Psychometrics of the moral distress scale in Iranian mental health nurses

Moral distress arises from the conflict between professional and individual values [1, 2] and is one of the challenges nurses face in many situations involving ethical decision making. Working with incompetent staff, unsafe working conditions, organizational constraints, and shortage of manpower and equipment are some of the problems that cause moral distress in nurses [3‐5]. Moral distress occurs when a person knows what a good job is, but organizational constraints or fears about the consequences of the job make it almost impossible to do the right thing [5].In the United States, one in three nurses suffers from moral distress [6]. Approximately 5.17% of novice nurses leave their job in the first year due to moral distress [7].

The moral distress experienced by nurses in various situations [8], causes feelings of failure and guilt, anger, job dissatisfaction, stress, turnover, sadness, anxiety, feelings of shame, low self-esteem, feelings of burnout, feelings of insecurity, fear, discouragement, and depression in nurses and these consequences can affect their personal lives and professional performance [3‐5, 8‐10]. The psychological trauma of moral distress disrupts nurses ‘daily lives [1, 11] and causes nurses to leave both their jobs and the profession itself [12‐14]. Therefore, understanding the concepts related to moral distress can play an important role for nurses and nurse managers in reducing moral distress, improving the quality of nursing services, and patient satisfaction [12, 15].

Moral distress not only has a negative impact on nurses, but also on the organization and patient care [3]. Moral distress can cause nurses to isolate themselves from patients, patients not to defend herself, and patients to become uncomfortable (effect of moral distress on the patient) [3, 12, 15].On the other hand, the effects of moral distress on nurses can take the form of resignation, burnout, and leaving the nursing profession [12, 14]. The negative effects of moral distress on organizations include increasing the number of nurses leaving the service, decreasing the number of experienced nurses and quality of nursing care, and the reputation of the organization [16]. Therefore, identifying moral distress and the factors behind it plays a vital role in management and future planning [17]. A valid and reliable cross-cultural scale would be beneficial to capture moral distress.

Moral Distress was defined in nursing in the 1980s [18], and Corley designed the scale with 36 items in 1995 [19] and modified it in 2005 [2] This modified scale showed good reliability and validity [14]. Considering that environmental and cultural factors influence moral distress and compliance with it [20], the perception of moral distress is different in different environments and cultures [8, 21] and moral distress differs according to the conditions and work environment [22], Corley’s scale was developed and psychometrically tested for critical care nurses [15] and therefore is not recommended for use in other settings.

Because moral distress varies by work setting, nurses in mental health care may experience a different type of moral distress than nurses in other settings because of restrictions on patient freedom (e.g., involuntary hospitalization, restraint). Little is known about the moral distress experienced by nurses in mental health care. Yet mental health wards are one of the environments with more moral distress [1]. The moral distress of nurses in mental health wards in caring for patients with severe mental illness at any stage of illness and with various conditions, including cases where the patient’s vision is impaired [16], is higher than in other treatment environments [1, 16]. They should also pay attention to families who suffer from caring for their patients and are often unknowingly exposed to internal and external constraints [16]. Therefore, specific scales are needed to study moral distress in mental health services.

For the first time, in 2010, Ohnishi et al. introduced the Scale for Measuring Moral Distress for Psychiatric nurses (MDS-P) to examine nurses’ experience of moral distress. Because the Moral Distress Scale (MDS) focuses primarily on moral distress about physical care, it is inappropriate for use in a mental health setting. The MDS-P uses some items from Corley’s 30-Phrase Moral Distress Scale, adding items applicable for mental health care [1]. It is a 15-item scale designed to include three subscales: “Unethical conduct by Caregivers” (six terms), “Low staffing” (Five phrases) and “Acquiescence to patients’ rights violations” (four cases) [1]. The MDS-P includes questions about long-term hospitalization and unethical behavior of caregivers, such as inadequate care, covertly mixing medications into patients’ food, ridiculing patients, searching for patients’ belongings, and handling shopping rather than letting patients go shopping [10]. The validity and reliability of this scale has been studied in Japan [1]. Due to the influence of environment on moral distress, further studies are needed in this field and the provided scales should be adapted to different cultures [20]. Considering the problems such as dissatisfaction and burnout that moral distress brings to nurses, it is necessary to have an appropriate instrument to assess it in nurses working in mental health wards. Despite the importance of the concept of moral distress among nurses working in mental health wards, there is no valid and reliable scale in this regard in Persian. A valid and reliable instrument to assess moral distress can be helpful in identifying the incidence of moral distress and developing prevention programs. Therefore, this study was conducted to validate the moral distress scale among mental health nurses in Iranian culture and Persian language.

The translation and cultural adaptation of the scale is done to better adapt the scale to the culture and language of the target community to better understand the items and respond to them [23, 27, 28]. After translation and back translation, validity and reliability are the key indicators in each scale [23, 27] which are confirmed in different ways. In this study, face validity was confirmed by quantitative and qualitative methods, and content validity of the translated scale was confirmed. Items 4, 1, 2, 13, 10, and 7 in the factor unethical Conduct by Caregivers, items 6, 9, 3, 15, 12 in the factor Low Staffing and other items 11, 8, 5, 14 were included in the factor Acquiescence to patients’ rights violations, which is consistent with the results of Ohnishi et al. [1].

If moral distress is not detected, it can lead to burnout and decreased patient safety and quality of care. Moral distress not only has a negative impact on the nurse, but also has negative consequences in patient care. Nurses must be able to cope with moral distress, make the right decision, and provide quality patient care. Therefore, considering the side effects, it is necessary to have a reliable and valid scale that can be studied. The results of this study showed that the Persian version of moral distress with 15 items of the three factors has validity and reliability. Similar studies that investigated this scale in different communities, were not found. Therefore, a comparison of the factors of MDS Corley’s and its studies in certain sections was used in the discussion.

The 36-item MDS Corley scale examines moral distress in nurses working in intensive care units [11, 29]. In the study of Shoorideh et al., who studied the moral distress in nurses working in intensive care unit in Iran using the Corley scale, three factors were identified: “inappropriate competencies and responsibilities”, “errors”, and “not respecting the ethics principles” [5]. Similarly, Soleimani et al. studied the scale of moral distress in the intensive care units and identified 5 factors for it, including the role of the health care provider, futile care, obedience to the physician, lack of trust of the patient, and limitation of the organization [30] which had different results from the results of Corley’s research. The results of the above research also emphasize the neglect of patients’ rights as well as the occurrence of errors. This finding was highlighted in the present study and the results of the research by Ohnishi et al. [1]. Therefore, it is necessary to familiarize nurses with educational decisions that ignore patients’ rights in educational programs.

The first factor from the current study is acquiescence to patients’ rights violations, which was also confirmed in the study by Ohnishi et al. [1]. Acquiescence to patients’ rights violations has also been emphasized in other studies such as Corley [2], Shoorideh et al. [5] and Soleimani et al. [30] in Iran, which shows that this factor causes moral distress when the nurse does not have the responsibility or the ability and confidence to support their patient and defend their rights.

Depending on the type of clinical area, different issues cause moral stress among nurses, and some issues are more important in mental health settings than in other units. It should be noted that in mental health settings, due to the patient being disoriented and being treated without his consent, there is a possibility of violation of his rights by his family or other caregivers. This can cause moral distress to those who witness these cases. Legal guidance in these cases, allowing nurses to feel more empowered to protect patients may help reduce the incidence of these cases. In the study by Ohnishi et al. the instrument was created according to the situations of moral distress prevalent in mental health settings [1]. Despite the confirmation of the validity of the scale by Ohnishi et al., studies on the application of the scales in different cultures seem necessary, as culture has a significant influence on values and ethical decisions and the occurrence of moral distress.

The next factor identified in the present study is the unethical conduct by caregivers which shows that the nurses do not have the necessary commitment to ethics. In the study of Shoorideh et al. the factor “not respecting the ethics principles” was identified, which emphasizes the observance of ethical principles by care providers [5]. Therefore, according to the results of the present study, which is in line with those of Ohnishi et al. [1] and has been studied in mental health wards, as well as the research of Shoorideh et al. [5], there seems to be a need to develop ethical commitment among care providers. This is to prevent unethical behaviors and the challenges associated with them, such as moral distress in and around the person and harm to the patient. This factor is also one of the important issues to be considered in this study. The development of ethical principles in nursing is a necessity. By developing ethical standpoint it is possible to prevent and address these cases. The best suggestion for developing ethical behavior is to introduce nurses to ethics as a nursing model.

The third factor identified in the present study, which is consistent with the study of Ohnishi et al. [1], is the low number of employees due to the shortage of staff and related challenges such as relying on less experienced staff. In the study of Shoorideh, inappropriate competencies and responsibilities were identified [5] and in the study of Soleimani et al. organizational factors were identified, one of the issues was the lack of qualified professionals [30]. The shortage of manpower and employment of the low skilled employees is influenced by organizational factors such as the cost of employment in the organization. It is a factor seen in different departments and nursing managers should take necessary steps to solve this problem.

Professional competence and scientific understanding and skill development among nurses and other care providers can help reduce the incidence of ethical distress. Assessing the skills and knowledge of nurses when they are first employed on a particular ward and periodically thereafter is one of the issues that is always emphasized. Unfortunately, due to manpower shortage, sometimes nurses are hired with low skills or little experience. In cases where nurses are guided by their values and ethical principles, the lack of sufficient knowledge and skills leads to unwanted mistakes, and unwanted errors cause severe moral distress and burnout in these individuals, which leads to leaving the job. Therefore, in order to improve the quality of care and prevent the occurrence of moral distress and burnout, it is necessary for nurses to have access to continuous professional development so that knowledge and skills can be evaluated and enhanced.

In the study of Ohnishi et al. KMO method was used to investigate the exploratory factor analysis and identify the factors, indicating the accuracy of the above study, and then the identified factors were confirmed by the confirmatory factor analysis. In the present study, the factors were confirmed by the confirmatory factor analysis. In the study of Ohnishi et al. Cronbach’s alpha was 0.80 for unethical behavior by caregivers, 0.75 for low staffing, 0.72 for patient rights compliance, and 0.89 for the whole scale [1]. The results of the reliability study of the instrument in Iran were also confirmed and showed that the instrument has the necessary validity and reliability. Despite the confirmation of the validity and reliability of Ohnishi et al.’S morality scale in Iran, it is necessary to conduct studies in other settings and cultures due to the influence of culture and conditions in mental health settings.

Based on the results of the present study, the Persian version of moral distress with 15 items and 3 validity and reliability factors is suitable for use in the study of moral distress in mental health wards. Given the various cultural factors impact on moral distress, [20] further studies should be conducted to validate and transcultural translation in different cultures.

If moral distress is not detected, it can lead to burnout, decreased patient safety, and quality of care. Moral distress not only has negative effects on the nurse, but also has negative consequences in patient care. Nurses must be able to assess and deal with moral distress, make the right decision, and provide quality patient care. Therefore, considering the side effects, it is necessary to have a reliable and valid scale that can be studied. The results of this study showed that the Persian version of moral distress with 15 items of the three factors has validity and reliability. According to the related findings, this scale can be used to study moral distress among nurses working in mental health wards.