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

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.