The study, published in BMC Nursing, recruited eighty second-semester nursing students at the Faculty of Nursing and Midwifery between October and December 2021. Participants were allocated one-to-one to an intervention or control group based on whether their student identification numbers were odd or even, a non-random procedure typical of quasi-experimental designs. Both groups received the same theoretical ethics instruction, but the practical component, delivered over an equal duration in both arms, took different forms: multimedia-supported e-learning for the intervention group and face-to-face workshops for the control group.

To measure outcomes, the researchers used two validated instruments administered at baseline and again two weeks after the intervention. Moral awareness was assessed with the Questionnaire on Nurses’ Awareness about the Iranian Nursing Code of Ethics, which captures how well students recognize the ethical standards codified for their profession. Moral sensitivity was measured with the Moral Sensitivity Questionnaire, a longer instrument reflecting how keenly students perceive ethical dimensions of care situations. Post-test scores were compared using analysis of covariance (ANCOVA) adjusted for baseline scores, conducted in SPSS version 26, a statistical approach that controls for pre-existing differences between groups.

The results revealed a striking asymmetry. On moral awareness, the two groups were statistically indistinguishable at follow-up: unadjusted post-test means were 30.17 (standard deviation 2.96) in the e-learning group versus 29.72 (2.89) in the control group, with an adjusted mean difference of 0.45, a 95 percent confidence interval spanning −1.06 to 1.96, and a p-value of 0.556. The effect size, partial eta squared of 0.005, was negligible, indicating that neither teaching method conferred a meaningful advantage in students’ knowledge of the professional ethics code.

Moral sensitivity told a different story. The e-learning group scored 145.55 (14.38) at post-test compared with 133.32 (21.64) in the face-to-face group, an adjusted mean difference of 12.1 points with a 95 percent confidence interval of 6.65 to 17.55 and a p-value below 0.001. The partial eta squared of 0.20 represents a large effect by conventional standards, suggesting that the multimedia format did not merely edge out the workshops but substantially amplified how acutely students perceived the ethical dimensions of clinical scenarios.

Why might a digital format outperform in-person instruction on this particular outcome? The authors suggest that multimedia-supported e-learning, by combining visual, auditory, and interactive elements, may engage students more deeply with practical ethical scenarios, allowing repeated exposure and self-paced reflection that face-to-face workshops cannot always accommodate. Moral sensitivity, unlike factual awareness of a professional code, involves recognizing ethical nuances in complex care situations, a capacity that may benefit from immersive, scenario-based digital content that students can revisit and process at their own rhythm.

The findings carry practical weight for nursing education worldwide. Ethics instruction in nursing programs often struggles to move beyond lectures on abstract principles, leaving graduates technically knowledgeable but poorly attuned to the ethical texture of real clinical encounters. If multimedia e-learning can reliably strengthen moral sensitivity, it could serve as a scalable complement to conventional teaching, particularly valuable in settings where faculty time, clinical placement capacity, or geographic dispersion limit access to in-person workshops.

Yet the study’s design imposes important caveats. Allocation was based on odd or even student identification numbers rather than randomization, so unmeasured differences between groups could influence outcomes. Only short-term, self-reported outcomes were assessed, meaning the researchers captured students’ perceptions two weeks after the intervention rather than observed ethical behavior in clinical practice. The authors themselves note that causal inference is limited and call for randomized studies to determine whether the sensitivity advantage persists and whether it translates into genuine ethical competence and sound clinical decision-making.

The study was approved by Tabriz University of Medical Sciences under ethical code IR.TBZMED.REC.1399.600, conducted in accordance with the Declaration of Helsinki, and supported by the university’s Deputy for Research and Technology. Electronic informed consent was obtained from all participants, and the authors declare no competing interests. As an open-access publication, the full article is freely available to educators, researchers, and clinicians interested in the detailed methods and statistical analyses.

For now, the message for nursing educators is nuanced rather than revolutionary. Multimedia-supported e-learning appears neither to replace nor to surpass face-to-face teaching across the board; it matched conventional instruction on moral awareness while excelling on moral sensitivity. Whether that advantage endures beyond two weeks, generalizes beyond a single Iranian faculty, and ultimately shapes how future nurses act when confronted with real ethical dilemmas remains an open{

Subject of Research: Comparison of multimedia-supported e-learning and face-to-face practical ethics education on nursing students' moral awareness and moral sensitivity

Article Title: Multimedia-supported e-learning versus face-to-face practical ethics education and nursing students’ moral awareness and moral sensitivity: a non-randomized quasi-experimental study

Article References: Behshid, M., Rahmani, P., Tavani, F. M., Seif-Farshad, M., & Musavi, S. (2026). Multimedia-supported e-learning versus face-to-face practical ethics education and nursing students’ moral awareness and moral sensitivity: a non-randomized quasi-experimental study. BMC Nursing. https://doi.org/10.1186/s12912-026-05505-y

Image Credits: AI Generated

DOI: 10.1186/s12912-026-05505-y

Keywords: nursing education, nursing ethics, moral sensitivity, moral awareness, e-learning, multimedia learning, quasi-experimental study, clinical ethics, Tabriz University of Medical Sciences, ANCOVA, Multimedia-supported, versus