Adaptation and validation of moral distress thermometer in Chinese nurses

doi:10.21203/rs.3.rs-3718174/v1

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Adaptation and validation of moral distress thermometer in Chinese nurses

https://doi.org/10.21203/rs.3.rs-3718174/v1

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Background: Moral distress seriously affects professional nurses, and a number of instruments have been developed to measure the level of moral distress. The moral distress thermometer (MDT) is one of the commonly used instruments that can rapidly measure real-time moral distress; however, it remains unclear whether it is still useful in the Chinese cultural context.

Aim: This study aimed to adapt and validate the MDT among Chinese registered nurses.

Research design: An online, cross-sectional, survey study of adapting and validating Chinese version of MDT.

Participants and research context: A total of 182 registered nurses effectively finished this survey. The correlation between MDT score and the score of the moral distress scale-revised version (MDS-R) was used for evaluating convergent validity, and MDT scores of registered nurses who working in different departments and who made different actions to the final question of the MDS-R were compared by using one-way ANOVA to evaluate construct validity.

Ethical considerations: The Ethics Committee of Chongqing Traditional Chinese Medicine Hospital approved this study (XYMS-20).

Results: The Chinese version of MDT was described as relevant to measure moral distress. The mean MDT score and mean MDS-R score were 2.54 and 38.66, respectively, and the correlation between these two scores was significantly moderate (r = 0.41). Nurses working different departments reported different levels of moral distress, and those working in intensive care unit reported the highest level of moral distress than those working in other departments (p = 0.04). The MDT scores between nurses who presented different actions to their position were also significantly different, and those who had ever left and those who had considered leaving but did not leave reported significantly higher moral distress.

Conclusion: The MDT is a reliable, valid, and easy-to-use instrument to rapidly measure the real-time moral distress of registered nurses in China.

Nursing

Moral distress

moral distress scale-revised

moral distress thermometer

registered nurses

cultural adaptation

Moral distress frequently challenges professional nurses when they provide care for their patients daily¹. A series of instruments are currently available for measuring the perceived level of moral distress among healthcare professionals². The moral distress scale-revised (MDS-R), which was developed by Hamric et al.³ based on the adaption of the initial MDS⁴, was the most recognized one². However, the MDS-R evaluates the level of moral distress by considering both frequency and intensity, making the use of this scale complex and time-consuming⁵. The MDT is a single-item instrument developed by Wocial and Weaver⁵, which has been widely used to quickly evaluate real-time moral distress and accurately track its changes over time⁶. However, it remains unclear whether the MDT was suitable for Chinese cultural context.

Healthcare professionals frequently encounter ethical conflicts in their daily work due to repeated exposure to a large number of patients and their deaths⁷; however, compared with other professionals, professional nurses face higher risk of ethical conflicts because they are often outposts that provide most medical care to patients⁸. Therefore, the nursing is actually regarded as an “ethical laden practice”⁹. Moral distress may occur when professional nurses realize that they need to take morally correct action but their ability to execute such action is limited¹⁰. Moral distress has become one the most common moral sufferings that professional nurses frequently encountered in their daily care of patients, especially when they need to make rapid decisions¹¹. Meta-analyses^{1, 7} showed that the frequency and severity of moral distress in professional nurses are high and are a serious problem in professional nurses.

The undiscovered and unresolved moral distress will inevitably bring a series of negative consequences to professional nurses¹². Studies have showed that moral distress is associated with increased stress, workplace fatigue, impaired professional relationships, job burnout, and poor professional identity, which can ultimately lead to an increased resignation rate of professional nurse^13–15. In addition, under the negative impact of moral distress, professional nurses may unintentionally reduce their support for patients due to insufficient attention to patient’s suffering and avoidance of certain patient demands or needs, thereby affecting health outcomes¹⁶. Therefore, early and accurate detection of moral distress is critically important for reducing moral distress, thereby helping professional nurses to improve their nursing care quality¹⁷.

Currently, several instruments have been developed to measure moral distress², such as the Ethical Stress Scale (ESS)¹⁸, the Moral Distress Questionnaire (MDQ)¹⁹ and the MDS⁴. Among these available instruments, MDS which was developed by Corley et al.⁴ has been the first one specific to intensive care nurses’ moral distress. Furthermore, Hamric et al.³ adapted the MDS to develop the MDS-R for use in healthcare professionals, reporting satisfactory internal reliability and construct validity. To date, the MDS-R has been adapted for use in different healthcare providers²⁰, such as adult-nurse, adult-physician, pediatric-nurse, and pediatric-physician, and it has also been cross-culturally adapted in different cultural contexts, such as Turkey²¹, Italy²², and Australia²³. The MDS-R has also been culturally adapted for use in the Chinese cultural context in 2012²⁴, and studies have used the Chinese version of the MDS-R to quantify moral distress and explore its influencing factors^{25, 26}. Nevertheless, the MDS-R exhibits three major limitations⁵: (1) response to this scale is complex because each item must be asked by simultaneously considering frequency and intensity, (2) more items require more time consumption, and (3) this scale doses not design specific time point reference to differentiate cumulative moral distress from current moral distress.

The MDT was a single-item instrument, which was developed by Wocial and Weaver for rapidly measuring real-time moral distress of nurses⁵. By analyzing the data collected from 529 nurses practicing in hospital setting, these authors reported that the MDT achieved acceptable convergent validity and concurrent validity, therefore recommending it as a potential tool for screening the risk of moral distress and for evaluating the impact of interventions on moral distress. To date, many practitioners and researchers around the world have used MDT to measure the real-time moral distress in different healthcare providers and clinical settings, such as school nurses²⁷, ICU nurses²⁸, neonatal nurse²⁹ and oncology nurse³⁰, as well as community and hospital care^{31, 32}.

Nevertheless, to our knowledge, the MDT has not yet been introduced to China², thereby resulting in an open question about the applicability of the MDT in Chinese cultural context. Therefore, we performed this study aiming to translate the MDT to Chinese and adapt and validate the Chinese version of the MDT among the Chinese registered nurses.

Aim

The aim of this study was to translate and culturally adapt the original MDT to Chinese, and evaluate the psychometrics of the Chinese version of the MDT in Chinese registered nurses.

Study design

An online, cross-sectional, survey study of translating, culturally adapting, and validating MDT in the Chinese cultural context.

Participants

Professional nurses legally registered in public hospitals in Chongqing municipal of China were eligible for inclusion. After the link of covering all questionnaires for survey was created, the principal investigator of this study shared the electronic link to the directors of nursing departments of targeted hospitals. Then, these directors forwarded this link to their working groups for the recruitment of participants. All working groups were created on WeChat application which is a popular social media platform in mainland of China. According to the Kendall sample estimation criteria³³, 5 to 10 participants per item are required for a stable evaluation of the reliability and validity of a scale, therefore minimal 110 participants were estimated in this study. Actually, this study included 182 respondents who returned valid questionnaires for the final data analysis.

Instruments

Moral distress thermometer

The MDT is a tool designed by Wocial and Weaver in 2012 to rapidly and accurately measure real-time moral distress and track the trajectory of the moral distress over time⁵. The MDT is a thermometer-like rating tool, with 0 to 2, 2 to 4, 4 to 6, 6 to 8, and 8 to 10 indicating different levels of moral distress, corresponding to none, mild, uncomfortable, distressing, intense and worst possible, respectively. These authors of the original MDT designed an introduction to interpret the concept of moral distress and how to use this tool to mark their perceived level of moral distress: ‘Moral distress occurs when you believe you know the ethically correct thing to do, but something or someone restricts your ability to pursue the right course of action. Please circle the number (0–10) on the thermometer that best describes how much moral distress you have been experiencing related to work in the past 2 weeks, including today’.⁵ These authors used the MDS 2009 as the criterion tool to evaluate the convergent validity of the MDT, reporting that MDT had a low correlation with pediatric MDS 2009 and had a moderate correlation with adult MDS 2009. In addition, these authors also calculated the mean MDT scores among different turnover groups and compared the results with those results measured by the MDS 2009, indicating that MDT had satisfactory concurrent validity.

Development of the Chinese version of the MDT

Translation

After obtaining the permission of the authors, two translators translated the original MDT into Chinese following the key steps of the Brislin’s translation process, including a translation with back-translation³⁴. The translation was done by two translators on the basis of fully considering both literal significance and context. Both translators are proficient in both Chinese and English, and translated the context into their respective native languages, with one in each direction. The individual performing the back translation did not see the original MDT. Next, the team of this study compared and discussed the translations until a consensus was reached, with the purpose of reaching operational similarity to the Chinese context.

Content validation

We built an expert panel to evaluate the content validity of the Chinese version of the MDT by assessing the relevance and comprehensiveness of the thermometer-like rating and the descriptive wordings³⁵. Specifically, six experts with rich experience in clinical nursing, nursing ethics, and nursing management, including 2 registered nurses, 2 nursing educators, and 2 nursing administrators, reviewed and discussed the relevance and comprehensiveness of the Chinese version of the MDT in relation to content, semantics, criteria and conceptual nature of the thermometer-like rating and descriptive wordings. All experts invited to participant in the expert panel consistently gave feedback that “the descriptive wordings were accurate, and the rating on the thermometer is related to the experience of capturing moral resilience”, and “the introduction was clear and easy to understand, and descriptive words accurately clarified the MDT rating”.

Moral distress scale-revised

The Chinese version of the MDS-R which was validated by Sun et al.²⁴ based on the MDS-R developed by Hamric et al.³, was used to as the criterion tool. The Chinese version of the MDS-R is a 22-item scale comprising the situations that cause moral distress in four subscales for “individual responsibility (8 items),” “not in the patient’s best interest (5 items),” “conflict of value (6 items),” and “damage patient’s interest (3 items).” Response to items measuring the frequency and intensity were rated on the 5-point Likert scale, with the rating scale ranging from 0 (never) to 4 (great extent). The score of moral distress was calculated by multiplying the scores of the frequency and intensity. The number of points of moral distress was calculated as the total score by adding all the scores for each question. A higher score indicated a stronger sense of moral distress. The Cronbach’s alpha coefficient in the initial version was 0.89, and the Chinese version of the MDS-R reported a Cronbach’s alpha coefficient of 0.88. In this study, a Cronbach’s alpha coefficient of 0.90 was obtained for the overall scale, with 0.85, 0.68, 0.69, and 0.72 for 4 subscales, respectively.

Data collection

We created the link for questionnaire based on the Sojump (available at: https://www.wjx.cn/) which is the most popular online survey platform in mainland of China. The principal investigator of this study firstly built the collaboration relationship with the nursing directors of some hospitals in Chongqing municipal and then shared the link to these nursing directors for the purpose of collecting data using demographics collection form, MDT, and MDS-R. After these nursing directors informed the purpose and procedure of this study, they transferred the link to their working group for asking all professional nurse to finish the data collection.

Statistical analysis

Descriptive statistics were used to describe demographic characteristics of participants. We used mean ± standard deviation (SD) to describe continuous outcomes because the violation of the normality assumption should not cause major problems when a large enough sample size was cumulated (> 30 or 40)³⁶. Convergent validity was evaluated by calculating the correlations between the MDT score and the scores of the MDS-R, which were indicated by Pearson’s correlation coefficients. Concurrent validity was evaluated by comparing: (1) the MDT scores of registered nurses working in different departments and (2) the MDT scores of registered nurses who represented different responses to the final questions in the MDS-R, ‘Have you ever left or considered leaving your working position due to moral distress’? - ‘No: I have never considered leaving or left’, ‘Yes: I have considered leaving my working position, but did not’ and ‘Yes: I have ever left a position’. A one-way ANOVA was used for these comparisons, and a Welch’s ANOVA was used if a homogeneity violation was found; however, a Games-Howell post-hoc test was used if a homogeneity was not violated. A p < 0.05 indicated statistical significance. IBM SPSS 26.0 software (SPSS Inc., Chicago, IL, USA) was used to perform data analysis.

Ethical considerations

We performed this study in strict accordance with the Helsinki Declaration (2013), and the protocol of this study was approved by the Ethics Committee of Chongqing Traditional Chinese Medicine Hospital (XYMS-20). All participants firstly signed the electronic informed consent before entering into the survey page. In addition, participants were informed that their participation in this study was entirely voluntary and would not have any consequences during the survey period due to withdrawal.

Demographic characteristics of participants

A total of 182 respondents returned valid questionnaires for data analysis eventually, with an average age of 32.24 (± 5.98) years. Most of the respondents were males (79.1%), had married (67.6%) and bachelor’s degree (83.5%), experienced night shift (61.0%), and signed as contract nurses (65.4%). The detailed demographics of all participants are documented in Table 1.

Table 1

Demographics of 182 respondents returned valid questionnaires.
Variables	Frequency	Percentage (%)
Sex
Male	38	20.9
Female	144	79.1
Birth place
Rural	128	70.3
Urban	54	29.7
Marital status
Married	123	67.6
Unmarried	59	32.4
Educational level
Associate bachelor degree or below	20	11.0
Bachelor’s degree	152	83.5
Master’s degree or above	10	5.5
Employment type
Contract nurse	119	65.4
Permanent nurse	63	34.6
Job title
Junior	89	48.9
Moderate	78	42.9
Senior	15	8.2
Night shift
Yes	111	61.0
No	71	39.0
Monthly income
2000–5000	23	12.6
5001–8000	89	48.9
> 8000	70	38.5
Working department
Emergency	12	6.6
Internal medicine	19	10.4
Surgical medicine	7	3.8
Pediatric	11	6.0
Gynecological	1	0.5
ICU	7	3.8
Oncological	6	3.3
Anesthesiologic	5	2.7
Others	114	62.6
ICU, intensive care unit.

Score of moral distress

The result showed 3 outliers assessing a score of 10, and after omitting these outliers, a mean MDT score of 2.54 (± 2.21, 95% CI: 2.22–2.86) was calculated. We graphically the distribution of MDT scores among all participants, which was depicted in Fig. 1. The overall mean moral distress score measured by using the MDS-R was 38.66 (± 36.08, 95% CI 33.39–43.94), with an average frequency and intensity of 0.92 and 0.88, respectively.

Convergent validity

We selected the MDS-R as the criterion tool to evaluate the convergent validity of the MDT. As presented in Table 2, the correlation coefficients of the MDT score with the total score of the MDS-R and the scores of its 4 subscales were 0.41, 0.46, 0.36, 0.31, and 0.42, respectively, indicating that the MDT score was moderately related to the total score of the MDS-R and the scores of 2 subscales, namely “not in the patient’s best interest” and “conflict of value. However, the correlations of the total score of the MDT and another 2 subscales of the MDS-R, namely “individual responsibility” and “damage patient’s interest”, were low.

Table 2

Correlation between the MDT and the MDS-R.
Variables	1	2	3	4	5	6
1. Mean MDT score	1.00
2. Total score of MDS-R	0.41^**	1.00
3. Score in ‘individual responsibility’	0.46^**	0.77^**	1.00
4. Score in ‘not in patient’s best interest’	0.36^**	0.90^**	0.61^**	1.00
5. Score in ‘conflict of value’	0.31^**	0.93^**	0.58^**	0.79^**	1.00
6. Score in ‘damage patient’s interest’	0.42^**	0.77^**	0.71^**	0.65^**	0.63^**	1.00
^**indicates p < 0.01. r of ranging from 0.0 to 0.2, from 0.2 to 0.4, from 0.4 to 0.6, from 0.6 to 0.8, and from 0.8 to 1.0 indicates very weaken, weaken, moderate, high, and very high correlation, respectively. MDT, moral distress thermometer; MDS-R, moral distress scale-revised.

Concurrent validity

The result of the Welch’s ANOVA showed that registered nurses working different departments reported different levels of moral distress (F = 4.22; df = 7, 22.19; p = 0.004), and the Games-Howell post-hoc analysis revealed that registered nurses working in ICU reported the highest level of moral distress than those working in other departments (p = 0.04). In addition, result showed difference in the mean MDT scores of registered nurses who presented different responses to the final question of the MDS-R (F = 13.94; df = 2, 13.63; p = 0.001), and results of the Games-Howell post-hoc analysis further showed that registered nurses who had left (mean score = 5.17) and those who had considered leaving but had not left (mean score = 3.34) reported significantly higher MDT scores than those who had never consider leaving (mean score = 1.94), but there was no significant difference between those who had left and those who had considered leaving but had not left (p = 0.153).

The MDT has been wildly used for measuring real-time moral distress and tracking the changes of moral distress over time⁶; however, this tool is still not evaluated in Chinese cultural context. In this study, we translated the original version into Chinese, and evaluated its psychometric properties based on a sample of 466 Chinese registered nurses. The results show that the Chinese version of the MDT has good content and construct validities, therefore is suitable to rapidly and reliably measure moral distress of Chinese registered nurses and easily track the trajectory of moral distress over time.

The Chinese version of the MDT was obtained by translating the original MDT into Chinese in strict accordance with the Brislin’s translation process³⁴. Two experts were firstly assigned to translate the original MDT into their representative languages by considering literal significance and context, then the study team to develop the final version based on the consensus principal. Furthermore, an expert panel involving 6 experts reviewed and discussed the relevance and comprehensibility of the Chinese version of the MDT. All results consistently indicate that the descriptive words in translation are relevant to rate moral resilience, and the introduction in translation clearly informs participants on how to use the tool, indicating that the Chinese version of MDT has achieved satisfactory content validity.

This study also evaluated the criterion validity of the Chinese version of MDT by referring the MDS-R²⁴. The Chinese version of MDS-R has satisfactory reliability, with a Cronbach’s alpha coefficient of 0.88. So, it is reasonable and reliable to evaluate the Chinese version of the MDT by using the Chinese version of the MDS-R as the criterion validity index. The result of Pearson correlation analysis showed that the Chinese version of the MDT had low to moderate correlation to the MDS-R and its 4 subscales (p < 0.01), implying that the Chinese version of the MDT did measure moral resilience of Chinese registered nurse. Considering that MDS-R consists of abundant items and complex response to items, the MDT may be more suitable for evaluating the real-time moral distress and tracking the changes of moral distress in intervention study^37–39.

Previous studies have shown that departments with more decisions regarding ethical issues (e.g., ICU and emergency) may cause more moral conflicts than those that had higher acuity and lower predictability^{40, 41}. Jawed et al.⁴² reported that the perceived moral distress varied by specialty, and critical care had more moral distress than specialties labeled as “other”. Moreover, the study performed by Wolf et al.⁴³ revealed that moral distress in ICU was higher than other departments because sources of moral distress are more frequent and intense with conflicting goals, more infliction of harm, pain and suffering. In our study, registered nurses’ perceived level of moral distress was compared by different departments, and the results showed that those working in ICU reported the highest degree of moral distress than those who worked in “other” departments, which is consistent with findings of previous studies, indicating a good discriminant validity of the MDT.

We also evaluated the concurrent validity of the Chinese version of the MDT by comparing the MDT scores between registered nurses who made different responses to the final question of the MDS-R. The results showed that registered nurses who had ever left and those who had considered leaving but had not left rated higher MDT scores than those who had never consider leaving. In their study, Wolf et al.⁴³ reported that the MDT scores of participants who currently intended to leave their working positions are significantly higher than those of other participants⁴³. In addition, when evaluated the psychometrics of the Swedish version of the MDT, Grönlund et al.⁶ also consistently found that healthcare professionals who had ever left and those who had considered leaving but had not left reported significantly higher moral distress than those who had never considered leaving their position. All these findings were consistent with our study, suggesting that the Chinese version of the MDT had acceptable concurrent validity and also implying that leaving the current working position seems to be one way for registered nurses to effectively address moral distress. According to the Rushton’s theoretical framework⁴⁴, unaddressed moral distress may impair an individual’s wellbeing and cause moral harm, further resulting in outrage and professional burnout; however, avoidance and abandonment can be ways to transparently respond to such suffering.

This study has three limitations. The first one is that we did not evaluate the reliability of the Chinese version of the MDT by designing the test-retest trial. However, as stated by Wocial and Weaver in their instrument development study⁵, moral distress is a changeable variable over time, therefore it may not be suitable to evaluate the test-retest reliability of the MDT. Second, the sample size of 182 registered nurses met the minimum criteria but did not reach the maximum criteria, therefore we suggest future studies also evaluate the psychometrics of the Chinese version of the MDT when they use this tool to measure moral distress. Third, we recruited participants through online platform, which inevitably undermines the robustness of our results due to sample bias.

The Chinese version of MDT accurately reflect the rating on moral distress and has acceptable criterion validity and concurrent validity, indicating that MDT can be used as a reliable and valid instrument to measure the perceived level of moral distress of Chinese registered nurses. As a result, when a study was performed to evaluate the effectiveness of interventions aimed at mitigating the moral distress of registered nurses, MDT should be preferentially selected as the instrument to easily and effectively evaluate the changes in moral distress over time.

Acknowledgements

The authors would like to thank the participants for contributing to the study.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed that they do not receive any financial support.

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Adaptation and validation of moral distress thermometer in Chinese nurses

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Abstract

Figures

Introduction

Background

Methods

Aim

Study design

Participants

Instruments

Moral distress thermometer

Development of the Chinese version of the MDT

Translation

Content validation

Moral distress scale-revised

Data collection

Statistical analysis

Ethical considerations

Result

Demographic characteristics of participants

Score of moral distress

Convergent validity

Concurrent validity

Discussion

Conclusion

Declarations

References

Status:

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