Study of the effect of teaching ethical principles using the flipped classroom method on moral distress and moral sensitivity in NICU and PICU nurses

Abstract

Background

Nurses working in NICU and PICU frequently encounter ethical dilemmas that can erode their moral sensitivity and trigger distress that can jeopardize patient safety, undermine staff well-being, and hinder interprofessional collaboration. Traditional lecture-based ethics education often fails to engage nurses deeply or produce durable improvements in ethical reasoning. The flipped classroom (FC) model, which delivers core content before class and uses face-to-face time for interactive case discussions, may offer a more effective route to strengthening ethical insight and reflective practice in critical care settings.

Methods

In this randomized controlled trial, 80 NICU and PICU nurses at Afzalipour Hospital in Kerman, Iran, were enrolled by census sampling and randomly assigned (1:1) to an FC intervention group (n = 40) or a control group (n = 40). Both groups received the hospital’s standard ethics in-service program. The FC group additionally reviewed five digital pre-class modules over 20 days and attended three 2-hour interactive workshops on managing moral distress, building resilience, and heightening moral sensitivity. Outcomes were assessed at baseline, immediately post-intervention, and at two-week follow-up using Corley’s Moral Distress Scale–Revised and Lützén’s Moral Sensitivity Questionnaire. Within-group changes were evaluated with paired t-tests and between-group differences with independent t-tests (α = 0.05).

Results

Baseline demographic and professional characteristics were similar between groups (all p > 0.05). The FC group’s mean moral distress score decreased from 70.44 ± 26.35 at baseline to 50.60 ± 36.46 immediately post-intervention (p < 0.001) and remained significantly lower at two-week follow-up (p < 0.01). Their mean moral sensitivity score increased from 171.37 ± 23.15 to 182.97 ± 18.24 immediately after training (p = 0.003) and remained elevated at follow-up (p = 0.005). The control group indicated no significant reduction in moral distress (p = 0.07) and only a non-sustained rise in moral sensitivity (p = 0.20).

Conclusions

Flipped classroom–based ethics education substantially mitigates moral distress and enhances moral sensitivity among NICU and PICU nurses compared with conventional training. Incorporating FC strategies into critical care nursing curricula may strengthen ethical competence in demanding clinical settings.

Trial registration

IRCT20220203053920N4 (Registered 03 February 2022).

Introduction

Ethics in health care is important because employees must recognize health care problems and make correct judgments and decisions based on ethical values, and at the same time observe the rules governing ethics [1]. Considering the critical role of nurses’ decision-making in patient care, professional ethics holds a central place in nursing practice. Accordingly, educating nurses in ethical principles, ethical sensitivity, and ethical decision-making skills is essential for ensuring the integrity and quality of professional practice [2] .

Moral distress is one of the most common issues in the field of healthcare ethics and refers to a situation in which a person, despite having the awareness and ability to act ethically, is unable to perform the correct ethical action under the existing conditions [3]. The importance of this phenomenon is to the extent that, if it occurs, it can have a different impact on the performance of nurses as well as the quality of care provided by them [2] .

In recent years, the pressures caused by manpower shortages, high workloads, critical decisions, and frequent ethical conflicts have exposed nurses working in neonatal intensive care units (NICU1) and pediatric intensive care units (PICUs) to chronic moral distress [4]. Moral distress occurs when a person fails to act in accordance with their moral values, especially when organizational, legal, or cultural factors prevent them from making the right decision. This situation not only threatens the mental health of nurses, but also leads to a weakening of professional performance, a decrease in the quality of care, and an increase in burnout [3] .

In neonatal and pediatric intensive care units, nurses deal with neonatal patients and children who are in critical situations [3, 5–7].

In a qualitative study, Gagnon and Kunyk (2022) examined the experience of ethical distress in pediatric intensive care unit (PICU) nurses when caring for patients at the end of life. By analyzing the interviews with nurses in six Canadian health centers, three main themes were identified, including prioritizing of child patient dignity, burden of insider knowledge, and environmental constraints in the role of nurse. The results of their study indicated that nurses suffer from moral distress in the face of the unhonorable death of patients, and organizational structures such as silo mentality prevent effective interprofessional interaction, which itself exacerbates this distress [3].

Moral sensitivity is an essential component of ethical action and a characteristic that enables the nurse to recognize ethical challenges, have a correct sensory and intellectual perception of the relevant situation, and ultimately make decisions based on ethical assessment results. Moral sensitivity is an individual’s ability to recognize ethical issues and respond appropriately to them plays a vital role in nurses’ daily decision-making. Increasing ethical sensitivity promotes professional commitment, strengthens empathy, and increases patient safety [8]. In contrast, diminished or absent moral sensitivity may result in ethically inappropriate care and compromise the quality of nursing practice [9] .

When a nurse lacks moral sensitivity, it becomes impossible to detect unethical problems that occur in the practice of nursing, therefore, it is very important to provide ethical education to nurses during professional training to increase their moral sensitivity [10]. Moreover, several studies have emphasized the importance of ethics education and the use of appropriate teaching strategies to help nurses manage moral distress and strengthen ethical sensitivity [10–12].

Nursing ethics education is crucial in preparing nurses to navigate complex ethical dilemmas in clinical practice. Traditional methods of teaching ethics are often based on one-way transfer of concepts and do not give an active role to learners and are associated with problems such as low motivation to learn and passive learning. and can lead to increased stress and distress in high-pressure environments for nurses [13].

To educate nurses in managing and controlling moral distress, innovative educational approaches should be employed. The Flipped Classroom Method (FCM), as a contemporary teaching strategy, offers a dynamic platform for learning professional ethics by assigning theoretical content to independent pre-class study and emphasizing interactive activities, problem-solving, and group discussions during class sessions. This approach can enhance learning motivation, promote critical thinking, and facilitate the application of ethical principles, thereby reducing moral distress and improving moral sensitivity.

[14–16].

The results of Howang’s (2021) study indicate that learners undergoing ethics education using the flipped classroom method reported lower levels of anxiety and increased self-confidence in addressing ethical issues [17]. Reduction in anxiety is attributed to the advanced support systems created through collaborative learning environments, where nurses can share experiences and strategies to address ethical challenges [13] .

A study was conducted by Khazaei et al. (2025) with a four-group design by Solomon and the participation of 80 nursing students, and the results indicated that teaching professional nursing ethics by flipped classroom method significantly increased students’ reflectivity ability and better performance in ethical learning components [18].

In the field of ethics education, the flipped classroom provides a suitable platform for internalizing professional values by providing an opportunity to reflect on experiences, analyze ethical situations, and practice decision-making. Especially in disciplines such as nursing, where day-to-day ethical decisions are part of clinical practice, this approach can help reduce ethical distress and increase ethical sensitivity [18].

Based on the professional experiences of the research team comprising nursing faculty members and clinical instructors working in neonatal and pediatric intensive care units (NICU and PICU) it was observed that nurses in these high-intensity settings frequently experience moral distress due to their constant exposure to patients with complex medical conditions. At the same time, providing ethically sound care to hospitalized infants and children requires nurses to possess a high level of moral sensitivity grounded in ethical knowledge and reflection. These observations highlight the necessity of strengthening ethics education for nurses. A review of the relevant literature further indicates that employing innovative and learner-centered teaching methods is essential for effective ethics education [19, 20] .

The flipped classroom model, as a relatively new pedagogical strategy, has been minimally explored in the context of ethics education but shows potential to enhance moral sensitivity and reduce moral distress among nurses. Accordingly, the present study aimed to examine the effect of teaching ethical principles using the flipped classroom method on moral distress and moral sensitivity among NICU and PICU nurses at Afzalipour Hospital in Kerman.

Materials and methods

Trial design This randomized clinical trial study was conducted in two groups with control and intervention groups and with a pre-test and post-test design to investigate the effect of teaching ethics by flipped classroom method on moral distress and moral sensitivity in nurses in neonatal intensive care units and pediatric intensive care units.

Setting and participants

All nurses working in the pediatric and neonatal intensive care units of Afzalipour Hospital in Kerman were eligible to participate in the study if they met the inclusion criteria. The inclusion criteria for nurses included having at least a bachelor’s degree in nursing and having at least 6 months of clinical work experience in the neonatal and pediatric intensive care units of Afzalipour Hospital, and exclusion criteria included; Failure to study the educational content after 3 reminds of the researcher (in the intervention group) and failure to complete 10% of the demographic questionnaires of moral sensitivity and moral distress. Based on the inclusion criteria, 80 nurses working in the neonatal and pediatric intensive care units of Afzalipour Hospital were selected by census method and then randomly assigned to two control and intervention groups. The control group received only the usual ethics education, which was neither structured nor systematically programmed. In addition to the routine instruction, the intervention group participated in an ethics course delivered through a flipped-classroom model.

Randomization

The subjects were entered into two equal groups (n = 40) using the census method, including a control group (received only usual hospital training) and an intervention group (received flipping classroom ethics in addition tothe usual hospital training).

Intervention

After obtaining ethical approval from the Ethics Committee of Kerman University of Medical Sciences and permission from the hospital administration, the researcher visited the neonatal and pediatric intensive care units (NICU and PICU) of Afzalipour Hospital to initiate the study. Following an introduction to the unit managers and staff, the researcher identified and recruited eligible participants from among the nurses working in these units according to the study’s inclusion criteria.

Following ethical approval from the Ethics Committee of Kerman University of Medical Sciences and authorization from the hospital administration, the researcher visited the neonatal and pediatric intensive care units of the study hospital to initiate the project. After introducing herself to the department heads and staff, she explained the study objectives and procedures, emphasized the voluntary nature of participation, and assured all potential participants of confidentiality. Eighty nurses who met the inclusion criteria were invited to take part in the study. After obtaining written informed consent, participants were randomly assigned, using a simple randomization procedure, to either the intervention group or the control group (n = 40 per group).

Both groups first completed baseline questionnaires on demographic characteristics, moral distress, and moral sensitivity. The control group received only the usual ethics education routinely provided by the institution, which was informal and unstructured.

In addition to this routine training, the intervention group participated in a structured ethics education program based on a flipped classroom (FC) approach. The educational content, developed by the research team and reviewed by three faculty experts in nursing ethics, consisted of five modules covering ethical principles in nursing practice, common sources of moral distress in intensive care settings, and strategies for ethical decision-making and reflection (table1). Each module included text materials, PowerPoint slides, short instructional videos, and ethical case scenarios adapted to neonatal and pediatric intensive care contexts.

The modules were distributed electronically over a 20-day period through a dedicated WhatsApp group created for the intervention. Participants received one module every four days and were reminded via text message every three days to review the assigned materials. After completing each module, they were encouraged to revisit and reflect on the content in preparation for the online sessions.

Each participant attended three interactive online sessions (two hours each; total duration six hours) conducted via Google Meet. Because nurses worked rotating shifts, small groups of four participants were scheduled for each session based on their availability. Prior to each class, participants were expected to review the learning materials and complete brief reflective exercises based on the provided ethical scenarios.

During each session, the first 10 min were devoted to reviewing the pre-class materials, followed by discussion, case analysis, questioning, and collaborative problem-solving activities. The sessions emphasized critical thinking, ethical reasoning, and application of concepts to real or hypothetical clinical situations. The researcher facilitated all sessions, monitored engagement, and provided individualized feedback throughout.

Two weeks after completion of the intervention, participants in both groups completed post-test questionnaires. Following data collection, the control group was provided access to the electronic educational materials to ensure equitable benefit from the intervention.

In this study, blinding was not possible for nurses and researchers, but the statistician was not aware of the method of assigning people to groups and analyzing their data.

In order to prevent the transfer of data between groups, each nurse was advised not to discuss the topics of the meeting with another person in order not to distort the study.

Also, the educational content was approved by three faculty members of the School of Nursing who were in the field of research and teaching ethics.

Data collection and study instruments

Data were collected using three questionnaires including Social Demographic Questionnaire, Corley’s Moral Distress Questionnaire (2002), and Lutzen et al.‘s Moral Distress Questionnaire (1993). In order to investigate and compare the effect of ethics training by flipped classroom method on distress and moral sensitivity, the questionnaires were completed by the participants twice before and after the intervention.

Social demographic questionnaire

The demographic questionnaire included gender, age, marital status, education level, employment status, position, general work experience, work experience inneonatal and child intensive care units, type of shift, monthly income, and history of receiving training on ethics education

Corley’s moral distress questionnaire

Moral distress was measured using Corley’s Moral Distress Scale (MDS), developed by Corley in 2002, which consists of 36 items assessing both the frequency and intensity of moral distress among nurses [21]. The instrument was translated into Persian and psychometrically validated by Bigmorad et al. (2012). Each item is rated on a 7-point Likert scale ranging from never encountered (0) to very frequently encountered [6] for the frequency subscale, and from causes no distress (0) to causes great distress [6] for the intensity subscale. The total score for each subscale ranges from 0 to 216, with higher scores indicating greater frequency or intensity of moral distress. Specifically, scores of 0–72 indicate low moral distress, 73–144 indicate moderate moral distress, and 145–216 indicate high moral distress [22].

The Persian version of the instrument demonstrated excellent psychometric properties. Content validity was confirmed by 17 faculty experts from Tehran and Qazvin Universities of Medical Sciences. Reliability was assessed through a test–retest procedure with 20 nurses from a similar population, showing a Pearson correlation coefficient of r = 0.82 and Cronbach’s alpha of α = 0.93, indicating high internal consistency (Soleimani et al., 2019). The instrument has been widely applied in national and international nursing studies [23].

Lutzen et al. .‘s moral sensitivity questionnaire

The Lutzen (1993) questionnaire was designed to measure moral sensitivity in decision-making and has 30 questions. It was rated using a seven-point Likert scale, ranging from completely agree (score of 7) to completely disagree (score of 1). It should be noted that the overall score of the participants is between the minimum score of “30” and the maximum score of “210”, and it should also be said that questions 8, 11 and 28 are scored in reverse. Ghasemi Rad (2015) stated that the validity of the moral sensitivity questionnaire in decision-making was 0.89. And the reliability of the moral sensitivity questionnaire in decision-making was announced by Cronbach’s alpha method of 0.75 [24].

Data analysis

To analyze the data, SPSS software version 22 was used. To describe the quantitative variables, mean and standard deviation and to describe the qualitative variables, frequency and percentage were reported. To compare the variables in the two groups at the beginning of the study, according to the type of variables, Chi-square, Fisher’s exact test, t-two independent samples (or Mann-Whitney U) tests, and for intra-group and intergroup comparison of the test, and Indepemndent t test Paired t-test was used. Also to control the effects of group factor before the intervention covariance test was done. The significance level was considered to be 0.05.

Results

In this study, 80 nurses working in the neonatal and pediatric intensive care units of Afzalipour Hospital were divided into two groups of intervention (40 people) and control (40 people) (100% response rate). All nurses were female. The mean age was 34.07 ± 6.81 years in the intervention group and in the control group was 33.32 ± 6.2 years. Most of the participants had 5–10 years of work experience (15 in the intervention group, 18 in the control group), 37 people from the two groups are in shift circulation,, 38 nurses in the intervention group and 37 people in the control group have bachelor’s education (Table 1).

Table 1.

Educational content overview

Section	Educational Content
1	Definitions of ethics, moral distress, and moral sensitivity
2	The necessity of having moral competence and knowledge in nurses in intensive neonatal and pediatric wards
3	Common cases of moral distress in nurses in pediatric and neonatal wards
4	How nurses deal with moral distress and control it
5	Ways to increase moral sensitivity

Also, based on independent chi-square and t-test, the intervention and control groups were similar in terms of demographic and backgound characteristics (Table 2).

Table 2.

Comparison of the demographic characteristics in the control and intervention groups

		Intervention		Control		Test Statistics	Significantation
Variable	Group Category	Count	Percentage	Count	Percentage
Marital Status	Single	15	37/5	17	42/5	x2= 20/0	0/64
	Married	25	62/5	23	57/5
Employment Status	Permaneny/Contra!!!	23	57/5	18	45	x2= 25/1	0/53
	Company	11	27/5	14	35
	Temporary	6	15	8	20
Shift Type	Rotating	37	92/5	37	92/5	x2= 0	1
	Fixed	3	7/5	3	7/5
Work Experience	Less Than 5 Years	15	37/5	14	35	x2= 0/52	0/76
	5-10 Years	15	37/5	18	45
	More Than 10 Years	10	25	8	20
Monthly Income	120-150 Million Rials	5	12/5	8	20	x2= 1/43	0/48
	150-200 Million Rials	28	70	23	57/5
	Above 200 Million Rials	7	17/5	9	22/5
Duration in Neonatal/Pediatric Ward	Up to 1 Year	6	15	8	20	x2= 1/002	0/91
	1-3 Years	10	25	12	30
	3-5 Years	12	30	11	27/5
	5-10 Years	6	15	4	10
	More than 10 Years	6	15	5	12/5
Education Level	Bachelor’s	38	95	37	92/5	x2= 0/21	0/64
	Master’s	2	5	3	7/5
		Count	Percentage	Count	Percentage	Test Statistics	Significantation
Age		34/07	6/81	33/32	6/20	t= 0/51	0/60

As shown in Table 3, the mean score of moral distress in the intervention group was ( 70.44 ± 26.35) and ( 50.6 ± 36.46) before and after the intervention, respectively. Paired t-test indicated that the statistical significant differences between the score of moral distress before and after in the intervention group (p.value = 3.001).

Table 3.

Comparison of the mean of moral distress and moral sensivity in and between the control and intervention groups in before and after

Varible	Group	Pre-Test		Post-Test		Mean Diference	Ffect Size	Paired t-Test Static & Significance
		Mean	Std. Deviatiob	Mean	Std. Deviation
Moral Distress	Intervention	70/44	26/35	50/60	26/36	19/84	0/68	t= 5/53 P<0/001
	Control	68/05	27/21	63/05	27.52	5.45	0/65	t=1/76 P=0/07
	Independent t-Test Statistic & Significance	t=-2/82		t=-1/84
		P=0/09		P=0/01
	Effect Size	0/64		0/41
Moral Distress	Intervention	171/37	23/15	182/97	18/24	11/6	0/55	t=-2/17 P=0/003
	Control	175/15	17/33	177/7	10/86	2/55	0/52	t= -3/26 P=0/2
	Independent t-Test Statistic & Significance	t= 3/01		t= 2/89
		P=0/3		P=0/005
	Effect Size	0/67		0/64

Also, the mean score of moral distress in the control group was (68.05 ± 27.16 ) and ( 63.05 ± 27.52 ) before and after the intervention. Paired t-test indicated that there was not statistically significant difference between before and after the intervention in the control group (p.value = 0.07).

The mean score of moral distress in the intervention group before and after intervention was (70.44 ± 26.33) and ( 68.05 ± 27.16 ), but according to independent t-test, there was no significant difference between the mean score between the intervention and control groups befor theintervention(p.value = 0.09).

The mean score of moral distress in the intervention group( 50.6 ± 26.36 ) was higher than in the control group ( 63.05 ± 27.52 ) after the intervention. According to independent t-test, there was a significant difference between the mean score of moral distress between the intervention and control groups in the post-test(p.value = 0.01).

As shown in Table 3, the mean score of moral sensitivity in the intervention group was( 171.37 ± 23.15) and ( 182.97 ± 18.24 ) before and after the intervention, respetively. Paired t-test indicated that there was statistically significant difference between the score of moral sensitivity before and after the intervention in the intervention group (p.value = 0.003).

Also, the mean score of moral sensitivity in the control group was (17.33 ± 175.15) and ( 177.71 ± 10.86 ) before and after the intervention, respectively. Paired t-test indicated that there was no statistically significant difference between them in the control group before and after the intervention(p.value = 0.2).

Also, the mean score of moral sensitivity before intervention in intervention group ( 171.37 ± 23.15 ) was lower than the control group ( 175.15 ± 17.33 ), but according to independent t-test, there was no significant difference between the mean score of moral sensitivity between the intervention and control groups before the intervention (P = 0.3).

Additionally, The mean score of moral sensitivity after the intervention in the intervention group (182.97 ± 18.24) was higher than in the control group after the intervention( 177.71 ± 10.86). According to independent t-test, there was a significant difference between them after the intervention (P = 0.005).

Table 4 indicated that the p-values for the intercept and the “before intervention moral distress are highly significant (p < 0.001), whereas the group effect is significant (p = 0.015), indicating a meaningful difference between groups in the post-intervention context when adjusting for covariates. Also, based on the covariance test, it was found that there was a significant difference between moral sensitivity before the intervention and the group factor, which is consistent with the results of Table 4.

Table 4.

Analytical results of covariance of nurses' ethical distress and moral sensitivity before and after the intervention

	Sum ofSquaresError	DegreesOf Freedom	MeanSquare	FStatistic	p-value
Intersept	67/42	1	67/42	19.25	0/001>
Moral DistressBefore Intervention	3750	1	3750	55.01	0/001>
Group	460.2	1	460.2	6.75	0.015
Error	1840.1	27	1840
Intercept	84/25	1	84/25	20	0/001>
Moral Sensitivity Before	1250	1	1250	89/32	0/001>
Intervention Group	580	1	580	15/26	0.001
Error	1026	27	1026

Discussion

In line with the first hypothesis of the study, “Teaching ethics by flipped class method has an effect on the moral sensitivity of nurses in neonatal and pediatric intensive care units.” The results indicated that the use of the flipped classroom method improved the moral sensitivity of nurses in the intervention group compared to the control group. As with the Khazaei et al. (2025) investigation, the current study also supported the positive effect of the flipping class on enhancing reflectivity and thus enhancing moral sensitivity [18]. Also, the study of Azarkish et al. (2023) that proved the effectiveness of the flipped classroom in increasing nursing students’ moral sensitivity to the Short Message Service method was consistent [15] .

The findings of the present study align with previous research demonstrating the positive impact of innovative educational methods on ethical sensitivity among nursing students and nurses. For instance, Azarkish et al. (2023) indicated that teaching professional ethics codes by flipped class method was more effective than the control group and the education group using SMS, and also the ethical sensitivity of nursing students in the flipped class group increased significantly (p < 0.001). Similarly, the use of interactive educational methods over 5 weeks enhanced both moral sensitivity and ethical knowledge among nurses [25]. Another study examining the effect of simulation-based training on ethical dilemmas reported improvements in nurses’ moral sensitivity [26]. In general, education using different traditional methods and new approaches had an effect on the moral sensitivity of nursing students and nurses [27]. Consistent with this body of literature, our study confirms the practicality and effectiveness of the flipped classroom method for teaching ethics, particularly in professional and intensive care contexts, as it yielded comparable enhancements in ethical sensitivity [28].

In the present study, the interactive classroom environment and role-playing practice, which is emphasized in the flipped classroom method, can increase the level of moral sensitivity of nurses in neonatal and pediatric intensive care units.

Regarding the second hypothesis of the study, “Teaching ethics by flipped classroom method has an effect on moral distress among nurses in neonatal and pediatric intensive care units of Afzalipour Hospital in Kerman”, the results indicated that the educational intervention significantly reduced moral distress in the intervention group compared to the control group.This result may be explained by the interactive and active nature of the flipped classroom method, because this educational method leads to a deeper understanding of ethical concepts by providing an opportunity to analyze ethical situations, exchange ideas, and practice decision-making.

Consistent with the current study is Chung’s (2021) study, which reported a reduction in anxiety and moral distress after inverted classroom instruction [17] Also, Morley’s (2021) study has also considered the teaching of ethical principles as an effective approach in managing ethical distress [29] .

In contrast, some research, such as the study of Carletto et al. (2022), although pointed to the importance of ethical education, indicated that the severity of moral distress is more influenced by organizational conditions and resource constraints, and that education alone cannot reduce all dimensions of moral distress [30]. This heterogeneity could imply that educational intervention should be implemented in conjunction with modification of environmental and management structures to be more effective, and the study of Mills and Cortezzo (2020) also indicated that even after education, moral distress in the face of end-of-life decisions or wasteful care remains high [4]. This difference can be due to the multidimensional complexity of ethical distress involving organizational, cultural, and legal factors, and mere education, without modifying workplace structures, may not be enough.

In general, the effectiveness of the flipped classroom in reducing ethical distress is related to several factors based on existing studies: first, it fosters active learning, which is directly effective in promoting ethical decision-making [31], second, group discussions and analysis of real-world scenarios internalize ethical principles [32], and third, it provides a safe space for reflection that is essential for processing difficult clinical experiences [33]. Almost all of the above were taken into account during the current study intervention and the educational content included knowledge sections as well as scenarios related to the pediatric and neonatal sections. Therefore, the present results may be considered as an effective step in reducing moral distress and promoting moral sensitivity, although organizational factors still require complementary interventions.

Limitations

One of the limitations of the current study was the self-report of the moral sensitivity and ethical distress questionnaires in nurses, which could affect the study data. Also, the study was conducted in an educational-therapeutic center, which can affect the generalization of the data. Also, the study was conducted in a short period of time, which is suggested to be conducted in subsequent studies in periods of more than one month.

Conclusions

The results of this study indicated that using the flipped classroom method as an active learning strategy can enhance nurses’ ability to address ethical challenges by providing opportunities for critical analysis and reflection in an interactive environment. Given the sensitivity and complexity of neonatal and pediatric intensive care settings, flipped classroom–based education can be employed as an effective approach in ethics-oriented continuing education programs for nurses. To sustain and further strengthen its impact, it is recommended that such training be implemented on an ongoing basis, supported by institutional commitment and regular evaluation.

Authors’ contributions

This manuscript is the consequence of the collaboration of all the authors. RB and MN and RM designed the study and wrote the study proposal and RMs conducted data collection and analysis. MN and RM analyzed the data, and RMs wrote the final draft of the manuscript and prepared tables. RMs submitted the document to the journal. The author(s) read and approved the final manuscript.

Funding

This study was financially supported by Kerman University of Medical Sciences, Kerman, Iran, with grant No. IR.KMU.REC.1403.471.

Data availability

The datasets used and analyzed in this study are available upon reasonable request from the corresponding author.

Declarations

Ethics approval and consent to participate

The study was conducted in accordance with the Helsinki declaration and was approved by the Ethics Committee of the Kerman University of Medical Sciences (IR.KMU.REC.1403.471). Written informed consent was obtained from each participant. The study was performed under all national and international ethical guidelines.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.