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Year : 2017  |  Volume : 6  |  Issue : 3  |  Page : 151-162

Translation, cultural adaptation, validity and reliability of the moral sensitivity questionnaire for use in Arab countries

1 Department of Nursing, College of Nursing; Cairo University, Giza, Egypt; King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
2 Department of Nursing, College of Nursing, Giza, Egypt; King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
3 Department of Nursing, College of Nursing, Giza, Egypt; King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia; Alexandria University, Alexandria, Egypt

Date of Web Publication6-Feb-2018

Correspondence Address:
Dr. Hala Mohamed Mohamed Bayoumy
College of Nursing-Jeddah, King Saud Bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, National Guard Health Affairs, P.O. Box. 9515, Jeddah, 21423

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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sjhs.sjhs_97_17

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Background: Moral sensitivity is a core element for decision-making among nurses. It is necessary to understand the existing levels of moral sensitivity among health professionals using validated instruments. The Moral Sensitivity Questionnaire (MSQ) is developed within the context of Western culture and there is no prior testing among Arab nurses. Materials and Methods: This study explored the psychometric properties of Arabic-translated version of the MSQ among a sample of 338 Saudi nursing students. Pilot testing of the Arabic version revealed a Cronbach's alpha of 0.73. Results: The questionnaire has a good internal consistency, with Cronbach's alpha of 0.82 and item-total correlation values ranging from 0.19 to 0.44. A 7-factor structure was illustrated by exploratory factor analysis. Conclusions: The questionnaire showed strong psychometric properties among the study individuals. Assessment of moral sensitivity among Arab nurses using this translated questionnaire is recommended for ensuring professional ethical conduct.

Keywords: Arab countries, cultural adaptation, Moral Sensitivity Questionnaire, psychometric analysis

How to cite this article:
Bayoumy HM, Halabi JO, Esheaba OM. Translation, cultural adaptation, validity and reliability of the moral sensitivity questionnaire for use in Arab countries. Saudi J Health Sci 2017;6:151-62

How to cite this URL:
Bayoumy HM, Halabi JO, Esheaba OM. Translation, cultural adaptation, validity and reliability of the moral sensitivity questionnaire for use in Arab countries. Saudi J Health Sci [serial online] 2017 [cited 2019 Jan 19];6:151-62. Available from: http://www.saudijhealthsci.org/text.asp?2017/6/3/151/224752

  Introduction Top

Moral values in nursing entail a wide range of ethical dilemmas regarding dynamic relationship between professional nurses, patients, and health-care team. Nurses can experience ethically driven situations during their patient's encounter that bring about legal and moral outcomes.[1],[2] In this regard, literature revealed that inadequate knowledge and understanding of ethical matters faced by nurses could bring about high levels of emotional stress provoked by ethical conflicts.[3]

Furthermore, developments in health care, particularly in technology, communication, and patients' rights, lead to potential ethical dilemmas in the provision of health-care services.[4] These instances therefore require nurses to have not only knowledge, but also more sensitivity skills to be able to identify the moral and ethical issues in each situation so that they can provide morally sensitive care.[1],[5],[6] Lack of moral sensitivity among health professionals can lead to negative health consequences, in addition to violations of patient's rights.[3]

Ethical sensitivity and moral sensitivity are evolving concepts. In literature, moral and ethical sensitivities were used interchangeably. Ethical sensitivity is the capacity to decide, with intelligence and compassion, drawing on a critical understanding of codes for ethical conduct, clinical experience, academic learning, and ability to anticipate consequences.[7],[8],[9] Moral sensitivity is described as an “attention” to the moral values involved in a conflict-laden situation and a self-awareness of one's own role and responsibility in the situation preconditioned by a moral motivation to “do good” and “to care.”[10]

Moral sensitivity is a core element of decision-making process in clinical settings, which can positively impact on the health-care quality.[1],[11] Nurses are required to have ethical knowledge of their profession to effectively participate in making ethical decisions.[6] According to Rest, moral behavior consists of a 4-component model which includes moral sensitivity, moral reasoning, moral judgment, and moral character.[8] Moral sensitivity is a prerequisite to moral reasoning and judgment.[9] Borhani et al. demonstrated that an individual's concern about morality can lead to greater sensitivity and result in moral behavior at the time of decision-making.[2]

Ethical issues occur when there is conflict of values with one another or conflict with another interest.[4] Ethical issues call for reasoned and rational approach to be dealt properly.[12] Nurses engage in moral reasoning as part of an ethical decision-making process; however, nurses must first be able to recognize the moral or ethical component within each situation, that is, to have moral sensitivity.[13] Sensitivity to the needs of patients and families is an essential precursor to clinically competent reasoning and nursing practice.[5]

The perceptions of morality vary in different regions.[2] Cultures differ not only from country to country, but also from region to region. Even though the technical nursing skills are rather similar all around the world, the actual experience is not the same everywhere. In this respect, the impact of cultural values should be considered. A morally sensitive and competent nurse must be receptive to the vulnerabilities of their care recipients.[5]

In the context of Arab countries, nurses are expected to follow the Islamic framework for all life decisions inclusive of morality and good deeds and behavior. Preparing professional nurses with solid moral and ethical background should start with assessing their beliefs and values and connecting them to nursing care situations. All Muslims are required to observe humbleness, faithfulness, humility, and piety in working with other humans. In a study cited by Ruhe and Lee (2008), they listed some of the values related to Islam including charity, courtesy, respect, fairness, justice, forgiveness, generosity, honesty, truth, loyalty, and trust.[14] Families are advised to engrave these morals in children at their early stages of life so as to adopt human rights and utilize them in all dimensions of life. This applies to students who are seeking knowledge and developing moral behaviors during their study including studying at the college level. These students are going to become the future generation of nurses who would uphold the nursing profession in the country. With socialization into nursing and emphasizing the moral principles, it is believed that students can develop higher level of moral sensitivity and implement them in patient care.

Moral sensitivity therefore develops over time and can be cultivated through adequate training and education.[15],[16] Cultural values play a key role in formulating the moral sensitivity among health-care providers. Several studies were conducted about moral sensitivity among nursing students in different countries. The increased global interest and awareness of moral sensitivity in nursing necessitates thorough examination of moral sensitivity among Arab nursing students.

Indeed, moral sensitivity has not been thoroughly studied using empirical data analysis, in spite of the increased interest in ethical issues in nursing, particularly due to the lack of appropriate assessment tools.[9] In particular, it is necessary to understand the existing level of moral sensitivity among health professionals to be able to introduce changes in educational curriculum. This requires identifying a valid and reliable instrument for assessing moral sensitivity among Arab nurses taskforce. Several questionnaires including “Moral Sensitivity Questionnaire” (MSQ) have been developed for health-care providers in general and nurses in particular. Validation of these scales is incomplete, since the scales were developed within a Western cultural context.

The MSQ, developed by Lutzen and Nordinand Lützén et al.,[11],[17] was translated into different languages and used in previous studies of ethical sensitivity among nurses in different countries including Korea,[1] Europe,[18] and China.[3] Literature supports the necessity of securing validity and reliability of any instrument or tool used for data collection to ensure obtaining confidence in data and interpreting results in a meaningful way.[1] Currently, there is no available Arabic translation of the MSQ and no publications are located among Arab nurses in general and Saudi nurses in particular. It is necessary to have a valid and reliable scale for measuring moral sensitivity among nurses in Arab countries.

Therefore, the purpose of this study was to describe the process of securing psychometric properties of the Arabic version of MSQ (A-MSQ) using a sample of Arabic-speaking students in Saudi Arabia. Previous empirical evidence depicted 3-, 5-, and 6-factor structure for the MSQ. Therefore, objectives of the current study were as follows: to describe the process of translation; verify the validity of the Arabic-translated tool and identify its reliability to identify a combination of items that best measures sensitivity among nursing students.

  Materials and Methods Top

Study design

A quantitative cross-sectional design was utilized. Data were collected only once; this type of study design is relatively cost-effective. The study was conducted at the College of Nursing, affiliated with King Saud Bin Abdulaziz University for Health Sciences. A convenient sample of 338 nursing students was recruited for the current study. This sampling technique is recommended by researchers for using readily accessible individuals who volunteered to participate.[19] Literature recommends using ten participants per item or an overall sample of at least 300 people for the psychometric studies.[20] The A-MSQ has a series of 27 items that measures the construct under study. Sample size should ideally have at least 10 cases for each of the 27 variables that require at least 270 participants for satisfactory data analysis. The inclusion criteria were as follows: active registration in the nursing program, willingness to participate in the study, and signing the informed consent.

Once the ethical approval for the study conduction was granted from the research committee of nursing college, the researchers proceeded with the data collection process for the A-MSQ. Students were assured that ethical considerations are maintained throughout the study process. Data were coded, stored, and secured in a closed cabinet. They were also assured of voluntary participation and anonymity of their responses. The data were analyzed and reported as a group data and no individual participant was highlighted out by any means.


The MSQ was originally developed by Lutzen and Nordin to measure moral sensitivity among nurses in practice.[11] The questionnaire included thirty items divided into six subscales, namely, interpersonal/relational orientation, structuring moral meaning, benevolence, modifying autonomy, experiencing moral conflict, trust in medical knowledge, principles of care/following the rules, and three items classified under others.

The MSQ was modified, translated, and validated into different languages such as Korean.[1] The Korean-MSQ (K-MSQ) consisted of only 27 items used to measure the moral sensitivity among general nurses rather than psychiatric specialty as originally intended by Lutzen and Nordin. Therefore, the authors believed that the shortened modified tool (K-MSQ) was most suitable for this study. K-MSQ includes five subscales, namely, patient-centered nursing (5 items), professional responsibility (7 items), experience of conflict (5 items), structuralizing of moral meaning (5 items), and expression of good deeds (5 items).[21] The K-MSQ has reasonable reliability scores of α = 0.76 and 0.85 in two different respective studies.[1],[21] The K-MSQ has a 7-point response scale ranging from “1” indicating “not at all” to “7” indicating “strongly agree.” Overall possible score ranges from 27 to 189. The higher score indicates a higher nurse's moral sensitivity and vice versa.

Process of translation

The K-MSQ achieved cultural and language equivalence in Korea, while the Arabic translation of the items retained in the K-MSQ aimed at assuring accurate measurement and cultural reflection of the meaning in Arab world. The A-MSQ would allow Arabic-speaking nurses to capture the meaning of moral sensitivity in Arabic language.

The focus of translation was to capture cultural meanings rather than literal word-by-word translation. This focus is recommended in the literature during translation of instruments into different languages. The process of questionnaire translation usually includes forward translation, expert panel, and back translation.[22],[23] It might also include a review by bilingual experts, in addition to pretesting and debriefing. Similar translation process was used in the current study using the techniques of translation–back translation and bilingual technique as suggested in the literature.[23],[24],[25]

Five independent bilingual nurse researchers translated the tool from English into Arabic. Clear instructions were given to the translators so as to consider the meaning and cultural aspects rather than the word-by-word literal translation to make sure that the tool will be widely used by Arabic-speaking people and not to limit it to one country. It was also emphasized that formal language that suits only professional or highly educated people should be avoided. Therefore, simplicity, clarity, and succinct or briefness were ensured.

The five independent translations were then compiled and synthesized into one Arabic form. The compiled tool was then checked by a panel of bilingual experts which included the main investigator, for meaning, possible discrepancies, and accuracy of Arabic language. The compiled Arabic version of the tool was further sent to two Arabic bilingual translators; one of them is a nursing faculty member who is fluent in both languages and to an English teacher in order to independently back translate the tool from Arabic into English. This process was needed to assure the accuracy of initial Arabic-to-English translation and to check for any issues related to translation problems.

The two English translations were further checked by a bilingual nursing professor against the Arabic translation to make sure that the two translations are accurate and equivalent, resulting in a unified English version of the tool. Finally, a nurse researcher who is an English-speaking faculty member checked the final new-English version tool with the original-English tool and made revisions to some items that were of special concern. Consequently, validation of the two English versions showed that the Arabic version of the tool was accurate and appropriate to the level of the participants. There was a high degree of equivalence between the two versions for all items.

Pilot testing

The necessity for pilot testing of any translated tool with respondents from the target population or what is called end users was highlighted in the literature.[23] The finalized A-MSQ was set for piloting and reliability testing. The A-MSQ was administered to 35 Arabic-speaking students. Reliability analysis showed reliability coefficient for the A-MSQ of α = 0.73. According to the literature, this alpha is acceptable and therefore the tool was used for further testing and data collection.

Data analysis

Factor and item analyses were carried out to confirm the psychometric properties of the A-MSQ of the K-MSQ. Principal component analysis was carried out using SPSS-20 (SPSS Inc., Chicago, IL, USA). This process of examining the construct validity was carried out using pair-wise deletion of missing values and conducting a factor analysis with principal component analysis method with varimax orthogonal methods of rotation for each item set. Varimax rotation was utilized because of the weak correlations between items. The sorted factor loadings, eigenvalues, and scree plots resulting from these analyses were examined to identify the number of dimensions or factors that made up the best solution for each item set. Descriptive statistics included means, standard deviations, and frequencies. Internal consistency reliability was checked using Cronbach's alpha analysis.

  Results Top

Out of the 366 recruited students, 338 participants with no missing data were included in the final analyses. The sample consisted of 79.6% from stream I who are secondary education graduates seeking a Bachelor degree in nursing and 20.4% from stream II who are graduate of college of science and seeking a second degree in nursing. Participants' ages ranged between 21.4 and 30.0 years, with a mean of 21.4 years. Grade point average ranged between 1.97 and 4.9 out of 5 among the study participants with a mean of 3.5. The vast majority were single (87.3%) and slightly less than half (46.2%) were at their 2nd year of study [Table 1]. Only 25.8% reported having had ethics education.
Table 1: Sociodemographics of the study participants (n=338)

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Construct validity

Principal component analysis with varimax rotation was conducted to assess the underlying structure for the 27 items of the A-MSQ. The assumption of independent sampling was met. The Kaiser–Meyer–Olkin measure of sampling adequacy (KMO-test) as a convenient option to check whether the sample is large enough revealed that the sample is adequate.[26] The 0.79 value of KMO is >0.5 which is required to ensure sampling adequacy.

The assumptions of linear relationships between pairs of variables and the variables being correlated at a low to a moderate level were met [Table 2]. The 0.003 value of determinant is larger than zero which is a good indication that the correlations are not near zero. Bartlett test of sphericity which further tested the intercorrelation was significant (P < 0.001), which rejected the null hypothesis that the original correlation matrix was an identity matrix.
Table 2: Bivariate correlations among Moral Sensitivity Questionnaire indicators

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The factor analysis was carried out using orthogonal rotation (varimax with factor extraction via eigenvalues >1), as items were partially correlated [Table 2]. The number of factors extracted was determined based on the scree plot and percentage of explained variance. The breaking point of the scree-plot was at 7 factors. Therefore, the result of the analysis was a rotated component matrix consisting of seven factors. Extraction of the 7 factors had accounted for 52.12% of the variance, but enhanced the overview of the rotated component matrix considerably.

[Table 3] displays the items and factor loadings for the rotated factors, with loadings <0.30 omitted to improve clarity. Some split loadings among items were shown in different factor structures. The first factor, which seems to index patient-centered care, had strong loadings on the first seven items, namely, questions 6, 7, 16, 19, 20, 24, and 27. Three of which showed split loading in different factors.
Table 3: Factor loadings from principal component analysis with varimax rotation of a 7-factor solution for the Arabic version of Moral Sensitivity Questionnaire

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The second factor, which seemed to index professional responsibility, included the next four items, namely, questions 4, 15, 21, and 22 as shown in [Table 3]. Item 22 had a cross-loading and a strong loading of over 0.5 on the second factor. The third factor, which seemed to index constructing a moral meaning, covered the items 2, 3, 5, and 8. There were split loadings among these items as well; however, their loadings on factor 3 were the highest.

Concerning factor 4, the experience of conflict, the following items presented high loadings: 9, 11, and 14, while factor 5, nurse–patient relation, five items, namely, 26, 13, 1, 18, and 10, respectively, from the highest to the lowest loading. These items also showed split loading in factors 1, 3, and 4. Factor six, expression of good deeds, had high loading of two items 23 and 25. Finally, factor seven, guiding rules, included items 12 and 17. Furthermore, after consideration of theoretical construct of the different factor structure, a decision was taken to move item 24 which showed high loading on both factors 1 and 7 to be finally relocated to factor 7 [Table 4].
Table 4: Final 7-factor structure for the Arabic version of Moral Sensitivity Questionnaire

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[Table 4] shows the final A-MSQ factor structure with item loadings arranged from the highest to lowest mean values under each factor. The mean of the A-MSQ among study participants was 136.80 ± 15.42. Concerning the seven extracted factors, nurse–patient relationship showed the highest mean score followed by the guiding rules, whereas expression of good deeds had the lowest mean score.

Moreover, total variance explained per each extracted factor is shown in [Table 5] together with the correlation between the seven extracted factors for the MSQ. Factor 1, namely, patient-centered care, accounted for 17.72% of the total variance; factors 2 and 3 accounted for 16.39% of total variance, while the rest, 18.02%, was equally explained by factors 4 through 7. Pearson's correlations among the extracted moral sensitivity factors were moderate [Table 5].
Table 5: Pearson's correlation, total variance explained, and eigenvalues among the seven extracted factors for the Arabic version of Moral Sensitivity Questionnaire

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Internal consistency and reliability

Inter-item consistency values (Cronbach's alpha) of 0.815 were obtained for the total sample which demonstrated an excellent internal consistency [Table 6]. Most important for the questionnaire reliability is the measure of alpha if an item was deleted. Results revealed that none of the items would greatly affect the overall reliability if being deleted. As shown, all values of alpha were around the total scale alpha of 0.82.
Table 6: Item-total correlations and alpha scores for individual items of the Arabic version of Moral Sensitivity Questionnaire

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Additionally, item consistency analysis was carried out for the A-MSQ by correlating item scores with the total scale score. The item-total correlation coefficient scores' range was 0.19–0.44, item total correlations were higher (r > 0.4) for items 22, 9, 14, and 10. In contrast, items 4, 8, 26, 23, 25, and 12 had a correlation coefficient of r < 0.3 with the total scale, which could be accepted given the large sample and the fact that despite the alpha would go up if they were deleted, but really not much, so researchers retained them.

The split-half reliability (Spearman–Brown coefficient) was 0.76 for the total scale, 0.70 for factor 1, and 0.68 for factor 2. Finally, the reliability of the subscales for this sample showed coefficient alphas of 0.67 for patient-centered care, 0.69 for professional responsibility, 0.57 for constructing moral meaning, 0.59 for experience of moral dilemma and conflict, 0.64 for nurse–patient relationship, 0.45 for experience of good deeds, and 0.28 for guiding rules. Given these overall results, therefore, the A-MSQ is considered a very reliable scale.

  Discussion Top

The purpose of this study was to describe the process of securing psychometric properties of the A-MSQ using a sample of Arabic-speaking students in Saudi Arabia. The authors used the MSQ developed by Lutzen and Nordin (1994) which has been modified and used among Korean nurses.[11] Therefore, it was important to investigate the responses of Arabic-speaking nurses to the questionnaire items and reveal new subconstructs.

The overall reliability of the A-MSQ was high. The internal consistency coefficient alpha was 0.82. The literature showed that the tool has good reliability scores when used in different languages and populations ranging between 0.76 and 0.93.[1],[3],[18],[21],[27],[28]

The principal component analysis showed a 7-factor solution, which explained 52.12% of the variance. These factors were labeled as patient-centered caring, professional responsibility, constructing a moral meaning, experience of conflict, nurse–patient relationship, expression of good deeds, and guiding rules. In comparison with the previous validation studies, the Korean version showed a 5-factor solution including (patient-centered care, professional responsibility, experience of conflict, constructing on moral meaning, and expression of good deeds). However, the original version by Lutzen and Nordin described six factors, namely, interpersonal orientation, structuring moral meaning, benevolence, modifying autonomy, experiencing moral conflict, and trust in medical knowledge and principles of care.[11] Further, five of the newly extracted 7-factor solution were to some extent similar to the Korean version (Friesen-Storms et al., 2015), two additional factors were identified in the current study, namely, nurse–patient relationship and guiding rules. These two factors were consistent with factor structure described by Lutzen and Nordin.[11]

The study participants reported a strong agreement on the importance of being honest with their patients regardless of the difficulties of the decision they make (item 6), with a mean of 6.34. The lowest response was given to item 23 “Sometimes, there could be reasonable grounds to threaten a patient with an injection if oral medication is refused,” with a mean of 2.64. This response might be explained by the fact that the statement reflects an ethical sensitive issue, which interferes with the patient's rights for autonomy and the human caring nature of nursing profession.

The first factor (patient-centered care) includes six items (6, 7, 16, 19, 20, and 27). These items were centered around respecting patient's right to choose, being honest with the patients even in difficult decisions, including the patient when making decisions, considering all values' and norms' influence on personal actions, using theoretical knowledge in complex ethical situations, and acknowledging professional role in helping patients to gain insight. Thus, the overall meaning of this factor reflects the importance of patient-focused approach rather than job-focused approach. This was supported in previous literature.[29]

In contrast with the Korean version, the study found agreement in four items (5, 7, 16, and 19), which reflects cross-cultural agreement. The Korean version included one additional factor, which measured nurse's belief in the importance of nurse–patient relationship for psychological nursing care. This item was strongly loaded under factor five (nurse–patient relationship) in the current study. It is worth noting that this factor explained 17.72% of the moral sensitivity construct in agreement with the amount of variance reported in the Korean study (17.4%).

The second factor (professional responsibility) includes four items (4, 15, 21, and 24), reflecting basing nursing on the knowledge of the best approach regardless of patient's protest, following procedures despite patient's refusal of treatment, making decisions based on patient's best interest, and getting involved in making decisions without patient's participation, respectively.

The overall meaning of these items reflects the traditional paternalistic approach of nursing profession and following guidelines or approved procedures which was considered as part of her professional responsibility.[30] The total variance explained by this factor was 9.32% of the total variance compared to 10.5% of the amount of variance reported in the Korean study.

We found that only two items (21, 4) were in agreement with the Korean study, which included items 27, 24, 26, 1, and 12 under the same factor. These items were loaded on other factor in the current study. This difference in item loadings is attributed to the fact that the current study had two newly emerging factors (guiding rules and nurse–patient relationship) which captured these items.

The third factor (constructing a moral meaning) accounted for 7.07% of the total variance in moral sensitivity among nurses, whereas in the Korean study, it was 5.5%. This factor covered four items; two of them centered around perceiving work as meaningless if patient's condition was not improved or if patient's trust was lost. The others focused on the need to get a positive response from the patient and developing patient's insight into his or her own illness. The current factor structure has high similarity with the Korean study, which indicates common perspective in nursing profession, which values the moral aspects of patient's care. This emerging factor structure is in line with Lützén et al's.[17] view of moral meaning. They described moral meaning as a process of reflection in making ethical decision and taking actions regardless of its effect on patient's rights for self-choice.

Factor 4, which described experience of conflict, explained 4.83% of the total variance addressing moral sensitivity of nurses compared to 7.2% reported by Han et al.[1] The authors found a considerable agreement with the Korean study since items 9, 11, and 14 which focus on experience conflict in approaching a patient, difficulties knowing ethically right action, and difficulties letting a patient make own decision were similarly loaded in both studies. The reason that factor 4 captured more of the variance of the construct of moral sensitivity in Korean than what have been reported in the current study could be explained in light of the number of items loaded in both studies. The Korean study had additional items (10 and 22) among those measures for experience of conflict whereas these items were loaded differently in the current study.

Factor 5, nurse–patient relationship, was a new factor that emerged in this study, which accounted for 4.62% of moral sensitivity. This factor covered items 1, 10, 13, 18, and 26 addressing nurse responsibilities to know patient's situation, having firm principles when caring for patients' psychological problems, believing in importance of nurse–patient relationship for psychological care, patient's reactions as indicator for making decision, and knowing what specific care the patients receive.

All loaded items are part of nurse–patient relationship since knowing overall patient situation and the patient care as a starting point of nursing care is considered basic for initiating and maintaining effective nurse–patient relationship as a cornerstone of proper nursing care. It was observed that some of the items had cross-loadings. Item 18 that addresses the importance of patient's reaction in determining right decision had significant lower loading on constructing moral meaning and experience of moral dilemma and conflict. This reflects the dimensionality of the issues addressed in this question. Whereas item 10 cross-loaded on patient-centered care with slightly stronger loading on factor 5, since having principles while caring for the patient is necessary to establish professional nurse–patient relationship.

Factor 6, expression of good deeds, contributed 4.33% of the total variance compared to the 4.9% reported in the Korean study. This factor included two items (23, 25). They addressed finding a reason in threatening a patient refusing medication; relying on own feelings in making a difficult decision. These were in agreements with the Korean study. While, the Korean study added items 17, 20, and 15 under this factor. These items were loaded under different factors in the current study: item 20 loaded in patient-centered care; item 15 cross-loaded under professional responsibility, and factor 7 (guiding rules). In addition, item 17 strongly loaded under factor 7 (guiding rules), as the meaning of the statement reasonably reflects rules rather than good deeds.

Factor 7, guiding rules, is the second new factor emerged in the study. It explained 4.24% of the total variance for moral sensitivity. The overall meaning of items under this factor gave guidance for nurses' daily activities. It included three items, namely, 12, 17, and 24. They centered on relying on the common procedures, relying on the knowledge of other nurses, and consulting with colleagues about what should be done in uncertain situations. The study revealed that item 24 is loaded under three factors (patient-centered care, nurse–patient relationship, and guiding rules). The researchers believed that the item is conceptually linked to items 12 and 17, which offer guiding principles for providing nursing care in uncertain circumstances.

  Conclusions Top

The aim of this study was to examine psychometric properties of the A-MSQ, used with a sample of 338 nursing students. It was predicted that the A-MSQ has superior psychometric properties, suggesting that the A-MSQ is a valid assessment of moral sensitivity.

In general, the A-MSQ revealed high reliability and validity similar to the original K-MSQ. Given the results of factor analysis and its eigenvalues, there was support for retaining the seven factors. Five of the revealed seven factors were similar to the Korean study (patient-centered care, professional responsibility, constructing a moral meaning, experience of conflict, and expression of good deeds), noting that the underlying items under each factor were to some extent different. Two new factors emerged in the current study, namely, nurse–patient relationship and guiding rules. Validity shown by the 7-factor solution explained 52.12% of the variances among the study participants. Reliability as assessed by internal consistency with the Cronbach's alpha coefficient reached a value of 0.82 in the study group of 338 students.

The A-MSQ is thus a valid and reliable tool that enables to measure moral sensitivity among Arabic-speaking nurses. It is recommended to use the tool in other populations who are part of the Arabic culture in different countries and further test its psychometric properties in various settings.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


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