Dimensionality of Moral Distress Among Emergency Nurses in a Non-Western Context: A Two-Stage Psychometric Validation

To evaluate the dimensional structure of moral distress in a non-Western emergency nursing context, cross-validate it in an independent subsample, and establish concurrent criterion-related validity against burnout and turnover intention.

Moral distress predicts burnout and turnover in emergency nursing but is usually analyzed as a single aggregate score, treating structurally distinct ethical conflicts as interchangeable.

Two-stage split-half psychometric study across six university-affiliated emergency departments in western Iran, reported per COSMIN and STROBE. Of 620 eligible nurses, 568 consented (91.6%) and were randomly allocated to exploratory (n = 298) and confirmatory (n = 242) subsamples after listwise deletion (pooled N = 540). Participants completed the culturally adapted 38-item Moral Distress Scale, the Maslach Burnout Inventory, and a turnover intention measure. Both subscales were analyzed by principal axis factoring with parallel analysis; the intensity model was tested by confirmatory factor analysis, compared against a unidimensional alternative, and examined for configural invariance. Hierarchical regression quantified incremental variance in the outcomes.

Exploratory analysis yielded congruent five-factor solutions across both subscales (mean Tucker's φ = 0.988 and Kaiser-Meyer-Olkin = 0.955 and 0.943): communication and autonomy conflicts, unprofessional and futile care, systemic and economic constraints, working with incompetent colleagues, and conflicts with family wishes. All 38 items loaded on their expected factor (0.777-0.899) with no cross-loading above 0.111. Confirmatory fit was excellent (χ²[655] = 731.00; comparative fit index [CFI] = 0.991; root mean square error of approximation [RMSEA] = 0.022; and standardized root mean square residual = 0.034) and held separately in educational and noneducational hospitals. Reliability (α = 0.925-0.963) and convergent validity (average variance extracted = 0.689-0.774) were supported. The dimensions added 49.4%, 40.5%, and 46.6% of variance in emotional exhaustion, depersonalization, and turnover intention (all p < 0.001), with communication and autonomy conflicts the strongest correlate throughout (β = 0.274-0.341). A unidimensional model fitted poorly (CFI = 0.415 and RMSEA = 0.176).

Moral distress was better represented as multidimensional than unidimensional. Constrained professional voice was the dimension most strongly associated with workforce vulnerability, identifying it as a priority for organizational attention. Associations are concurrent, invariance was established only at the configural level, and cross-national replication is required.

Nurse managers should move beyond aggregate moral distress scores and identify the specific ethical conflict domains that place emergency nurses at greatest risk. Management strategies should prioritize strengthening nurses' professional voice, improving interdisciplinary communication, supporting ethical decision-making, and addressing organizational constraints that limit autonomy. Targeted interventions in these areas may help reduce burnout, improve retention, and create ethically supportive emergency care environments.