence interval analysis suggests that its impact on the study’s overall conclusions remains minimal.
Conclusion
The results of this study showed that the ethical sensitivity of Iranian nurses is at an average level and has remained unchanged over time. These findings suggest that factors such as the stability of the educational system, persistent yet stressful working conditions, staff shortages, and inadequate organizational support significantly contribute to this issue. Additionally, the average age of nurses did not have a significant impact on their ethical sensitivity, possibly due to the complex interplay between age, work experience, and environmental factors. While regional differences were not statistically significant, they highlight the potential influence of cultural and social conditions on ethical sensitivity.
To effectively address these challenges, targeted interventions are needed, including the enhancement of ethics education, the creation of supportive work environments, the revision of educational policies, and the development of structured programs to strengthen nurses’ ethical sensitivity. These measures can play a crucial role in improving ethics-based care and increasing nurses’ confidence in ethical decision-making. Beyond the Iranian context, these findings underscore the global need for continuous professional ethics training and systemic improvements in healthcare settings. Incorporating internationally recognized ethical frameworks and adapting successful strategies from other countries could further enhance nurses’ ethical competence. These measures can play a crucial role in improving ethics-based care and increasing nurses’ confidence in ethical decision-making.
Acknowledgements
This study is an approved project of Shahid Beheshti University of Medical Sciences. The authors express their heartfelt gratitude to the Vice Chancellor for Research and Innovation at the university for their support. We also extend our sincere thanks to the entire research team for their invaluable contributions, which provided essential insights and significantly enriched the quality of this study. Our deepest appreciation goes to the editor and reviewers who dedicated their time and expertise to the peer review process. Their constructive feedback and thoughtful suggestions played a crucial role in enhancing the quality of this article. Additionally, we would like to acknowledge the assistance of the AI tool, Chat GPT version 3.5, for its support in the grammatical editing of the manuscript. This tool helped refine the language, ensuring accuracy and coherence, thus improving the clarity of the article.
Declarations
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Competing interests
The authors declare no competing interests.
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