A Context-Based Narrative Moral Distress Scale for Nurses and Nursing Students

Traditional moral distress scales primarily measure sources rather than contextualized responses. This study developed and validated the Narrative Moral Distress Scale, a context-based instrument for assessing multidimensional moral distress in nurses and nursing students. In Phase 1, narrative stories and items were generated from previous qualitative transcripts of 32 nurses, followed by expert validation and face validation. Phase 2 involved testing with 291 nurses and 52 nursing students in Taiwan using Exploratory Factor Analysis, Confirmatory Factor Analysis, and measurement invariance tests. The final 14-story 29-item scale comprises five factors. The second-order model demonstrated acceptable fit, good internal consistency, and robust measurement equivalence, confirming the model's stability. Participants reported moderate moral distress, primarily in value conflict and emotional distress. In clinical practice, the scale could identify moral distress factors driving burnout, enabling managers to design targeted interventions to improve interprofessional communication. In nursing education, it provides a framework for quantifying the efficacy of ethics curricula, while supporting administrative policy efforts to enhance supportive ethical environments and improve professional retention.