Sage Journals: Discover world-class research

Abstract

Background

Moral distress occurs when ethically appropriate actions cannot be implemented, resulting in cognitive and emotional strain linked to outcomes like burnout and staff turnover. Despite extensive cross-cultural validation of the Measure of Moral Distress for Healthcare Professionals (MMD-HP), no Italian adaptation currently exists, limiting research in Italian contexts.

Aim

To culturally adapt and validate the Italian version of the Measure of Moral Distress for Healthcare Professionals (MMD-HP-ITA) within two major Italian healthcare settings.

Methods

An observational multicenter cross-sectional study was conducted from December 2022 to September 2023. The original questionnaire underwent forward-backward translation. Confirmatory and exploratory factor analyses evaluated structural validity, and Cronbach’s alpha assessed internal consistency. Construct validity was tested by correlating scores with the Ethical Leadership Scale.

Participants

A sample of 567 healthcare professionals (median age 43 years; 74% female; 74% nurses) was recruited and completed the Italian version of the questionnaire online.

Ethical consideration

The study was approved by the Ethics Committees of the two healthcare institutions involved. Informed consent was obtained from all participants.

Results

The Italian version demonstrated strong internal consistency (Cronbach’s α = 0.96). Exploratory factor analysis supported a three-factor model explaining 58.6% of the variance, with dimensions reflecting: (1) System-level constraints, (2) Team-level dynamics, and (3) Patient/family-level conflicts. Convergent validity was confirmed via significant associations with related constructs: moral distress scores were higher among nurses, younger professionals, and those considering job departure, and negatively correlated with ethical leadership ratings (r = −0.375, p < 0.001).

Conclusion

The Italian version of the Measure of Moral Distress for Healthcare Professionals is a reliable and valid instrument for assessing moral distress among Italian healthcare professionals, effectively capturing the multidimensionality of the construct in a culturally relevant way.

Keywords

moral distress health personnel cross-cultural comparison psychometrics surveys and questionnaires burnout

Get full access to this article

View all access options for this article.

References

Epstein

Whitehead

Prompahakul

, et al. Enhancing understanding of moral distress: the measure of moral distress for health care professionals. AJOB Empir Bioeth 2019; 10: 113–124.

Jameton

. Nursing practice: the ethical issues. Prentice-Hall, 1984.

Berger

. Moral distress in medical education and training. J Gen Intern Med 2014; 29: 395–398.

De Veer

AJE

Francke

Struijs

, et al. Determinants of moral distress in daily nursing practice: a cross sectional correlational questionnaire survey. Int J Nurs Stud 2013; 50: 100–108.

Luo

Bao

Chen

, et al. The correlation analysis of turnover intention, moral distress and stressor in nurses. Zhonghua Lao Dong Wei Sheng Zhi Ye Bing Za Zhi Zhonghua Laodong Weisheng Zhiyebing Zazhi Chin J Ind Hyg Occup Dis 2018; 36: 590–593.

McAndrew

Leske

Schroeter

. Moral distress in critical care nursing: the state of the science. Nurs Ethics 2018; 25: 552–570.

Almutairi

Salam

Adlan

, et al. Prevalence of severe moral distress among healthcare providers in Saudi Arabia. Psychol Res Behav Manag 2019; 12: 107–115.

Bayanzay

Amoozgar

Kaushal

, et al. Impact of profession and wards on moral distress in a community hospital. Nurs Ethics 2022; 29: 356–363.

Cheung

Hon

Leung

, et al. Moral distress and psychological status among healthcare workers in a newly established paediatric intensive care unit. Hong Kong Med J 2023; 29: 489.

10.

Shoorideh

Ashktorab

Yaghmaei

, et al. Relationship between ICU nurses’ moral distress with burnout and anticipated turnover. Nurs Ethics 2015; 22: 64–76.

11.

De Brasi

Giannetta

Ercolani

et al. Nurses’ moral distress in end-of-life care: A qualitative study. Nurs Ethics. 2021; 28(5): 614–627.

12.

Carletto

Ariotti

Garelli

, et al. Moral distress and burnout in neonatal intensive care unit healthcare providers: a cross-sectional study in Italy. Int J Environ Res Public Health 2022; 19: 8526.

13.

Grasso

Massidda

Maslak

, et al. Moral distress in healthcare providers who take care of critical pediatric patients throughout Italy—cultural adaptation and validation of the Italian pediatric instrument. Int J Environ Res Public Health 2022; 19: 3880.

14.

Maffoni

Fiabane

Setti

, et al. Moral distress among frontline physicians and nurses in the early phase of COVID-19 pandemic in Italy. Int J Environ Res Public Health 2022; 19: 9682.

15.

Donkers

Gilissen

VJHS

Candel

MJJM

, et al. Moral distress and ethical climate in intensive care medicine during COVID-19: a nationwide study. BMC Med Ethics 2021; 22: 73.

16.

Plouffe

Nazarov

Heesters

, et al. The mediating roles of workplace support and ethical work environment in associations between leadership and moral distress: a longitudinal study of Canadian health care workers during the COVID-19 pandemic. Front Psychol 2023; 14: 1235211.

17.

Silverman

. Ethical decision-making climate, moral distress, and intention to leave among ICU professionals in a tertiary academic hospital center. BMC Med Ethics 23: 45.

18.

Corley

Elswick

Gorman

, et al. Development and evaluation of a moral distress scale. J Adv Nurs 2001; 33: 250–256.

19.

Hamric

Borchers

Epstein

. Development and testing of an instrument to measure moral distress in healthcare professionals. AJOB Prim Res 2012; 3: 1–9.

20.

Fujii

Katayama

Miyazaki

, et al. Translation and validation of the Japanese version of the measure of moral distress for healthcare professionals. Health Qual Life Outcomes 2021; 19: 120.

21.

Rodriguez-Ruiz

Campelo-Izquierdo

Estany-Gestal

, et al. Validation and psychometric properties of the Spanish version of the Measure of Moral Distress for Health Care Professionals (MMD-HP-SPA). Med Intensiva 2022; 46: 169–170.

22.

Fischer-Grönlund

Brännström

Isaksson

. Psychometric testing of the Swedish version of the measure of moral distress for healthcare professionals (MMD-HP). BMC Med Ethics 2023; 24: 35.

23.

Beltrão

Bernardelli

, et al. Adaptation and validation of the Brazilian version of the Measure of Moral Distress for Healthcare Professionals (MMD-HP BR) in the context of palliative care. BMC Palliat Care 2023; 22: 154.

24.

Prompahakul

Keim-Malpass

LeBaron

, et al. Thai translation and psychometric testing of the measure of moral distress for healthcare professionals. J Health Sci Med Res 2020; 41: 2023975.

25.

Behling

Law

. Translating questionnaires and other research instruments. Sage Publications, Inc, 2000.

26.

MacCallum

Widaman

Zhang

, et al. Sample size in factor analysis. Psychol Methods 1999; 4: 84–99.

27.

Meyer

Benjamens

Moumni

, et al. Global overview of response rates in patient and health care professional surveys in surgery: a systematic review. Ann Surg 2022; 275: e75–e81.

28.

Ministero della Salute - Personale del Servizio sanitario, i dati del 2022. https://www.salute.gov.it/new/it/news-e-media/notizie/personale-del-servizio-sanitario-i-dati-del-2022/

29.

Zappalà

Toscano

. The ethical leadership scale (ELS): Italian adaptation and exploration of the nomological network in a health care setting. J Nurs Manag 2020; 28: 634–642.

30.

Brown

Treviño

Harrison

. Ethical leadership: a social learning perspective for construct development and testing. Organ Behav Hum Decis Process 2005; 97: 117–134.

31.

Bedi

Alpaslan

Green

. A meta-analytic review of ethical leadership outcomes and moderators. J Bus Ethics 2016; 139: 517–536.

32.

Bentler

. On the fit of models to covariances and methodology to the Bulletin. Bulletin 1992; 112: 400–404.

33.

Bentler

. Cutoff criteria for fit indexes in covariance structure analysis: conventional criteria versus new alternatives. Struct Equ Model Multidiscip J 1999; 6: 1–55.

34.

MacCallum

Browne

Sugawara

. Power analysis and determination of sample size for covariance structure modeling. Psychol Methods 1996; 1: 130–149.

35.

Barrett

. Structural equation modelling: adjudging model fit. Pers Individ Dif 2007; 42: 815–824.

36.

Tavakol

Dennick

. Making sense of Cronbach’s alpha. Int J Med Educ 2011; 2: 53–55.

37.

Shaver

Michaelson

Whitehead

, et al. Structural validity of a brief scale adapted to measure adolescent spiritual health. SSM Popul Health 2020; 12: 100670.

38.

Shi

Lee

Maydeu-Olivares

. Understanding the model size effect on SEM fit indices. Educ Psychol Meas 2019; 79: 310–334.

39.

Lloret

Ferreres

Hernández

, et al. El análisis factorial exploratorio de los ítems: análisis guiado según los datos empíricos y el software. An Psicol 2017; 33: 417.

40.

Giannetta

Villa

Bonetti

et al. Moral Distress Scores of Nurses Working in Intensive Care Units for Adults Using Corley’s Scale: A Systematic Review. International Journal of Environmental Research and Public Health. 2022; 19(17): 10640.

41.

Boulton

Farquharson

. Does moral distress in emergency department nurses contribute to intentions to leave their post, specialisation, or profession: a systematic review. Int J Nurs Stud Adv 2024; 6: 100164.

42.

Gagnier

Lai

Mokkink

, et al. COSMIN reporting guideline for studies on measurement properties of patient-reported outcome measures. Qual Life Res 2021; 30: 2197–2218.

43.

Gorini

Parati

. Cultural adaptation and validation of the Measure of Moral Distress for Healthcare Professionals (MMD-HP) in Italy: a multicentre cross-sectional study. Zenodo; 2025.

Italian validation of the Measure of Moral Distress for Healthcare Professionals (MMD-HP): A multicenter cross-sectional study