Initially identified in nursing, moral distress is now understood to be a serious problem in other healthcare disciplines such as medicine, respiratory therapy, and social work (Allen et al., 2013; Aultman & Wurzel, 2014; Hamric & Blackhall, 2007; Schwenzer & Wang, 2006; Whitehead et al., 2015). For clinicians at the bedside, moral distress can have negative implications such as burnout, (Meltzer & Huckabay, 2004; Rushton et al., 2015) and intent to leave a position, (Allen et al., 2013; Hamric & Blackhall, 2007; Hamric et al., 2012; Trautmann, Epstein, Rovnyak, & Snyder, 2015; Whitehead et al., 2015). As active work in this field continues to explore the impact of moral distress on providers and organizations, identify effective interventions to resolve morally distressing clinical situations, and describe the association between moral distress and patient care quality, valid and reliable instruments to measure moral distress are critical. In 2001, Corley introduced the Moral Distress Scale (MDS), a 38-item scale designed for nurses in critical care settings. In 2012, Hamric and colleagues shortened and revised the MDS to be applicable to all health professions and acute care clinical settings (Hamric et al., 2012). While the instrument has demonstrated good reliability, several studies in the past 5 years have indicated that there are additional important root causes not captured by the current MDS-R. Additionally, it has been suggested that the 6 versions of the MDS-R (adult and pediatric versions for physicians, nurses, and other providers) could be condensed to one standard instrument. Thus, the purpose of this project is to update the MDS-R and to psychometrically test the new version, the MDS-2017.
Method
We undertook a multi-step process to revise and update the MDS-R. First, we have received 20 MDS-R datasets from principal investigators which, when combined, yielded a dataset of over 4,300 respondents. We are analyzing this large dataset to determine which of the current 21 items are most and least often indicated as significant causes of moral distress. From this analysis, we will identify items that should be deleted. Second, an exploratory factor analysis is currently underway to determine whether the current MDS-R has an underlying factor structure. Concurrent with this statistical analysis, we reviewed the literature and identified 15 recent publications in which additional causes of moral distress were found or proposed. From these articles, we extracted potential new causes and compared them to the items on the current MDS-R. Finally, the current MDS-R provides space for respondents to insert additional causes of moral distress. We have reviewed and evaluated additional causes listed by respondents in eight different studies to determine whether they constitute new items that should be represented in the MDS-2017. Once a final MDS-2017 has been constructed, we will test the instrument, with IRB approval, at 2 academic medical centers.
Results
Based upon the review of articles, evaluation of respondent comments, and statistical analyses, the current MDS-R items are being refined and updated for accuracy, clarity, and relevance. Thus far, five items are proposed to be eliminated, twelve items refined, and 11-13 items added. IRB approval is being obtained to test the MDS-2017. The proposed MDS-2017 and preliminary results of the testing phase will be presented at this conference.
Discussion
Identifying specific sources of moral distress is imperative to better target interventions to mitigate moral distress within institutions. The significant relationship between moral distress and leaving a position is well documented and supports the importance of minimizing moral distress to improve staff retention. The updated MDS-2017 will include the most contemporary understanding of the root causes of moral distress. If testing yields a psychometrically stable instrument, the MDS-2017 should replace the MDS-R.