Scientific letter
Validation and psychometric properties of the Spanish version of the Measure of Moral Distress for Health Care Professionals (MMD-HP-SPA)
Validación y propiedades psicométricas de la versión en español de la medida de desasosiego moral para profesionales sanitarios (MMD-HP-SPA)
E. Rodriguez-Ruiza,b,c,
, M. Campelo-Izquierdod, A. Estany-Gestale, A.B. Hortase, M.S. Rodríguez-Calvof, A. Rodríguez-Núñezb,c,g
Corresponding author
a Intensive Care Medicine Department, University Clinic Hospital of Santiago de Compostela (CHUS), Galician Public Health System (SERGAS), Santiago de Compostela, Spain
b Life Support and Medical Simulation Research Group, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
c CLINURSID Research Group, University of Santiago de Compostela, Santiago de Compostela, Spain
d Division of Nursing, Intensive Care Medicine Department, University Clinic Hospital of Santiago de Compostela (CHUS), Galician Public Health System (SERGAS), Santiago de Compostela, Spain
e Epidemiology and Clinical Research Unit, Health Research Institute of Santiago (IDIS), Santiago de Compostela, Spain
f Institute of Forensic Sciences, University of Santiago de Compostela, Spain
g Paediatric Intensive Care Unit, Department of Pediatrics, University Clinic Hospital of Santiago de Compostela (CHUS), Galician Public Health System (SERGAS), Santiago de Compostela, Spain
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"apellidos" => "Rodríguez-Núñez" "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">g</span>" "identificador" => "aff0035" ] ] ] ] "afiliaciones" => array:7 [ 0 => array:3 [ "entidad" => "Intensive Care Medicine Department, University Clinic Hospital of Santiago de Compostela (CHUS), Galician Public Health System (SERGAS), Santiago de Compostela, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Life Support and Medical Simulation Research Group, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "CLINURSID Research Group, University of Santiago de Compostela, Santiago de Compostela, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Division of Nursing, Intensive Care Medicine Department, University Clinic Hospital of Santiago de Compostela (CHUS), Galician Public Health System (SERGAS), Santiago de Compostela, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Epidemiology and Clinical Research Unit, Health Research Institute of Santiago (IDIS), Santiago de Compostela, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Institute of Forensic Sciences, University of Santiago de Compostela, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] 6 => array:3 [ "entidad" => "Paediatric Intensive Care Unit, Department of Pediatrics, University Clinic Hospital of Santiago de Compostela (CHUS), Galician Public Health System (SERGAS), Santiago de Compostela, Spain" "etiqueta" => "g" "identificador" => "aff0035" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Validación y propiedades psicométricas de la versión en español de la medida de desasosiego moral para profesionales sanitarios (MMD-HP-SPA)" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Moral distress (MD) is the psychological consequence that occurs when healthcare professionals (HCPs) cannot carry on what they believe is the ethically correct action.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> This serious problem threats the integrity not only of HCPs but of healthcare organizations as well. MD has been associated with risk of burnout, employee attrition, propensity to leave a position and decreased quality of care.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2–6</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In order to precise and study MD, valid and reliable tools to measure its impact are needed.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> In this sense Epstein et al., in 2019, developed and validated the most recent instrument to explore MD.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> The Measure of Moral Distress for Healthcare Professionals (MMD-HP) is a 27-item scale that captures the five key components of MD directly and indirectly: complicity in wrongdoing, lack of voice, wrongdoing associated with professional (not personal) values, repeated experiences, and three levels of etiologies (patient, unit, system). This tool is a self-administered questionnaire, the participants rate each item on a Likert scale for how often it occurs in their practice (frequency: 0<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>never, 4<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>very frequently) and for how distressing it is when it occurs (distress: 0<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>none, 4<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>very distressing). The frequency score (<span class="elsevierStyleItalic">f</span>) is multiplied by the distress score (<span class="elsevierStyleItalic">d</span>) to create a composite score (“<span class="elsevierStyleItalic">f</span>×<span class="elsevierStyleItalic">d</span>,” range 0–16) for each item. These composite item scores are summed to create an overall MMD-HP score (range 0–432), with higher scores indicating higher levels of MD. Additionally, two open boxes were created for respondents to add other situations that cause MD in their particular practice in order to gain further data on root causes. Write-in items are not included in the composite score. In the original study, the MMD-HP had an excellent reliability, with Cronbach's <span class="elsevierStyleItalic">α</span> ranging from 0.90 to 0.93, depending on professional group.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">To the best of our knowledge, no prior instruments to measure MD has been validated in Spanish. Therefore, as part of the <span class="elsevierStyleItalic">Desasosiego Moral en la Unidad de Cuidados Intensivos</span> (DEMOUCI) research project, we aim to develop and validate the Spanish version of the MMD-HP (MMD-HP-SPA) (<a class="elsevierStyleCrossRef" href="#sec0030">Appendix B</a>). Firstly, a structured 10-step cultural adaptation and translation process<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> was carried out as it follows:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">•</span><p id="par0020" class="elsevierStylePara elsevierViewall">Step 1 involved preparation by the researchers working with the instrument developer. Written permissions to use the MMD-HP was obtained from Prof. Ann B. Hamric, who developed this tool (written permissions received by e-mail in August 2019).</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">•</span><p id="par0025" class="elsevierStylePara elsevierViewall">Step 2 was the initial forward translation of the MMD-HP from English to Spanish provided by two bilingual expert researchers who work in ICU.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">•</span><p id="par0030" class="elsevierStylePara elsevierViewall">Step 3 was ensuring that this translation was appropriate for the Spanish critical care setting.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">•</span><p id="par0035" class="elsevierStylePara elsevierViewall">Step 4 was back translation from Spanish to English by two professional translators who can understand and speak both languages (English and Spanish), and who had not seen the original scales.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">•</span><p id="par0040" class="elsevierStylePara elsevierViewall">Step 5, the authors compared the back translation of the scales with the original scales in order to verify the equivalence in terms of grammar between the two versions.</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">•</span><p id="par0045" class="elsevierStylePara elsevierViewall">Step 6, harmonization included reaching consensus among the research team.</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">•</span><p id="par0050" class="elsevierStylePara elsevierViewall">Step 7, the scales were then pilot tested on two physicians and three nurses to resolve ambiguous expressions that could lead to item misunderstanding. A supporting text was included in order to collect any doubts that could be raised with any question regarding comprehension and writing, and to prove the overall assessment of the questionnaire by the HCPs.</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">•</span><p id="par0055" class="elsevierStylePara elsevierViewall">Step 8 was to analyze the results of the pilot test and to complete the translation by the research team.</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">•</span><p id="par0060" class="elsevierStylePara elsevierViewall">Step 9 was to edit the questionnaires.</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">•</span><p id="par0065" class="elsevierStylePara elsevierViewall">Step 10 is the final report of the research team.</p></li></ul></p><p id="par0070" class="elsevierStylePara elsevierViewall">Afterwards, we conducted a cross-sectional study across Spanish ICUs. The study population included intensivists and critical care nurses directly involved in critically ill patient care. The questionnaire was electronically distributed via <span class="elsevierStyleItalic">Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias</span> (SEMICYUC), <span class="elsevierStyleItalic">Sociedad Galega de Medicina Intensiva y Unidades Coronarias</span> (SOGAMIUC), <span class="elsevierStyleItalic">Sociedad Española de Enfermería Intensiva y Unidades Coronarias</span> (SEEIUC), and <span class="elsevierStyleItalic">Sociedad Española de Cuidados Intensivos Pediátricos</span> (SECIP) mailing lists. A total of 1065 HCPs, 608 critical care nurses and 457 intensivists, completed the questionnaire between October and December 2019.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Cronbach's <span class="elsevierStyleItalic">α</span> computations suggested good reliability of the MMD-HP-SPA for the overall sample (Cronbach's <span class="elsevierStyleItalic">α</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.97) and for each provider group; nurse Cronbach's <span class="elsevierStyleItalic">α</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.97 and physician Cronbach's <span class="elsevierStyleItalic">α</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.94. Item-to-item correlations and changes in alpha calculations if particular items were deleted were evaluated and no problematic items were identified. In addition, ordinal alpha calculation also showed good reliability of the MMD-HP-SPA for the overall sample (ordinal alpha<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.98) and for each provider group; nurse ordinal alpha<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.98 and physician ordinal alpha<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.98. To evaluate construct validity, we tested four hypotheses. Each hypothesis is supported by previous studies. First, we hypothesized that physicians would have lower levels of MD than nurses.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5,7,9</span></a> Second, we hypothesized that healthcare professionals who were considering leaving their position due to MD would have higher MMD-HP-SPA scores than those not considering leaving. Third, based on previous studies,<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> we hypothesized that higher MMD-HP scores would be associated with poorer provider perceptions of their Unit's ethical climate. Finally, we hypothesized that the MMD-HP-SPA would have a three-level structure (patient, team, and system), reflective of the levels of MD identified from MD consultation.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> The MMD-HP-SPA proved to be a valid instrument to measure MD as three of the four validity hypotheses were supported.</p><p id="par0080" class="elsevierStylePara elsevierViewall">In conclusion, the MMD-HP-SPA is a valid and reliable instrument that will assist in the assessment of specific MD root causes. We hope it can be of help for future studies in ICUs located both in Spain and Latin-American countries in order to target interventions for particular units, teams, and professionals.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Ethics approval and consent to participate</span><p id="par0085" class="elsevierStylePara elsevierViewall">The local Research Ethics Committee approved the study (ref. CAEIG 2019/471). Participation was on a voluntary anonymous basis and informed consent was assumed by return of completed survey.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Authors’ contributions</span><p id="par0090" class="elsevierStylePara elsevierViewall">ERR and MCI wrote and prepared the manuscript. AEG and ABH performed statistical analysis. MSRC and ARN supervised and approved the final version of the manuscript.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Funding</span><p id="par0095" class="elsevierStylePara elsevierViewall">This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conflict of interest</span><p id="par0100" class="elsevierStylePara elsevierViewall">The authors have no conflict of interest to declare regarding this article.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Ethics approval and consent to participate" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Authors’ contributions" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Funding" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflict of interest" ] 4 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0110" class="elsevierStylePara elsevierViewall">The following are the supplementary data to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0030" ] ] ] ] "multimedia" => array:1 [ 0 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:2 [ "fichero" => "mmc1.pdf" "ficheroTamanyo" => 189711 ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Nursing practice: the ethical issues" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "A. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 4 | 1 | 5 |
| 2024 October | 54 | 37 | 91 |
| 2024 September | 56 | 30 | 86 |
| 2024 August | 52 | 44 | 96 |
| 2024 July | 39 | 25 | 64 |
| 2024 June | 63 | 45 | 108 |
| 2024 May | 66 | 38 | 104 |
| 2024 April | 59 | 40 | 99 |
| 2024 March | 49 | 19 | 68 |
| 2024 February | 46 | 40 | 86 |
| 2024 January | 38 | 35 | 73 |
| 2023 December | 38 | 39 | 77 |
| 2023 November | 49 | 48 | 97 |
| 2023 October | 24 | 64 | 88 |
| 2023 September | 29 | 62 | 91 |
| 2023 August | 32 | 34 | 66 |
| 2023 July | 34 | 46 | 80 |
| 2023 June | 32 | 43 | 75 |
| 2023 May | 45 | 65 | 110 |
| 2023 April | 19 | 44 | 63 |
| 2023 March | 46 | 66 | 112 |
| 2023 February | 28 | 48 | 76 |
| 2023 January | 24 | 68 | 92 |
| 2022 December | 59 | 76 | 135 |
| 2022 November | 45 | 77 | 122 |
| 2022 October | 62 | 57 | 119 |
| 2022 September | 37 | 57 | 94 |
| 2022 August | 35 | 61 | 96 |
| 2022 July | 38 | 48 | 86 |
| 2022 June | 34 | 33 | 67 |
| 2022 February | 1 | 2 | 3 |
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