Cross-cultural adaptation, reliability, and validity of the Turkish Version of the Moral Courage Scale for Physicians

Cross-cultural adaptation, reliability, and validity of the Turkish Version of the Moral Courage Scale for Physicians | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Cross-cultural adaptation, reliability, and validity of the Turkish Version of the Moral Courage Scale for Physicians Şerife Yılmaz, Gamze Özbek Güven, Feyza İnceoğlu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4821326/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Physicians, like other healthcare professionals, frequently encounter situations requiring moral courage in their professional lives. However, studies on the moral courage of physicians are limited in the literature. This study aims to evaluate the Turkish adaptation, validity, and reliability of the Moral Courage Scale for Physicians (MCSP) and to contribute to national and international studies on moral courage among physicians. Materials and methods This methodological study involved the adaptation, validity, and reliability assessment of the MCSP in Turkish. The scale's internal consistency was evaluated using Cronbach's α coefficient, and the total correlation coefficients for the items were calculated. Test-retest reliability was assessed using a two-group design. Results The Turkish version of the MCSP demonstrated high internal consistency, with a Cronbach's α coefficient of 0.91. The total correlation coefficients for the items ranged from 0.387 to 0.797. A significant positive correlation was found between the test and retest scores of the MCSP (p < 0.05). Conclusion The Turkish version of the MCSP is a valid and reliable tool for assessing moral courage among physicians. Moral Courage physician validity reliability ethics Figures Figure 1 Introduction Moral courage is a concept that represents an individual's courage and inner strength to act in accordance with moral and ethical values (1). This concept involves the ability to defend what is right despite negative consequences (2). It also signifies the strength that emerges when dealing with threats to one's own moral and ethical values (3). From a healthcare and medical perspective, moral courage includes the ability to advocate for the needs of patients, protect their treatment rights, and intervene in patient care. This is critically important in terms of being committed to acting in the best interests of patients. Moral courage requires helping patients confront their vulnerabilities and pains, witnessing their vulnerabilities and pains, and acting with determination and dedication to provide professional care (2,4–7)In this context, the demonstration of moral courage by healthcare professionals can contribute to gaining patients' trust, acting in accordance with ethical standards, and protecting individuals' rights in the process of receiving healthcare. Moral courage holds great value for healthcare personnel. However, the demonstration of moral courage is influenced not only by an individual's internal values but also by environmental factors. Factors such as working conditions, role conflicts, power dynamics, and organizational culture in the healthcare sector are significant barriers that individuals face when demonstrating moral courage. Additionally, demonstrating moral courage can sometimes expose individuals to negative reactions, intimidation, and even the risk of psychological or physical violence from colleagues or superiors. These situations imply the risk of individuals losing their jobs or status. Personal or organizational barriers can lead healthcare personnel to struggle to act in accordance with ethical values and experience traumatic experiences despite knowing what is right (8). The lack of moral courage can have potentially significant consequences for both healthcare personnel and patients (9). For healthcare personnel, a lack of moral courage can lead to difficulties in making ethical decisions or behaving in accordance with moral values. This can lead to healthcare personnel having difficulty coping with moral stress, which can affect their professional satisfaction and performance. For patients, a lack of moral courage can pave the way for unethical behaviors or negative events. When healthcare personnel struggle to uphold ethical principles, patients' rights to respect and receive treatment in accordance with ethical standards may be at risk. This can lead to patients losing their trust and negatively impacting their treatment processes. Medical educators should continue to demonstrate and emphasize examples of moral courage in medical practice and encourage trainees to do the right thing despite potential negative outcomes (10). Physicians often encounter ethical challenges in their professional practice. One of the important qualities that physicians need to overcome such challenges is courage (11). Various strategies are implemented during medical education to develop physicians' moral courage. These strategies include discussing ethical principles, case studies, and role-playing activities. However, there is limited evidence regarding the effectiveness of these strategies, partly due to the difficulty in effectively measuring physicians' moral courage (12). In recent years, both national (such as devastating earthquakes affecting many provinces in Türkiye) and global (such as the Coronavirus pandemic) extraordinary situations have affected the healthcare system and consequently, physicians, leaving them facing ethical conflicts. In this context, determining the levels of moral courage of physicians after events with societal and global impacts is particularly important. Studies on moral courage in healthcare professionals generally focus on nurses, and research on the moral courage of physicians is limited. In the Turkish literature, the lack of a scale to evaluate the level of moral courage of physicians highlights this gap. In this context, a comprehensive study is aimed to be conducted by conducting a Turkish validity and reliability study of the Moral Courage Scale for Physicians/MCSP developed by Martinez and colleagues (2016), in order to understand cultural differences in this field. Materials and methods Study Design and Sample The Turkish adaptation of the Moral Courage Scale has a methodological study design. The sample size to be used in the study was determined taking into account the number of items in the scale. It was planned to include at least 10 times the number of items in the scale (9) as sampling units in the study (13), and the study was completed with 106 participants. Participants were selected using non-probabilistic sampling methods, specifically volunteer sampling and snowball sampling. Data Analysis SPSS 26.0 (Statistical Program in Social Sciences) was used for descriptive factor analyses, descriptive information, and reliability analyses, while AMOS 24 was used for confirmatory factor analysis. A reliability coefficient of 0.95 and a significance level (p-value) of 0.05 were accepted for the analyses, and interpretations were made. Descriptive statistics were used, with mean ± standard deviation for quantitative data and number and percentage for qualitative data. Language Validity After obtaining permission for the Turkish adaptation of the "Moral Courage Scale" by Martinez (2016), a blind Turkish translation was made by two language experts who were aware of the study's purpose but not its content. After the translation, the two forms were compared, and the items that best matched the scale were selected. The prepared form was then translated back into Turkish by a language expert proficient in Turkish and whose native language is English, and compared with the original form. The items were selected, and a 9-item questionnaire pool was prepared (14). Content (Expert) Validity The scale form was sent to 12 different experts (experts in medical history and ethics, experts in nursing ethics) to score the items of the scale (15) according to their level of understandability on a scale of 1 and 3 (1: the scale item is not necessary, 2: the scale item is useful but not sufficient, 3: the scale item is necessary and should be included in the questionnaire). The responses from the experts were used to calculate the content validity index. The calculated Kendall W value was 0.029, which was statistically significant (ꭓ2=2.737, p=0.950). It was observed that the 9 items in the questionnaire pool were understandable and suitable for the Turkish population, and the study proceeded to the pilot application stage (15,16). Pilot Application A pilot application of the Moral Courage Scale, consisting of 9 items, was conducted with 20 individuals. When the responses to the items were examined, it was observed that there were no difficulties in understanding, the responses were given easily, and the questions were suitable for the population. Therefore, data collection for the scale was initiated. Psychometric Testing of the Moral Courage Scale During the data collection process, 106 participants were reached, and the collected data were prepared for analysis. Variance homogeneity, normal distribution, independence, randomness, and absence of autocorrelation in error terms were checked in the data controls for multivariate analysis. Outlier distributions in the data were checked, and it was observed that all data forms were within the ±2.5 limit, so data exclusion was not performed. Exploratory factor analysis (EFA) was applied to prepare the initial model for the scale, and confirmatory factor analysis (CFA) was applied to obtain the final model. After determining the scale model, reliability tests were performed using Cronbach's α coefficient and test-retest analyses. Multivariate Normal Distribution To check for multivariate normal distribution, the Mahalanobis Distance criterion was applied to the questionnaire form of the 106 participants, and no form was observed to fall outside the ±2.5 value range (16). Using the "Observations farthest from the centroid (Mahalanobis Distance)" subtab in the AMOS program, the index value was calculated as 5.193, which is less than 8, indicating that multivariate normal distribution was achieved (17). With the assumption of normality satisfied for the scale, validity and reliability analyses were conducted. Results Demographic Information of Participants The demographic information of the participants is presented in the table below (Table 1 ). Table 1 Demographic Information of the Participants Variable Groups Frequency Percent Gender Female 48 45.3 Male 58 54.7 Marital Status Married 67 63.2 Single 39 36.8 Title Intern doctor 51 48.1 Resident doctor 1 0.9 General Practitioner 16 15.1 Family Physician 2 1.9 Medical Specialist 17 16.0 Assistant Professor 9 8.5 Associate Professor 7 6.6 Professor 3 2.8 Specialty field Intern doctor 11 10.4 Internal Medicine 74 69.8 Surgical Medicine 18 17.0 Basic Medicine 3 2.8 Ethics Education Received Yes 65 61.3 No 41 38.7 Ethics Education Undergraduate Education 50 47.2 Course, Seminar, Symposium 6 5.7 In-service training 7 6.6 Doctorate Education 2 1.9 No Education 41 38.7 Encountering Ethical Issues Status Rarely 21 19.8 Sometimes 45 42.5 Very Often 11 10.4 Quite Often 26 24.5 Constantly 3 2.8 Receiving Ethical Consultancy Status Yes 9 8.5 No 97 91.5 Frequency of Moral Courage Encounters Rarely 20 18.9 Sometimes 50 47.2 Very Often 10 9.4 Quite Often 25 23.6 Constantly 1 0.9 Total 106 100.0 Variable Mean ± SD Min - Max Age 37.39 ± 11.15 20–70 Years of experience 12.39 ± 11.08 1–46 SD; standard deviation Table 1 . Demographic Information of Participants Construct Validity First, the Kaiser-Meyer-Olkin (KMO) test was conducted to assess the adequacy of the data for Exploratory Factor Analysis (EFA). The KMO value is a measure indicating the suitability of the data for analysis, with a minimum value of 0.60 considered acceptable. Additionally, a high value for Bartlett’s Test of Sphericity supports the appropriateness of the data structure for the model ( 14 ). The results of Bartlett’s Test of Sphericity calculated with the KMO test for the Moral Courage Scale are presented in the table below (Table 2 ). Table 2 KMO and Bartlett’s test of sphericity Kaiser‒Meyer‒Olkin Measure of Sampling Adequacy. 0.900 Bartlett's Test of Sphericity Approx. Chi-Square 601.126 df 36 p 0.001* df; degree of freedom, *p < 0,05; the test is statistically significant. Table 2 . KMO and Bartlett’s Test of Sphericity Test The KMO value was calculated as 0.900, and the Bartlett’s Test of Sphericity value was 601.126. A KMO test value of 0.90 indicates that the sample size is highly adequate for the scale. The sample size and structure were found to be suitable for the application of EFA ( 14 ). The factor loadings, Corrected Item-total Correlations, and % Variance Explained obtained from the applied EFA are presented in the table below. Table 3 . Factor Loadings and Item-Total Correlations of the Moral Courage Scale Table 3 Factor Loadings and Item–Total Correlations of the Moral Courage Scale Items Factor Loadings Q1 0.728 Q2 0.841 Q3 0.798 Q4 0.850 Q5 0.850 Q6 0.642 Q7 0.847 Q8 0.453 Q9 0.845 % Variance Explained 73.6 Factor loadings for the items in the scale were analyzed, considering a minimum threshold of 0.30. Upon examining the scale model, it was observed that there were no factor loadings below 0.30. The percentage of explained variance for the scale was calculated to be 73.6%, indicating that the explained variance ratio was at the desired level for the scale. The range of factor loadings varied between 0.453 and 0.850 (Table 3 ). In the selection of the subdimensions, subdimensional ranges with eigenvalues above 1 and the varimax rotation method were used ( 18 ). In EFA analyses, the number of factors is determined by different methods ( 19 ). The first and most preferred criterion is the Kaisen criterion, and the roots (λ ≥ 1) greater than one in the covariance and correlation matrix are preferred. The points where the slope starts to disappear in the number of factors determined by the Scree Plot Method are taken into consideration Joliffe Criterion (taking as many factors as the number of eigenvalues greater than 0.7); as many factors as the number of eigenvalues 0.7 and greater (λ ≥ 7) are determined, It is a practical method to determine as many factors as the number of eigenvalues greater than one, Comprehensibility; selecting variables that can be explained by the structure of the variables, The explained variance criterion; the number of factors is selected as the number of eigenvalues so that the cumulative variance explained by the eigenvalues is at least 67% (70%-95%), and it is necessary to determine the number of factors that will explain a very high variance. There are different views on the explained variance criterion; M to indicate the number of significant eigenvalues; \(\:\sum\:_{j=1}^{m}\frac{{\lambda\:}\text{i}}{p}\:\ge\:\) 2/3 or \(\:\sum\:_{j=1}^{m}\frac{{\lambda\:}\text{i}}{p}\:\ge\:\) 0.66 The smallest value of m satisfying the condition gives the number of significant principal components. On the other hand, while a cut-off point of 0.66 is considered appropriate by some authors, the cumulative variance ratio can be taken as 0.95 in science and natural sciences and 0.60 in social sciences where information is less precise ( 20 ). In the selection of the subdimensions, subdimensional ranges with eigenvalues above 1 and the varimax rotation method were used ( 21 , 22 ). Following the Exploratory Factor Analysis (EFA), the Confirmatory Factor Analysis (CFA) stage was conducted for the "Moral Courage Scale," which consists of 9 items representing a single underlying dimension. Confirmatory Factor Analysis Confirmatory Factor Analysis (CFA) was conducted to test the accuracy of the scale model consisting of a single underlying dimension with 9 items obtained in the first stage of construct validity ( 21 , 22 ). The initial structure of the scale was prepared and analysed. The goodness of fit indices obtained from the analysis were calculated as follows: χ2 (Chi-Square Goodness of Fit) = 76.730 and χ2/df = 2.842. The RMSEA (Root Mean Square Error of Approximation) value, used for sample adequacy, was found to be 0.132. While the NFI (Normed Fit Index) was 0.877, the CFI (Comparative Fit Index) and GFI (Goodness of Fit Index) were 0.915, and the IFI (Incremental Fit Index) was 0.917. It was observed that the NFI and RMSEA values did not fall within the desired range ( 23 ). Due to the calculated values not meeting the desired level, modifications were required in the model, which may be due to relationships within the model, measurement errors, or existing relationships in the model that could not be analysed ( 24 ). To apply modifications, covariances were added in pairs to the error terms of observable variables (scale items). Relationships between error terms within the same subscale were considered in covariance drawing. The main purpose of covariance drawing is to include abstract concepts explained simultaneously by two error terms without calculating them in the model ( 25 ). The effects of external factors were included in the model through covariances, and modifications were made to the scale model. For the "Moral Courage Scale," the highest residual terms, with modification index values, were e5-e7 and e8-e9, and covariances were drawn between these pairs of error terms in the model. The diagram of the final model of the scale is given below (Fig. 1 ). Figure 1 . Diagram of the "Moral Courage Scale" in IBM SPSS AMOS 23 Program. Confirmatory factor analysis (CFA) is one of the sub-analyses of structural equation modeling (SEM). In SEM analyses, multiple indices are provided and interpreted for model fit ( 26 , 27 ). In the modified new model of the "Moral Courage Scale," the χ2 value was found to be 39.904 and the χ2/df value was 1.596. The RMSEA value was calculated as 0.075, indicating that the sample size was sufficient for the scale model. It was also observed that the GFI value increased to 0.919, the CFI and IFI values increased to 0.975, and the NFI value increased to 0.936. The χ2/df (χ2/sd ≤ 5) value decreased, and the RMSEA (RMSEA ≤ 0.08), GFI, CFI, NFI, and IFI values increased, indicating a good fit of the model. Due to the statistically significant and sufficient relationship established between the constructed SEM and the scales, the multiple group analysis stage was entered ( 28 , 29 ). The single subscale 9-item scale model prepared with EFA for the "Moral Courage Scale" was confirmed by modifying the DFA model. Thus, the validity analysis of the "Moral Courage Scale" has been completed. Reliability In order to calculate the reliability of the scale, Cronbach's Alpha (α) coefficient of internal consistency and Split-Half method were used. The Cronbach's α coefficient value ranges from 0 to 1, where values below 0.50 indicate that the scale is not reliable. As the coefficient value approaches 1, the reliability value also increases ( 30 ). While increasing the number of items in the scale can increase the reliability value ( 31 ), in cases where the number of items is low, a Cronbach's α coefficient value of 0.50 is considered acceptable ( 32 ). Item-total correlation coefficients are also preferred for reliability. An item-total correlation coefficient value of at least 0.20 for items in a scale is considered sufficient for reliability ( 33 ). Table 4 . Moral Courage Scale" Cronbach’s alpha (α) values Table 4 Moral Courage Scale Cronbach’s alpha (α) values Items Corrected Item-Total Correlation Q1 0.660 Q2 0.770 Q3 0.705 Q4 0.773 Q5 0.749 Q6 0.553 Q7 0.756 Q8 0.387 Q9 0.797 Cronbach's α 0.91 The Cronbach's α coefficient for the Moral Courage Scale was calculated as 0.91, and the range of total correlation coefficients for the items in the scale was found to be 0.387–0.797 (Table 4 ). The second stage of reliability analysis for the scale, which is the test-retest analysis, used a sample of 30 participants( 34 ). The results of the tests are presented in the table below (Table 5 ). Table 5 Test-Retest Results Moral Courage Scale Grup Mean ± sd Cronbach’s α t p 1 r p 2 Test 56.81 ± 3.65 0.754 0.773 0.449 0.927 < 0.001* Retest 56.55 ± 2.92 0.791 sd; standard deviation, t; paired t test, r; Pearson correlation coefficient Table 5 . Test-Retest Results When the total score of the Moral Courage Scale was examined, a very high level of statistically significant positive relationship was found between the test and retest groups (p < 0.05). Scale Score Calculation In the scale scoring, a 7-point Likert-type scoring was used for the responses. The maximum score that can be obtained from the scale is 63, while the minimum score is 7. The values for the 106 participants in the study are given in the table below. Table 6 . Descriptive Statistics for Scores Obtained from the Moral Courage Scale Table 6 Descriptive Statistics for the Moral Courage Scale Scores Moral Courage Scale Mean ± sd Min–Max Scores to Receive From the Scale 54.43 ± 8.02 11–63 sd; standard deviation Of the 106 participants in the study, the lowest score obtained from the scale total was 11, and the highest score was 63, with a mean score of 54.43 ± 8.02 standard deviation (Table 6 ). Discussion The studies on moral courage directed towards physicians are quite limited. Understanding the level of moral courage of physicians from the pre-graduation period throughout their professional lives to prepare them for ethical problems they may encounter and to enable them to cope with these problems is of great importance. Although various views have been put forward regarding moral courage, there is no Turkish tool that measures these characteristics in physicians. Therefore, this study was conducted to evaluate the appropriateness, validity, and reliability of the Turkish version of the scale developed by Martinez (2016) to determine the level of moral courage of physicians. The fact that such a study is conducted for the first time in Türkiye is one of the strongest aspects of this study. The lack of research on the moral courage of physicians at the national and international levels limits the discussions on this subject. This study makes an important contribution to understanding and improving physicians' capacity to cope with ethical challenges. A total of 106 participants were included in the study. The Kaiser-Meyer-Olkin (KMO) test value of the scale, which ensured multivariate normal distribution, was 0.90, indicating that the sample size was quite high in terms of evaluating the adequacy of the scale. The basic model of the scale, which formed the basis of the analyses, was prepared using exploratory factor analysis (EFA) and was confirmed by modifications made in the confirmatory factor analysis (CFA) model. Cronbach's α coefficient was calculated to evaluate the internal consistency of the scale and found to be 0.91. Additionally, the range of total correlation coefficients for the items in the scale was calculated to be between 0.387 and 0.797. These results indicate that the scale was designed reliably and consistently and can be used. In the analysis of the test-retest groups of the scale, statistically significant and highly positive relationships were found (p < 0.05). According to the results obtained with the 7-point Likert-type scoring used in the scale scoring, the maximum score that can be obtained from the scale was determined to be 63, while the lowest score was determined to be 7. The lowest score obtained from the scale total by the 106 participants included in the study was 11, the highest score was 63, and the mean score was found to be 54.43 ± 8.02 standard deviation. These results indicate that the scale is reliable and stable. It can be said that the participants' levels of moral courage are generally high, and the scale successfully measures these differences. In conclusion, this study includes the adaptation study of the Moral Courage Scale into Turkish, and the obtained data show that the scale can provide valid and reliable results. These results suggest that the scale can be an effective tool for evaluating the level of moral courage and can provide reliable results in studies. Additionally, the scale's low number of items increases its usability and facilitates the answering of relevant items. Therefore, this scale will be able to determine the levels of moral courage of physicians, reveal cultural differences, and allow for the planning of necessary arrangements in both undergraduate and in-service trainings starting from the pre-graduation period, and the results obtained can offer solution proposals regarding the situation. Declarations Ethical Considerations The study was conducted in accordance with the Helsinki Declaration and was approved by the Duzce University Non-Interventional Ethics Committee (Ref: 2022/80). Source of Finance This study was funded internally. Informed Consent Statement Informed consent was obtained from all subjects involved in the study. Data Availability Statement Data will be available upon request from the corresponding author of the study. Conflicts of Interest The authors declare no conflict of interest. Consent for publication Not Applicable. References Pajakoski E, Rannikko S, Leino‐Kilpi H, Numminen O. Moral courage in nursing – An integrative literature review. Nurs Health Sci [Internet]. 2021 Sep [cited 2024 Feb 12];23(3):570–85. Available from: https://onlinelibrary.wiley.com/doi/10.1111/nhs.12805 Murray J. Moral courage in healthcare: acting ethically even in the presence of risk. OJIN Online J Issues Nurs [Internet]. 2010 Sep 30 [cited 2024 Feb 19];15(3). Available from: https://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol152010/No3-Sept-2010/Moral-Courage-and-Risk.html Sadooghiasl A, Parvizy S, Ebadi A. Concept analysis of moral courage in nursing: A hybrid model. Nurs Ethics [Internet]. 2018 Feb [cited 2024 Feb 19];25(1):6–19. Available from: http://journals.sagepub.com/doi/10.1177/0969733016638146 Baughman KR, Aultman JM, Ludwick R, O’Neill A. Narrative analysis of the ethics in providing advance care planning. Nurs Ethics [Internet]. 2014 Feb [cited 2024 Feb 19];21(1):53–63. Available from: http://journals.sagepub.com/doi/10.1177/0969733013486795 Borracci RA, Ciambrone G, Gallesio JMA. Correlations between moral courage scores and social desirability scores among medical residents and fellows in Argentina. J Educ Eval Health Prof [Internet]. 2020 Feb 18 [cited 2024 Feb 12];17:6. Available from: http://jeehp.org/DOIx.php?id=10.3352/jeehp.2020.17.6 Hawkins SF, Morse J. The praxis of courage as a foundation for care. J Nurs Scholarsh [Internet]. 2014 Jul [cited 2024 Feb 19];46(4):263–70. Available from: https://sigmapubs.onlinelibrary.wiley.com/doi/10.1111/jnu.12077 Thorup CB, Rundqvist E, Roberts C, Delmar C. Care as a matter of courage: vulnerability, suffering and ethical formation in nursing care. Scand J Caring Sci [Internet]. 2012 Sep [cited 2024 Feb 19];26(3):427–35. Available from: https://onlinelibrary.wiley.com/doi/10.1111/j.1471-6712.2011.00944.x Kovanci MS, Hi̇çdurmaz D. Ahlaki cesaret: tanımı, ahlaki sıkıntı ve ahlaki duyarlılık ile ilişkisi ve geliştirilmesi. Düzce Üniversitesi Sağlık Bilim Enstitüsü Derg [Internet]. 2020 Dec 25 [cited 2024 Feb 12]; Available from: https://dergipark.org.tr/tr/doi/10.33631/duzcesbed.683548 Bruun AMG, Valeberg BT, Leonardsen ACL. Moral courage: student registered nurse anesthetist experiences on the operating team. AANA J. 2022 Apr;90(2):121–6. Caldicott CV. Revisiting moral courage as an educational objective. Acad Med [Internet]. 2023 Aug [cited 2024 Feb 19];98(8):873–5. Available from: https://journals.lww.com/10.1097/ACM.0000000000005239 Escolar-Chua RL. Moral sensitivity, moral distress, and moral courage among baccalaureate Filipino nursing students. Nurs Ethics [Internet]. 2018 Jun [cited 2024 Feb 12];25(4):458–69. Available from: http://journals.sagepub.com/doi/10.1177/0969733016654317 Martinez, W., Bell, SK., Etchegaray, JM., Lehman, LS. Measuring moral courage for ınterns and residents: scale development and ınitial psychometrics. Acad. Med. 2016;91(10):1431–8. Karakoç FY, Dönmez L. Ölçek geliştirme çalışmalarında temel ilkeler. Tıp Eğitimi Dünyası, 2014;13(40):39–49. https://doi.org/10.25282/ted.228738 Alpar, R. Uygulamalı İstatistik ve Geçerlik-Güvenirlik. 6th ed. Ankara: Detay Yayıncılık; 2020. Bowling A, Ebrahim S. Handbook of health research methods: investigation, measurement and analysis. UK: McGraw-Hill Education; 2005. Mardia K. Applications of some measures of multivariate skewness and kurtosis ın testing normality and robustness studies. The Indian Journal of Statistics. 1974;36(2):115–28. İnceoğlu F, Demi̇r P, Aydoğdu H. Adaptation of fear of missing out scale (FoMOs) to dentistry. Selcuk Dental Journal. 2021;8(2):530-537. Available from: https://dergipark.org.tr/en/doi/10.15311/selcukdentj.946507 Büyüköztürk YDDŞ. Faktör analizi: temel kavramlar ve ölçek geliştirmede kullanımı. Kuram ve Uygulamada Eğitim Yönetimi, 2002:32(32), Article 32. Available from: https://dergipark.org.tr/tr/pub/kuey/issue/10365/126871 Özdamar, K. [Statistical Data Analysis With Package Programs-2]: Setlerarası Korelasyon Analizi: Paket Programlar İle İstatistiksel Veri Analizi 2. 5. Eskişehir: Kaan Kitabevi; 2010. 407–434 p. İnceoğlu. Doğrulayıcı Faktör Analizinde Yarışan Modeller ve Klinik Bir Uygulaması. İnönü Üniversitesi, Doktora Tezi; 2018. Bollen KA, Long JS. Testing Structural Equation Models. Sage Publications, Inc.1993. Maruyama GM. Basics Of Structural Equation Modeling. London: Sage Publications; 1998. Arbuckle JL. Ibm SPSS IBM SPSS AMOS 21 User’s Guide. USA: IBM SPSS AMOS Corp: Ibm Corp.; 2012. Kline R.B. Principles and Practice Of Structural Equation Modeling. 3nd ed. Newyork: Guilford Publications; 2011. Civelek ME. Yapısal Eşitlik Modellemesi Metodolojisi. İstanbul: Beta Yayıncılık; 2018. Cole DA. Utility of confirmatory factor analysis in test validation research. J Consult Clin Psychol, 1987;55(4):584-594. doi: 10.1037/0022-006X.55.4.584. Jöreskog KG, Sörbom D. Structural equation modeling with the sımplıs command language. Scientific Software, 1993:13–43. Inceoglu F, Yologlu S, Kanik E. Comparative analysis of models in confirmatory factor analysis: Exploring clinical applications and interpretation. Med Sci Int Med J [Internet]. 2023 [cited 2024 Jan 15];12(2):562. Available from: http://www.medicinescience.org/article/3471 İnceoğlu F, Porgalı Zayman E. Moderator Effect of Chronic Disease on The Relationship Between Marriage Adjustment and Satisfaction in Married Couples. Eur J Ther [Internet]. 2023 Aug 10 [cited 2024 Jan 15];29(3):459–68. Available from: https://eurjther.com/index.php/home/article/view/1722 Gliem AJ, Gliem RR. Calculating, Interpreting and Reporting Cronbach’s Alpha Reliability Coefficient for Likert-Type Scales. In USA: Midwest Research To Practice Conference In Adult, Continuing and Community Education; 2003. p. 82–8. Urbina, S. Essentials of psychological testing. 2nd ed. USA: John Wiley & Sons; 2014. Raines-Eudy R. Using Structural equation modeling to test for differential reliability and validity: an empirical demonstration. Structural Equation Modeling: A Multidisciplinary Journal, 2000;7(1):124–141. Available from: http://www.tandfonline.com/doi/abs/10.1207/S15328007SEM0701_07 Briggs SR, Cheek JM. The role of factor analysis in the development and evaluation of personality scales. Journal of Personality, 1986;54(1):106–148. Available from: https://onlinelibrary.wiley.com/doi/10.1111/j.1467-6494.1986.tb00391.x Aksayan S, Gözüm S. Kültürlerarası ölçek uyarlaması için rehber II: psikometri özellikler ve kültürlerarası karşılaştırma. Hemşirelikte Araştırma ve Geliştirme Dergisi, 2003; 5(1):3–14. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4821326","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":345123927,"identity":"74b7815d-16c6-4458-bea4-b7e5bf12642d","order_by":0,"name":"Şerife Yılmaz","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABEklEQVRIiWNgGAWjYJCCAxUMDDx8INbHBpgYGwEtZ4BaQGoYZyJr4cGn5wzUWGZeYrTIt/c+PHCg4rAMm9jhx59td9jlm7efPcDwoewwg730AaxaDM4cNzhw4MxhHjbpNAPj3DPJlnPO5CUwzjh3GOi9BOxaJNIYDn9sA2lJMEjObWM2kGDIMWDmbQNqweEy+fnPGA4c/AfSkv7hsGVbvYEE/xsD5r94tDDcYANqaQBpyTFsZmw7bCAhAbSFEY8WgzNpDAcOHEsHaSlm7G07DtTyxuBgz7l0Hp4zuELsGPOHAzXW9vzS6Zs//GyrBjosx/DBjzJrOfYeHA6DgGZU7gEGAjEJBHUE5EfBKBgFo2BEAwAg9VmEmwYlHwAAAABJRU5ErkJggg==","orcid":"","institution":"Harran University","correspondingAuthor":true,"prefix":"","firstName":"Şerife","middleName":"","lastName":"Yılmaz","suffix":""},{"id":345123929,"identity":"5be31b08-b983-460a-81f9-2931f1d23a59","order_by":1,"name":"Gamze Özbek Güven","email":"","orcid":"","institution":"Yüksek İhtisas Üniversitesi","correspondingAuthor":false,"prefix":"","firstName":"Gamze","middleName":"Özbek","lastName":"Güven","suffix":""},{"id":345123931,"identity":"381c82a0-cbfe-44c4-9ccd-ee4c63fc07a8","order_by":2,"name":"Feyza İnceoğlu","email":"","orcid":"","institution":"Malatya Turgut Özal Üniversitesi","correspondingAuthor":false,"prefix":"","firstName":"Feyza","middleName":"","lastName":"İnceoğlu","suffix":""}],"badges":[],"createdAt":"2024-07-29 10:47:22","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4821326/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4821326/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":63492419,"identity":"67f205ec-697b-47cc-9a1f-de74fda796e4","added_by":"auto","created_at":"2024-08-28 18:16:56","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":141800,"visible":true,"origin":"","legend":"\u003cp\u003eDiagram of the \"Moral Courage Scale\" in IBM SPSS AMOS 23 Program.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4821326/v1/2f4bf244cef7b18527873c62.jpeg"},{"id":63968399,"identity":"e24b7b7f-d121-4cf3-85e1-86e970ce6308","added_by":"auto","created_at":"2024-09-04 10:17:38","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":870675,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4821326/v1/4c3f7c6c-a1e9-41d4-82cc-793955b824c1.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Cross-cultural adaptation, reliability, and validity of the Turkish Version of the Moral Courage Scale for Physicians","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMoral courage is a concept that represents an individual's courage and inner strength to act in accordance with moral and ethical values\u0026nbsp;(1). This concept involves the ability to defend what is right despite negative consequences\u0026nbsp;(2). It also signifies the strength that emerges when dealing with threats to one's own moral and ethical values\u0026nbsp;(3).\u003c/p\u003e\n\u003cp\u003eFrom a healthcare and medical perspective, moral courage includes the ability to advocate for the needs of patients, protect their treatment rights, and intervene in patient care. This is critically important in terms of being committed to acting in the best interests of patients. Moral courage requires helping patients confront their vulnerabilities and pains, witnessing their vulnerabilities and pains, and acting with determination and dedication to provide professional care\u0026nbsp;(2,4–7)In this context, the demonstration of moral courage by healthcare professionals can contribute to gaining patients' trust, acting in accordance with ethical standards, and protecting individuals' rights in the process of receiving healthcare.\u003c/p\u003e\n\u003cp\u003eMoral courage holds great value for healthcare personnel. However, the demonstration of moral courage is influenced not only by an individual's internal values but also by environmental factors. Factors such as working conditions, role conflicts, power dynamics, and organizational culture in the healthcare sector are significant barriers that individuals face when demonstrating moral courage. Additionally, demonstrating moral courage can sometimes expose individuals to negative reactions, intimidation, and even the risk of psychological or physical violence from colleagues or superiors. These situations imply the risk of individuals losing their jobs or status. Personal or organizational barriers can lead healthcare personnel to struggle to act in accordance with ethical values and experience traumatic experiences despite knowing what is right\u0026nbsp;(8).\u003c/p\u003e\n\u003cp\u003eThe lack of moral courage can have potentially significant consequences for both healthcare personnel and patients\u0026nbsp;(9). For healthcare personnel, a lack of moral courage can lead to difficulties in making ethical decisions or behaving in accordance with moral values. This can lead to healthcare personnel having difficulty coping with moral stress, which can affect their professional satisfaction and performance. For patients, a lack of moral courage can pave the way for unethical behaviors or negative events. When healthcare personnel struggle to uphold ethical principles, patients' rights to respect and receive treatment in accordance with ethical standards may be at risk. This can lead to patients losing their trust and negatively impacting their treatment processes. Medical educators should continue to demonstrate and emphasize examples of moral courage in medical practice and encourage trainees to do the right thing despite potential negative outcomes\u0026nbsp;(10).\u003c/p\u003e\n\u003cp\u003ePhysicians often encounter ethical challenges in their professional practice. One of the important qualities that physicians need to overcome such challenges is courage\u0026nbsp;(11). Various strategies are implemented during medical education to develop physicians' moral courage. These strategies include discussing ethical principles, case studies, and role-playing activities. However, there is limited evidence regarding the effectiveness of these strategies, partly due to the difficulty in effectively measuring physicians' moral courage\u0026nbsp;(12).\u003c/p\u003e\n\u003cp\u003eIn recent years, both national (such as devastating earthquakes affecting many provinces in Türkiye) and global (such as the Coronavirus pandemic) extraordinary situations have affected the healthcare system and consequently, physicians, leaving them facing ethical conflicts. In this context, determining the levels of moral courage of physicians after events with societal and global impacts is particularly important.\u003c/p\u003e\n\u003cp\u003eStudies on moral courage in healthcare professionals generally focus on nurses, and research on the moral courage of physicians is limited. In the Turkish literature, the lack of a scale to evaluate the level of moral courage of physicians highlights this gap. In this context, a comprehensive study is aimed to be conducted by conducting a Turkish validity and reliability study of the Moral Courage Scale for Physicians/MCSP developed by Martinez and colleagues (2016), in order to understand cultural differences in this field.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003eStudy Design and Sample\u003c/p\u003e\n\u003cp\u003eThe Turkish adaptation of the Moral Courage Scale has a methodological study design. The sample size to be used in the study was determined taking into account the number of items in the scale. It was planned to include at least 10 times the number of items in the scale (9) as sampling units in the study\u0026nbsp;(13), and the study was completed with 106 participants. Participants were selected using non-probabilistic sampling methods, specifically volunteer sampling and snowball sampling.\u003c/p\u003e\n\u003cp\u003eData Analysis\u003c/p\u003e\n\u003cp\u003eSPSS 26.0 (Statistical Program in Social Sciences) was used for descriptive factor analyses, descriptive information, and reliability analyses, while AMOS 24 was used for confirmatory factor analysis. A reliability coefficient of 0.95 and a significance level (p-value) of 0.05 were accepted for the analyses, and interpretations were made. Descriptive statistics were used, with mean ± standard deviation for quantitative data and number and percentage for qualitative data.\u003c/p\u003e\n\u003cp\u003eLanguage Validity\u003c/p\u003e\n\u003cp\u003eAfter obtaining permission for the Turkish adaptation of the \"Moral Courage Scale\" by Martinez (2016), a blind Turkish translation was made by two language experts who were aware of the study's purpose but not its content. After the translation, the two forms were compared, and the items that best matched the scale were selected. The prepared form was then translated back into Turkish by a language expert proficient in Turkish and whose native language is English, and compared with the original form. The items were selected, and a 9-item questionnaire pool was prepared\u0026nbsp;(14).\u003c/p\u003e\n\u003cp\u003eContent (Expert) Validity\u003c/p\u003e\n\u003cp\u003eThe scale form was sent to 12 different experts (experts in medical history and ethics, experts in nursing ethics) to score the items of the scale\u0026nbsp;(15)\u0026nbsp;according to their level of understandability on a scale of 1 and 3 (1: the scale item is not necessary, 2: the scale item is useful but not sufficient, 3: the scale item is necessary and should be included in the questionnaire). The responses from the experts were used to calculate the content validity index. The calculated Kendall W value was 0.029, which was statistically significant (ꭓ2=2.737, p=0.950). It was observed that the 9 items in the questionnaire pool were understandable and suitable for the Turkish population, and the study proceeded to the pilot application stage\u0026nbsp;(15,16).\u003c/p\u003e\n\u003cp\u003ePilot Application\u003c/p\u003e\n\u003cp\u003eA pilot application of the Moral Courage Scale, consisting of 9 items, was conducted with 20 individuals. When the responses to the items were examined, it was observed that there were no difficulties in understanding, the responses were given easily, and the questions were suitable for the population. Therefore, data collection for the scale was initiated.\u003c/p\u003e\n\u003cp\u003ePsychometric Testing of the Moral Courage Scale\u003c/p\u003e\n\u003cp\u003eDuring the data collection process, 106 participants were reached, and the collected data were prepared for analysis. Variance homogeneity, normal distribution, independence, randomness, and absence of autocorrelation in error terms were checked in the data controls for multivariate analysis. Outlier distributions in the data were checked, and it was observed that all data forms were within the ±2.5 limit, so data exclusion was not performed. Exploratory factor analysis (EFA) was applied to prepare the initial model for the scale, and confirmatory factor analysis (CFA) was applied to obtain the final model. After determining the scale model, reliability tests were performed using Cronbach's α coefficient and test-retest analyses.\u003c/p\u003e\n\u003cp\u003eMultivariate Normal Distribution\u003c/p\u003e\n\u003cp\u003eTo check for multivariate normal distribution, the Mahalanobis Distance criterion was applied to the questionnaire form of the 106 participants, and no form was observed to fall outside the ±2.5 value range (16). Using the \"Observations farthest from the centroid (Mahalanobis Distance)\" subtab in the AMOS program, the index value was calculated as 5.193, which is less than 8, indicating that multivariate normal distribution was achieved (17). With the assumption of normality satisfied for the scale, validity and reliability analyses were conducted.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eDemographic Information of Participants\u003c/h2\u003e \u003cp\u003eThe demographic information of the participants is presented in the table below (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic Information of the Participants\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eGroups\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePercent\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003eFemale\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e45.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003eMale\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e54.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eMarital Status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003eMarried\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e63.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003eSingle\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e36.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"7\" rowspan=\"8\"\u003e \u003cp\u003e\u003cb\u003eTitle\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003eIntern doctor\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e48.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003eResident doctor\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003eGeneral Practitioner\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003eFamily Physician\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003eMedical Specialist\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003eAssistant Professor\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003eAssociate Professor\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003eProfessor\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eSpecialty field\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003eIntern doctor\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003eInternal Medicine\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e69.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003eSurgical Medicine\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e17.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003eBasic Medicine\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eEthics Education Received\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003eYes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e61.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003eNo\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e38.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cb\u003eEthics Education\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003eUndergraduate Education\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e47.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003eCourse, Seminar, Symposium\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003eIn-service training\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003eDoctorate Education\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003eNo Education\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e38.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cb\u003eEncountering Ethical Issues Status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003eRarely\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003eSometimes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e42.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003eVery Often\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003eQuite Often\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e24.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003eConstantly\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eReceiving Ethical Consultancy Status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003eYes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003eNo\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e91.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cb\u003eFrequency of Moral Courage Encounters\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003eRarely\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003eSometimes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e47.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003eVery Often\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003eQuite Often\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e23.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003eConstantly\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e106\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e100.0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eVariable\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e\u003cb\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eMin - Max\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e37.39\u0026thinsp;\u0026plusmn;\u0026thinsp;11.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e20\u0026ndash;70\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eYears of experience\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e12.39\u0026thinsp;\u0026plusmn;\u0026thinsp;11.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u0026ndash;46\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eSD; standard deviation\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Demographic Information of Participants\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eConstruct Validity\u003c/h2\u003e \u003cp\u003eFirst, the Kaiser-Meyer-Olkin (KMO) test was conducted to assess the adequacy of the data for Exploratory Factor Analysis (EFA). The KMO value is a measure indicating the suitability of the data for analysis, with a minimum value of 0.60 considered acceptable. Additionally, a high value for Bartlett\u0026rsquo;s Test of Sphericity supports the appropriateness of the data structure for the model (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). The results of Bartlett\u0026rsquo;s Test of Sphericity calculated with the KMO test for the Moral Courage Scale are presented in the table below (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eKMO and Bartlett\u0026rsquo;s test of sphericity\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eKaiser‒Meyer‒Olkin Measure of Sampling Adequacy.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.900\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eBartlett's Test of Sphericity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eApprox. Chi-Square\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e601.126\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003edf\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003ep\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003edf; degree of freedom, *p\u0026thinsp;\u0026lt;\u0026thinsp;0,05; the test is statistically significant.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. KMO and Bartlett\u0026rsquo;s Test of Sphericity Test\u003c/p\u003e \u003cp\u003eThe KMO value was calculated as 0.900, and the Bartlett\u0026rsquo;s Test of Sphericity value was 601.126. A KMO test value of 0.90 indicates that the sample size is highly adequate for the scale. The sample size and structure were found to be suitable for the application of EFA (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe factor loadings, Corrected Item-total Correlations, and % Variance Explained obtained from the applied EFA are presented in the table below.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. Factor Loadings and Item-Total Correlations of the Moral Courage Scale\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFactor Loadings and Item\u0026ndash;Total Correlations of the Moral Courage Scale\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItems\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFactor Loadings\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eQ1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.728\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eQ2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.841\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eQ3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.798\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eQ4\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.850\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eQ5\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.850\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eQ6\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.642\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eQ7\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.847\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eQ8\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.453\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eQ9\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.845\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e% Variance Explained\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e73.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eFactor loadings for the items in the scale were analyzed, considering a minimum threshold of 0.30. Upon examining the scale model, it was observed that there were no factor loadings below 0.30. The percentage of explained variance for the scale was calculated to be 73.6%, indicating that the explained variance ratio was at the desired level for the scale. The range of factor loadings varied between 0.453 and 0.850 (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn the selection of the subdimensions, subdimensional ranges with eigenvalues above 1 and the varimax rotation method were used (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn EFA analyses, the number of factors is determined by different methods (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eThe first and most preferred criterion is the Kaisen criterion, and the roots (λ\u0026thinsp;\u0026ge;\u0026thinsp;1) greater than one in the covariance and correlation matrix are preferred.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eThe points where the slope starts to disappear in the number of factors determined by the Scree Plot Method are taken into consideration\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eJoliffe Criterion (taking as many factors as the number of eigenvalues greater than 0.7); as many factors as the number of eigenvalues 0.7 and greater (λ\u0026thinsp;\u0026ge;\u0026thinsp;7) are determined,\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eIt is a practical method to determine as many factors as the number of eigenvalues greater than one,\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eComprehensibility; selecting variables that can be explained by the structure of the variables,\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eThe explained variance criterion; the number of factors is selected as the number of eigenvalues so that the cumulative variance explained by the eigenvalues is at least 67% (70%-95%), and it is necessary to determine the number of factors that will explain a very high variance.\u003c/p\u003e \u003cp\u003eThere are different views on the explained variance criterion;\u003c/p\u003e \u003cp\u003eM to indicate the number of significant eigenvalues;\u003c/p\u003e \u003cp\u003e \u003cspan class=\"InlineEquation\"\u003e \u003cspan class=\"mathinline\"\u003e\\(\\:\\sum\\:_{j=1}^{m}\\frac{{\\lambda\\:}\\text{i}}{p}\\:\\ge\\:\\)\u003c/span\u003e \u003c/span\u003e 2/3 or \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\sum\\:_{j=1}^{m}\\frac{{\\lambda\\:}\\text{i}}{p}\\:\\ge\\:\\)\u003c/span\u003e\u003c/span\u003e 0.66\u003c/p\u003e \u003cp\u003eThe smallest value of m satisfying the condition gives the number of significant principal components. On the other hand, while a cut-off point of 0.66 is considered appropriate by some authors, the cumulative variance ratio can be taken as 0.95 in science and natural sciences and 0.60 in social sciences where information is less precise (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn the selection of the subdimensions, subdimensional ranges with eigenvalues above 1 and the varimax rotation method were used (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFollowing the Exploratory Factor Analysis (EFA), the Confirmatory Factor Analysis (CFA) stage was conducted for the \"Moral Courage Scale,\" which consists of 9 items representing a single underlying dimension.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eConfirmatory Factor Analysis\u003c/h2\u003e \u003cp\u003eConfirmatory Factor Analysis (CFA) was conducted to test the accuracy of the scale model consisting of a single underlying dimension with 9 items obtained in the first stage of construct validity (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). The initial structure of the scale was prepared and analysed. The goodness of fit indices obtained from the analysis were calculated as follows: χ2 (Chi-Square Goodness of Fit)\u0026thinsp;=\u0026thinsp;76.730 and χ2/df\u0026thinsp;=\u0026thinsp;2.842. The RMSEA (Root Mean Square Error of Approximation) value, used for sample adequacy, was found to be 0.132. While the NFI (Normed Fit Index) was 0.877, the CFI (Comparative Fit Index) and GFI (Goodness of Fit Index) were 0.915, and the IFI (Incremental Fit Index) was 0.917. It was observed that the NFI and RMSEA values did not fall within the desired range (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDue to the calculated values not meeting the desired level, modifications were required in the model, which may be due to relationships within the model, measurement errors, or existing relationships in the model that could not be analysed (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTo apply modifications, covariances were added in pairs to the error terms of observable variables (scale items). Relationships between error terms within the same subscale were considered in covariance drawing. The main purpose of covariance drawing is to include abstract concepts explained simultaneously by two error terms without calculating them in the model (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). The effects of external factors were included in the model through covariances, and modifications were made to the scale model. For the \"Moral Courage Scale,\" the highest residual terms, with modification index values, were e5-e7 and e8-e9, and covariances were drawn between these pairs of error terms in the model. The diagram of the final model of the scale is given below (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Diagram of the \"Moral Courage Scale\" in IBM SPSS AMOS 23 Program.\u003c/p\u003e \u003cp\u003eConfirmatory factor analysis (CFA) is one of the sub-analyses of structural equation modeling (SEM). In SEM analyses, multiple indices are provided and interpreted for model fit (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). In the modified new model of the \"Moral Courage Scale,\" the χ2 value was found to be 39.904 and the χ2/df value was 1.596. The RMSEA value was calculated as 0.075, indicating that the sample size was sufficient for the scale model. It was also observed that the GFI value increased to 0.919, the CFI and IFI values increased to 0.975, and the NFI value increased to 0.936.\u003c/p\u003e \u003cp\u003eThe χ2/df (χ2/sd\u0026thinsp;\u0026le;\u0026thinsp;5) value decreased, and the RMSEA (RMSEA\u0026thinsp;\u0026le;\u0026thinsp;0.08), GFI, CFI, NFI, and IFI values increased, indicating a good fit of the model. Due to the statistically significant and sufficient relationship established between the constructed SEM and the scales, the multiple group analysis stage was entered (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe single subscale 9-item scale model prepared with EFA for the \"Moral Courage Scale\" was confirmed by modifying the DFA model. Thus, the validity analysis of the \"Moral Courage Scale\" has been completed.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eReliability\u003c/h2\u003e \u003cp\u003eIn order to calculate the reliability of the scale, Cronbach's Alpha (α) coefficient of internal consistency and Split-Half method were used. The Cronbach's α coefficient value ranges from 0 to 1, where values below 0.50 indicate that the scale is not reliable. As the coefficient value approaches 1, the reliability value also increases (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). While increasing the number of items in the scale can increase the reliability value (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e), in cases where the number of items is low, a Cronbach's α coefficient value of 0.50 is considered acceptable (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Item-total correlation coefficients are also preferred for reliability. An item-total correlation coefficient value of at least 0.20 for items in a scale is considered sufficient for reliability (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. Moral Courage Scale\" Cronbach\u0026rsquo;s alpha (α) values\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMoral Courage Scale Cronbach\u0026rsquo;s alpha (α) values\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItems\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCorrected Item-Total Correlation\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eQ1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.660\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eQ2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.770\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eQ3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.705\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eQ4\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.773\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eQ5\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.749\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eQ6\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.553\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eQ7\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.756\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eQ8\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.387\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eQ9\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.797\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCronbach's α\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.91\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe Cronbach's α coefficient for the Moral Courage Scale was calculated as 0.91, and the range of total correlation coefficients for the items in the scale was found to be 0.387\u0026ndash;0.797 (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe second stage of reliability analysis for the scale, which is the test-retest analysis, used a sample of 30 participants(\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). The results of the tests are presented in the table below (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTest-Retest Results\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eMoral Courage Scale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGrup\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;sd\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCronbach\u0026rsquo;s α\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003et\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003er\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ep\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eTest\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e56.81\u0026thinsp;\u0026plusmn;\u0026thinsp;3.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.754\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.773\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.449\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.927\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eRetest\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e56.55\u0026thinsp;\u0026plusmn;\u0026thinsp;2.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.791\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003esd; standard deviation, t; paired t test, r; Pearson correlation coefficient\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e. Test-Retest Results\u003c/p\u003e \u003cp\u003eWhen the total score of the Moral Courage Scale was examined, a very high level of statistically significant positive relationship was found between the test and retest groups (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eScale Score Calculation\u003c/h2\u003e \u003cp\u003eIn the scale scoring, a 7-point Likert-type scoring was used for the responses. The maximum score that can be obtained from the scale is 63, while the minimum score is 7.\u003c/p\u003e \u003cp\u003eThe values for the 106 participants in the study are given in the table below.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e. Descriptive Statistics for Scores Obtained from the Moral Courage Scale\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDescriptive Statistics for the Moral Courage Scale Scores\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eMoral Courage Scale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;sd\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMin\u0026ndash;Max Scores to Receive From the Scale\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54.43\u0026thinsp;\u0026plusmn;\u0026thinsp;8.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11\u0026ndash;63\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003esd; standard deviation\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eOf the 106 participants in the study, the lowest score obtained from the scale total was 11, and the highest score was 63, with a mean score of 54.43\u0026thinsp;\u0026plusmn;\u0026thinsp;8.02 standard deviation (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe studies on moral courage directed towards physicians are quite limited. Understanding the level of moral courage of physicians from the pre-graduation period throughout their professional lives to prepare them for ethical problems they may encounter and to enable them to cope with these problems is of great importance. Although various views have been put forward regarding moral courage, there is no Turkish tool that measures these characteristics in physicians. Therefore, this study was conducted to evaluate the appropriateness, validity, and reliability of the Turkish version of the scale developed by Martinez (2016) to determine the level of moral courage of physicians. The fact that such a study is conducted for the first time in T\u0026uuml;rkiye is one of the strongest aspects of this study. The lack of research on the moral courage of physicians at the national and international levels limits the discussions on this subject. This study makes an important contribution to understanding and improving physicians' capacity to cope with ethical challenges.\u003c/p\u003e \u003cp\u003eA total of 106 participants were included in the study. The Kaiser-Meyer-Olkin (KMO) test value of the scale, which ensured multivariate normal distribution, was 0.90, indicating that the sample size was quite high in terms of evaluating the adequacy of the scale. The basic model of the scale, which formed the basis of the analyses, was prepared using exploratory factor analysis (EFA) and was confirmed by modifications made in the confirmatory factor analysis (CFA) model. Cronbach's α coefficient was calculated to evaluate the internal consistency of the scale and found to be 0.91. Additionally, the range of total correlation coefficients for the items in the scale was calculated to be between 0.387 and 0.797. These results indicate that the scale was designed reliably and consistently and can be used.\u003c/p\u003e \u003cp\u003eIn the analysis of the test-retest groups of the scale, statistically significant and highly positive relationships were found (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). According to the results obtained with the 7-point Likert-type scoring used in the scale scoring, the maximum score that can be obtained from the scale was determined to be 63, while the lowest score was determined to be 7. The lowest score obtained from the scale total by the 106 participants included in the study was 11, the highest score was 63, and the mean score was found to be 54.43\u0026thinsp;\u0026plusmn;\u0026thinsp;8.02 standard deviation. These results indicate that the scale is reliable and stable. It can be said that the participants' levels of moral courage are generally high, and the scale successfully measures these differences.\u003c/p\u003e \u003cp\u003eIn conclusion, this study includes the adaptation study of the Moral Courage Scale into Turkish, and the obtained data show that the scale can provide valid and reliable results. These results suggest that the scale can be an effective tool for evaluating the level of moral courage and can provide reliable results in studies. Additionally, the scale's low number of items increases its usability and facilitates the answering of relevant items. Therefore, this scale will be able to determine the levels of moral courage of physicians, reveal cultural differences, and allow for the planning of necessary arrangements in both undergraduate and in-service trainings starting from the pre-graduation period, and the results obtained can offer solution proposals regarding the situation.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical Considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted in accordance with the Helsinki Declaration and was approved by the Duzce University Non-Interventional Ethics Committee (Ref: 2022/80).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSource of Finance\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was funded internally.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed Consent Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all subjects involved in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData will be available upon request from the corresponding author of the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003ePajakoski E, Rannikko S, Leino‐Kilpi H, Numminen O. Moral courage in nursing \u0026ndash; An integrative literature review. Nurs Health Sci [Internet]. 2021 Sep [cited 2024 Feb 12];23(3):570\u0026ndash;85. Available from: https://onlinelibrary.wiley.com/doi/10.1111/nhs.12805\u003c/li\u003e\n\u003cli\u003eMurray J. Moral courage in healthcare: acting ethically even in the presence of risk. OJIN Online J Issues Nurs [Internet]. 2010 Sep 30 [cited 2024 Feb 19];15(3). Available from: https://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol152010/No3-Sept-2010/Moral-Courage-and-Risk.html\u003c/li\u003e\n\u003cli\u003eSadooghiasl A, Parvizy S, Ebadi A. Concept analysis of moral courage in nursing: A hybrid model. Nurs Ethics [Internet]. 2018 Feb [cited 2024 Feb 19];25(1):6\u0026ndash;19. Available from: http://journals.sagepub.com/doi/10.1177/0969733016638146\u003c/li\u003e\n\u003cli\u003eBaughman KR, Aultman JM, Ludwick R, O\u0026rsquo;Neill A. Narrative analysis of the ethics in providing advance care planning. Nurs Ethics [Internet]. 2014 Feb [cited 2024 Feb 19];21(1):53\u0026ndash;63. Available from: http://journals.sagepub.com/doi/10.1177/0969733013486795\u003c/li\u003e\n\u003cli\u003eBorracci RA, Ciambrone G, Gallesio JMA. Correlations between moral courage scores and social desirability scores among medical residents and fellows in Argentina. J Educ Eval Health Prof [Internet]. 2020 Feb 18 [cited 2024 Feb 12];17:6. Available from: http://jeehp.org/DOIx.php?id=10.3352/jeehp.2020.17.6\u003c/li\u003e\n\u003cli\u003eHawkins SF, Morse J. The praxis of courage as a foundation for care. J Nurs Scholarsh [Internet]. 2014 Jul [cited 2024 Feb 19];46(4):263\u0026ndash;70. Available from: https://sigmapubs.onlinelibrary.wiley.com/doi/10.1111/jnu.12077\u003c/li\u003e\n\u003cli\u003eThorup CB, Rundqvist E, Roberts C, Delmar C. Care as a matter of courage: vulnerability, suffering and ethical formation in nursing care. Scand J Caring Sci [Internet]. 2012 Sep [cited 2024 Feb 19];26(3):427\u0026ndash;35. Available from: https://onlinelibrary.wiley.com/doi/10.1111/j.1471-6712.2011.00944.x\u003c/li\u003e\n\u003cli\u003eKovanci MS, Hi̇\u0026ccedil;durmaz D. Ahlaki cesaret: tanımı, ahlaki sıkıntı ve ahlaki duyarlılık ile ilişkisi ve geliştirilmesi. D\u0026uuml;zce \u0026Uuml;niversitesi Sağlık Bilim Enstit\u0026uuml;s\u0026uuml; Derg [Internet]. 2020 Dec 25 [cited 2024 Feb 12]; Available from: https://dergipark.org.tr/tr/doi/10.33631/duzcesbed.683548\u003c/li\u003e\n\u003cli\u003eBruun AMG, Valeberg BT, Leonardsen ACL. Moral courage: student registered nurse anesthetist experiences on the operating team. AANA J. 2022 Apr;90(2):121\u0026ndash;6. \u003c/li\u003e\n\u003cli\u003eCaldicott CV. Revisiting moral courage as an educational objective. Acad Med [Internet]. 2023 Aug [cited 2024 Feb 19];98(8):873\u0026ndash;5. Available from: https://journals.lww.com/10.1097/ACM.0000000000005239\u003c/li\u003e\n\u003cli\u003eEscolar-Chua RL. Moral sensitivity, moral distress, and moral courage among baccalaureate Filipino nursing students. Nurs Ethics [Internet]. 2018 Jun [cited 2024 Feb 12];25(4):458\u0026ndash;69. Available from: http://journals.sagepub.com/doi/10.1177/0969733016654317\u003c/li\u003e\n\u003cli\u003eMartinez, W., Bell, SK., Etchegaray, JM., Lehman, LS. Measuring moral courage for ınterns and residents: scale development and ınitial psychometrics. Acad. Med. 2016;91(10):1431\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eKarako\u0026ccedil; FY, D\u0026ouml;nmez L. \u0026Ouml;l\u0026ccedil;ek geliştirme \u0026ccedil;alışmalarında temel ilkeler. Tıp Eğitimi D\u0026uuml;nyası, 2014;13(40):39\u0026ndash;49. https://doi.org/10.25282/ted.228738 \u003c/li\u003e\n\u003cli\u003eAlpar, R. Uygulamalı İstatistik ve Ge\u0026ccedil;erlik-G\u0026uuml;venirlik. 6th ed. Ankara: Detay Yayıncılık; 2020. \u003c/li\u003e\n\u003cli\u003eBowling A, Ebrahim S. Handbook of health research methods: investigation, measurement and analysis. UK: McGraw-Hill Education; 2005. \u003c/li\u003e\n\u003cli\u003eMardia K. Applications of some measures of multivariate skewness and kurtosis ın testing normality and robustness studies. The Indian Journal of Statistics. 1974;36(2):115\u0026ndash;28. \u003c/li\u003e\n\u003cli\u003eİnceoğlu F, Demi̇r P, Aydoğdu H. Adaptation of fear of missing out scale (FoMOs) to dentistry. Selcuk Dental Journal. 2021;8(2):530-537. Available from: https://dergipark.org.tr/en/doi/10.15311/selcukdentj.946507\u003c/li\u003e\n\u003cli\u003eB\u0026uuml;y\u0026uuml;k\u0026ouml;zt\u0026uuml;rk YDDŞ. Fakt\u0026ouml;r analizi: temel kavramlar ve \u0026ouml;l\u0026ccedil;ek geliştirmede kullanımı. Kuram ve Uygulamada Eğitim Y\u0026ouml;netimi, 2002:32(32), Article 32. Available from: https://dergipark.org.tr/tr/pub/kuey/issue/10365/126871\u003c/li\u003e\n\u003cli\u003e\u0026Ouml;zdamar, K. [Statistical Data Analysis With Package Programs-2]: Setlerarası Korelasyon Analizi: Paket Programlar İle İstatistiksel Veri Analizi 2. 5. Eskişehir: Kaan Kitabevi; 2010. 407\u0026ndash;434 p. \u003c/li\u003e\n\u003cli\u003eİnceoğlu. Doğrulayıcı Fakt\u0026ouml;r Analizinde Yarışan Modeller ve Klinik Bir Uygulaması. İn\u0026ouml;n\u0026uuml; \u0026Uuml;niversitesi, Doktora Tezi; 2018. \u003c/li\u003e\n\u003cli\u003eBollen KA, Long JS. Testing Structural Equation Models. Sage Publications, Inc.1993.\u003c/li\u003e\n\u003cli\u003eMaruyama GM. Basics Of Structural Equation Modeling. London: Sage Publications; 1998. \u003c/li\u003e\n\u003cli\u003eArbuckle JL. Ibm SPSS IBM SPSS AMOS 21 User\u0026rsquo;s Guide. USA: IBM SPSS AMOS Corp: Ibm Corp.; 2012. \u003c/li\u003e\n\u003cli\u003eKline R.B. Principles and Practice Of Structural Equation Modeling. 3nd ed. Newyork: Guilford Publications; 2011. \u003c/li\u003e\n\u003cli\u003eCivelek ME. Yapısal Eşitlik Modellemesi Metodolojisi. İstanbul: Beta Yayıncılık; 2018. \u003c/li\u003e\n\u003cli\u003eCole DA. Utility of confirmatory factor analysis in test validation research. J Consult Clin Psychol, 1987;55(4):584-594. doi: 10.1037/0022-006X.55.4.584. \u003c/li\u003e\n\u003cli\u003eJ\u0026ouml;reskog KG, S\u0026ouml;rbom D. Structural equation modeling with the sımplıs command language. Scientific Software, 1993:13\u0026ndash;43.\u003c/li\u003e\n\u003cli\u003eInceoglu F, Yologlu S, Kanik E. Comparative analysis of models in confirmatory factor analysis: Exploring clinical applications and interpretation. Med Sci Int Med J [Internet]. 2023 [cited 2024 Jan 15];12(2):562. Available from: http://www.medicinescience.org/article/3471\u003c/li\u003e\n\u003cli\u003eİnceoğlu F, Porgalı Zayman E. Moderator Effect of Chronic Disease on The Relationship Between Marriage Adjustment and Satisfaction in Married Couples. Eur J Ther [Internet]. 2023 Aug 10 [cited 2024 Jan 15];29(3):459\u0026ndash;68. Available from: https://eurjther.com/index.php/home/article/view/1722\u003c/li\u003e\n\u003cli\u003eGliem AJ, Gliem RR. Calculating, Interpreting and Reporting Cronbach\u0026rsquo;s Alpha Reliability Coefficient for Likert-Type Scales. In USA: Midwest Research To Practice Conference In Adult, Continuing and Community Education; 2003. p. 82\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eUrbina, S. Essentials of psychological testing. 2nd ed. USA: John Wiley \u0026amp; Sons; 2014. \u003c/li\u003e\n\u003cli\u003eRaines-Eudy R. Using Structural equation modeling to test for differential reliability and validity: an empirical demonstration. Structural Equation Modeling: A Multidisciplinary Journal, 2000;7(1):124\u0026ndash;141. Available from: http://www.tandfonline.com/doi/abs/10.1207/S15328007SEM0701_07\u003c/li\u003e\n\u003cli\u003eBriggs SR, Cheek JM. The role of factor analysis in the development and evaluation of personality scales. Journal of Personality, 1986;54(1):106\u0026ndash;148. Available from: https://onlinelibrary.wiley.com/doi/10.1111/j.1467-6494.1986.tb00391.x\u003c/li\u003e\n\u003cli\u003eAksayan S, G\u0026ouml;z\u0026uuml;m S. K\u0026uuml;lt\u0026uuml;rlerarası \u0026ouml;l\u0026ccedil;ek uyarlaması i\u0026ccedil;in rehber II: psikometri \u0026ouml;zellikler ve k\u0026uuml;lt\u0026uuml;rlerarası karşılaştırma. Hemşirelikte Araştırma ve Geliştirme Dergisi, 2003; 5(1):3\u0026ndash;14. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Moral Courage, physician, validity, reliability, ethics","lastPublishedDoi":"10.21203/rs.3.rs-4821326/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4821326/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePhysicians, like other healthcare professionals, frequently encounter situations requiring moral courage in their professional lives. However, studies on the moral courage of physicians are limited in the literature. This study aims to evaluate the Turkish adaptation, validity, and reliability of the Moral Courage Scale for Physicians (MCSP) and to contribute to national and international studies on moral courage among physicians.\u003c/p\u003e\u003ch2\u003eMaterials and methods\u003c/h2\u003e \u003cp\u003eThis methodological study involved the adaptation, validity, and reliability assessment of the MCSP in Turkish. The scale's internal consistency was evaluated using Cronbach's α coefficient, and the total correlation coefficients for the items were calculated. Test-retest reliability was assessed using a two-group design.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe Turkish version of the MCSP demonstrated high internal consistency, with a Cronbach's α coefficient of 0.91. The total correlation coefficients for the items ranged from 0.387 to 0.797. A significant positive correlation was found between the test and retest scores of the MCSP (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe Turkish version of the MCSP is a valid and reliable tool for assessing moral courage among physicians.\u003c/p\u003e","manuscriptTitle":"Cross-cultural adaptation, reliability, and validity of the Turkish Version of the Moral Courage Scale for Physicians","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-28 18:16:51","doi":"10.21203/rs.3.rs-4821326/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2ffa2b20-12ec-47c9-ac61-7e313b9d3000","owner":[],"postedDate":"August 28th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-09-04T10:09:31+00:00","versionOfRecord":[],"versionCreatedAt":"2024-08-28 18:16:51","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4821326","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4821326","identity":"rs-4821326","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}