Cross-cultural adaptation, reliability, and validity of the Turkish Version of the Moral Courage Scale for Physicians

doi:10.21203/rs.3.rs-4821326/v1

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Cross-cultural adaptation, reliability, and validity of the Turkish Version of the Moral Courage Scale for Physicians

https://doi.org/10.21203/rs.3.rs-4821326/v1

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Background

Physicians, like other healthcare professionals, frequently encounter situations requiring moral courage in their professional lives. However, studies on the moral courage of physicians are limited in the literature. This study aims to evaluate the Turkish adaptation, validity, and reliability of the Moral Courage Scale for Physicians (MCSP) and to contribute to national and international studies on moral courage among physicians.

Materials and methods

This methodological study involved the adaptation, validity, and reliability assessment of the MCSP in Turkish. The scale's internal consistency was evaluated using Cronbach's α coefficient, and the total correlation coefficients for the items were calculated. Test-retest reliability was assessed using a two-group design.

Results

The Turkish version of the MCSP demonstrated high internal consistency, with a Cronbach's α coefficient of 0.91. The total correlation coefficients for the items ranged from 0.387 to 0.797. A significant positive correlation was found between the test and retest scores of the MCSP (p < 0.05).

Conclusion

The Turkish version of the MCSP is a valid and reliable tool for assessing moral courage among physicians.

Moral Courage

physician

validity

reliability

ethics

Moral courage is a concept that represents an individual's courage and inner strength to act in accordance with moral and ethical values (1). This concept involves the ability to defend what is right despite negative consequences (2). It also signifies the strength that emerges when dealing with threats to one's own moral and ethical values (3).

From a healthcare and medical perspective, moral courage includes the ability to advocate for the needs of patients, protect their treatment rights, and intervene in patient care. This is critically important in terms of being committed to acting in the best interests of patients. Moral courage requires helping patients confront their vulnerabilities and pains, witnessing their vulnerabilities and pains, and acting with determination and dedication to provide professional care (2,4–7)In this context, the demonstration of moral courage by healthcare professionals can contribute to gaining patients' trust, acting in accordance with ethical standards, and protecting individuals' rights in the process of receiving healthcare.

Moral courage holds great value for healthcare personnel. However, the demonstration of moral courage is influenced not only by an individual's internal values but also by environmental factors. Factors such as working conditions, role conflicts, power dynamics, and organizational culture in the healthcare sector are significant barriers that individuals face when demonstrating moral courage. Additionally, demonstrating moral courage can sometimes expose individuals to negative reactions, intimidation, and even the risk of psychological or physical violence from colleagues or superiors. These situations imply the risk of individuals losing their jobs or status. Personal or organizational barriers can lead healthcare personnel to struggle to act in accordance with ethical values and experience traumatic experiences despite knowing what is right (8).

The lack of moral courage can have potentially significant consequences for both healthcare personnel and patients (9). For healthcare personnel, a lack of moral courage can lead to difficulties in making ethical decisions or behaving in accordance with moral values. This can lead to healthcare personnel having difficulty coping with moral stress, which can affect their professional satisfaction and performance. For patients, a lack of moral courage can pave the way for unethical behaviors or negative events. When healthcare personnel struggle to uphold ethical principles, patients' rights to respect and receive treatment in accordance with ethical standards may be at risk. This can lead to patients losing their trust and negatively impacting their treatment processes. Medical educators should continue to demonstrate and emphasize examples of moral courage in medical practice and encourage trainees to do the right thing despite potential negative outcomes (10).

Physicians often encounter ethical challenges in their professional practice. One of the important qualities that physicians need to overcome such challenges is courage (11). Various strategies are implemented during medical education to develop physicians' moral courage. These strategies include discussing ethical principles, case studies, and role-playing activities. However, there is limited evidence regarding the effectiveness of these strategies, partly due to the difficulty in effectively measuring physicians' moral courage (12).

In recent years, both national (such as devastating earthquakes affecting many provinces in Türkiye) and global (such as the Coronavirus pandemic) extraordinary situations have affected the healthcare system and consequently, physicians, leaving them facing ethical conflicts. In this context, determining the levels of moral courage of physicians after events with societal and global impacts is particularly important.

Studies on moral courage in healthcare professionals generally focus on nurses, and research on the moral courage of physicians is limited. In the Turkish literature, the lack of a scale to evaluate the level of moral courage of physicians highlights this gap. In this context, a comprehensive study is aimed to be conducted by conducting a Turkish validity and reliability study of the Moral Courage Scale for Physicians/MCSP developed by Martinez and colleagues (2016), in order to understand cultural differences in this field.

Study Design and Sample

The Turkish adaptation of the Moral Courage Scale has a methodological study design. The sample size to be used in the study was determined taking into account the number of items in the scale. It was planned to include at least 10 times the number of items in the scale (9) as sampling units in the study (13), and the study was completed with 106 participants. Participants were selected using non-probabilistic sampling methods, specifically volunteer sampling and snowball sampling.

Data Analysis

SPSS 26.0 (Statistical Program in Social Sciences) was used for descriptive factor analyses, descriptive information, and reliability analyses, while AMOS 24 was used for confirmatory factor analysis. A reliability coefficient of 0.95 and a significance level (p-value) of 0.05 were accepted for the analyses, and interpretations were made. Descriptive statistics were used, with mean ± standard deviation for quantitative data and number and percentage for qualitative data.

Language Validity

After obtaining permission for the Turkish adaptation of the "Moral Courage Scale" by Martinez (2016), a blind Turkish translation was made by two language experts who were aware of the study's purpose but not its content. After the translation, the two forms were compared, and the items that best matched the scale were selected. The prepared form was then translated back into Turkish by a language expert proficient in Turkish and whose native language is English, and compared with the original form. The items were selected, and a 9-item questionnaire pool was prepared (14).

Content (Expert) Validity

The scale form was sent to 12 different experts (experts in medical history and ethics, experts in nursing ethics) to score the items of the scale (15) according to their level of understandability on a scale of 1 and 3 (1: the scale item is not necessary, 2: the scale item is useful but not sufficient, 3: the scale item is necessary and should be included in the questionnaire). The responses from the experts were used to calculate the content validity index. The calculated Kendall W value was 0.029, which was statistically significant (ꭓ2=2.737, p=0.950). It was observed that the 9 items in the questionnaire pool were understandable and suitable for the Turkish population, and the study proceeded to the pilot application stage (15,16).

Pilot Application

A pilot application of the Moral Courage Scale, consisting of 9 items, was conducted with 20 individuals. When the responses to the items were examined, it was observed that there were no difficulties in understanding, the responses were given easily, and the questions were suitable for the population. Therefore, data collection for the scale was initiated.

Psychometric Testing of the Moral Courage Scale

During the data collection process, 106 participants were reached, and the collected data were prepared for analysis. Variance homogeneity, normal distribution, independence, randomness, and absence of autocorrelation in error terms were checked in the data controls for multivariate analysis. Outlier distributions in the data were checked, and it was observed that all data forms were within the ±2.5 limit, so data exclusion was not performed. Exploratory factor analysis (EFA) was applied to prepare the initial model for the scale, and confirmatory factor analysis (CFA) was applied to obtain the final model. After determining the scale model, reliability tests were performed using Cronbach's α coefficient and test-retest analyses.

Multivariate Normal Distribution

To check for multivariate normal distribution, the Mahalanobis Distance criterion was applied to the questionnaire form of the 106 participants, and no form was observed to fall outside the ±2.5 value range (16). Using the "Observations farthest from the centroid (Mahalanobis Distance)" subtab in the AMOS program, the index value was calculated as 5.193, which is less than 8, indicating that multivariate normal distribution was achieved (17). With the assumption of normality satisfied for the scale, validity and reliability analyses were conducted.

Demographic Information of Participants

The demographic information of the participants is presented in the table below (Table 1).

Table 1

Demographic Information of the Participants
Variable	Groups		Frequency	Percent
Gender	Female		48	45.3
Gender	Male		58	54.7
Marital Status	Married		67	63.2
Marital Status	Single		39	36.8
Title	Intern doctor		51	48.1
	Resident doctor		1	0.9
	General Practitioner		16	15.1
	Family Physician		2	1.9
	Medical Specialist		17	16.0
	Assistant Professor		9	8.5
	Associate Professor		7	6.6
	Professor		3	2.8
Specialty field	Intern doctor		11	10.4
	Internal Medicine		74	69.8
	Surgical Medicine		18	17.0
	Basic Medicine		3	2.8
Ethics Education Received	Yes		65	61.3
Ethics Education Received	No		41	38.7
Ethics Education	Undergraduate Education		50	47.2
	Course, Seminar, Symposium		6	5.7
	In-service training		7	6.6
	Doctorate Education		2	1.9
	No Education		41	38.7
Encountering Ethical Issues Status	Rarely		21	19.8
	Sometimes		45	42.5
	Very Often		11	10.4
	Quite Often		26	24.5
	Constantly		3	2.8
Receiving Ethical Consultancy Status	Yes		9	8.5
Receiving Ethical Consultancy Status	No		97	91.5
Frequency of Moral Courage Encounters	Rarely		20	18.9
	Sometimes		50	47.2
	Very Often		10	9.4
	Quite Often		25	23.6
	Constantly		1	0.9
Total			106	100.0
Variable		Mean ± SD		Min - Max
Age		37.39 ± 11.15		20–70
Years of experience		12.39 ± 11.08		1–46
SD; standard deviation

Table 1. Demographic Information of Participants

Construct Validity

First, the Kaiser-Meyer-Olkin (KMO) test was conducted to assess the adequacy of the data for Exploratory Factor Analysis (EFA). The KMO value is a measure indicating the suitability of the data for analysis, with a minimum value of 0.60 considered acceptable. Additionally, a high value for Bartlett’s Test of Sphericity supports the appropriateness of the data structure for the model (14). The results of Bartlett’s Test of Sphericity calculated with the KMO test for the Moral Courage Scale are presented in the table below (Table 2).

Table 2

KMO and Bartlett’s test of sphericity
Kaiser‒Meyer‒Olkin Measure of Sampling Adequacy.		0.900
Bartlett's Test of Sphericity	Approx. Chi-Square	601.126
	df	36
	p	0.001*
df; degree of freedom, *p < 0,05; the test is statistically significant.

Table 2. KMO and Bartlett’s Test of Sphericity Test

The KMO value was calculated as 0.900, and the Bartlett’s Test of Sphericity value was 601.126. A KMO test value of 0.90 indicates that the sample size is highly adequate for the scale. The sample size and structure were found to be suitable for the application of EFA (14).

The factor loadings, Corrected Item-total Correlations, and % Variance Explained obtained from the applied EFA are presented in the table below.

Table 3. Factor Loadings and Item-Total Correlations of the Moral Courage Scale

Table 3

Factor Loadings and Item–Total Correlations of the Moral Courage Scale
Items	Factor Loadings
Q1	0.728
Q2	0.841
Q3	0.798
Q4	0.850
Q5	0.850
Q6	0.642
Q7	0.847
Q8	0.453
Q9	0.845
% Variance Explained	73.6

Factor loadings for the items in the scale were analyzed, considering a minimum threshold of 0.30. Upon examining the scale model, it was observed that there were no factor loadings below 0.30. The percentage of explained variance for the scale was calculated to be 73.6%, indicating that the explained variance ratio was at the desired level for the scale. The range of factor loadings varied between 0.453 and 0.850 (Table 3).

In the selection of the subdimensions, subdimensional ranges with eigenvalues above 1 and the varimax rotation method were used (18).

In EFA analyses, the number of factors is determined by different methods (19).

The first and most preferred criterion is the Kaisen criterion, and the roots (λ ≥ 1) greater than one in the covariance and correlation matrix are preferred.
The points where the slope starts to disappear in the number of factors determined by the Scree Plot Method are taken into consideration
Joliffe Criterion (taking as many factors as the number of eigenvalues greater than 0.7); as many factors as the number of eigenvalues 0.7 and greater (λ ≥ 7) are determined,
It is a practical method to determine as many factors as the number of eigenvalues greater than one,
Comprehensibility; selecting variables that can be explained by the structure of the variables,

The explained variance criterion; the number of factors is selected as the number of eigenvalues so that the cumulative variance explained by the eigenvalues is at least 67% (70%-95%), and it is necessary to determine the number of factors that will explain a very high variance.

There are different views on the explained variance criterion;

M to indicate the number of significant eigenvalues;

\(\:\sum\:_{j=1}^{m}\frac{{\lambda\:}\text{i}}{p}\:\ge\:\) 2/3 or \(\:\sum\:_{j=1}^{m}\frac{{\lambda\:}\text{i}}{p}\:\ge\:\) 0.66

The smallest value of m satisfying the condition gives the number of significant principal components. On the other hand, while a cut-off point of 0.66 is considered appropriate by some authors, the cumulative variance ratio can be taken as 0.95 in science and natural sciences and 0.60 in social sciences where information is less precise (20).

In the selection of the subdimensions, subdimensional ranges with eigenvalues above 1 and the varimax rotation method were used (21, 22).

Following the Exploratory Factor Analysis (EFA), the Confirmatory Factor Analysis (CFA) stage was conducted for the "Moral Courage Scale," which consists of 9 items representing a single underlying dimension.

Confirmatory Factor Analysis

Confirmatory Factor Analysis (CFA) was conducted to test the accuracy of the scale model consisting of a single underlying dimension with 9 items obtained in the first stage of construct validity (21, 22). The initial structure of the scale was prepared and analysed. The goodness of fit indices obtained from the analysis were calculated as follows: χ2 (Chi-Square Goodness of Fit) = 76.730 and χ2/df = 2.842. The RMSEA (Root Mean Square Error of Approximation) value, used for sample adequacy, was found to be 0.132. While the NFI (Normed Fit Index) was 0.877, the CFI (Comparative Fit Index) and GFI (Goodness of Fit Index) were 0.915, and the IFI (Incremental Fit Index) was 0.917. It was observed that the NFI and RMSEA values did not fall within the desired range (23).

Due to the calculated values not meeting the desired level, modifications were required in the model, which may be due to relationships within the model, measurement errors, or existing relationships in the model that could not be analysed (24).

To apply modifications, covariances were added in pairs to the error terms of observable variables (scale items). Relationships between error terms within the same subscale were considered in covariance drawing. The main purpose of covariance drawing is to include abstract concepts explained simultaneously by two error terms without calculating them in the model (25). The effects of external factors were included in the model through covariances, and modifications were made to the scale model. For the "Moral Courage Scale," the highest residual terms, with modification index values, were e5-e7 and e8-e9, and covariances were drawn between these pairs of error terms in the model. The diagram of the final model of the scale is given below (Fig. 1).

Figure 1. Diagram of the "Moral Courage Scale" in IBM SPSS AMOS 23 Program.

Confirmatory factor analysis (CFA) is one of the sub-analyses of structural equation modeling (SEM). In SEM analyses, multiple indices are provided and interpreted for model fit (26, 27). In the modified new model of the "Moral Courage Scale," the χ2 value was found to be 39.904 and the χ2/df value was 1.596. The RMSEA value was calculated as 0.075, indicating that the sample size was sufficient for the scale model. It was also observed that the GFI value increased to 0.919, the CFI and IFI values increased to 0.975, and the NFI value increased to 0.936.

The χ2/df (χ2/sd ≤ 5) value decreased, and the RMSEA (RMSEA ≤ 0.08), GFI, CFI, NFI, and IFI values increased, indicating a good fit of the model. Due to the statistically significant and sufficient relationship established between the constructed SEM and the scales, the multiple group analysis stage was entered (28, 29).

The single subscale 9-item scale model prepared with EFA for the "Moral Courage Scale" was confirmed by modifying the DFA model. Thus, the validity analysis of the "Moral Courage Scale" has been completed.

Reliability

In order to calculate the reliability of the scale, Cronbach's Alpha (α) coefficient of internal consistency and Split-Half method were used. The Cronbach's α coefficient value ranges from 0 to 1, where values below 0.50 indicate that the scale is not reliable. As the coefficient value approaches 1, the reliability value also increases (30). While increasing the number of items in the scale can increase the reliability value (31), in cases where the number of items is low, a Cronbach's α coefficient value of 0.50 is considered acceptable (32). Item-total correlation coefficients are also preferred for reliability. An item-total correlation coefficient value of at least 0.20 for items in a scale is considered sufficient for reliability (33).

Table 4. Moral Courage Scale" Cronbach’s alpha (α) values

Table 4

Moral Courage Scale Cronbach’s alpha (α) values
Items	Corrected Item-Total Correlation
Q1	0.660
Q2	0.770
Q3	0.705
Q4	0.773
Q5	0.749
Q6	0.553
Q7	0.756
Q8	0.387
Q9	0.797
Cronbach's α	0.91

The Cronbach's α coefficient for the Moral Courage Scale was calculated as 0.91, and the range of total correlation coefficients for the items in the scale was found to be 0.387–0.797 (Table 4).

The second stage of reliability analysis for the scale, which is the test-retest analysis, used a sample of 30 participants(34). The results of the tests are presented in the table below (Table 5).

Table 5

Test-Retest Results
Moral Courage Scale	Grup	Mean ± sd	Cronbach’s α	t	p¹	r	p²
	Test	56.81 ± 3.65	0.754	0.773	0.449	0.927	< 0.001*
	Retest	56.55 ± 2.92	0.791
sd; standard deviation, t; paired t test, r; Pearson correlation coefficient

Table 5. Test-Retest Results

When the total score of the Moral Courage Scale was examined, a very high level of statistically significant positive relationship was found between the test and retest groups (p < 0.05).

Scale Score Calculation

In the scale scoring, a 7-point Likert-type scoring was used for the responses. The maximum score that can be obtained from the scale is 63, while the minimum score is 7.

The values for the 106 participants in the study are given in the table below.

Table 6. Descriptive Statistics for Scores Obtained from the Moral Courage Scale

Table 6

Descriptive Statistics for the Moral Courage Scale Scores
Moral Courage Scale	Mean ± sd	Min–Max Scores to Receive From the Scale
	54.43 ± 8.02	11–63
sd; standard deviation

Of the 106 participants in the study, the lowest score obtained from the scale total was 11, and the highest score was 63, with a mean score of 54.43 ± 8.02 standard deviation (Table 6).

The studies on moral courage directed towards physicians are quite limited. Understanding the level of moral courage of physicians from the pre-graduation period throughout their professional lives to prepare them for ethical problems they may encounter and to enable them to cope with these problems is of great importance. Although various views have been put forward regarding moral courage, there is no Turkish tool that measures these characteristics in physicians. Therefore, this study was conducted to evaluate the appropriateness, validity, and reliability of the Turkish version of the scale developed by Martinez (2016) to determine the level of moral courage of physicians. The fact that such a study is conducted for the first time in Türkiye is one of the strongest aspects of this study. The lack of research on the moral courage of physicians at the national and international levels limits the discussions on this subject. This study makes an important contribution to understanding and improving physicians' capacity to cope with ethical challenges.

A total of 106 participants were included in the study. The Kaiser-Meyer-Olkin (KMO) test value of the scale, which ensured multivariate normal distribution, was 0.90, indicating that the sample size was quite high in terms of evaluating the adequacy of the scale. The basic model of the scale, which formed the basis of the analyses, was prepared using exploratory factor analysis (EFA) and was confirmed by modifications made in the confirmatory factor analysis (CFA) model. Cronbach's α coefficient was calculated to evaluate the internal consistency of the scale and found to be 0.91. Additionally, the range of total correlation coefficients for the items in the scale was calculated to be between 0.387 and 0.797. These results indicate that the scale was designed reliably and consistently and can be used.

In the analysis of the test-retest groups of the scale, statistically significant and highly positive relationships were found (p < 0.05). According to the results obtained with the 7-point Likert-type scoring used in the scale scoring, the maximum score that can be obtained from the scale was determined to be 63, while the lowest score was determined to be 7. The lowest score obtained from the scale total by the 106 participants included in the study was 11, the highest score was 63, and the mean score was found to be 54.43 ± 8.02 standard deviation. These results indicate that the scale is reliable and stable. It can be said that the participants' levels of moral courage are generally high, and the scale successfully measures these differences.

In conclusion, this study includes the adaptation study of the Moral Courage Scale into Turkish, and the obtained data show that the scale can provide valid and reliable results. These results suggest that the scale can be an effective tool for evaluating the level of moral courage and can provide reliable results in studies. Additionally, the scale's low number of items increases its usability and facilitates the answering of relevant items. Therefore, this scale will be able to determine the levels of moral courage of physicians, reveal cultural differences, and allow for the planning of necessary arrangements in both undergraduate and in-service trainings starting from the pre-graduation period, and the results obtained can offer solution proposals regarding the situation.

Ethical Considerations

The study was conducted in accordance with the Helsinki Declaration and was approved by the Duzce University Non-Interventional Ethics Committee (Ref: 2022/80).

Source of Finance

This study was funded internally.

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement

Data will be available upon request from the corresponding author of the study.

Conflicts of Interest

The authors declare no conflict of interest.

Consent for publication

Not Applicable.

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Cross-cultural adaptation, reliability, and validity of the Turkish Version of the Moral Courage Scale for Physicians

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Abstract

Background

Materials and methods

Results

Conclusion

Figures

Introduction

Materials and methods

Results

Demographic Information of Participants

Construct Validity

Confirmatory Factor Analysis

Reliability

Scale Score Calculation

Discussion

Declarations

References

Additional Declarations

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