Validation of a moral distress instrument in nurses of primary health care

this is a methodological study carried out with 391 nurses of primary health care, applied to the Brazilian Scale of Moral Distress in Nurses with 57 questions. Validation for primary health care was performed through expert committee evaluation, pre-test, factorial analysis, and Cronbach’s alpha.

Results:

there were 46 questions validated divided into six constructs: Health Policies, Working Conditions, Nurse Autonomy, Professional ethics, Disrespect to patient autonomy and Work Overload. The instrument had satisfactory internal consistency, with Cronbach’s alpha 0.98 for the instrument, and between 0.96 and 0.88 for the constructs.

Conclusion:

the instrument is valid and reliable to be used in the identification of the factors that trigger moral distress in primary care nurses, providing subsidies for new research in this field of professional practice.

Descriptors:
Validation Studies; Nurses; Primary Health Care; Ethics; Stress Psychological; Moral

Authorship

Priscila Orlandi Barth

PhD, Nursing Department, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil. Post-doctorate degree student, Programa de Pós Graduação em Enfermagem da UFSC (PEN/UFSC).Universidade Federal de Santa CatarinaBrazilFlorianópolis, SC, Brazil PhD, Nursing Department, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil. Post-doctorate degree student, Programa de Pós Graduação em Enfermagem da UFSC (PEN/UFSC).

Flávia Regina Souza Ramos

PhD, Full Professor, Nursing Department, Univerisdade Federal de Santa Catarina, Florianópolis, SC, Brazil.Univerisdade Federal de Santa CatarinaBrazilFlorianópolis, SC, Brazil PhD, Full Professor, Nursing Department, Univerisdade Federal de Santa Catarina, Florianópolis, SC, Brazil.

Edison Luiz Devos Barlem

PhD, Adjunct Professor, Nursing Department, Universidade Federal de Rio Grande, Rio Grande, SC, Brazil.Universidade Federal de Rio GrandeBrazilRio Grande, SC, Brazil PhD, Adjunct Professor, Nursing Department, Universidade Federal de Rio Grande, Rio Grande, SC, Brazil.

Graziele de Lima Dalmolin

PhD, Adjunct Professor, Nursing Department, Universidade Federal de Santa Maria, Santa Maria, RS, Brazil.Universidade Federal de Santa MariaBrazilSanta Maria, RS, Brazil PhD, Adjunct Professor, Nursing Department, Universidade Federal de Santa Maria, Santa Maria, RS, Brazil.

Dulcinéia Ghizoni Schneider

PhD, Adjunct Professor, Nursing Department, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil.Universidade Federal de Santa CatarinaBrazilFlorianópolis, SC, Brazil PhD, Adjunct Professor, Nursing Department, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil.

Corresponding Author: Priscila Orlandi Barth Rua Jardim Giselle, 23 Cachoeira do Bom Jesus Florianópolis, Santa Catarina 88056-608 E-mail: priscilabarth@yahoo.com.br

SCIMAGO INSTITUTIONS RANKINGS

Figures | Tables

Figures (1)
Tables (4)

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Figure 1
Conceptual presentation of the constructs constituted by the factorial and Cronbach´s Alpha analysis. Florianópolis, SC, Brazil, 2017

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Table 1
Quantitative nurses and primary care nurses in the Brazilian regions, Florianópolis, SC, Brazil, 2017

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Table 2
Exploratory Factor Analysis (Varimax rotation) of the instrument of moral distress in primary care nurses, presentation of two constructs. Florianópolis, SC, Brazil, 2017

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Table 3
Exploratory Factorial Analysis (Varimax rotation) of the instrument of moral distress in primary care nurses, presentation of four constructs. Florianópolis-SC, Brazil, 2017.

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Table 4
Test of Kaiser-Meyer-Olkin and Bartlett*. Florianópolis - SC, Brazil, 2017.

Figure 1 Conceptual presentation of the constructs constituted by the factorial and Cronbach´s Alpha analysis. Florianópolis, SC, Brazil, 2017

Table 1 Quantitative nurses and primary care nurses in the Brazilian regions, Florianópolis, SC, Brazil, 2017

Region	Health Establishment	Nurses
Northeast	18.407	17.038
Southeast	16.502	23.602
South	7.315	9.220
North	4.460	4.634
Midwest	3.481	4.542
Total	50.165	59.036

Table 2 Exploratory Factor Analysis (Varimax rotation) of the instrument of moral distress in primary care nurses, presentation of two constructs. Florianópolis, SC, Brazil, 2017

Rotary component matrix *
Indicators^†		Components^‡
Health policies		C1	C2	C3	C4	C5	C6
	29. To recognize that the demands of continuity of patient/user care are not met	757	237	198	199	267	197
	30. To recognize the lack of resolution of health actions due to social problems	727	219	182	172	307	188
	32. To recognize that educational actions with the patient are insufficient	723	253	202	151	211	197
	28. To recognize that the patient´s hosting is inappropriate	699	265	250	187	218	159
	33. To experience on the humanized care practices advocated by public policies	651	307	333	202	264	156
	27. To recognize insufficient access to the service for the patient	637	218	231	172	400	104
	31. To recognize the lack of resolution of health actions due to the poor quality of care	632	209	359	240	251	194
	37. To recognize impairments to care due to inadequate integration between services/sectors	624	253	314	154	284	207
	34. To recognize routines and practices that are unsuitable for professional safety	552	265	350	182	271	212
	35. To recognize routines and practices that are inappropriate for patient safety	545	218	457	238	219	097
	44. To experience the suspension and postponement of procedures for reasons that are contrary to the needs of the patient/user	501	261	480	185	309	104
Professional Visibility/Nurse Autonomy
	47. Feeling disrespected by hierarchical superiors	187	746	277	187	180	075
	17. Feeling discriminated against by other professionals	309	681	003	265	107	083
	48. To recognize ethically incorrect attitudes of managers or superiors	298	639	277	175	331	112
	38. To have their autonomy limited in the decision of specific behaviors of the nursing team	197	638	305	205	210	185
	18. Feeling devalued compared to other professionals	372	625	007	273	025	145
	41. To recognize situations of offense to the professional	245	623	311	173	251	295
	39. To experience conflicting relationships regarding the attributions of health team members	295	591	284	149	243	284
	49. Feeling pressured to agree or silence against fraud on behalf of the institution	074	560	436	177	123	075
	40. Working under pressure for insufficient time to reach goals or perform tasks	331	557	230	072	142	406
	42. To recognize situations of disrespect to the professional’s privacy	159	538	416	207	228	288

*Rotation Method: Varimax with Kaiser Standardization. a. Converted rotation in 10 iterations.
† Indicators, indicating the issues of the instrument with their respective numbering.
‡ Components, indicating the value (intensity) of each construct (C1 to C6).

Table 3 Exploratory Factorial Analysis (Varimax rotation) of the instrument of moral distress in primary care nurses, presentation of four constructs. Florianópolis-SC, Brazil, 2017.

Rotary component matrix *
Indicadotors^†		Components^‡
Right to Health/Disrespect for patient autonomy		C1	C2	C3	C4	C5	C6
	55. To recognize situations of disrespect to the patient’s right to confidentiality/secrecy	153	153	781	285	122	107
	54. To recognize situations of disrespect to the patient’s right to privacy/privacy	270	206	758	215	221	024
	56. To recognize situations of disrespect to patients ‘and family members’ right to information	289	209	757	208	131	110
	46. To experience care behaviors that disregard patients’ beliefs and culture	244	151	697	165	145	072
	45. To experience or participate in unnecessary care behaviors to the patient/user’s conditions/needs	270	234	634	194	148	159
	53. To recognize situations of disrespect/maltreatment by professionals in relation to the patient	385	223	599	297	181	120
Professional Ethics Competence
	24.To experience the recklessness by the nurse	066	282	365	719	160	048
	22. To experience the recklessness by the doctor	251	250	161	701	142	094
	4. To work with unprepared doctors	277	090	100	656	311	324
	23. To experience the omission by the nurse	145	265	408	651	144	054
	21. To experience the omission by the doctor	340	210	224	627	133	218
	5. Work with unprepared nurses	153	074	254	590	184	459
	25. To experience the omission by professionals of other categories	174	443	328	590	233	010
	26. To experience the recklessness by professionals from other categories	152	409	314	574	244	009
Work conditions
	14. To recognize that the available permanent equipment/materials are inadequate	313	175	242	192	733	196
	11. To recognize that consumer materials are insufficient	315	245	152	195	722	211
	13. To recognize that the available permanent equipment/materials are insufficient	311	248	246	152	721	259
	16. To recognize that the physical structure of the service is inadequate	300	180	161	246	691	165
	12. To recognize that consumer materials are inadequate	275	182	221	247	687	255
	15. To recognize that the physical structure of the service is insufficient	324	194	153	246	650	191
Work overload
	1. To work with insufficient number of professionals to demand	256	346	098	064	259	657
	3. To experience work overload conditions	274	425	034	131	275	621
	2. Incomplete multiprofessional health team	297	253	105	137	350	620
	6. To work with unprepared nursing assistants and technicians	153	057	210	516	204	614
	7.To work with professionals from other unprepared categories	198	104	099	497	299	535

*Método de Rotação: Varimax com Normalização de Kaiser.
a. Converted rotation in 10 iterations.
† Indicators, with the questions of the instrument and their respective numbering.
‡ Components, with the value (intensity) of each construct (C1 to C6).

Table 4 Test of Kaiser-Meyer-Olkin and Bartlett*. Florianópolis - SC, Brazil, 2017.

Kaiser-Meyer-Olkin measure of sampling suitability.	.958
Bartlett sphericity test	15908.435
Approx. Chi-square df	1035
Sig.	.000

* Kaiser-Meyer-Olkin’s test of sampling suitability and Barllet’s sphericity.

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