Role-Playing and Mobile Ethics Training Both Boost Nurses’ Moral Sensitivity in Hospital Study

Every shift, nurses walk into a minefield of ethical dilemmas that no textbook fully prepares them for. A dying patient’s family demands the truth about a prognosis the physician has withheld. Staffing shortages force a choice between safe care and leaving colleagues overwhelmed. These moments require more than clinical skill—they demand moral sensitivity, the capacity to recognize that an ethical issue even exists, and sound clinical decision-making to act on it. A new quasi-experimental study from Iran, published in BMC Nursing, suggests that two very different teaching methods—one ancient, one thoroughly modern—can sharpen both competencies in working nurses.

The research team, led by Rasoul Goli of Urmia University of Medical Sciences together with colleagues from Islamic Azad University, recruited 114 nurses working at Imam Khomeini Hospital in Urmia in 2022. Using convenience sampling, they enrolled participants and randomly assigned them to three groups: one trained through role-playing, one trained through mobile phone–based education, and a control group that received no additional training. The design was a pre-test–post-test quasi-experiment, meaning the researchers measured each nurse’s moral sensitivity and clinical decision-making before the interventions began and again afterward, allowing them to track change within individuals and compare outcomes across groups.

The two interventions could hardly have been more different in structure. The role-playing group attended five interactive training sessions built around ethical scenarios, each lasting roughly 90 to 120 minutes, for a total engagement of approximately 480 to 600 minutes. In these sessions, nurses stepped into simulated ethical conflicts, argued positions, and reflected on the choices they made—essentially rehearsing the emotional and cognitive demands of real dilemmas in a safe environment. The mobile-based group, by contrast, received two educational messages per day for 14 days, with an estimated engagement time of about 10 minutes per day, totaling roughly 140 minutes. This drip-feed of ethics content was supplemented by scheduled weekly telephone interactions of approximately 30 minutes per session, in which the research team clarified points and led reflective discussion. Participants could also call the team whenever they needed additional explanation.

Moral sensitivity was measured with the Moral Sensitivity Questionnaire developed by Lützén, a widely used instrument that probes how aware nurses are of ethical issues in their practice and how they relate to patients in morally charged situations. Clinical decision-making was assessed with the questionnaire by Lauri and colleagues, which captures the mix of intuitive and analytical processes nurses draw on when making judgments at the bedside. Data collection also included a demographic questionnaire, and the analysis relied on descriptive statistics, paired and independent t-tests, chi-square tests, and one-way ANOVA, with significance set at p < 0.05.

The results were striking. Both intervention groups showed statistically significant improvements in moral sensitivity and clinical decision-making after their training, with p values below 0.001. The control group, meanwhile, showed no significant change on either measure. Between-group comparisons after the intervention revealed significant differences between each intervention group and the control group, again at p < 0.001. Perhaps most notably, when the researchers compared the two training methods directly, they found no statistically significant difference between the role-playing and mobile-based groups in post-intervention scores.

That equivalence finding carries real weight for anyone designing nursing education. Role-playing delivered roughly three to four times more total instructional time than the mobile approach, yet the shorter, smartphone-delivered program achieved comparable gains. The mobile format’s structure—brief daily messages paired with weekly reflective telephone discussion—appears to have compensated for its reduced contact hours. This suggests that the pedagogical quality of ethics content, including opportunities for clarification and reflection, may matter as much as the sheer volume of training. It also hints that spaced learning, in which material arrives in small doses over two weeks, could consolidate ethical reasoning effectively, consistent with broader evidence on distributed practice in cognitive psychology.

The study’s technical design deserves scrutiny alongside its headline findings. As a quasi-experimental study, it lacked the full randomization of a true randomized controlled trial at the sampling stage, though participants were randomly assigned to the three groups after recruitment. Convenience sampling means the nurses were not randomly drawn from the broader population of Iranian nurses, which limits how far the results generalize. The single-hospital setting in Urmia, and the use of self-report questionnaires rather than observed behavior, further constrain interpretation. Moral sensitivity measured on a questionnaire may not translate directly into morally sensitive conduct at the bedside, and the researchers acknowledge that identifying effective strategies requires evaluation in real clinical settings.

Still, the theoretical significance of the outcome measures is hard to overstate. Moral sensitivity, as the study’s authors frame it, is a key component of ethical competence: it enables nurses to recognize ethical issues in the first place and provides the foundation for appropriate clinical decision-making. Without it, even a technically flawless decision can be ethically blind. Ensuring the quality and safety of healthcare services, the researchers argue, requires not only clinical competence but strong ethical capabilities among nurses. In practice, nurses frequently encounter complex ethical dilemmas that demand high levels of moral sensitivity and effective decision-making, yet evidence about the most effective educational approaches for building these competencies—particularly in real clinical settings—has remained limited.

The study was approved by the Ethics Committee of Urmia University of Medical Sciences under ethics code IR.UMSU.REC.1402.019, and all procedures followed the Declaration of Helsinki. Written informed consent was obtained from all participants, who were assured that participation was voluntary and that they could withdraw at any time without consequences. The work was supported by Islamic Azad Urmia University as part of a master’s thesis, and the authors declare no competing interests. The article was published open access on 29 August 2026, received on 15 March 2026, and accepted on 25 August 2026.

For hospital administrators and nursing educators watching this space, the message is clear: innovative, learner-centered strategies can move the needle on ethical competence, and the choice between immersive simulation and mobile learning may be less important than committing to one of them. Integrating approaches like these into professional training programs, the researchers conclude, may enhance ethical competence and improve the quality of patient care. As healthcare systems worldwide grapple with workforce shortages and rising ethical complexity—from end-of-life care to resource allocation—training methods that fit into a nurse’s pocket, or into a simulation suite, could become essential tools for keeping care not only effective but ethically awake.

Subject of Research: Nursing ethics education

Article Title: Comparing the effects of role-playing and mobile-based ethics education on nurses’ moral sensitivity and clinical decision-making: a quasi-experimental study

Article References: Goli, R., Heidari, S., Farhadi, S., & Hajiesmaeilloo, M. (2026). Comparing the effects of role-playing and mobile-based ethics education on nurses’ moral sensitivity and clinical decision-making: a quasi-experimental study. BMC Nursing. https://doi.org/10.1186/s12912-026-05310-7

Image Credits: AI Generated

DOI: 10.1186/s12912-026-05310-7

Keywords: nursing, moral sensitivity, clinical decision-making, ethics education, role-playing, mobile learning, quasi-experimental study, BMC Nursing, Comparing, effects, mobile-based, ethics