Development and validation of a questionnaire to measure moral distress in community pharmacists
Development and validation of a questionnaire to measure moral distress in community pharmacists
Jayne L. Astbury 0 1
Cathal T. Gallagher 0 1
0 School of Life and Medical Sciences, University of Hertfordshire , Hatfield, Herts AL10 9AB , UK
1 & Cathal T. Gallagher
Background Pharmacists work within a highlyregulated occupational sphere, and are bound by strict legal frameworks and codes of professional conduct. This regulatory environment creates the potential for moral distress to occur due to the limitations it places on acting in congruence with moral judgements. Very little research regarding this phenomenon has been undertaken in pharmacy: thus, prominent research gaps have arisen for the development of a robust tool to measure and quantify moral distress experienced in the profession. Objective The aim of this study was to develop an instrument to measure moral distress in community pharmacists. Setting Community pharmacies in the United Kingdom. Method This study adopted a three-phase exploratory sequential mixedmethod design. Three semi-structured focus groups were then conducted to allow pharmacists to identify and explore scenarios that cause moral distress. Each of the identified scenarios were developed into a statement, which was paired with twin seven-point Likert scales to measure the frequency and intensity of the distress, respectively. Content validity, reliability, and construct validity were all tested, and the questionnaire was refined. Main outcome measure The successful development of the valid instrument for use in the United Kingdom. Results This research has led to the development of a valid and reliable instrument to measure moral distress in community pharmacists in the UK. The questionnaire has already been distributed to a large sample of community pharmacists. Conclusion Results from this distribution will be used to inform the
Community pharmacy; Professional ethics
Impacts of Findings
The recognition of moral distress is a significant barrier
to well-being in community pharmacists.
Tools could be developed to quickly assess both the
frequency and intensity of distress in the population, and
to determine which common scenarios precipitate it.
Since the term was first coined to describe some of the
ethical challenges and moral conflicts inherent in the
provision of nursing care , the definition of moral distress
has undergone numerous refinements by subsequent
authors [2–9]. However, the following consolidated
definition, proposed by Nathaniel, encapsulates the
phenomenon of moral distress in contemporary healthcare:
Moral distress is the pain affecting the mind, body or
relationships that results from a patient care situation,
in which the [practitioner] is aware of a moral
problem, acknowledges moral responsibility and
makes a moral judgement about the correct action,
yet, as a result of real or perceived constraints,
participates, either by act or omission, in a manner he or
she perceives to be morally wrong .
Studies concerning moral distress in the nursing profession
have identified significant negative consequences for both
health of the clinician and the quality of patient care. The initial
feelings of anger and outrage that are experienced during the
event often develop into enduring feelings of guilt,
hopelessness, loss of confidence, decreased self-esteem, exhaustion
and burnout . Moral distress has also been found to be
associated with an exodus from the profession [12–14].
As the conceptual boundaries of moral distress have
developed, so too has the research interest in the
experiences of other professional groups. Although moral distress
was initially delineated within nursing, the concept is
relevant across other healthcare professions, as each role
carries its own code of ethics, professional regulations and
legal requirements to be balanced against the individual
practitioner’s moral framework . Subsequent studies
have suggested that moral distress is relevant to and
reported by various disciplines including psychiatric
nurses, psychiatrists, podiatrists, psychologists,
physiotherapists and respiratory therapists [16–21].
Pharmacists working in the UK operate within a
highlyregulated occupational sphere, and are bound by strict legal
frameworks and codes of professional conduct. This
regulatory environment creates the potential for moral distress
to occur due to the limitations it places on acting in
congruence with moral judgements. The level of legal
regulation of pharmacists compared to other healthcare
professionals is marked: for example, a single error in the
dispensing of medicines may be considered a criminal
offence under s.64(1) of the Medicines Act 1968 .
Futhermore, as pharmacists expand their roles to include
more clinical care, there are significantly more
opportunities for ethical and moral problems to arise. Additionally,
community pharmacists are generally more isolated from
support networks than their hospital-based colleagues.
This research builds upon a 2015 literature review and
research agenda by Astbury and co-workers for the study of
moral distress in community pharmacy practice .
Aim of the study
The aim of this study was to develop an instrument to
measure moral distress in community pharmacists working
within the UK’s National Health Service (NHS).
The study adopted Myers and Oetzel’s three-phase
exploratory sequential mixed method design , as
described by Creswell and Plano Clark . An initial
(qualitative) stage was used to explore moral distress from
the perspective of practicing community pharmacists and
to identify the pharmacy practice situations that they
associate with experiences of moral distress. During the
second stage, the qualitative findings were used to inform
the development of an instrument to capture data regarding
the intensity of moral distress and the frequency of its
occurrence as experienced by community pharmacists. The
instrument was then subjected to content validity testing
before being trialed with a pilot sample in the third
(quantitative) phase of the study. The results of the pilot
sample were then used to carry out construct validity and
An initial literature search was undertaken of several
electronic databases including PubMed, Scopus, Web of
Science and Google Scholar using combinations of the
search terms ‘‘moral’’, ‘‘ethical’’, ‘‘distress’’, ‘‘stress’’,
‘‘instrument’’, ‘‘scale’’, and ‘‘questionnaire’’. The resulting
literature and existing moral distress instruments were
parsed for clinical practice issues and scenarios with
potential relevance to pharmacists, which were used to
create an initial item pool.
Three semi-structured focus groups were then conducted
to explore whether the practice scenarios highlighted in the
literature review were applicable to community
pharmacists within their working lives, while simultaneously
providing opportunity for the participants to identify any
other scenarios or issues for item development [26, 27].
The initial group session was conducted in conjunction a
Royal Pharmaceutical Society (RPS) Local Practice Forum
(LPF) for [REDACTED] and [REDACTED], and attracted
17 participants, 13 of which worked primarily within
community pharmacy settings. A further two participants
worked in each of the pharmaceutical industry and the
hospital pharmacy sector, respectively. The topic guide
created from the findings of the literature review was used
to stimulate discussion, and participants were encouraged
to raise any other issues they felt were relevant.
Participants were asked to complete a demographic questionnaire
as part of the registration process for the event. As there
was a notable under-representation of newly-qualified and
junior pharmacists in the initial group, two further focus
groups were convened. The membership of these groups
were made up of community-based practitioners with less
than five, and ten years of post-qualification experience,
respectively. These groups was drawn from alumni of the
four-year Master of Pharmacy qualifying degree program
at the University of [REDACTED], and newly-qualified
pharmacists employed in its immediate vicinity. Each
session lasted for approximately two hours, and each was
recorded using a proprietary audio-visual recording system.
The audio recordings of the focus group sessions were
transcribed verbatim and thematically coded using the
broad principles of grounded theory . The transcripts
were read through in their entirety several times before
being combined and subjected to open coding. These initial
codes were then organised into categories, each of which
were further divided into themes.  An inductive
approach was applied, allowing themes to be derived from
the data using open coding, grouping and categorising.
This enabled abstraction and conceptual mapping to create
a resonant description of the phenomenon . The
category content was re-examined and compared at various
stages throughout the analysis, and categories felt to
capture the same entity within the data were merged and
reconfigured. Coding was carried out using test–retest
methodology with a 1 month coding interval .
Four categories relating to moral distress were
identified, namely: legislative constraints; commercial pressures;
challenges to professionalism; and risk taking & resilience.
Fifteen individual themes, including emergency hormonal
contraception (EHC), whistleblowing, and patient
confidentiality were identified within the four categories; of
which thirteen themes in three groups related directly to
causes of moral distress (Fig. 1).
It was in the category of legislative constraints that the
potential for moral distress was most immediately obvious:
Off licence drugs
Buy one get one free
in the scenarios described by participants, acting in
accordance with their respective consciences would have
resulted in a breach of statutory law. The scenarios that
appeared to be most strongly associated with the
experience of moral distress concerned situations in which the
pharmacists felt unable to lawfully dispense controlled
drugs despite their belief that to do so would be in the
patient’s best interests. The Misuse of Drugs Regulations
2001 place unambiguous procedural requirements on
pharmacists regarding the storage, supply, and use of
medicines that are classified as controlled drugs by the
Misuse of Drugs Act 1971 (as amended) [32, 33].
Contravention of the regulations constitutes a criminal
offence, and may additionally constitute an impairment of
the pharmacist’s fitness to practise under the General
Pharmaceutical Council (Fitness to Practise and
Disqualification etc.) Rules 2010 . A finding of impairment by
the General Pharmaceutical Council’s (GPhC) Fitness to
Practise Committee is associated with sanctions ranging
from a warning to removal of the pharmacist from the
Register of Pharmacists. In the focus groups, the
pharmacists described situations in which they felt confident that
the request made by the patient was legitimate, but that the
required procedural aspects of dispensing could not be
complied with due to absent or incorrectly written
prescriptions presented at a time when sourcing a replacement
was logistically difficult (such as on a Sunday or outside
normal business hours). In these situations the perceived
needs of the patient conflicted with the professional
requirement to act within legislative guidelines. When
coupled with an acute awareness of the potential personal
consequences of acting outside of the regulations, the
potential for moral distress is clear.
Practice scenarios that the pharmacists shared often
involved the supply of methadone as part of
pharmacological withdrawal treatment for patients addicted to
heroin. For pharmacists working consistently from the same
pharmacy the frequent and regular contact with patients
using the methadone service created a heightened sense of
professional involvement in, and engagement with, the
individual’s treatment plan and wellbeing. The pharmacists
spoke of an acute awareness of the possible consequences
for the individual patient of not supplying, and their
distress at being unable to do what they felt was in the
patient’s best interests:
At the end of the day, you’ve got someone who is a
family member, that’s going to be somebody’s
mother, somebody’s father, somebody’s husband,
somebody’s wife. I am never comfortable with not
dispensing [methadone]. If I don’t supply this guy,
he’s going to start using [heroin]. I want to keep the
guy clean, if he starts using again he goes backwards,
and that’s no use to anyone.
Similar legislative and professional constraints are
associated with the supply of EHC and of the supply in an
emergency of prescription-only medicines (POMs) without
a prescription, and with the requirement to breach patient
confidentiality under legislation unrelated to the provision
In May 2001, the exemption from the general ban on resale
price maintenance enjoyed by proprietary non-prescription
medicines was removed. The Proprietary Association of
Great Britain (PAGB) withdrew their opposition to this
removal following an indication by the Restrictive
Practices Court that it was unsympathetic to the points they
were making . Since that time, pharmacies have been
permitted to offer promotions on the sale of medicines that
were previously prohibited under the Restrictive Practices
Court (Resale Prices) Rules 1976 . This has, in the
opinion of focus group members, lead to a degree of
commercialisation that conflicts with the core professional
values of pharmacy. A number of the pharmacists
described feeling pressurised to generate and influence purchases
that were not necessarily required or advised. They felt
compelled to promote and facilitate commercial incentives
even when they conflicted with their professional opinion
regarding optimal use of medicines.
Feeling compelled to generate additional sales through
the use of ‘‘three-for-two’’ offers and linked-selling
strategies was cited as a source of moral distress by a
number of participants. In addition, pressure from
employers to promote and sell unregulated products such
as e-cigarettes, homeopathic products and slimming aids
was also cited as a cause of moral distress by some.
I feel I’m expected – due to my professional standing
– to promote the sale or supply of products that have
not been proven effective, or that have been proven
ineffective, so I don’t like selling homeopathic
products … I feel we shouldn’t be selling them in
pharmacies because they are not medicines, they
work contrary to what we are told.
The perceived pressure to prioritise sales targets over
customer needs was echoed throughout the focus groups.
Challenges to professionalism
autonomy; whistleblowing; and confidentiality. Each of
these themes arose from situations in which the pharmacist
was required to ‘‘speak up’’ against a decision that another
party was trying to impose upon them. Unlike the other
categories, in which there were discrete penalties or
sanctions for acting with their conscience, the decision-making
process here tends to be affected by the fear less tangible
consequences, such as the erosion working relationships or
the loss of autonomy. The major hurdle that must be
overcome is the assertion of professional judgement in the
face of others who may disagree with it.
For example, one participant was particularly concerned
that some patients’ habitual failure to collect expensive
made-to-order medicines in a timely manner constituted a
waste of NHS resources and public money, but felt unable
to challenge this behaviour:
There are also patients that need some creams, or
some ‘specials’ made up for them and they don’t
come to collect them, and I feel so bad because the
creams they expire [quickly], sometimes in only a
few days. They cost a lot. It happens a lot.
One theme consistently raised in this category was that
of the use by savvy patients of medicines outside their
Participants raised a number of situations concerning
requests for medicines to be used outside of their
officiallylicensed indications. Specifically, the pharmacists
highlighted situations in which they suspected that medicines
were being sourced for reasons other than those described
by the patient. A focus group participant provided the
following example in which a customer made repeated
visits to the pharmacy to request a specific antihistamine
which the participant suspected was being used as a
sedative for a child:
There is so much going on in your head because, you
know, they are there asking for two or three boxes of
[sedative antihistamine], saying, ‘‘It’s for me and my
husband, for allergies.’’ But I know she has also got
an 8-year-old and you know that this is just a story
they tell to get it.
Acquiescing to the customer’s requests for medicines
for uses outside of licensed indications created feelings of
unease and conflict due to concerns that this constituted
poor professional judgement and practice, and facilitated
the misuse of medicines.
Risk taking and resilience
Six themes in total were identified under the category of
‘‘challenges to professionalism’’, namely: NHS resources;
asserting clinical judgement; time constraints; patient
Not all of the themes identified involved scenarios that
could result in moral distress. The final category described
instances where pharmacists deviated from the rules
governing from their profession in order to avoid moral
distress. Ka¨lvemark and co-workers also reported instances
in which pharmacists ignored legal and professional
requirements in order to act in congruence with what they
felt was morally right . Such avoidance strategies
straddled each of other categories and their themes. For
example, rather than suffer the moral distress associated
with legally declining to supply a CD in an emergency:
I would dispense it, and I’ve done that before, and I’d
do it again. I’m sure it’s illegal and I accept that, but
at the end of the day I have a duty of care to that
The most frequently cited motivating value for deciding
to act against regulatory requirements was a concern for the
Newly-qualified pharmacists described feeling
particularly vulnerable to experiences of moral distress whilst
navigating the transition from being a student to qualified
pharmacist. This period of role adaptation may be
associated with a sense of generalised anxiety regarding the
marked increase in levels of professional responsibility and
accountability, which, in turn, makes these ‘‘adolescent’’
professionals more likely to experience moral distress as
they strive to adhere to legislative and procedural
requirements. Adolescent professionals may also face an
elevated risk of moral distress due to the additional
challenge of asserting their professional judgement with senior
colleagues [38, 39].
Each of the 13 themes relating to practice scenarios were
developed into a statement that described a practice
situation that could generate moral distress. A seven point
Likert scale was chosen for this instrument, with each item
being rated for both intensity and frequency. Each item
asked the same question, ‘‘Have you ever experienced
moral distress as a result of a situation that could be
described in the following way?’’, before going on to
describe a practice scenario in a single statement (Fig. 2).
For example, the scenario for EHC was described as
follows: ‘‘Dispensing emergency hormonal contraception
though this conflicts with my moral beliefs.’’
In order to explore the content validity of the instrument,
the item pool and questionnaire format were submitted for
review to a panel of 12 academics working in the
Department of Pharmacy at the University of
Hertfordshire. Reviewers were selected as described by
Grant and Davis , taking in account their academic
interests and professional experience of community
pharmacy practice. They were asked to consider and comment
on the clarity of the introductory text and general layout of
the questionnaire. They were also required to evaluate the
relevance of each item to the concept of moral distress,
together with the clarity and conciseness of each item.
Suggestions for additional item domains were also
encouraged to ensure that the item set reflected the
construct of moral distress in its totality. Reviewers rated the
relevance of each item on a four point Likert Scale
(1 = not relevant; 2 = somewhat relevant; 3 = quite
relevant; 4 = highly relevant). This data was then used to
compute item-level (I-CVI) and scale-level (S-CVI)
content validity index scores (Table 1) . Polit and Beck
recommend that I-CVI values of above 0.9 and S-CVI
values of 0.78 be considered indicative of excellent content
validity . Only item 13 (unregulated products) fell
below the cut-off: however, it was decided to retain this
item in the initial piloting due to the strong emphasis that
was placed on this issue in the focus groups.
A hyperlink and invitation to pilot the questionnaire was
emailed to members of two LPFs and the National Institute
for Health Research (NIHR) Clinical Research Network
(CRN) Eastern region. The pilot was closed when a sample
of 50 community pharmacists had completed the
self-administered online survey. All of the respondents were
working in a community pharmacy or undertook regular
additional work in a community pharmacy setting
(Table 2). An additional response box was added at the end
of the pilot questionnaire inviting comments regarding the
content and structure of the questionnaire. Feedback
indicated that one item (unregulated products) lacked clarity
and required rewording. Only one participant did not
complete every aspect of the questionnaire, indicating that
the scenarios held relevance for the respondents.
Both the frequency (a = 0.801; n = 50) and intensity
(a = 0.816; n = 50) subscales were found to have a good
level of internal consistency. Inspection of the item total
correlations revealed that only the removal of item 11
(confidentiality) would have created an increase in either
value of a: however, this increase was so small as to be
considered negligible (0.004 and 0.005 for frequency and
Fig. 2 Item 1 (Controlled Drugs) as it appears on the online pilot survey for the questionnaire. Matching 7-point Likert scales for each of the two
dimensions in which moral distress is to be measured are included for each of the 13 items
Table 1 Item-level (I-CVI) and scale-level (S-CVI) content validity index scores for the 13-item moral distress questionnaire
Supply of controlled drugs in the best interest of a patient when legal requirements are unmet
Wasting NHS resources to elicit patient compliance
Actively challenging prescribers regarding prescriptions that contained medicines or doses thought to be inappropriate
Feeling unable to provide an adequate level of service due to time constraints
Professional judgement conflicts with the preferences and wishes of the customer
Commercial values and a pressure to link sell to generate additional sales
Emergency supply of POMs when procedural requirements are unmet
Request from patients for medication for use outside of their licenced indications
Supply of emergency hormonal contraception in conflict with religious or moral beliefs
Professional requirement to engage in whistleblowing though this may be to the detriment of one’s career
Compulsion to release confidential patient data under non-healthcare-related legislation
Commercial incentives that are in opposition to best clinical practice
The sale of unregulated or unproven products
Principal component analysis
The sample used for the pilot study was insufficiently large
to allow either a meaningful principal component analysis
(PCA) or Spearman’s rho to be conducted: however,
returns from a larger probability sample (n = 1340), which
was subsequently distributed, did allow for construct
validity and reliability calculations to be carried out.
The 13 frequency subscale items were subjected to
principal component analysis (PCA) using varimax rotation
following a favourable assessment of sampling adequacy
using the Kaiser–Meyer–Olkin (KMO) measure
(KMO = 0.892) . Bartlett’s test supported the
factorability of the correlation matrix (v2(78) = 1869.444,
p \ 0.001) . Criterion for factor loadings was set at
0.30 or greater. PCA revealed the presence of two
categories with eigenvalues exceeding 1.0, explaining a total
43.28% of the variance: the first component accounting for
34.75%; the second accounting for 8.50%. The majority of
items (n = 12) loaded on their respective categories at
above 0.50. There was a moderate positive correlation
between the two categories (r = 0.399). Inspection of the
scree plot revealed a clear point of inflection after the first
component, indicating that only the first component should
Table 2 Demographic data for the 50 participants in the pilot sample
n = 50
be retained. Parallel analysis provided further support for
the retention of a single component . The first
component returned a criterion eigenvalue of 1.252 against an
actual value of 4.518 from the PCA, while the second
component returned a criterion value (1.186) that was
significantly higher than that derived from PCA (1.105).
For the 13 intensity subscale items a KMO value of
0.905 was returned. Again, Bartlett’s test returned a
favourable result (v2(78) = 1995.501, p \ 0.001), and the
criterion for factor loadings was set at 0.30 or greater. Two
categories accounted for 37.44 and 8.59% of total variance,
respectively. Eleven items loaded on their respective
categories at above 0.50. As before, there was a moderate
positive correlation between the two (r = 0.422).
Inspection of the scree plot again revealed a clear point of
inflection after the first component indicating that only one
should be retained. This was further supported by parallel
analysis, in which the criterion eigenvalue (1.252) was less
than the derived value (4.867) for the first component only.
The single-category structure was found to be comprised
of the same item variables for both frequency and intensity
subscales. The item clusters on each category indicated that
the original themes were highly correlated, and could be
reduced to a single category.
Construct validity was explored through correlation of
individual item subscale scores with the summated score of
a truncated version of the Ethical Environment
Questionnaire (EEQ) , which was appended to the moral distress
questionnaire for optional completion. The Cronbach a of
this abbreviated scale was 0.79. Moral distress has been
previously found to be negatively correlated with
perceptions of ethical environment in studies concerning nurses
and physicians, with high levels of moral distress being
associated with low perceptions of ethical environment
[13, 14, 46]. The relationship between individual intensity
and frequency scores and the EEQ score was explored
using Spearman’s rank correlation coefficient (n = 529).
A statistically significant negative correlation was observed
between the two variables for all but one item on both the
frequency and intensity subscales, with low levels of
perceived ethical environment being associated high levels of
moral distress, confirming the predicted relationship.
This research has led to the development of a valid and
reliable instrument to measure moral distress in community
pharmacists in the UK. The questionnaire has already been
distributed to a large sample of community pharmacists.
An e-mail inviting pharmacists to participate was
successfully delivered to the mailboxes of 20,433 recipients.
50.7% (10,360) of recipients opened the e-mail. This
compares to an average of 37.8% (equivalent to 7724
recipients opening the e-mail) for distributions on this list,
and an industry average in the non-profit sector of 20.3%
(4148). 1618 (15.6%) of those recipients who opened the
e-mail clicked through to the survey. The expected
response, based on industry averages, would be 450
(4.3%). A total of 1340 pharmacists completed the survey
following a reminder.
In developing a questionnaire of this type, it is important
to consider how the collected data will be treated. There are
two approaches to the interpretation of questionnaires of
this type: individual recording and cumulative scoring.
Although both methods appear throughout the literature,
we contend that the latter is often invalid, due to the nature
of the points on Likert-type scales.
Likert scales are presented as linear scales with the
equidistant differences between interval points: however
the differences in attitudinal intensity between the intervals
cannot be precisely quantified . On the intensity scale,
the separation between mild to moderate and moderate to
severe intensity cannot be assumed to be the same; while
on the frequency subscales, the interval points refer to
easily recognised measures of time that do not have a linear
relationship with each other, but that better reflect how
people recall the recurrence of events. Cumulative scoring,
although common in instruments of this kind , is
premised on a known and quantifiable relationship between
intervals. In the former scale, there is no such relationship.
Furthermore, even on the frequency scale, where such a
relationship does exist, two identical cumulative scores can
be derived from significantly different sets of sub-scores.
For these reasons, including an interpretation of individual
item responses has been suggested to provide more a more
meaningful reading of the data . It is intended that each
item of this questionnaire be reported separately, and that
items measuring the moral distress associated with
different themes in the same category be subsequently compared
with a view to determining which aspects of practice cause
the greatest degree of moral stress.
Factors affecting scenarios occurring with lower
frequencies will be examined to determine to determine if
these may be applied to scenarios with high recurrence
rates, with a view to reducing these rates. For example, if
the GPhC’s guidance with regard to one the scenario
generating moral distress is essentially pragmatic, while
another is paternalistic or deontological, an examination of
the consistency of such guidance would be warranted.
Similarly, those scenarios scoring lower for intensity can
be compared, and common factors identified, with a view
to developing coping strategies for higher-scoring
Age, experience, gender, and religious background have
all been shown to have an effect on susceptibility to moral
distress in other healthcare professions
[6, 7, 11, 18, 20, 21, 50], and will be examined in detail. It
is hoped that the results of this large-scale survey will help
in the development of strategies to reduce both the
Conflicts of interest The authors declare that they have no conflicts
of interest to disclose.
Authors’ contributions All authors state that they had complete
access to the study data that support the publication.
Ethics approval Ethical approval for this research was granted by
the University of Hertfordshire Research Ethics Committee (Protocol
Approval Number: LMS/SF/UH /00006).
Open Access This article is distributed under the terms of the
Creative Commons Attribution 4.0 International License (http://crea
tivecommons.org/licenses/by/4.0/), which permits unrestricted use,
distribution, and reproduction in any medium, provided you give
appropriate credit to the original author(s) and the source, provide a
link to the Creative Commons license, and indicate if changes were
1. Jameton A. Nursing practice the ethical issues . New Jersey: Prentice Hall Inc .; 1984 . ISBN 9780136274483.
2. Wilkinson JM . Moral distress in nursing practice: experience and effect . Nurs Forum . 1988 ; 23 ( 1 ): 16 - 29 .
3. Jameton A. Dilemmas of moral distress: moral responsibility and nursing practice . AWHONNS Clin Issues Perinat Womens Health Nurs . 1993 ; 4 ( 4 ): 542 - 51 .
4. Houston S , Casanova MA , Leveille M , Schmidt KL , Barnes SA , Trungale KR , Fine RL . The intensity and frequency of moral distress among different healthcare disciplines . J Clin Ethic . 2013 ; 24 ( 2 ): 98 - 112 .
5. Gibson K. Contrasting role morality and professional morality: implications for practice . J Appl Philos . 2003 ; 20 ( 1 ): 17 - 29 .
6. Laabs CA . Primary care nurse practitioners' integrity when faced with moral conflict . Nurs Ethics . 2007 ; 14 : 795 - 809 .
7. Corley MC . Moral distress of critical care nurses . Am J Crit Care . 1995 ; 4 ( 4 ): 280 - 5 .
8. Laabs CA . Perceptions of moral integrity: contradictions in need of explanation . Nurs Ethics . 2011 ; 18 ( 3 ): 431 - 40 .
9. Hanna DR . Moral distress: the state of the science . Res Theor Nurs Pract . 2004 ; 18 ( 1 ): 73 - 93 .
10. Nathaniel AK . Moral reckoning in nursing . West J Nurs Res . 2006 ; 28 ( 4 ): 419 - 38 .
11. Burston AS , Tuckett AG . Moral distress in nursing: contributing factors, outcomes and interventions . Nurs Ethics . 2013 ; 20 ( 3 ): 312 - 24 .
12. Corley MC . Nurse moral distress: a proposed theory and research agenda . Nurs Ethics . 2002 ; 9 ( 6 ): 636 - 50 .
13. Hamric AB , Blackhall LJ . Nurse-physician perspectives on the care of dying pateints in critical care units: collaboration, moral distress and ethical climate . Crit Care Med . 2007 ; 35 ( 2 ): 422 - 9 .
14. Hamric AB , Borchers CT , Epstein EG . Development and testing of an instrument to measure moral distress in healthcare professionals . AJOB Prim Res . 2012 ; 3 ( 2 ): 1 - 9 .
15. Jameton A. A reflection on moral distress in nursing together with a current application of the concept . J Bioeth Inq . 2013 ; 10 : 297 - 308 .
16. Losa Iglesias ME , de Bengoa Becerro , Vallejo R , Salvadores Fuentes P. Moral distress related to ethical dilemmas among Spanish podiatrists . J Med Ethics . 2010 ; 36 ( 5 ): 310 - 4 .
17. Austin WJ , Rankel M , Kagan L , Bergum V , Lemermeyer G. To stay or to go, to speak or stay silent, to act or not to act: moral distress as experienced by psychologists . Ethics Behav . 2005 ; 15 ( 3 ): 197 - 212 .
18. Austin WJ , Kagan L , Rankel M , Bergum V. The balancing act: psychiatrists' experience of moral distress . Med Health Care Philos . 2008 ; 11 ( 1 ): 89 - 97 .
19. Schwenzer KJ , Wang L. Assessing moral distress in respiratory care practitioners . Crit Care Med . 2006 ; 34 ( 12 ): 2967 - 73 .
20. Carpenter C. Moral distress in physical therapy practice . Physiother Theory Pract . 2010 ; 26 ( 2 ): 69 - 78 .
21. Austin WJ , Bergum V , Goldberg L. Unable to answer the call of our patients: mental heath nurses' experience of moral distress . Nurs Inq . 2003 ; 10 ( 3 ): 177 - 83 .
22. United Kingdom of Great Britain and Northern Ireland . Medicines Act 1968 . Chap. 67. London: HMSO ; 1968 .
23. Astbury JL , Gallagher CT , O'Neill RC . The issue of moral distress in community pharmacy practice: background and research agenda . Int J Pharm Pract . 2015 ; 23 ( 5 ): 361 - 6 .
24. Myers KK , Oetzel JG . Exploring the dimensions of organizational assimilation: creating and validating a measure . Commun Q . 2003 ; 51 ( 4 ): 438 - 57 .
25. Creswell JW , Plano Clark VL. Designing and conducting mixed method research. California: SAGE Publications Inc ; 2011 .
26. Streiner DL , Norman GR . Health measurment scales . 4th ed. Oxford: Oxford University Press ; 2008 .
27. Nassar-McMillan S , Borders L. Use of focus groups in survey item development . Qual Rep . 2002 ; 7 ( 1 ): 1 - 12 .
28. Glaser BG , Strauss AL . The discovery of grounded theory: stratergies for qualitative research . London: Weidenfield and Nicolson ; 1968 .
29. Graneheim UH , Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness . Nurse Educ Today . 2004 ; 24 : 105 - 12 .
30. Elo S , Kyngas H. The qualitative content analysis process . J Adv Nurs . 2008 ; 62 ( 1 ): 107 - 15 .
31. Fink A. How to manage, analyze, and interpret survey data . 2nd ed. London: Sage; 2002 . ISBN 9780761925767.
32. United Kingdom of Great Britain and Northern Ireland . Misuse of Drugs Act 1971 . Chap. 38. London: HMSO ; 1971 .
33. Misuse of Drugs Regulations 2001 . SI 2001 /3998. London: The Stationery Office; 2001 .
34. General Pharmaceutical Council (Fitness to Practise and Disqualification etc.) Rules 2010 , SI 2010 /1615, London: The Stationery Office.
35. Director General of Fair Trading v Proprietary Association of Great Britain and another  1 All ER 853.
36. Restrictive Practices Court (Resale Prices) Rules 1976 , SI 1976 / 1899 , London: The Stationery Office.
37. Ka¨lvemark S , Ho¨glund AT, Hansson MG , Westerholm P , Arnetz B. Living with conflicts-ethical dilemmas and moral distress in the health care system . Soc Sci Med . 2004 ; 58 ( 6 ): 1075 - 84 .
38. Kitchener M , Caronna CA , Shortell SM . From the doctor's workshop to the iron cage? Evolving modes of physician control in US health systems . Soc Sci Med . 2005 ; 60 ( 6 ): 1311 - 22 .
39. Maben J , Latter S , Clark JM . The theory-practice gap: impact of professional-bureaucratic work conflict on newly-qualified nurses . J Adv Nurs . 2006 ; 55 ( 4 ): 465 - 77 .
40. Grant JS , Davis LL . Selection and use of content experts for instrument development . Res Nurs Health . 1997 ; 20 ( 3 ): 269 - 74 .
41. Polit DF , Beck CT , Owen SV . Is the CVI an acceptable indicator of content validity? Appraisal and recommendations . Res Nurs Health . 2007 ; 30 : 459 - 67 .
42. Kaiser HF . An index of factorial simplicity . Psychometrika . 1974 ; 39 : 31 - 6 .
43. Bartlett MS . A note on multiplying factors for various Chi squared approximations . J R Stat Soc Ser B . 1954 ; 16 : 296 - 8 .
44. Horn JL . A rationale and test for the number of factors in factor analysis . Psychometrika . 1965 ; 30 ( 2 ): 179 - 85 .
45. McDaniel C. Development and psychometric properties of the ethics environment questionnaire . Med Care . 1997 ; 35 ( 9 ): 901 - 14 .
46. Corley MC , Minick P , Elswick RK , Jacobs M. Nurse moral distress and ethical work environment . Nurs Ethics . 2005 ; 12 ( 4 ): 381 - 90 .
47. McDowell I . Measuring health: a guide to rating scales and questionnaires . Oxford: Oxford University Press ; 2006 .
48. Falco-Pegueroles A , Lluch-Canut T , Guardia-Olmos J. Development process and initial validation of the ethical conflict in nursing questionnaire-critical care version . BMC Med Ethics 2013 ; 14 (22).
49. Bowling A. Research methods in health . 3rd ed. Maidenhead: Open University Press ; 2009 .
50. Austin W , Lemermeyer G , Goldberg L , Bergum V , Johnson MS . Moral distress in healthcare practice: the situation of nurses . Alta RN . 2008 ; 64 ( 4 ): 4 - 5 .