Design and psychometric evaluation of the moral distress questionnaire for nurses in pediatric wards

Design and psychometric evaluation of the moral distress questionnaire for nurses in pediatric wards | 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 Design and psychometric evaluation of the moral distress questionnaire for nurses in pediatric wards FatemehSadat SeyedNematollah Roshan, Narges Rahmani, Majedeh Nabavian This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6518919/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Introduction: Recognizing the significance of moral distress in pediatric settings and the potential of a valid and reliable tool to identify its occurrence and aid in developing preventive strategies, this study aimed to design and evaluate the psychometric properties of a moral distress instrument specifically for nurses in pediatric wards. Method A mixed-methods approach with a sequential exploratory design, based on Creswell’s methodology, was employed. The study was conducted in three phases from 2024 to 2025 in Mazandaran Province: ( 1 ) a qualitative phase to clarify the key concept, ( 2 ) item development for the instrument, and ( 3 ) an experimental phase involving psychometric evaluation. The initial qualitative phase explored nurses’ experiences of moral distress in pediatric wards using a phenomenological approach. Lived experiences were gathered through in-depth, structured, and semi-structured interviews with 12 nurses from hospitals in Tehran and Babol, and analyzed using Van Manen’s method. In the second phase, instrument items were developed, and validation processes, including face validity, content validity, and construct validity (using exploratory factor analysis), were conducted. Reliability was assessed through internal consistency and stability. Findings: Following the initial phase, a pool of 76 preliminary items was generated. After assessing face and content validity, the number of items was reduced to 22. The content validity index for the overall instrument (S-CVI/Ave) was 0.89, indicating acceptable validity. Exploratory factor analysis, using the Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy and Bartlett’s test of sphericity, was performed on the 22 items. The analysis identified three factors accounting for the majority of the variance (53.64%). The KMO statistic was 0.711, and Bartlett’s test yielded P = 0.000. Cronbach’s alpha and the Intraclass Correlation Coefficient (ICC) were 0.814, indicating good internal consistency and reliability of the instrument. Conclusion Moral distress among nurses can lead to burnout, increased patient safety risks, and reduced quality of care. This instrument can assist healthcare managers and policymakers in assessing moral distress in pediatric nurses and implementing necessary support interventions. Instrument Development Validation Distress Ethics Nurses Children Figures Figure 1 Introduction Jameton (1984) identified three ethics-related experiences in nursing: moral uncertainty, moral dilemmas, and moral distress. Moral distress arises when one knows the ethically correct action but faces organizational constraints that make it nearly impossible to pursue( 1 ). Although initially defined within the nursing population, studies suggest that moral distress can affect all healthcare professionals, representing a response to any ethical conflict( 2 ). Recent studies have focused on moral distress in healthcare systems and its impact on healthcare professionals, categorizing it at the patient, unit, and system levels( 3 – 5 ).Ethical challenges occur across various healthcare settings( 6 – 9 ). Risk factors for moral distress in nurses include resource shortages, substandard care by medical staff, medical errors, colleague incompetence, and conflicts among medical teams( 10 ). Patient and family circumstances, conflicting demands, and mistrust can also heighten moral distress levels( 11 ). Nurses in certain specialized wards face greater exposure to ethical decision-making in patient care and treatment due to intense physical and emotional demands; consequently, facing these stressful situations increases the occurrence of moral distress among them( 12 ). Pediatric nurses face intense physical and emotional demands, increasing their exposure to ethical decision-making challenges( 13 ). Direct interaction with young patients and their parents necessitates high levels of scientific and ethical competence( 14 ). Ethical care for children involves comprehensive knowledge, attention to physical and psychosocial development, effective communication with children and their families, adherence to children’s rights, and collaboration with relevant professionals( 15 ). A Swedish study indicated that less than one-third of pediatric nurses felt they could consistently provide good ethical care( 16 ). Studies also link ethical decision-making to job satisfaction and moral distress( 17 ). Caring for sick children exposes nurses to numerous ethical challenges. Despite good intentions to provide good ethical care, personal and professional ethical values are challenged in clinical practice. This becomes apparent when pediatric nurses use treatment methods that are unpleasant and painful or when parents do not tell the truth ( 18 ). Ethical distress is a phenomenon that can have different effects on the nurse, patient, and health systems, leading to detrimental consequences. This phenomenon can cause the nurse to experience conflict in caring for the patient and avoid facing the patient and providing quality care to them( 19 ).These conditions themselves create the ground for defects in the recovery process and increase the length of stay ( 20 ). Also, in addition to the mentioned cases, ethical distress, if it continues, can cause emotional reactions such as anger, frustration, guilt, physical disorders such as headaches, and sleep disorders in nurses( 21 ). Ethical distress can affect nurses’ sense of their abilities and power to take initiative. Studies have shown that due to ethical tension, 81% of nurses in special care units described themselves as powerless and ineffective ( 22 ). Nurses face discomfort and anxiety when dealing with things that are beyond their control and cannot do the right thing for their patient ( 16 ). The scarcity and limitation of resources puts pressure on nurses and has a negative impact on their efficiency and effectiveness, which in turn leads to more ethical dilemmas( 23 ). In addition, the work environment and cultural organization should be considered as factors that contribute to moral distress. Nurses in Iran face ambiguity in their job descriptions, heavy workloads, and lack of resources, a shortage that affects their levels of moral distress. Responsibilities that do not allow them to engage in the areas of policy development and governance( 24 ). Given the potential adverse outcomes of moral distress, such as decreased job satisfaction and compromised quality of care, developing appropriate measurement tools is crucial. Several instruments have been developed to assess moral distress in nurses, including those by Corley et al. (2005)( 25 ), Hamric et al. (2009)( 26 ), and Glasberg et al. (2006)( 27 ). However, there is a lack of validated scales for measuring moral distress among nurses in Iran. Considering that ethical stressors must be identified in the cultural context and nurses with different social and cultural backgrounds have different ethical and religious knowledge that affects their moral distress and ethical dilemmas( 28 , 29 ), and various studies in this regard have shown that context and culture play a fundamental role in ethical dilemmas and moral distress. This makes each country a unique case for study( 30 ), and national and international research is necessary ( 26 ).This study addresses this gap by designing and psychometrically evaluating a moral distress instrument for nurses in pediatric wards, involving qualitative and experimental phases. The findings are expected to contribute to the identification and prevention of moral distress in this population. Methods This study employed a mixed-methods, sequential exploratory design, following Creswell’s methodology. The research was conducted in three phases from 2024 to 2025 in Mazandaran Province: (1) a qualitative phase to clarify the key concept, (2) item development for the instrument, and (3) an experimental phase involving psychometric evaluation(31). Qualitative Phase: This phase aimed to explore nurses’ experiences related to moral distress in pediatric wards, utilizing a qualitative phenomenological approach. Lived experiences were gathered through in-depth, structured, and semi-structured interviews with 12 nurses working in hospitals in Tehran and Babol. Data were analyzed using Van Manen’s method(32). Instrument Development Phase: Items for the instrument were developed, and validation processes were conducted, including face validity, content validity, and construct validity using exploratory factor analysis. The reliability of the instrument was assessed through internal consistency and stability. In this study, the face and content validity of a questionnaire on the moral distress of nurses in the pediatric ward was examined. Initially, using 10 nurses, the importance of the items was evaluated through a 5-point Likert scale, and items with a score above 1.5 were considered appropriate. To determine the qualitative content validity, the opinions of 10 experts were reviewed. Quantitative content validity was assessed using CVR and CVI criteria, and finally, 22 items reached the factor analysis stage. KMO and Bartlett’s tests were used to examine the adequacy of the samples and the significance of the analysis. The results showed that KMO was equal to 0.711 and Bartlett’s test was significant (p<0.001), confirming a significant relationship between the variables. In this research, the methods of scree plot and eigenvalue (characteristic value) were used to determine the number of factors constructing the questionnaire(31). In this research, the criterion for categorizing factors based on a cutoff point of 0.4 was considered as the minimum factor loading required to maintain the expression in the factors extracted from factor analysis, and an eigenvalue greater than 1 was considered. Findings In the first phase of the research, using phenomenological research, the lived experiences of nurses in pediatric units regarding moral distress included 3 main themes and 7 sub-themes: moral distress related to colleagues (lack of competence and physician-centricity), hospital policies (shortage of human resources, high workload, and lack of adequate equipment), and psychological tensions following ethical distress (negative effects following the sudden death of a child and feelings of inadequacy and helplessness). in the second phase of the research, after forming the item pool and holding brainstorming sessions with research colleagues, a total of 37 items in four domains – “Moral Distress Related to Colleagues,” “Moral Distress Related to Family,” “Psychological Tensions Following Moral Distress,” and “Moral Distress Related to Lack of Resources and Equipment” – reached the psychometric testing stage. To ensure the validity of the questionnaire, three methods of validity assessment were used: face validity, content validity, and construct validity. In the qualitative and quantitative face validity assessments, based on the feedback from participants, none of the items were changed or removed. Ultimately, in the face validity phase of the questionnaire, all 37 items were deemed appropriate in terms of importance, with an impact score of more than 1.5, and were entered into the content validity phase. After conducting a qualitative content validity assessment by experts and merging some of the phrases, 30 items entered the quantitative content validity phase. Thus, after removing 8 items from the total of 30 items in the quantitative content validity phase, 22 items remained for the next phase, namely determining the construct validity and determining the final reliability. in this study, exploratory factor analysis was used with the Kaiser-Meyer-Olkin (KMO) test and Bartlett’s test, alongside principal component analysis, on the 22 items. This revealed categories of variables that had the greatest interrelation. The KMO test is used to determine the adequacy of samples. Generally, a KMO index value above 0.7 is considered suitable for factor analysis. Bartlett’s test indicates whether the obtained correlation matrix significantly differs from the null hypothesis of sphericity, thus justifying the performance of factor analysis. As shown in Table 1, the Kaiser-Meyer-Olkin measure of sampling adequacy was 0.711, indicating an adequate sample size. Bartlett’s test of sphericity was significant (P = 0.000), supporting the use of factor analysis based on the correlation matrix obtained from the study sample. Table 1. Factor Analysis, Kaiser-Meyer-Olkin Sampling Index, and Bartlett’s Test Results KMO and Bartlett's Test Kaiser-Meyer-Olkin Measure of Sampling Adequacy. .711 Bartlett's Test of Sphericity Approx. Chi-Square 2115.752 df 231 Sig. .000 Exploratory Factor Analysis (EFA): The scree plot method and eigenvalue approach were used to determine the number of factors constructing the questionnaire. In this study, a factor loading cutoff of 0.4 was set as the minimum required for retaining an item, and an eigenvalue greater than 1 was considered. Table 2. Total Variance Explained Total Variance Explained Component Initial Eigenvalues Extraction Sums of Squared Loadings Rotation Sums of Squared Loadings Total % of Variance Cumulative % Total % of Variance Cumulative % Total % of Variance Cumulative % 1 6.528 29.674 29.674 6.528 29.674 29.674 5.343 24.287 24.287 2 4.019 18.268 47.943 4.019 18.268 47.943 4.002 18.189 42.476 3 2.021 9.189 57.131 2.021 9.189 57.131 2.458 11.172 53.648 4 1.607 7.304 64.435 1.607 7.304 64.435 2.004 9.108 62.756 5 1.380 6.272 70.707 1.380 6.272 70.707 1.626 7.392 70.148 6 1.131 5.139 75.846 1.131 5.139 75.846 1.253 5.697 75.846 7 .912 4.144 79.990 8 .888 4.037 84.027 9 .844 3.837 87.864 10 .553 2.516 90.379 11 .473 2.149 92.528 12 .387 1.757 94.286 13 .251 1.140 95.425 14 .222 1.007 96.433 15 .184 .834 97.267 16 .165 .752 98.019 17 .122 .553 98.571 18 .099 .448 99.019 19 .091 .411 99.431 20 .069 .316 99.746 21 .039 .176 99.923 22 .017 .077 100.000 Extraction Method: Principal Component Analysis. As shown in the table 2, there are six factors with eigenvalues greater than one. However, the first three factors accounted for the majority of the variance (53.64%). Specifically, the first factor accounted for 24.29% of the variance, the second factor accounted for 18.19%, and the third factor accounted for 11.17%. Diagram 1. Scree Plot for Determining the Number of Factors The scree plot also supports the selection of three factors, as the plot shows a clear elbow after the third factor. After extracting the factors, each one was named based on the variables (items) of each factor, and the consistency of these factors with the concepts and dimensions of the moral distress instrument in pediatric nurses was determined in this research was examined (Tables 3, 4, 5) Table 3. Factors Extracted from Factor Analysis Using Varimax Rotation (Factor 1: Moral Distress Related to Family) Factor Loading Item Number 0.910 19 0.901 11 0.873 12 0.854 8 0.842 Due to a lack of staff, I am forced to delegate the care of the child to the parents. 22 0.819 I am afraid of transmitting infections due to the family’s insistence on frequent visits with the child. 10 Table 4. Factors Extracted from Factor Analysis Using Varimax Rotation (Factor 2: Moral Distress Related to Colleagues) Factor Loading Item Number 0.920 6 0.899 7 0.886 2 0.882 4 0.837 The lack of adequate medication and equipment for proper patient care creates stress for me. 20 Table 5. Factors Extracted from Factor Analysis Using Varimax Rotation (Factor 3: Psychological Tensions Following Moral Distress / Internal Ethical Tensions) Factor Loading Item Number 0.778 16 0.762 18 0.651 15 0.577 13 To evaluate reliability, 30 nurses completed the questionnaire, and the analysis was conducted using Cronbach’s alpha coefficient. The results showed that all subscales and the entire test had a Cronbach’s alpha above 0.7, confirming good internal consistency (Table 6). Table 6. Intra-class correlation coefficient of each dimension and the entire scale Intraclass Correlation Coefficient Intraclass Correlation b 95% Confidence Interval F Test with True Value 0 Lower Bound Upper Bound Value df1 df2 Sig Single Measures .226 a .135 .371 5.380 29 406 .000 Average Measures .814 .700 .899 5.380 29 406 .000 Two-way random effects model where both people effects and measures effects are random. a. The estimator is the same, whether the interaction effect is present or not. b. Type C intraclass correlation coefficients using a consistency definition. The between-measure variance is excluded from the denominator variance. For scoring, a 5-point Likert scale was used, and the scores ranged from 15 to 75. Values determining the level of moral distress were defined as low, moderate, and high according to specified ranges. If a person’s score is between 15-34.9, the level of moral distress will be in the low range. If a person’s score is between 35-55, their level of moral distress will be in the moderate range. If a person’s score is between 55.1-75, the level of moral distress is in the high range. Table 7 shows the score ranges of each of the instrument’s categories. Table 7. Score Ranges of the Instrument for Measuring the Level of Moral Distress in Nurses Working in the Pediatric Ward Dimensions Minimum Score Maximum Score Low Moderate High Moral Distress Related to Family 6 30 6-13.9(7.9) 14-22(8) 22.1-30(7.9) Moral Distress Related to Colleagues 5 25 5-11.6(6.6) 11.7-18.3(6.6 ) 18.4-25(6.6) Internal Ethical Tensions 4 20 4-9.2(5.2) 9.3-14.7(5.4) 14.8-20(5.2) Total Scale 15 75 15-34.9(19.9) 35-55(20) 55.1-75(19.9) Discussion The present study was conducted with the aim of “designing and psychometrically evaluating the moral distress questionnaire in nurses in pediatric wards.” The final questionnaire was extracted in the form of 15 items and 3 dimensions, including moral distress related to family, moral distress related to colleagues, and internal ethical tensions. Evidence showed that the questionnaire had acceptable validity and reliability. Moral distress related to family was the first dimension of the questionnaire, so that nurses considered not having enough opportunity to pay attention to the patient’s and family’s condition despite feeling the need for it and the family’s lack of trust in them as factors of moral distress. In fact, the patient’s and his family’s condition, as well as the unavailability of doctors in some areas of care, are factors that may exacerbate moral distress in nurses( 11 ). Hanna reported that disagreement between nurses and patients’ families about their views on patient care is an important factor that may lead to the onset of moral distress( 33 ). The results of various studies indicate that nurses who are active in the pediatric ward and are in contact with children and their families are more exposed to moral distress( 13 , 34 ). Nurses experience a high level of moral distress when they use painful treatment cares and the need of families to discharge emotions and aggression is felt( 16 ). Young painful and futile care, denial of prognosis, unrealistic family expectations and expectations are stated as the most common causes of ethical distress ( 35 ). The lack of time for nurses and insufficient staffing levels, heavy workload and busy work shifts( 36 ) have caused concern among pediatric oncology nurses, because the lack of time prevented them from supporting the family in the way they felt( 37 ). So that failure to provide compassionate and high-quality care exacerbated ethical distress among pediatric oncology nurses( 38 ). This finding is consistent with the findings of the current study, in which nurses considered the presence of mothers while providing care to the child and their inappropriate requests effective in ethical distress, and due to the lack of manpower and the high workload, they were not able to support the family and despite the desire, they assigned some of the tasks of caring for the child to the parents. Based on the items in the second factor identified in the exploratory factor analysis, the lack of sufficient skills of colleagues and the obligation to implement some inappropriate requests of the doctor cause the intensification of nurses’ moral distress. In the study of Soleimani et al. (2019), which examined the scale of moral distress in intensive care units, 5 factors were identified as the role of health care provider, useless care, obedience to the doctor, patient distrust, and organizational limitation. In this regard, unquestioning obedience to the doctor’s orders and working with unsafe colleagues, providing inadequate care or prescribing tests and drugs that do not improve the patient’s quality of life have been identified as factors that can play a role in the nurse’s experience of moral distress( 30 ). In fact, factors such as poor medical team collaboration, the presence of unsafe nurses who do not have enough control to provide care to patients can be effective in creating and exacerbating moral distress. Many studies have stated that members of the team and managers of health services often face problems in the field of patient care and treatment decision-making. These issues may be related to economic or political factors existing in the medical center( 39 , 40 ). On the other hand, Gutierrez (2005) stated that the inability of nurses to show courageous behaviors in the medical team makes it difficult for them to communicate effectively with patients and other members of the treatment team. Therefore, they suffer from moral distress( 1 ). Another study showed that increasing the risk of harming the patient and the inadequacy of nurses’ responsibilities can lead to increased moral distress in nurses and their colleagues( 41 ). The patient’s and his family’s condition, as well as the lack of access to doctors in some areas of care, are factors that can strengthen moral distress in nurses. In fact, the lack of trust that the patient and his family may show to the treatment team can make the nurse prone to moral distress( 11 ). Disagreement between nurses and patients’ families about their opinions about patient care is one of the important factors that may lead to moral distress( 33 ). In addition, sometimes doctors tend to increase the dose of the patient’s medicine due to side effects. This issue can frustrate some nurses; Because they see the pain and suffering that their patient suffers from taking the drugs, but they are not able to prescribe a drug to reduce these symptoms. Therefore, they must act according to the doctor’s orders( 42 ). Internal ethical tensions indicate that nurses experience tensions following non-compliance with the patient’s privacy, sudden death of the infant, and ignoring their abilities. Some studies have reported the negative effects of ethical distress on the physical health of nurses in the form of night nightmares, insomnia, heart palpitations and neck pain, feelings of worthlessness, anger, depression, shame and discomfort in their professional life( 25 , 43 , 44 ). Ignoring the causes of moral distress leads to negative consequences such as the movement of nurses in departments, job abandonment, withdrawal from patients, reduced communication with other members of the treatment team, reduced organizational support, fear of legal consequences( 1 , 43 , 45 – 47 ), job dissatisfaction and reduced safety and quality of patient care( 13 , 48 , 49 ). These findings are in line with the findings of the present study, in which nurses felt upset and guilty following moral distress in the pediatric ward and preferred to take a period of time away from the ward and patient care. In the current study, the KMO method was used to examine the exploratory factor analysis and identify the factors, which shows the accuracy of the mentioned study, then the factors identified by the confirmatory factor analysis were confirmed. The Cronbach’s alpha coefficient in all subscales and the whole test was more than 0.7, which is consistent with the studies conducted ( 25 ). One of the limitations of the present study is that it was conducted in Iran and the information was collected with cultural backgrounds appropriate to this country, therefore the results cannot be generalized to other societies and the application of the tool in other countries should be evaluated and validated. Conclusion The present study is a valid and reliable tool for quantitative assessment of moral distress in pediatric nurses. This tool has 15 items in three dimensions: moral distress related to family, moral distress related to colleagues, and internal ethical tensions. It is the first tool with a sequential exploratory approach based on qualitative data of nurses’ experiences of moral distress in the pediatric ward in Iran. According to the findings of the current study and the fact that the family’s lack of trust in nurses and inadequate support for families can cause the intensification of moral distress, gaining professional competence and scientific understanding and developing interpersonal skills among nurses and other caregivers can help reduce the occurrence of moral distress. Assessing the skills and knowledge of nurses when hiring in a specific department and periodically thereafter is one of the issues that should be emphasized by managers and policy makers. In cases where nurses are guided by their ethical values and principles, lack of adequate knowledge and skills leads to unwanted mistakes, and unwanted mistakes cause severe ethical distress and burnout in these people, which leads to job abandonment. Abbreviations CVR Content validity ratio CVI Content validity index KMO Kaiser-Meyer-Olkin ICC Intraclass Correlation Coefficient Declarations Ethics approval and consent to participate The Ethics Committee of the Azad University of Babol, Iran, approved this study (code: IR.IAU.BABOL.REC.1403.127). Since all participants were over 16 years old, an informed consent letter was obtained from all the participants before starting the study. All methods were carried out following relevant guidelines and regulations in the Ethical Declarations. The study did not involve human or animal testing. Consent for publication Not Applicable. Availability of data and materials The datasets generated and/or analyzed during the current study are not publicly available because individual privacy could be compromised. However, they are available from the corresponding author upon reasonable request. Competing interests The authors have declared no conflict of interest. Funding None Authors’ contributions NR supervised the analysis and research process, data analysis, and wrote the manuscript. F. SNR data analysis and wrote the manuscript. MN undertook the data collection. All the authors read and approved the final manuscript. Acknowledgments The authors would like to thank the deputy of research of Islamic Azad University, Babol Branch, for supporting them in this study and thank all the nurses who cooperated in the project. Authors’ information 1 Assistant Professor, Department of Nursing,TeMS.C., Islamic Azad University, Tehran, Iran. 2 Department of Nursing and Midwifery, Bab.C., Islamic Azad University, Babol, Iran. Comprehensive Health Research Center, Bab.C., Islamic Azad University, Babol, Iran. 3 Department of Nursing and Midwifery, Bab.C., Islamic Azad University, Babol, Iran. References Giannetta N, Villa G, Bonetti L, Dionisi S, Pozza A, Rolandi S, et al. 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Hec forum. Springer; 2012. Brazil K, Kassalainen S, Ploeg J, Marshall D. Moral distress experienced by health care professionals who provide home-based palliative care. Soc Sci Med. 2010;71(9):1687–91. Abbaszadeh A, Nakhaei N, Borhani F, Roshanzadeh M. The relationship between moral distress and retention in nurses in Birjand teaching hospitals. Iran J Med Ethics History Med. 2013;6(2):57–66. Duarte CG, Lunardi VL, Silveira RSd, Barlem ELD, Dalmolin GL. Moral suffering among nurse educators of technical courses in nursing. Revista brasileira de enfermagem. 2017;70(2):301–7. Paganini MC, Bousso RS. Nurses’ autonomy in end-of-life situations in intensive care units. Nurs Ethics. 2015;22(7):803–14. Cavinder C. The relationship between providing neonatal palliative care and nurses' moral distress: an integrative review. Adv Neonatal Care. 2014;14(5):322–8. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 17 Jun, 2025 Reviews received at journal 08 Jun, 2025 Reviewers agreed at journal 07 Jun, 2025 Reviewers agreed at journal 06 Jun, 2025 Reviewers invited by journal 04 Jun, 2025 Editor assigned by journal 05 May, 2025 Submission checks completed at journal 03 May, 2025 First submitted to journal 03 May, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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-6518919","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":466187936,"identity":"f5e9f17c-3b77-4c05-a316-96ca72cb20aa","order_by":0,"name":"FatemehSadat SeyedNematollah Roshan","email":"","orcid":"","institution":"TeMS.C, Islamic Azad University","correspondingAuthor":false,"prefix":"","firstName":"FatemehSadat","middleName":"SeyedNematollah","lastName":"Roshan","suffix":""},{"id":466187937,"identity":"f527a1cd-9ca0-4133-b10a-929a5840edab","order_by":1,"name":"Narges Rahmani","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAtElEQVRIiWNgGAWjYFAC/uc/GBhsGBgkiNfCA1KcRrqWwyRoMWc/e8C4ouZ8Yv/s5oMPGGpsoglqsezJS0g8c+x24ow7x5INGI6l5TYQ0mJwIMHgYAPb7cSGGzlmEowNh4nQcv6BYWPDv3OJ84nXciPHmLGx7UDiBhK0PEtjbOxLNt54Iy3ZIIEov5xPPsbY8M1Odt6N5IMPPtTYENYCA45glQnEKgcBe1IUj4JRMApGwQgDACtzRJZMPkhtAAAAAElFTkSuQmCC","orcid":"","institution":"Bab.C, Islamic Azad University","correspondingAuthor":true,"prefix":"","firstName":"Narges","middleName":"","lastName":"Rahmani","suffix":""},{"id":466187938,"identity":"79d8c05c-9e73-4cf2-bf46-5228cd053d79","order_by":2,"name":"Majedeh Nabavian","email":"","orcid":"","institution":"Bab.C, Islamic Azad University","correspondingAuthor":false,"prefix":"","firstName":"Majedeh","middleName":"","lastName":"Nabavian","suffix":""}],"badges":[],"createdAt":"2025-04-24 08:53:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6518919/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6518919/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":84275263,"identity":"c98a7b05-dfcd-44ce-8c25-a59f1c421561","added_by":"auto","created_at":"2025-06-10 05:36:43","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":14845,"visible":true,"origin":"","legend":"\u003cp\u003eDiagram 1. Scree Plot for Determining the Number of Factors\u003c/p\u003e","description":"","filename":"Picture1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6518919/v1/40d7132eac05d9d703a150c5.jpg"},{"id":84278022,"identity":"5830e004-17a1-4ea8-89d1-17c5688dc587","added_by":"auto","created_at":"2025-06-10 06:03:59","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":719099,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6518919/v1/ed029d2f-9ebb-4a2c-98ac-1e6782e30f76.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Design and psychometric evaluation of the moral distress questionnaire for nurses in pediatric wards","fulltext":[{"header":"Introduction","content":"\u003cp\u003eJameton (1984) identified three ethics-related experiences in nursing: moral uncertainty, moral dilemmas, and moral distress. Moral distress arises when one knows the ethically correct action but faces organizational constraints that make it nearly impossible to pursue(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Although initially defined within the nursing population, studies suggest that moral distress can affect all healthcare professionals, representing a response to any ethical conflict(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eRecent studies have focused on moral distress in healthcare systems and its impact on healthcare professionals, categorizing it at the patient, unit, and system levels(\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).Ethical challenges occur across various healthcare settings(\u003cspan additionalcitationids=\"CR7 CR8\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eRisk factors for moral distress in nurses include resource shortages, substandard care by medical staff, medical errors, colleague incompetence, and conflicts among medical teams(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Patient and family circumstances, conflicting demands, and mistrust can also heighten moral distress levels(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eNurses in certain specialized wards face greater exposure to ethical decision-making in patient care and treatment due to intense physical and emotional demands; consequently, facing these stressful situations increases the occurrence of moral distress among them(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePediatric nurses face intense physical and emotional demands, increasing their exposure to ethical decision-making challenges(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Direct interaction with young patients and their parents necessitates high levels of scientific and ethical competence(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Ethical care for children involves comprehensive knowledge, attention to physical and psychosocial development, effective communication with children and their families, adherence to children\u0026rsquo;s rights, and collaboration with relevant professionals(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). A Swedish study indicated that less than one-third of pediatric nurses felt they could consistently provide good ethical care(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Studies also link ethical decision-making to job satisfaction and moral distress(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eCaring for sick children exposes nurses to numerous ethical challenges. Despite good intentions to provide good ethical care, personal and professional ethical values are challenged in clinical practice. This becomes apparent when pediatric nurses use treatment methods that are unpleasant and painful or when parents do not tell the truth (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Ethical distress is a phenomenon that can have different effects on the nurse, patient, and health systems, leading to detrimental consequences. This phenomenon can cause the nurse to experience conflict in caring for the patient and avoid facing the patient and providing quality care to them(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).These conditions themselves create the ground for defects in the recovery process and increase the length of stay (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Also, in addition to the mentioned cases, ethical distress, if it continues, can cause emotional reactions such as anger, frustration, guilt, physical disorders such as headaches, and sleep disorders in nurses(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Ethical distress can affect nurses\u0026rsquo; sense of their abilities and power to take initiative. Studies have shown that due to ethical tension, 81% of nurses in special care units described themselves as powerless and ineffective (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Nurses face discomfort and anxiety when dealing with things that are beyond their control and cannot do the right thing for their patient (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). The scarcity and limitation of resources puts pressure on nurses and has a negative impact on their efficiency and effectiveness, which in turn leads to more ethical dilemmas(\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). In addition, the work environment and cultural organization should be considered as factors that contribute to moral distress. Nurses in Iran face ambiguity in their job descriptions, heavy workloads, and lack of resources, a shortage that affects their levels of moral distress. Responsibilities that do not allow them to engage in the areas of policy development and governance(\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eGiven the potential adverse outcomes of moral distress, such as decreased job satisfaction and compromised quality of care, developing appropriate measurement tools is crucial. Several instruments have been developed to assess moral distress in nurses, including those by Corley et al. (2005)(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e), Hamric et al. (2009)(\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e), and Glasberg et al. (2006)(\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). However, there is a lack of validated scales for measuring moral distress among nurses in Iran. Considering that ethical stressors must be identified in the cultural context and nurses with different social and cultural backgrounds have different ethical and religious knowledge that affects their moral distress and ethical dilemmas(\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e), and various studies in this regard have shown that context and culture play a fundamental role in ethical dilemmas and moral distress. This makes each country a unique case for study(\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e), and national and international research is necessary (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e).This study addresses this gap by designing and psychometrically evaluating a moral distress instrument for nurses in pediatric wards, involving qualitative and experimental phases. The findings are expected to contribute to the identification and prevention of moral distress in this population.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis study employed a mixed-methods, sequential exploratory design, following Creswell’s methodology. The research was conducted in three phases from 2024 to 2025 in Mazandaran Province: (1) a qualitative phase to clarify the key concept, (2) item development for the instrument, and (3) an experimental phase involving psychometric evaluation(31).\u003c/p\u003e\n\u003cp\u003eQualitative Phase: This phase aimed to explore nurses’ experiences related to moral distress in pediatric wards, utilizing a qualitative phenomenological approach. Lived experiences were gathered through in-depth, structured, and semi-structured interviews with 12 nurses working in hospitals in Tehran and Babol. Data were analyzed using Van Manen’s method(32).\u003c/p\u003e\n\u003cp\u003eInstrument Development Phase: Items for the instrument were developed, and validation processes were conducted, including face validity, content validity, and construct validity using exploratory factor analysis. The reliability of the instrument was assessed through internal consistency and stability.\u003c/p\u003e\n\u003cp\u003eIn this study, the face and content validity of a questionnaire on the moral distress of nurses in the pediatric ward was examined. Initially, using 10 nurses, the importance of the items was evaluated through a 5-point Likert scale, and items with a score above 1.5 were considered appropriate. To determine the qualitative content validity, the opinions of 10 experts were reviewed. Quantitative content validity was assessed using CVR and CVI criteria, and finally, 22 items reached the factor analysis stage. KMO and Bartlett’s tests were used to examine the adequacy of the samples and the significance of the analysis. The results showed that KMO was equal to 0.711 and Bartlett’s test was significant (p\u0026lt;0.001), confirming a significant relationship between the variables.\u003c/p\u003e\n\u003cp\u003eIn this research, the methods of scree plot and eigenvalue (characteristic value) were used to determine the number of factors constructing the questionnaire(31). In this research, the criterion for categorizing factors based on a cutoff point of 0.4 was considered as the minimum factor loading required to maintain the expression in the factors extracted from factor analysis, and an eigenvalue greater than 1 was considered.\u003c/p\u003e"},{"header":"Findings","content":"\u003cp\u003eIn the first phase of the research, using phenomenological research, the lived experiences of nurses in pediatric units regarding moral distress included 3 main themes and 7 sub-themes: moral distress related to colleagues (lack of competence and physician-centricity), hospital policies (shortage of human resources, high workload, and lack of adequate equipment), and psychological tensions following ethical distress (negative effects following the sudden death of a child and feelings of inadequacy and helplessness).\u003c/p\u003e\n\u003cp\u003ein the second phase of the research, after forming the item pool and holding brainstorming sessions with research colleagues, a total of 37 items in four domains \u0026ndash; \u0026ldquo;Moral Distress Related to Colleagues,\u0026rdquo; \u0026ldquo;Moral Distress Related to Family,\u0026rdquo; \u0026ldquo;Psychological Tensions Following Moral Distress,\u0026rdquo; and \u0026ldquo;Moral Distress Related to Lack of Resources and Equipment\u0026rdquo; \u0026ndash; reached the psychometric testing stage. To ensure the validity of the questionnaire, three methods of validity assessment were used: face validity, content validity, and construct validity. In the qualitative and quantitative face validity assessments, based on the feedback from participants, none of the items were changed or removed. Ultimately, in the face validity phase of the questionnaire, all 37 items were deemed appropriate in terms of importance, with an impact score of more than 1.5, and were entered into the content validity phase.\u003c/p\u003e\n\u003cp\u003eAfter conducting a qualitative content validity assessment by experts and merging some of the phrases, 30 items entered the quantitative content validity phase. Thus, after removing 8 items from the total of 30 items in the quantitative content validity phase, 22 items remained for the next phase, namely determining the construct validity and determining the final reliability.\u003c/p\u003e\n\u003cp\u003ein this study, exploratory factor analysis was used with the Kaiser-Meyer-Olkin (KMO) test and Bartlett\u0026rsquo;s test, alongside principal component analysis, on the 22 items. This revealed categories of variables that had the greatest interrelation. The KMO test is used to determine the adequacy of samples. Generally, a KMO index value above 0.7 is considered suitable for factor analysis. Bartlett\u0026rsquo;s test indicates whether the obtained correlation matrix significantly differs from the null hypothesis of sphericity, thus justifying the performance of factor analysis.\u003c/p\u003e\n\u003cp\u003eAs shown in Table 1, the Kaiser-Meyer-Olkin measure of sampling adequacy was 0.711, indicating an adequate sample size. Bartlett\u0026rsquo;s test of sphericity was significant (P = 0.000), supporting the use of factor analysis based on the correlation matrix obtained from the study sample.\u003c/p\u003e\n\u003cp\u003eTable 1. Factor Analysis, Kaiser-Meyer-Olkin Sampling Index, and Bartlett\u0026rsquo;s Test Results\u003c/p\u003e\n\u003ctable width=\"450\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"3\" width=\"450\"\u003e\n\u003cp\u003eKMO and Bartlett's Test\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"371\"\u003e\n\u003cp\u003eKaiser-Meyer-Olkin Measure of Sampling Adequacy.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"78\"\u003e\n\u003cp\u003e.711\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"3\" width=\"226\"\u003e\n\u003cp\u003eBartlett's Test of Sphericity\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"145\"\u003e\n\u003cp\u003eApprox. Chi-Square\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"78\"\u003e\n\u003cp\u003e2115.752\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"145\"\u003e\n\u003cp\u003edf\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"78\"\u003e\n\u003cp\u003e231\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"145\"\u003e\n\u003cp\u003eSig.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"78\"\u003e\n\u003cp\u003e.000\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eExploratory Factor Analysis (EFA): The scree plot method and eigenvalue approach were used to determine the number of factors constructing the questionnaire. In this study, a factor loading cutoff of 0.4 was set as the minimum required for retaining an item, and an eigenvalue greater than 1 was considered.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 2. Total Variance Explained\u003c/p\u003e\n\u003ctable width=\"624\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"10\" width=\"624\"\u003e\n\u003cp\u003e\u003cstrong\u003eTotal Variance Explained\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" width=\"57\"\u003e\n\u003cp\u003eComponent\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"3\" width=\"189\"\u003e\n\u003cp\u003eInitial Eigenvalues\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"3\" width=\"189\"\u003e\n\u003cp\u003eExtraction Sums of Squared Loadings\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"3\" width=\"189\"\u003e\n\u003cp\u003eRotation Sums of Squared Loadings\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003eTotal\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e% of Variance\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003eCumulative %\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003eTotal\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e% of Variance\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003eCumulative %\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"47\"\u003e\n\u003cp\u003eTotal\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e% of Variance\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003eCumulative %\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e6.528\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e29.674\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e29.674\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e6.528\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e29.674\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e29.674\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"47\"\u003e\n\u003cp\u003e5.343\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e24.287\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e24.287\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e4.019\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e18.268\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e47.943\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e4.019\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e18.268\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e47.943\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"47\"\u003e\n\u003cp\u003e4.002\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e18.189\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e42.476\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e2.021\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e9.189\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e57.131\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e2.021\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e9.189\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e57.131\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"47\"\u003e\n\u003cp\u003e2.458\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e11.172\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e53.648\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e1.607\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e7.304\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e64.435\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e1.607\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e7.304\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e64.435\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"47\"\u003e\n\u003cp\u003e2.004\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e9.108\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e62.756\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e1.380\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e6.272\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e70.707\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e1.380\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e6.272\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e70.707\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"47\"\u003e\n\u003cp\u003e1.626\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e7.392\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e70.148\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e1.131\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e5.139\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e75.846\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e1.131\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e5.139\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e75.846\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"47\"\u003e\n\u003cp\u003e1.253\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e5.697\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e75.846\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e.912\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e4.144\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e79.990\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"47\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e.888\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e4.037\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e84.027\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"47\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e.844\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e3.837\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e87.864\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"47\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e.553\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e2.516\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e90.379\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"47\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e11\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e.473\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e2.149\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e92.528\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"47\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e12\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e.387\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e1.757\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e94.286\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"47\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e13\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e.251\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e1.140\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e95.425\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"47\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e14\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e.222\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e1.007\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e96.433\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"47\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e15\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e.184\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e.834\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e97.267\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"47\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e16\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e.165\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e.752\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e98.019\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"47\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e17\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e.122\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e.553\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e98.571\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"47\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e18\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e.099\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e.448\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e99.019\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"47\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e19\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e.091\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e.411\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e99.431\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"47\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e20\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e.069\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e.316\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e99.746\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"47\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e21\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e.039\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e.176\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e99.923\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"47\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e22\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e.017\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e.077\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e100.000\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"47\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"10\" width=\"624\"\u003e\n\u003cp\u003eExtraction Method: Principal Component Analysis.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAs shown in the table 2, there are six factors with eigenvalues greater than one. However, the first three factors accounted for the majority of the variance (53.64%). Specifically, the first factor accounted for 24.29% of the variance, the second factor accounted for 18.19%, and the third factor accounted for 11.17%.\u003c/p\u003e\n\u003cp\u003eDiagram 1. Scree Plot for Determining the Number of Factors\u003c/p\u003e\n\u003cp\u003eThe scree plot also supports the selection of three factors, as the plot shows a clear elbow after the third factor.\u003c/p\u003e\n\u003cp\u003eAfter extracting the factors, each one was named based on the variables (items) of each factor, and the consistency of these factors with the concepts and dimensions of the moral distress instrument in pediatric nurses was determined in this research was examined (Tables 3, 4, 5)\u003c/p\u003e\n\u003cp\u003eTable 3. Factors Extracted from Factor Analysis Using Varimax Rotation (Factor 1: Moral Distress Related to Family)\u003c/p\u003e\n\u003ctable width=\"554\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"92\"\u003e\n\u003cp\u003e\u003cstrong\u003eFactor Loading\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"353\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e\u003cstrong\u003eItem Number\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"92\"\u003e\n\u003cp\u003e0.910\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"353\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e19\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"92\"\u003e\n\u003cp\u003e0.901\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"353\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e11\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"92\"\u003e\n\u003cp\u003e0.873\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"353\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e12\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"92\"\u003e\n\u003cp\u003e0.854\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"353\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e8\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"92\"\u003e\n\u003cp\u003e0.842\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"353\"\u003e\n\u003cp\u003eDue to a lack of staff, I am forced to delegate the care of the child to the parents.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e22\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"92\"\u003e\n\u003cp\u003e0.819\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"353\"\u003e\n\u003cp\u003eI am afraid of transmitting infections due to the family\u0026rsquo;s insistence on frequent visits with the child.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e10\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 4. Factors Extracted from Factor Analysis Using Varimax Rotation (Factor 2: Moral Distress Related to Colleagues)\u003c/p\u003e\n\u003ctable width=\"536\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"64\"\u003e\n\u003cp\u003e\u003cstrong\u003eFactor Loading\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"396\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e\u003cstrong\u003eItem Number\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"64\"\u003e\n\u003cp\u003e0.920\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"396\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e6\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"64\"\u003e\n\u003cp\u003e0.899\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"396\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e7\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"64\"\u003e\n\u003cp\u003e0.886\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"396\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"64\"\u003e\n\u003cp\u003e0.882\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"396\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"64\"\u003e\n\u003cp\u003e0.837\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"396\"\u003e\n\u003cp\u003eThe lack of adequate medication and equipment for proper patient care creates stress for me.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e20\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable width=\"536\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"3\" width=\"536\"\u003e\n\u003cp\u003eTable 5. Factors Extracted from Factor Analysis Using Varimax Rotation (Factor 3: Psychological Tensions Following Moral Distress / Internal Ethical Tensions)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"64\"\u003e\n\u003cp\u003e\u003cstrong\u003eFactor Loading\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"396\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e\u003cstrong\u003eItem Number\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"64\"\u003e\n\u003cp\u003e0.778\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"396\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e16\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"64\"\u003e\n\u003cp\u003e0.762\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"396\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e18\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"64\"\u003e\n\u003cp\u003e0.651\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"396\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e15\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"64\"\u003e\n\u003cp\u003e0.577\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"396\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e13\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTo evaluate reliability, 30 nurses completed the questionnaire, and the analysis was conducted using Cronbach\u0026rsquo;s alpha coefficient. The results showed that all subscales and the entire test had a Cronbach\u0026rsquo;s alpha above 0.7, confirming good internal consistency (Table 6).\u003c/p\u003e\n\u003cp\u003eTable 6. Intra-class correlation coefficient of each dimension and the entire scale\u003c/p\u003e\n\u003ctable width=\"595\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"8\" width=\"595\"\u003e\n\u003cp\u003e\u003cstrong\u003eIntraclass Correlation Coefficient\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" width=\"108\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"2\" width=\"81\"\u003e\n\u003cp\u003eIntraclass Correlation\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"170\"\u003e\n\u003cp\u003e95% Confidence Interval\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"4\" width=\"236\"\u003e\n\u003cp\u003eF Test with True Value 0\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003eLower Bound\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003eUpper Bound\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003eValue\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003edf1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003edf2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003eSig\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eSingle Measures\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"81\"\u003e\n\u003cp\u003e.226\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e.135\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e.371\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e5.380\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e29\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e406\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e.000\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eAverage Measures\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"81\"\u003e\n\u003cp\u003e.814\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e.700\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e.899\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e5.380\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e29\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e406\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e.000\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"8\" width=\"595\"\u003e\n\u003cp\u003eTwo-way random effects model where both people effects and measures effects are random.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"8\" width=\"595\"\u003e\n\u003cp\u003ea. The estimator is the same, whether the interaction effect is present or not.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"8\" width=\"595\"\u003e\n\u003cp\u003eb. Type C intraclass correlation coefficients using a consistency definition. The between-measure variance is excluded from the denominator variance.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eFor scoring, a 5-point Likert scale was used, and the scores ranged from 15 to 75. Values determining the level of moral distress were defined as low, moderate, and high according to specified ranges.\u003c/p\u003e\n\u003cp\u003eIf a person\u0026rsquo;s score is between 15-34.9, the level of moral distress will be in the low range. If a person\u0026rsquo;s score is between 35-55, their level of moral distress will be in the moderate range. If a person\u0026rsquo;s score is between 55.1-75, the level of moral distress is in the high range. Table 7 shows the score ranges of each of the instrument\u0026rsquo;s categories.\u003c/p\u003e\n\u003cp\u003eTable 7. Score Ranges of the Instrument for Measuring the Level of Moral Distress in Nurses Working in the Pediatric Ward\u003c/p\u003e\n\u003ctable\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003eDimensions\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003eMinimum Score\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003eMaximum Score\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003eLow\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003eModerate\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003eHigh\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003eMoral Distress Related to Family\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e30\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e6-13.9(7.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e14-22(8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e22.1-30(7.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003eMoral Distress Related to Colleagues\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e25\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e5-11.6(6.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e11.7-18.3(6.6 )\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e18.4-25(6.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003eInternal Ethical Tensions\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e20\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e4-9.2(5.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e9.3-14.7(5.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e14.8-20(5.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003eTotal Scale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e15\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e75\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e15-34.9(19.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e35-55(20)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e55.1-75(19.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe present study was conducted with the aim of \u0026ldquo;designing and psychometrically evaluating the moral distress questionnaire in nurses in pediatric wards.\u0026rdquo; The final questionnaire was extracted in the form of 15 items and 3 dimensions, including moral distress related to family, moral distress related to colleagues, and internal ethical tensions. Evidence showed that the questionnaire had acceptable validity and reliability.\u003c/p\u003e \u003cp\u003eMoral distress related to family was the first dimension of the questionnaire, so that nurses considered not having enough opportunity to pay attention to the patient\u0026rsquo;s and family\u0026rsquo;s condition despite feeling the need for it and the family\u0026rsquo;s lack of trust in them as factors of moral distress. In fact, the patient\u0026rsquo;s and his family\u0026rsquo;s condition, as well as the unavailability of doctors in some areas of care, are factors that may exacerbate moral distress in nurses(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Hanna reported that disagreement between nurses and patients\u0026rsquo; families about their views on patient care is an important factor that may lead to the onset of moral distress(\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). The results of various studies indicate that nurses who are active in the pediatric ward and are in contact with children and their families are more exposed to moral distress(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Nurses experience a high level of moral distress when they use painful treatment cares and the need of families to discharge emotions and aggression is felt(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Young painful and futile care, denial of prognosis, unrealistic family expectations and expectations are stated as the most common causes of ethical distress (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). The lack of time for nurses and insufficient staffing levels, heavy workload and busy work shifts(\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e) have caused concern among pediatric oncology nurses, because the lack of time prevented them from supporting the family in the way they felt(\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). So that failure to provide compassionate and high-quality care exacerbated ethical distress among pediatric oncology nurses(\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). This finding is consistent with the findings of the current study, in which nurses considered the presence of mothers while providing care to the child and their inappropriate requests effective in ethical distress, and due to the lack of manpower and the high workload, they were not able to support the family and despite the desire, they assigned some of the tasks of caring for the child to the parents.\u003c/p\u003e \u003cp\u003eBased on the items in the second factor identified in the exploratory factor analysis, the lack of sufficient skills of colleagues and the obligation to implement some inappropriate requests of the doctor cause the intensification of nurses\u0026rsquo; moral distress. In the study of Soleimani et al. (2019), which examined the scale of moral distress in intensive care units, 5 factors were identified as the role of health care provider, useless care, obedience to the doctor, patient distrust, and organizational limitation. In this regard, unquestioning obedience to the doctor\u0026rsquo;s orders and working with unsafe colleagues, providing inadequate care or prescribing tests and drugs that do not improve the patient\u0026rsquo;s quality of life have been identified as factors that can play a role in the nurse\u0026rsquo;s experience of moral distress(\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). In fact, factors such as poor medical team collaboration, the presence of unsafe nurses who do not have enough control to provide care to patients can be effective in creating and exacerbating moral distress. Many studies have stated that members of the team and managers of health services often face problems in the field of patient care and treatment decision-making. These issues may be related to economic or political factors existing in the medical center(\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). On the other hand, Gutierrez (2005) stated that the inability of nurses to show courageous behaviors in the medical team makes it difficult for them to communicate effectively with patients and other members of the treatment team. Therefore, they suffer from moral distress(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Another study showed that increasing the risk of harming the patient and the inadequacy of nurses\u0026rsquo; responsibilities can lead to increased moral distress in nurses and their colleagues(\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). The patient\u0026rsquo;s and his family\u0026rsquo;s condition, as well as the lack of access to doctors in some areas of care, are factors that can strengthen moral distress in nurses. In fact, the lack of trust that the patient and his family may show to the treatment team can make the nurse prone to moral distress(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Disagreement between nurses and patients\u0026rsquo; families about their opinions about patient care is one of the important factors that may lead to moral distress(\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). In addition, sometimes doctors tend to increase the dose of the patient\u0026rsquo;s medicine due to side effects. This issue can frustrate some nurses; Because they see the pain and suffering that their patient suffers from taking the drugs, but they are not able to prescribe a drug to reduce these symptoms. Therefore, they must act according to the doctor\u0026rsquo;s orders(\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eInternal ethical tensions indicate that nurses experience tensions following non-compliance with the patient\u0026rsquo;s privacy, sudden death of the infant, and ignoring their abilities. Some studies have reported the negative effects of ethical distress on the physical health of nurses in the form of night nightmares, insomnia, heart palpitations and neck pain, feelings of worthlessness, anger, depression, shame and discomfort in their professional life(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). Ignoring the causes of moral distress leads to negative consequences such as the movement of nurses in departments, job abandonment, withdrawal from patients, reduced communication with other members of the treatment team, reduced organizational support, fear of legal consequences(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan additionalcitationids=\"CR46\" citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e), job dissatisfaction and reduced safety and quality of patient care(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e). These findings are in line with the findings of the present study, in which nurses felt upset and guilty following moral distress in the pediatric ward and preferred to take a period of time away from the ward and patient care.\u003c/p\u003e \u003cp\u003eIn the current study, the KMO method was used to examine the exploratory factor analysis and identify the factors, which shows the accuracy of the mentioned study, then the factors identified by the confirmatory factor analysis were confirmed. The Cronbach\u0026rsquo;s alpha coefficient in all subscales and the whole test was more than 0.7, which is consistent with the studies conducted (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOne of the limitations of the present study is that it was conducted in Iran and the information was collected with cultural backgrounds appropriate to this country, therefore the results cannot be generalized to other societies and the application of the tool in other countries should be evaluated and validated.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe present study is a valid and reliable tool for quantitative assessment of moral distress in pediatric nurses. This tool has 15 items in three dimensions: moral distress related to family, moral distress related to colleagues, and internal ethical tensions. It is the first tool with a sequential exploratory approach based on qualitative data of nurses\u0026rsquo; experiences of moral distress in the pediatric ward in Iran.\u003c/p\u003e \u003cp\u003eAccording to the findings of the current study and the fact that the family\u0026rsquo;s lack of trust in nurses and inadequate support for families can cause the intensification of moral distress, gaining professional competence and scientific understanding and developing interpersonal skills among nurses and other caregivers can help reduce the occurrence of moral distress. Assessing the skills and knowledge of nurses when hiring in a specific department and periodically thereafter is one of the issues that should be emphasized by managers and policy makers. In cases where nurses are guided by their ethical values and principles, lack of adequate knowledge and skills leads to unwanted mistakes, and unwanted mistakes cause severe ethical distress and burnout in these people, which leads to job abandonment.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCVR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eContent validity ratio\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCVI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eContent validity index\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eKMO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eKaiser-Meyer-Olkin\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eICC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eIntraclass Correlation Coefficient\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Ethics Committee of the Azad University of Babol, Iran, approved this study (code: IR.IAU.BABOL.REC.1403.127). Since all participants were over 16 years old, an informed consent letter was obtained from all the participants before starting the study. All methods were carried out following relevant guidelines and regulations in the Ethical Declarations. The study did not involve human or animal testing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Not Applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;The datasets generated and/or analyzed during the current study are not publicly available because individual privacy could be compromised. However, they are available from the corresponding author upon reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;The authors have declared no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;Funding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;None\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;NR supervised the analysis and research process, data analysis, and wrote the manuscript. F. SNR data analysis and wrote the manuscript. MN undertook the data collection. All the authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;The authors would like to thank the deputy of research of Islamic Azad University, Babol Branch, for supporting them in this study and thank all the nurses who cooperated in the project.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e1\u0026nbsp;Assistant Professor, Department of Nursing,TeMS.C., Islamic Azad University, Tehran, Iran.\u003c/p\u003e\n\u003cp\u003e2 Department of Nursing and Midwifery, Bab.C., Islamic Azad University, Babol, Iran.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eComprehensive Health Research Center, Bab.C., Islamic Azad University, Babol, Iran.\u003c/p\u003e\n\u003cp\u003e3\u0026nbsp;Department of Nursing and Midwifery, Bab.C., Islamic Azad University, Babol, Iran.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGiannetta N, Villa G, Bonetti L, Dionisi S, Pozza A, Rolandi S, et al. 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Framing the issues: moral distress in health care. Hec forum. Springer; 2012.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrazil K, Kassalainen S, Ploeg J, Marshall D. Moral distress experienced by health care professionals who provide home-based palliative care. Soc Sci Med. 2010;71(9):1687\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbbaszadeh A, Nakhaei N, Borhani F, Roshanzadeh M. The relationship between moral distress and retention in nurses in Birjand teaching hospitals. Iran J Med Ethics History Med. 2013;6(2):57\u0026ndash;66.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDuarte CG, Lunardi VL, Silveira RSd, Barlem ELD, Dalmolin GL. Moral suffering among nurse educators of technical courses in nursing. Revista brasileira de enfermagem. 2017;70(2):301\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePaganini MC, Bousso RS. Nurses\u0026rsquo; autonomy in end-of-life situations in intensive care units. Nurs Ethics. 2015;22(7):803\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCavinder C. The relationship between providing neonatal palliative care and nurses' moral distress: an integrative review. Adv Neonatal Care. 2014;14(5):322\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"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":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Instrument Development, Validation, Distress, Ethics, Nurses, Children","lastPublishedDoi":"10.21203/rs.3.rs-6518919/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6518919/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction:\u003c/h2\u003e \u003cp\u003eRecognizing the significance of moral distress in pediatric settings and the potential of a valid and reliable tool to identify its occurrence and aid in developing preventive strategies, this study aimed to design and evaluate the psychometric properties of a moral distress instrument specifically for nurses in pediatric wards.\u003c/p\u003e\u003ch2\u003eMethod\u003c/h2\u003e \u003cp\u003eA mixed-methods approach with a sequential exploratory design, based on Creswell\u0026rsquo;s methodology, was employed. The study was conducted in three phases from 2024 to 2025 in Mazandaran Province: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) a qualitative phase to clarify the key concept, (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) item development for the instrument, and (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) an experimental phase involving psychometric evaluation. The initial qualitative phase explored nurses\u0026rsquo; experiences of moral distress in pediatric wards using a phenomenological approach. Lived experiences were gathered through in-depth, structured, and semi-structured interviews with 12 nurses from hospitals in Tehran and Babol, and analyzed using Van Manen\u0026rsquo;s method. In the second phase, instrument items were developed, and validation processes, including face validity, content validity, and construct validity (using exploratory factor analysis), were conducted. Reliability was assessed through internal consistency and stability.\u003c/p\u003e\u003ch2\u003eFindings:\u003c/h2\u003e \u003cp\u003eFollowing the initial phase, a pool of 76 preliminary items was generated. After assessing face and content validity, the number of items was reduced to 22. The content validity index for the overall instrument (S-CVI/Ave) was 0.89, indicating acceptable validity. Exploratory factor analysis, using the Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy and Bartlett\u0026rsquo;s test of sphericity, was performed on the 22 items. The analysis identified three factors accounting for the majority of the variance (53.64%). The KMO statistic was 0.711, and Bartlett\u0026rsquo;s test yielded P\u0026thinsp;=\u0026thinsp;0.000. Cronbach\u0026rsquo;s alpha and the Intraclass Correlation Coefficient (ICC) were 0.814, indicating good internal consistency and reliability of the instrument.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eMoral distress among nurses can lead to burnout, increased patient safety risks, and reduced quality of care. This instrument can assist healthcare managers and policymakers in assessing moral distress in pediatric nurses and implementing necessary support interventions.\u003c/p\u003e","manuscriptTitle":"Design and psychometric evaluation of the moral distress questionnaire for nurses in pediatric wards","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-10 05:36:38","doi":"10.21203/rs.3.rs-6518919/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-06-17T13:27:21+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-09T02:01:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"5724906465122272137125698204751849927","date":"2025-06-07T05:25:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"20711376009583009809041073307402248170","date":"2025-06-07T02:22:45+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-04T04:48:17+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-05T10:52:58+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-03T13:04:05+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nursing","date":"2025-05-03T13:03:02+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9fd1e295-3e32-42b3-896d-eb46bbf8e930","owner":[],"postedDate":"June 10th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-06-10T05:36:38+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-10 05:36:38","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6518919","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6518919","identity":"rs-6518919","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}