Measuring moral distress in nurses during a pandemic: Development and validation of the COVID-MDS

Res Nurs Health. 2022 Oct;45(5):549-558. doi: 10.1002/nur.22254. Epub 2022 Jul 23.


The COVID-19 pandemic created novel patient care circumstances that may have increased nurses' moral distress, including COVID-19 transmission risk and end-of-life care without family present. Well-established moral distress instruments do not capture these novel aspects of pandemic nursing care. The purpose of this study was to develop and evaluate the psychometric properties of the COVID-19 Moral Distress Scale (COVID-MDS), which was designed to provide a short MDS that includes both general and COVID-19-specific content. Researcher-developed COVID-19 items were evaluated for content validity by six nurse ethicist experts. This study comprised a pilot phase and a validation phase. The pilot sample comprised 329 respondents from inpatient practice settings and the emergency department in two academic medical centers. Exploratory factor analysis (EFA) was conducted with the pilot data. The EFA results were tested in a confirmatory factor analysis (CFA) using the validation data. The validation sample comprised 5042 nurses in 107 hospitals throughout the United States. Construct validity was evaluated through CFA and known groups comparisons. Reliability was assessed by the omega coefficient from the CFA and Cronbach's alpha. A two-factor CFA model had good model fit and strong loadings, providing evidence of a COVID-19-specific dimension of moral distress. Reliability for both the general and COVID-19-specific moral distress subscales was satisfactory. Known groups comparisons identified statistically significant correlations as theorized. The COVID-MDS is a valid and reliable short tool for measuring moral distress in nurses including both broad systemic sources and COVID-19 specific sources.

Keywords: environment and health; ethical issues; infectious diseases; instrument development and validation; methodological research; organizational structure; professional issues; systems research; systems research/multi-system issues.

MeSH terms

  • COVID-19*
  • Humans
  • Morals
  • Nurses*
  • Pandemics
  • Psychometrics
  • Reproducibility of Results
  • Surveys and Questionnaires