title: Measuring Moral Distress Among Critical Care Clinicians: Validation and Psychometric Properties of the Italian Moral Distress Scale-Revised.
abstract: OBJECTIVE
  Moral distress is a common experience among critical care professionals, leading to frustration, withdrawal from patient care, and job abandonment. Most of the studies on moral distress have used the Moral Distress Scale or its revised version (Moral Distress Scale-Revised). However, these scales have never been validated through factor analysis. This article aims to explore the factorial structure of the Moral Distress Scale-Revised and develop a valid and reliable scale through factor analysis.
  
  
  METHODS
  Validation study using a survey design.
  
  
  METHODS
  Eight medical-surgical ICUs in the north of Italy.
  
  
  METHODS
  A total of 184 clinicians (64 physicians, 94 nurses, and 14 residents).
  
  
  METHODS
  The Moral Distress Scale-Revised was translated into Italian and administered along with a measure of depression (Beck Depression Inventory-Second Edition) to establish convergent validity. Exploratory factor analysis was conducted to explore the Moral Distress Scale-Revised factorial structure. Items with low (less than or equal to 0.350) or multiple saturations were removed. The resulting model was tested through confirmatory factor analysis.
  
  
  RESULTS
  The Italian Moral Distress Scale-Revised is composed of 14 items referring to four factors: futile care, poor teamwork, deceptive communication, and ethical misconduct. This model accounts for 59% of the total variance and presents a good fit with the data (root mean square error of approximation = 0.06; comparative fit index = 0.95; Tucker-Lewis index = 0.94; weighted root mean square residual = 0.65). The Italian Moral Distress Scale-Revised evinces good reliability (α = 0.81) and moderately correlates with Beck Depression Inventory-Second Edition (r = 0.293; p < 0.001). No significant differences were found in the moral distress total score between physicians and nurses. However, nurses scored higher on futile care than physicians (t = 2.051; p = 0.042), whereas physicians scored higher on deceptive communication than nurses (t = 3.617; p < 0.001). Moral distress was higher for those clinicians considering to give up their position (t = 2.778; p = 0.006).
  
  
  CONCLUSIONS
  The Italian Moral Distress Scale-Revised is a valid and reliable instrument to assess moral distress among critical care clinicians and develop tailored interventions addressing its different components. Further research could test the generalizability of its factorial structure in other cultures.
authors.affiliation: 1Department of Health Sciences, Università degli Studi di Milano, Milano, Italy. 2Department of Brain and Behavioral Sciences, Università degli Studi di Pavia, Pavia, Italy. 3Psychology Unit, Department of Mental Health, San Paolo Hospital, Milan, Italy. 4Department of Health Sciences, Università degli Studi di Milano, Milano, Italy.
authors.forename: Giulia
authors.initials: G
authors.lastname: Lamiani
authors.forename: Ilaria
authors.initials: I
authors.lastname: Setti
authors.forename: Luca
authors.initials: L
authors.lastname: Barlascini
authors.forename: Elena
authors.initials: E
authors.lastname: Vegni
authors.forename: Piergiorgio
authors.initials: P
authors.lastname: Argentero
mesh_terms: D000328:Adult; D003422:Critical Care; D008192:Deception; D004992:Ethics, Medical; D004993:Ethics, Nursing; D005163:Factor Analysis, Statistical; D005260:Female; D006126:Group Processes; D006801:Humans; D007362:Intensive Care Units; D007558:Italy; D008297:Male; D018447:Medical Futility / Q000941:ethics / Q000523:psychology*; D008875:Middle Aged; D009014:Morals; D009726:Nurses / Q000523:psychology*; D010820:Physicians / Q000941:ethics / Q000523:psychology*; D028743:Professional Misconduct / Q000941:ethics / Q000523:psychology*; D011569:Psychiatric Status Rating Scales; D011594:Psychometrics; D013315:Stress, Psychological / Q000209:etiology*