Adattamento italiano e studio psicometrico pilota su uno strumento di misura in sanità. Una proposta di applicazione per il Moral Distress

Italian adaptation and pilot psychometric study on a health measurement instrument: A proposal for the application to Moral Distress.

Autori

Marchetti Filippo [University of Siena, Siena, Italy]

Introduction

Nel 1984 Andrew Jameton definì il Moral Distress (MD) come: “Una situazione in cui il soggetto conosce il giusto corso d’azione, ma è impedito dal metterlo in atto” (Jameton, 1984). Positivamente associati al Distress Morale sono: L’intenzione di lasciare la propria job position (Lamiani et al., 2017; Epstein et al., 2019; Shoorideh et al., 2015; Almutairi et al., 2019), la scarsa soddisfazione lavorativa (de Veer et al., 2013), sintomi ansiosi e depressivi (Schneider et al., 2021; Lamiani et al., 2017), aumentato turnover (Luo et al., 2018), riduzione della qualità delle cure (McAndrew et al., 2018) e la Burnout Syndrome (Badolamenti et al., 2017; Epstein et al., 2019; Baele and Fontaine, 2021; Shoorideh et al., 2015), mentre correlazione negativa è stata riscontrata tra MD e clima etico (Hamric et al., 2012; Epstein et al., 2019; Hamric and Blackhall, 2007)

Methods

Esplorare le proprietà psicometriche della traduzione italiana del questionario MMD-HP tramite : (a)Analisi struttura fattoriale dello strumento attraverso procedure di analisi fattoriale confermativa, (b) Affidabilità sotto forma di indici di consistenza interna, (c) Potenziali differenze nei punteggi al questionario in base al genere e in base al profilo professionale, (d) Associazione tra i punteggi ottenuti al questionario e le seguenti variabili: Età, anzianità professionale misurata in termini di anni dall’inizio dell’attività, punteggi al questionario Ethical Leadership Scale (Brown et al., 2005; versione italiana di Zappalà & Toscano, 2020).

Results

Su 160 pazienti è stata condotta un’analisi fattoriale esplorativa data la limitata numerosità campionaria su cui sono state studiate caratteristiche descrittive a livello statistico degli item all’interno della sottoscala Frequenza e Livello di Distress per verificarne la normale distribuzione delle variabili. Successivamente l’indice KMO e il Test Chi Quadrato di Bartlett hanno confermato che era possibile procedere con un analisi fattoriale esplorativa. Successivamente sono state rilevate varie misurazioni quali l’Analisi della Comunalità statistica, il calcolo degli Eigenvalues o Autovalori, la rappresentazione con il grafico scree Plot, le correlazioni fattoriali, la Matrice dei modelli con metodo di rotazione pattern Matrix, il calcolo dell’Affidabilità come consistenza interna ed infine le correlazioni di genere uomo-donna e tra Età-Anzianità lavorativa- punteggio scala ELS.

Discussion and Conclusion

Discussione: Il processo di traduzione in italiano del MMD-HP è stato effettuato secondo un protocollo conforme agli standard internazionali (Behling & Law, 2000). Il questionario tradotto è stato somministrato al campione tramite la piattaforma Google Form da cui sono stati estrapolati in data 25/03/2023 i dati all’interno di un foglio di calcolo Excel. Il totale dei partecipanti è risultato di 160 e su questi è stata condotta una preliminare Analisi Fattoriale Esplorativa che ha evidenziato che gli items di questa matrice per entrambe le sottoscale che compongono la MMD-HP corrispondono agli items presenti nel questionario originale della autrice Epstein, con simili caratteristiche fattoriali.

Questo lavoro fornisce i primi risultati psicometrici preliminari dello strumento MMD-HP tradotto in italiano che dovrà essere indagato ulteriormente in futuro, con sperimentazioni su campioni più ampi, e diventare uno strumento a disposizione dei dirigenti nell’area delle Scienze Riabilitative per monitorare e esplorare i livelli di stress su un aspetto misconosciuto e poco considerato nei contesti clinici sanitari e riabilitativi.

REFERENCES

  • Almutairi A.F., Salam M., Adlan A.A., Alturki A.S. (2019) Prevalence of severe moral distress among healthcare providers in Saudi Arabia. Psychol Res Behav Manag. 12:107-115. doi: 10.2147/PRBM.S191037. PMID: 30804690; PMCID: PMC6375112.
  • American Association of Critical-Care Nurses, Ethics Work Group. The 4A’ to rise above moral distress. AlisoVicjo, CA; 2004.
    http://www.aacn.org/WD/Practice/DOcs/4As_to_Rise_Above_Moral_Distress.pdf.
  • Atabay G, et al. Impact of ethical climate on moral distress revisited: multidimensional view. Nurs Ethics 2015; 22(1): 103-16.
  • Austin W, et al. An overview of moral distress and the pediatric intensive care team. Nurs Ethics 2009;16(1):57-68.
  • Austin W. Moral distress and the contemporary plight of health professionals. HEC Forum 2012;24(1):27-38.
  • Badolamenti S., Fida R., Biagioli V., Caruso R., Zaghini F., Sili A., Rea T. (2017) Modified Moral Distress Scale (MDS-11): Validation Study Among Italian Nurses. Prof Inferm. 70(4):238-248. English. doi: 10.7429/pi.2017.704238. PMID: 29460561.
  • Baele C.A., Fontaine J.R.J. (2021) The Moral Distress-Appraisal Scale: Scale development and validation study. J Adv Nurs. 77(10):4120-4130. doi: 10.1111/jan.14923. Epub 2021 Jun 25. PMID: 34171142.
  • Bayanzay K., Amoozgar B., Kaushal V., Holman A., Som V., Sen S. (2022) Impact of profession and wards on moral distress in a community hospital. Nurs Ethics. 29(2):356-363. doi: 10.1177/09697330211015349. Epub 2021 Nov 2. PMID: 34727763.
  • Behling, O. and Law, K.S. (2000) Translating Questionnaires and Other Research Instruments: Problems and solutions. SAGE Publications, Inc., Thousand Oaks. https://doi.org/10.4135/9781412986373
  • Berger, J. (2014). Word of mouth and interpersonal communication: A review and directions for future research. Journal of Consumer Psychology, 24(4), 586–607. https://doi.org/10.1016/j.jcps.2014.05.002
  • Beumer CM. Innovative solutions: the effect of a workshop on reducing the experience of moral distress in an intensive care unit setting. Dimens Crit Care Nurs 2008;27(6):263-7.
  • Brandon D, et al. Impact of a pediatric quality of life program on providers’ moral distress. MCN Am | Matern Child Nurs 2014;39(3):189-97.
  • Brown ME, Trevifio LK, Harrison DA. Ethical leadership: A social learning perspective for construct development and testingé Organ Behav Hum Decis Process. 2005;97(2):117-134. doi:10.1016/j.0bhdp.2005.03.002
  • Brown-Saltaman K, et al. An intervention to improve respiratory therapists’ comfort with end-of life care. Respir Care 2010;55(7):858-65.
  • Browning AM. CNE article: moral distress and psychological empowerment in critical care nurses caring for adults at end of life. Am ] Crit Care 2013 143-51.
  • Bruce CR, Miller SM, Zimmerman JL. A qualitative study exploring moral distress in the ICU team: the importance of unit functionality and intrateam dynamics. Crit Care Med. 2015 Apr;43(4):823-31. doi: 10.1097/CCM.0000000000000822. PMID: 25525754.
  • Burston AS, Tuckett AG. Moral distress in nursing: contributing factors, outcomes and interventions. Nurs Ethics 2013; 20(3):312-24.
  • Corley M.C., Elswick R.K., Gorman M., Clor T. (2001) Development and evaluation of a moral distress scale. J Adv Nurs. 33(2):250-6. doi: 10.1046/j.1365-2648.2001.01658.x. PMID: 11168709.
  • Cosentino, C., Carofano D., Cominotti E., Dibello A., Floris E., Hadif J., Zanetti D., Zavaroni E., Artiou G., Saru L. (2018) Le determinanti della soddisfazione lavorativa degli infermieri in area critica.Scenario, [S.l.], v. 35, n. 3, p. 5-10. ISSN 2239-6403. Disponibile all’indirizzo <https://scenario.aniarti.it/index.php/scenario/article/view/360>.
  • De Veer A.J., Francke A.L., Struijs A., Willems D.L. (2013) Determinants of moral distress in daily nursing practice: a cross sectional correlational questionnaire survey. Int J Nurs Stud. 50(1):100-8. doi: 10.1016/j.ijnurstu.2012.08.017. Epub 2012 Sep 16. PMID: 22989404.
  • Deady R, McCarthy. A study of the situations, features, and coping mechanisms experienced by Irish psychiatric nurses experiencing moral distress. Perspect Psychiatr Care 2010;46(3): 209-20. Distress Scale (MDS-11): Validation Study Among Italian Nurses. Prof Inferm. 70(4):238-248. English. doi: 10.7429/pi.2017.704238. PMID: 29460561.
  • Epsein E.G., Whitehead P.B., Prompahakul C., Thacker L.R., Hamric A.B. (2019) Enhancing Understanding of Moral Distress: The Measure of Moral Distress for Health Care Professionals. AJOB Empir Bioeth. 10(2):113-124. doi: 10.1080/23294515.2019.1586008. Epub 2019 Apr PMID: 31002584.
  • Fischer-Grönlund C., Brännström M. (2021) The Swedish translation and cultural adaptation of the Measure of Moral Distress for Healthcare Professionals (MMD-HP). BMC Med Ethics. 22(1):151. doi: 10.1186/s12910-021-00722-3. PMID: 34772400; PMCID: PMC8588668.
  • Fujii T, Katayama S, Miyazaki K, Nashiki H, Niitsu T, Takei T, Utsunomiya A, Dodek P, Hamric A, Nakayama T. (2021) Translation and validation of the Japanese version of the measure of moral distress for healthcare professionals. Health Qual Life Outcomes. 19(1):120. doi: 10.1186/s12955- 021-01765-1. PMID: 33849571; PMCID: PMC8045393.
  • Grace PJ, et al. Clinical ethics residency for nurses: an education model to decrease moral distress and strengthen nurse retention in acute care.]NursAdm 2014;44(12):640-6.
  • Grady C, et al. Does ethics education influence the moral action of practicing nurses and social workers? Am ] Bioeth 2008;8(4):4-1.
  • Hallett K. The sanctity of life—the sanctity of choice. Narat Inq Bioeth 2013;3(2):95-8.
  • Hamric A. B, Borchers C. D and Epstein E. G (2012) Development and Testing of an Instrument to Measure Moral Distress in Healthcare Professionals, AJOB Primary Research, 3:2, 1-9, DOI: 10.1080/21507716.2011.652337
  • Hamric AB, Blackhall LJ. (2007) Nurse-physician perspectives on the care of dying patients in intensive care units: collaboration, moral distress, and ethical climate. Crit Care Med. 35(2):422-9. doi: 10.1097/01.CCM.0000254722.50608.2D. PMID: 17205001.
  • Helfe PR, et al. Facilitated ethics conversations: a novel program for managing moral distress in bedside nursing staff. JONAS Healthe Law Ethics Regul 2009;11(1):27-33.
  • Henrich NJ, Dodek PM, Alden L, Keenan SP, Reynolds S, Rodney P. Causes of moral distress in the intensive care unit: A qualitative study. J Crit Care. 2016 Oct;35:57-62. doi: 10.1016/j.jcrc.2016.04.033. Epub 2016 May 12. PMID: 27481736.
  • Jameton, A. (1984). Nursing practice: The ethical issues. Englewood Cliffs, N.J: Prentice-Hall. Joint Commission. Comprehensive accreditation manual for hospitals. Oakbrook Terace,IL;2015.
  • Lamiani G, Setti I, Barlascini L, Vegni E, Argentero P. Measuring Moral Distress Among Critical Care Clinicians: Validation and Psychometric Properties of the Italian Moral Distress Scale-Revised. Crit Care Med. 2017 Mar;45(3):430-437. doi: 10.1097/CCM.0000000000002187. PMID: 27930369.
  • Lawrence LA. Work engagement, moral distress, education level, and critical reflective practice in intensive care nurses. Nurs Forum 2011;46(4):256-68. Lewis-Newby M, et al. An official American Thoracic Society policy statement: managing conscientious objections in intensive care medicine. Am ] Respir Crit Care Med 2015; 191(2):219-27.
  • Luo Y, Bao GJ, Chen RM, Mao C, Jia BF, Yu YQ, Yu GF. (2018) [The Correlation Analysis of Turnover Intention,Moral Distress and Stressor in Nurses]. Zhonghua Lao Dong Wei Sheng Zhi Ye Bing Za Zhi. 20;36(8):590-593. Chinese. doi: 10.3760/cma.j.issn.1001-9391.2018.08.006. PMID: 30317807.
  • MacCallum RC, Widaman KF, Zhang S, Hong S. Sample size in factor analysis. Psycho! Methods. 1999;4(1):84-99. doi:10.1037/1082-989X.4.1.84
  • McAndrew NS, Leske J, Schroeter K. Moral distress in critical care nursing: The state of the science. Nurs Ethics. 2018 Aug;25(5):552-570. doi: 10.1177/0969733016664975. Epub 2016 Sep 22. PMID: 27660185
  • Mealer M. and Moss M. (2016) “Moral distress in ICU nurses.” Intensive care medicine 42.10: 1615- 1617. Musto LC, et al Toward interventions to address moral distress: navigating structure and agency. Nurs Ethics 2015; 22(1):91-102.
  • Negrisolo A, Brugnaro L. (2012) Il moral distress nell’assistenza infermieristica [Moral distress in nursing care]. Prof Inferm. 65(3):163-70. Italian. PMID: 23121881.
  • Nelson HL. Damaged identities, narrative repair. Ithaca, NY: Cornell University Press; 2001. Oberle K, Hughes D. Doctors’ and nurses’ perceptions of ethical problems in end-of-life decisions. J Adv Nurs 2001; 13(6):707-15.
  • Park M, et al. The relationship of ethics educations to moral sensitivity and moral reasoning skills of nursing students. Nurs Ethics 2012;19(4):568-80.
    Pennebaker JW. Why write about trauma or emotional upheaval? In: Writing to heal: a guided journal for recovering from trauma and emotional upheaval. Oakland, CA: New Harbinger Publications; 2004. p.3-16. Pniewski J. Black horseman lane: a reflection. Narrat Ing Bioeth 2013;3(2):117-20.
    Robinson EM, et al. Enhancing moral agency: clinical ethics residency for nurses. Hastings Cent Rep 2014;44(5):12-20.
  • Rodney PA. Secing our selves as moral agents in relation to our organizational and sociopolitical contexts: commentary on “a reflection on moral distress in nursing together with a current application of the concept” by Andrew Jameton.] BioethIng 2013;10(3):313-5.
  • Rodriguez-Ruiz E, Campelo-Izquierdo M, Estany-Gestal A, Hortas AB, Rodríguez-Calvo MS, Rodríguez- Núñez A. (2021) Validation and psychometric properties of the Spanish version of the Measure of Moral Distress for Health Care Professionals (MMD-HP-SPA). Med Intensiva (Engl Ed). S0210-5691(21)00037- English, Spanish. doi: 10.1016/j.medin.2021.03.002. Epub ahead of print. PMID: 33867177.
  • Rushton CH, et al. A framework for understanding moral distress among palliative care clinicians.]PaliatMed 2013; 16(9):1074-9.
  • Rushton CH, et al. Addressing moral distress: application of a framework to palliative care
  • ]PaliatMed 2013; 16(9):1080-8.
  • Rushton CH. Moral resilience: a capacity for navigating moral distress in critical care. AACN AduCritCare 2016 270):1119.
  • Sauerland J, et al. Assessing and addressing moral distress and ethical climate. Part II: Neonatal and pediatric perspectives. Dimens Crit Care Nurs 2015;34(1):33-46.
  • Sauerland J, et al. Assessing and addressing moral distress and ethical climate, part 1. Dimens Crit Care Nurs 2014; 3(4):234-45.
  • Schneider JN, Hiebel N, Kriegsmann-Rabe M, Schmuck J, Erim Y, Morawa E, Jerg-Bretzke L, Beschoner P, Albus C, Hannemann J, Weidner K, Steudte-Schmiedgen S, Radbruch L, Brunsch H, Geiser F. (2021) Moral Distress in Hospitals During the First Wave of the COVID-19 Pandemic: A Web-Based Survey Among 3,293 Healthcare Workers Within the German Network University Medicine. Front Psychol. 18;12:775204. doi: 10.3389/fpsyg.2021.775204. PMID: 34867685; PMCID: PMC8636670.
  • Sexton JD, Pennebaker JW. The healing powers of expressive writing. In: Kaufman SB, Kaufman JC, eds. The psychology of creative writing. New York: Cambridge University Pres;209. p. 26473,
  • Shoorideh FA, Ashktorab T, Yaghmaei F, Alavi Majd H. (2015) Relationship between ICU nurses’ moral distress with burnout and anticipated turnover. Nurs Ethics. 22(1):64-76. doi: 10.1177/0969733014534874. Epub 2014 Jun 19. PMID: 24948793.
  • Truog RD, et al. Microethics: the ethics of everyday clinical practice. Hastings Cent Rep 2015;45(1):11-7.
  • Whitehead PB, Herbertson RK, Hamric AB, Epstein EG, Fisher JM. (2015) Moral distress among healthcare professionals: report of an institution-wide survey. J Nurs Scholarsh. 47(2):117-25. doi: 10.1111/jnu.12115. Epub 2014 Nov 29. PMID: 25440758.
  • Wilson MA, et al. Moral distress: levels, coping and preferred interventions in critical care and transitional care nurses. ]Clin Nurs 2013;22(9-10):1455-66.
  • Zappalà S, Toscano F. The Ethical Leadership Scale (ELS): Italian adaptation and exploration of the nomological network in a health care setting. J NursManag. 2020;28(3):634-642. doi:10.1111/jonm.12967