Validation of a moral distress instrument in nurses of primary health care 1

ABSTRACT Objective: to validate an instrument to identify situations that trigger moral distress in relation to intensity and frequency in primary health care nurses. Method: 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.


How to cite this article
PO, Ramos FRS, Barlem

Introduction
Moral distress (MD) has been discussed for more than three decades since in 1984 the first concept of moral distress in nursing was presented. Identified as a psychological imbalance caused by the failure to perform an action viewed as morally correct, due to institutional barriers, managerial reluctance, lack of human and material resources, among others (1) .
In the 2000s, moral distress was related to the situation when a nurse is unable to perform an action, the psychological responses are triggered and presented in the work environment (2) . Since then, the concept has undergone changes and extensions by researchers from different parts of the world.
As a theoretical reference supporting this study, the extension of the concept proposed in Brazil was adopted, whereby moral distress is identified as a procedural phenomenon and at the same time a unique experience that integrates the ethical and moral experience of the subject. In this perspective, the moral distraction encompasses elements articulated from the ethical experience of each human being, such as the moral problem, moral uncertainty, moral sensibility, moral deliberation and moral professional ethical skills. The MD or moral suffering is considered as the interruption or failure of the process of moral deliberation and not only by its negative consequences but in its productivity or potential to propel and promote the development of moral skills, reflexivity, and resources for deliberation (3) .
A pioneer scale was developed in the North American context between 1994 and 1997 (4) , to verify the triggering factors and to infer the intensity and frequency of moral distress. The Moral Distress Scale (MDS) contained 32 items on a Likert scale from 1 to 7, where 1 is never frequent/none and 7 is very frequent/ very intense, as commonly used in psychometric studies, that is, to measure attitudes or behaviors, such as the case of MDS. The first version of MDS was applied to 214 hospital nurses (working in intensive and occupational units), showing moderate levels of moral distress in these professionals (4)(5) .
A second MDS application containing 38 questions was performed with 106 nurses from medical and surgical units at two American hospitals to assess the intensity and frequency of moral distress. It was pointed out the cause "to work with levels of personnel that I consider to be insecure" as greater frequency and intensity and "to respond to the patient´s request for assistance to euthanasia when the patient has a poor prognosis" as lower frequency and intensity of moral distress (6) .
In Brazil, the MDS was translated and validated in its original form for the first time in 2009, containing 38 questions, and 21 questions validated by the application in 136 hospital nurses (7) . This validation obtained results similar to the application of MDS in the American scenario, with the factor of greater intensity and frequency 20 "lack of competence of the work team" (6) . Since then, in several scenarios in the world context, MDS has been applied, reviewed and expanded (9)(10)(11) . Its last MDS-Revised or MDS-R version is structured with 22 items on a Likert scale from 0 to 4 for frequency and intensity, where 0 is never frequent/no intensity and 4 is very frequent/very intense (9) . However, it has its orientation to the hospital scope, and although it is broadened and validated in the Brazilian hospital scenario (7)(8) , it is limited to the other scenarios of professional nurse performance.
Given the breadth and specificity of the Brazilian scenario and specifically the configuration of Primary  (13) , including content, criterion and construct validation, described below.
In the first step, on a clear determination of what will be measured (13) , an integrative review on moral distress was performed in PHC to identify its The analysis of the articles was carried out from the three stages of the Content Analysis: pre-analysis, material exploration and material interpretation (14) .
In the end, it came in three main categories: Work Organization, Working Conditions, and Professional/ Personal Relationships, pointing out the dynamism in the relationships among staff, among patients and with health education activities.
The second step, elaboration of a set of items (13) was carried out from the integrative review, in which the categories elucidated helped in the evaluation of In the third step, the measurement format (13) was determined, and two Likert six-point scales were In the sixth step, administration of the items in a sample (13) , the instrument was applied in a sample of  A simple random sampling was defined for the study, based on the selection of a random sample of a population, used when a population is believed to be homogeneous, as in the case of this study (15) . Nurses with a minimum of six months' work in the PHC were included.

Results
Regarding the characterization of the study   Table   2 and Table 3) and described conceptually (Figure 1), and the Kaiser-Meyer-Olkin test of Barllet's sampling adequacy and sphericity was presented (Table 4 ).

Discussion
Moral distress in the context of primary health care, especially in the Brazilian scenario, is still a phenomenon with innumerable gaps to be explored. The validation of this instrument allows some of these gaps to be visualized and discussed to identify the factors that trigger moral distress.  (4) . These three factors were the same as those adopted for the application of MDS in other studies (6) . The instrument validated for primary care nurses is characterized by 6 constructs. From these constructs, "Health policies" and "Professional ethical competence" are presented as new elements in the identification of the factors that trigger moral distress.

Health policies
Health policy in its various stages of construction, development and implantation/implementation is a dynamic process, with constant interference by the various actors involved (16) . In Brazil, the Brazilian Unified National System (SUS) is a public policy defined in the Brazilian Constitution that establishes public health actions and services, which form a network and constitute a single system governed by Organic Health Law 8,080/90 and its complementing 8.142/90 SUS has as principles and guidelines: universality, equity, integrality, hierarchization and regionalization, decentralization and popular participation (17) .

Professional Autonomy
Autonomy is intrinsic in the individuals´ ability to determine and follow their laws and rules without being defined by others, to be able to self-determine, to be independent. Professional autonomy involves, a continuous process of actions, attitudes, and postures acquired by the right and professional value besides issues related to power. Part of the delimitation of professional identity, responsibilities based on scientific knowledge, the formation of self-knowledge and the role of the profession itself (18) .

Disrespect for patient autonomy
The autonomy of the patient can be seen through actions that foster the patient's right to choose and participate in his therapeutic process, which is seen as a citizen with rights to be respected. However, disrespect for this autonomy occurs through the imposition of norms and routines that do not consider the subjectivity of the patient (19) .

Professional Ethics Competence
Ethical competence is structured in 3 pillars, values, teaching and practice. The values related to their culture, family teachings, social coexistence; education in ethical education in vocational training; and the practice of professionals' experiences, with spaces for moral deliberation (20) . Ethical competence is constantly being built and has as its main attribute moral sensitivity, as a focus on ethical actions in a transversal way, both in teaching and in practice, showing to be an important tool in coping with situations of moral stress (21)(22) .

Work conditions
Working conditions refer to the labor force, that is, to the specifics of those who perform it, to the required qualification, to the division of labor, to contractual relationships (contract modality, working day, benefits, social protection). It also involves the socio-technical environment to carry out the work, including adequate instruments in quantity and quality, as well as the knowledge to operate them and the physical space (23) .

Work overload
Work overload is an increase in the amount of work required in relation to the number of skilled and available workers, as well as appropriate conditions for their execution. Load (quantity) and workloads (concept proposed by Laurell and Noriega, as elements of the work process that interact with each other and with the worker's body) are concepts that converge and complement each other. The overload causes damage to the health of the worker, withdrawals from work and increases the consequence on the workers that work in teams that are not working (24) .   in their reality (33) .
The lack of autonomy and the devaluation of the nurse professional are factors that have been shown to trigger moral distress in other international settings, in which these factors are influenced by the position of other team members regarding the nurses' conduct and the institutional rules imposed on them (34) .  (35) . It is in this scenario that (re) builds the ethical competence of each professional, from the moment he has problems, he assumes responsibility and builds his action based on values and beliefs, allied to his scientific knowledge and professional experience (20)(21) .
The fifth construct Disrespect for patient´s autonomy grouped elements derived from patient´s right to privacy, choice of conduct, secrecy, access to information, devaluation of beliefs and cultures, and unnecessary conduct of care. The recognition of the singularity, individuality, completeness, legitimacy, freedom, choices of treatments and services by the patient is still incipient in the health professional's view, participation in their therapeutic process and their right to choose, rights that must be respected for a performance of the patient (19) .
The last construct Work Overload has integrated imminent issues of insufficient human resources and disqualified human resources as factors that increase workload. Overworking due to such elements together with adverse working conditions tends to cause harm to the health of professionals, resulting in an increase in the lack of human resources, and consequently an increase in workload for those who remain in the service (23)(24) . Evaluation and quality of care are interfered with by work overload, compromising patient safety, and consequently the trigger for experiencing moral distress (31)(32) .
Thus, the 6 constructs validated 46 of the 57 questions of the instrument for the primary care sample, obeying the statistical and conceptual criteria.

Conclusion
The results show that the instrument is able