Skip to main content
Download PDF

Development and psychometric properties of the nursing ethical decision-making ability scale

BMC Medical Ethics volume 26, Article number: 35 (2025) Cite this article

Abstract

Background

Nursing ethical decision-making ability is a core competency of nurses. However, no tool has been developed to measure the ethical decision-making ability of nurses in China. Therefore, we aimed to develop a nursing ethical decision-making ability scale (EDMAS) and assess its validity and reliability.

Methods

A literature review, qualitative study, and the Delphi method were employed to identify the most common ethical dilemmas and original scale items. A cross-sectional study was conducted to evaluate the items. The reliability and validity of the scale were evaluated. Exploratory factor analysis (EFA) was employed to investigate the factor structure based on data from group 1 (N = 404). Confirmatory factor analysis (CFA) was employed to assess the construct validity based on the data from group 2 (N = 503). Convergent validity was evaluated using composite reliability (CR) and average variance extracted (AVE). Discriminant validity was assessed by analyzing the maximum shared variance (MSV). We invited 15 experts to evaluate the content validity of the EDMAS. This study was conducted between December 2021 and January 2023.

Results

We defined 4 nursing ethical dilemmas and 71 original items. We deleted 4 items during the screening process. Additionally, 3 items were deleted from the EFA. The EFA revealed that the EDMAS with 64 items had a four-factor structure (ethical sensitivity, motivation, judgment, and action), accounting for 56.05% of the total variance. The CFA revealed that χ2/df = 1.291, RMSEA = 0.024, CFI = 0.976, TLI = 0.974, NFI = 0.902, and IFI = 0.976. The CR values were between 0.945 and 0.964. The AVE values were between 0.583 and 0.588. The MSV values were between 0.533 and 0.572. The value of I-CVI varied from 0.867 to 1.000, and the S-CVI/Ave was 0.965. The Cronbach’s of the scale was 0.982. The test–retest reliability of the EDMAS was 0.982.

Conclusion

EDMAS is a reliable and valid tool for evaluating nurses’ ethical decision-making ability and enhancing its ability through ethics training programs.

Peer Review reports

Introduction

As medical technology advances rapidly with the increasing complexity of the work environment, nurses must meet the needs of patients and their families while fulfilling the requirements of teamwork and hospital administration [1, 2]. Consequently, nurses encounter various ethical problems, including ethical dilemmas or distress, more rapidly and inevitably than other healthcare professionals [3, 4]. Previous studies demonstrated that nurses experienced moral distress at moderate or higher levels [5, 6]. Of all ethical problems nurses encountered, more than half remained unresolved [7]. Prolonged confusion among nurses regarding ethical problems would impact their ability to remain engaged, constructive, and nonreactive, leading to diminished nursing quality and jeopardizing the health of patients [8, 9]. Rational ethical decision-making is inseparable from the health outcomes of patients and concurrently aids nurses in avoiding mental and physical disorders [10, 11].

Nursing ethical decision-making is characterized as a systemic process involving professional accountability and moral components, enabling the formulation of the most appropriate decision regarding an ethical issue based on intuition, ethical nursing principles, codes of ethics, and moral reasoning in clinical nursing practice [11, 12]. Previous studies have demonstrated that ethical decision-making ability in nursing is closely associated with the quality of nursing care and the nurse-patient relationship [11, 13]. Fostering ethical decision-making skills is crucial for enhancing the clinical competencies of nurses [14]. It is imperative to have a validated tool to evaluate the ethical decision-making competencies of nurses to achieve this, followed by the implementation of targeted interventions to improve their ethical decision-making skills in nursing practice based on the assessment outcomes.

Various tools have been created to evaluate different aspects of ethical decision-making competencies in healthcare professionals across diverse cultural settings [15,16,17]. Tools, including those developed by Hébert PC et al. [18] and Pai et al. [19] focus on assessing the ethical sensitivity or decision-making competence of medical and nursing students, while Crisham developed an instrument to evaluate the moral judgment of nurses [16], and Ketefian developed the judgment about nurses’ decisions to measure nurses’ ethical behaviors [20]. Due to the varying cultural backgrounds and medical environments, nurses encounter ethical dilemmas or distinct ethical issues and address them according to different ethical principles or ethical values [21, 22]. These tools may inadequately address the specific ethical dilemmas encountered by nurses in distinct healthcare settings in China, and a gap remains in the availability of a tool specifically tailored to assess nursing ethical decision-making competencies in China. It is imperative to create a dependable instrument based on unique cultural backgrounds and healthcare challenges for assessing the ethical decision-making capabilities of nurses in China.

According to Rest’s four-component model, making ethical decisions is recognizing an ethical issue and implementing justifiable behavior [23]. It included ethical sensitivity, judgment, motivation, and action, which are the core abilities of ethical decision-making. All four core abilities are interactional: information processing, design, choice, and inspection [24]. Emphasis on the process of thinking and the actions that accompany [25]. Furthermore, the four abilities were consistent with the definition of ethical ability, which included the ability to recognize ethical situations and make judgments and the willingness to act in the best interest of patients [26, 27]. However, as Katayama H et al. stated, the above did not include specific methods that nurses could use in clinical practice [25].

Terry L. Cooper developed an ethical decision-making model that involves describing the situation, defining ethical problems, analyzing alternative methods, considering potential consequences, and selecting the best action strategy [28]. Cooper’s ethical decision-making model provided direct thinking, action skills, and methods for resolving ethical issues. Simultaneously, it revealed the required information, design, selection, and inspection characteristics consistent with the connotations of Rest’s four-component model [28]. For instance, we can improve our ethical sensitivity by describing our situation and making an ethical decision based on alternative methods and potential consequences. Rest’s four-component model stated the core components of ethical decision-making abilities, and Cooper’s ethical decision-making model stated the specific thinking and doing methods for demonstrating ethical decision-making abilities.

Accordingly, we aimed to create a nursing ethical decision-making ability scale based on Rest’s four-component and Cooper’s ethical decision-making models. Furthermore, Palermo J et al. reported that respondents had to be placed in the context of an ethical dilemma to reflect the influence of individual value on ethical decision-making [29]. Therefore, we expanded our scale to include representative ethical dilemmas in nursing practice. Besides, this study will assess the reliability and validity of the EDMAS using data from nurses in China. Hence, we hope to provide a tool that can effectively evaluate and improve the ethical decision-making skills of nurses in China, thereby improving patient care and supporting the professional development of nurses.

Methods

Design of study

This study was conducted between December 2021 and January 2023. The study comprised three components: (1) generating ethical dilemmas in nursing and original items through literature review, qualitative interview, and the Delphi method; (2) items screening; (3) testing of the scale’s validity and reliability.

Sample size

Participants for the qualitative interviews were recruited from hospitals in Sichuan Province, China, using purposive sampling. The interviews continued until data saturation was achieved, as the sample size for qualitative studies could not be predetermined [30]. The inclusion criteria included (1) registered clinical nurses with at least one year of work experience and who have received education and training in nursing ethics; (2) nurses who provided informed consent and voluntarily agreed to participate in the study. The exclusion criteria included (1) nurses who were not on duty during the study period and (2) nurses undergoing training, further education, or rotation.

To evaluate the items and assess the validity and reliability of EDMAS, we performed cross-sectional studies in two stages: the samples for stage one (Group 1) were utilized to screen the items and execute exploratory factor analysis. The sample size was determined based on existing guidelines, which recommend 100 to 250 participants [31]. In our study, we set the minimum sample size for EFA at 250. Considering the 30% missing values, we ensured the sample size of Group 1 was 357. Simultaneously, samples from stage two (Group 2) were collected to analyze the CFA, CR, AVE, and MSV. The literature indicates that the sample size for conducting CFA should be < 300 [32]. The adjusted sample size of Group 2, which accounts for a 30% increase due to missing values, was 429. The inclusion criteria for the two-stage survey included (1) registered clinical nurses and (2) nurses who provided informed consent and voluntarily agreed to participate in the study. The exclusion criteria included (1) nurses who were not on duty during the study period and (2) nurses undergoing training, further education, or rotation.

Generating ethical dilemmas in nursing and original items

We employed a literature review, qualitative interview, and the Delphi method to obtain the ethical dilemma scenarios and original components of EDMAS. We included 14 clinical nurses from hospitals in the qualitative interview, which followed these outlines: (1) What ethical dilemma have you encountered in your nursing duties that you were uncertain how to address? (2) What aspect of this ethical dilemma was particularly challenging? (3) What did you believe was the initial approach to address this ethical dilemma? (4) What actions can be taken regarding this matter? What motivated you to undertake this? (5) Could you please elaborate on the process of solving this problem and explain the rationale behind your chosen approach?. We collected the audio recordings and notes within 24 h after the interview.

We identified four ethical dilemma scenarios within clinical nursing practice: the ethical dilemmas between nurses and doctors, nurses and nurses, nurses and patients, and nurses and nursing management, respectively. Furthermore, according to different ethical dilemmas, we obtained 71 original items from literature, interviews, and the Delphi method that aligned with the principles of Cooper’s ethical decision-making model. Each ethical dilemma would evaluate nurses’ ethical decision-making ability from four aspects: ethical sensitivity, judgment, motivation, and action, which was in keeping with the meaning of Rest’s four core ethical decision-making abilities. The final score reflected their overall ethical decision-making capabilities. Participants assessed their ethical decision-making abilities using a 5-point Likert scale with ratings ranging from 1 very low to 5 very high per item. 1 = strongly oppose, 2 = oppose, 3 = neutrality, 4 = agree, and 5 = strongly agree. However, items marked with an asterisk are scored in reverse. Higher scores indicate a higher level of ethical decision-making abilities.

Screening of items

We employed the critical ratio method (retaining items with P < 0.05), correlation analysis (retaining items with a correlation coefficient ≥ 0.4), discrete trend analysis (retaining items with standard deviation ≥ 0.08), and Cronbach’s coefficient method (retaining items if the Cronbach’s α of the total scale decreased upon their deletion) to filter the scale items. If an item was recommended for deletion by more than two of the four methods above, it would be removed [33].

Testing the validity and reliability of the scale

Validity

Construct validity was assessed using EFA and CFA. The EFA was performed to evaluate the factor structure. Items with a factor loading < 0.4 or those under factors with fewer than three items were eliminated [34]. For CFA, the maximum likelihood confirmatory factor analysis was used to examine the underlying latent variable structure of the EDMAS. The chi-square/degree of freedom (χ2/df), root mean square error of approximation (RMSEA), comparative fit index (CFI), tucker-Lewis Index(TLI), normalized fit index(NFI), and incremental fit index(IFI) were employed to assess the goodness of model fit. The acceptable fit indices were: χ2/df < 3, RMSEA < 0.08, CFI > 0.90, TLI > 0.90, NFI > 0.90, and IFI > 0.90 [35]. Convergent validity was evaluated using CR and AVE. A CR value > 0.7 and an AVE value > 0.5 indicated acceptable convergent validity. Discriminant validity was evaluated by examining MSV, where MSV values must be less than the corresponding AVE values for each construct to demonstrate adequate discriminant validity [36].

The content validity was assessed by a panel of 15 experts, comprising three experts from clinical nursing, six from medical or nursing ethics, three from nursing management, and three from scale development. Experts evaluated each item of the EDMAS using a 5-point Likert-type scale based on relevance to nursing ethical decision-making ability to the associated category: 1 = not relevant, 2 = somewhat relevant, 3 = relevant, but needs minor changes, and 4 = very relevant. The content validity index for the scale items (I-CVI) was calculated by assessing the ratio of items rated 3 or 4 by all the experts. Furthermore, the average scale content validity index(S-CVI/ave) was calculated by the average of all I-CVI. According to the recommendation, the I-CVI > 0.83 and S-CVI/Ave > 0.90 were acceptable [36].

Reliability

Internal consistency reliability was evaluated using Cronbach’s α coefficient. An alpha value > 0.7 was deemed acceptable [37]. The 2-week test–retest reliability was evaluated by calculating the correlation coefficient. The test–retest reliability was considered sufficient when the intraclass correlation coefficient (ICC) values exceeded 0.70 [38].

Ethical considerations

This study was approved by the ethics committee of Jinniu District People’s Hospital of Chengdu with approval number (QYYLL-2024–13). All aims and methods of this study were explained to all the participants. The methods were performed in accordance with the applicable guidelines and regulations (Helsinki Declaration), and all participants provided written informed consent.

Statistical analysis

Statistical Package for the Social Sciences software (version 24.0) and AMOS software (version 24.0; SPSS Inc., Chicago, IL, USA) were used for the statistical analyses. Quantitative variables are presented as mean (standard deviation), and categorical variables are presented using frequency. The psychometric process included the Kaiser–Meyer–Olkin (KMO) measure of sampling adequacy and Bartlett’s test of sphericity to evaluate the suitability of the data for exploratory factor analysis. P < 0.05 was considered statistically significant.

Results

Characteristics of participants

Group 1 comprised 49 (12.13%) male nurses and 355 (87.87%) female nurses. Group 2 comprised 55 (10.90%) males and 448 (89.10%) females who were recruited. Among the two groups, most of the nurses were 18–40 years old.

Generation of nursing ethical dilemmas and original items

After the literature review, qualitative interview, and Delphi expert consultation, the original version of EDMAS was developed, comprising 4 nursing ethical dilemmas and 71 items.

Screening of items

We employed the critical ratio method, correlation analysis, discrete trend analysis, and Cronbach’s coefficient method to screen items. During the item screening process, 4 items were simultaneously recommended for deletion by three of the four methods above. We developed the preliminary version of EDMAS comprising 4 nursing ethical dilemmas and 67 items.

Assessment of the scale’s validity and reliability

Validity

The principal components extraction method of EFA with varimax rotation was employed to assess the construct validity of the initial version of EDMAS. The results revealed that the KMO was 0.959 (P < 0.01), indicating the significance of the factor analysis model. Additionally, 3 items were removed because there were < 3 items under the factor. The results of the second-time EFA revealed that the four-factor solution accounted for 56.05% of the total variance and comprised 64 items: ethical motivation, ethical judgment, ethical sensitivity, and ethical action, which explained 14.975%, 13.733%, 10.581%, and 16.764% of the variance, respectively. Table 1 presents the factor loadings. Furthermore, CFA was performed to evaluate the goodness-of-fit of EDMAS. The results revealed that χ2/df = 1.291, RMSEA = 0.024, CFI = 0.976, TLI = 0.974, NFI = 0.902, and IFI = 0.976. The standardized path coefficients for all items were > 0.4. Figure 1 depicts the final model. Furthermore, the results indicate that the AVE values for the four dimensions exceeded 0.50, while the CRs surpassed 0.90. Additionally, the MSV for each dimension was > 0.50 but was smaller than the AVE value of this dimension. Table 2 displays the AVEs, CRs, and MSVs values of the final EDMAS model.

Table 1 Final component rotated matrix of the EDMAS and its items’ loading
Full size table
Fig. 1
figure 1

Model of the 64-item EDMA with standardized regression weights and correlations. Note: F1: ethical judgement; F2: ethical motivation; F3: ethical sensitivity; F4: ethical action

Full size image
Table 2 The AVEs, CRs, and MSVs values of the final EDMAS model
Full size table

We invited 15 experts to identify the content validity of the EDMA with 64 items. The results revealed that the value of I-CVI varied from 0.867 to 1.000, and the S-CVI/Ave was 0.965 (Table 3).

Table 3 Index expert scores for content validity (n = 15)
Full size table

Reliability

Table 4 presents the descriptive statistics for the scale and dimension. Cronbach’s α for EDMAS exhibited high internal consistency, yielding an alpha coefficient of 0.982 for the total instrument. All Cronbach’s α values for EDMAS dimensions and the total scale were > 0.90. The 2-week test–retest reliability was assessed by calculating the ICC. Of the 503 participants, 26 were randomly selected and asked to answer the survey again 2 weeks later. The correlation coefficient for the total EDMAS was 0.982, while the correlation coefficient for each dimension varied between 0.961 and 0.982. We produced the final version of EDMAS with good validity and reliability (Supplementary File 1).

Table 4 Descriptive information of EDMAS dimensions and reliability
Full size table

Discussion

Nursing ethical decision-making requires nurses to approach ethical dilemmas from an ethical nursing perspective, develop solutions, and apply nursing ethics theories, principles, and standards to practice [39]. Nursing ethics issues inherently encompass value judgments and cultural selections, reflecting the ethnic and cultural influences shaped by a society’s development and transformation [40]. Consequently, in developing the EDMAS, we identified ethical dilemmas reflective of China through a literature review and qualitative interviews with Chinese nurses, ensuring that the content of the scale was congruent with the medical, ethical, and cultural context of China.

According to the results of the Delphi method and items screening, 4 nursing ethical dilemmas and 67 items were retained. The EFA and CFA were utilized to confirm the construct validity of the instrument. We developed a reliable and valid 64-item EDMAS with four nursing ethical dilemmas in China, from which three items were eliminated during the exploratory factor analysis. Four factors were identified: ethical sensitivity, motivation, judgment, and action, respectively.

Ethical sensitivity represents the ability of nurses to identify ethical issues [41]. Studies stressed that ethical sensitivity played a key role in clinical ethical decision-making and the execution of ethical action [42, 43]. An instrument was developed to assess the degree of ethical sensitivity [42]. However, the moral sensitivity questionnaire (MSQ), developed by Kim Lützén, primarily evaluates the capability of the nurse to perform a task rather than the methodology for executing it. For instance, “I am keen to discern when a patient is not receiving adequate care.” Ethical motivation refers to the ability of nurses to ascertain their subjective intention of action from an ethical standpoint when confronted with ethical dilemmas. Ethical judgment is the ability of nurses to evaluate multiple alternative solutions to ethical dilemmas and to anticipate the consequences of each solution. It aids in recognizing potential risks and benefits through evidence-based analysis [19]. Ethical action refers to the ability of nurses to select the optimal course of action based on moral principles and ethical guidelines. The study demonstrated that ethical behavior can enhance the motivation of nurses, establish them as role models for peers, foster a sense of safety, and empower them [44]. Şahin Ş et al. developed a scale to assess the ethical conduct of nurses based on five dimensions: attitude, ethical values, behavior, patient safety, and belief [45]. The objective of the scale paralleled our scale, both focusing on whether nurses adopt ethical action in clinical practice. The ethical actions in our study were designed for specific ethical dilemmas. They included non-ethical behaviors, including pro-organizational non-ethical behaviors, to more effectively assess whether nurses can engage in ethical behaviors when confronted with ethical dilemmas.

Rest developed the four elements of ethical sensitivity, motivation, judgment, and action in our study. In addition to the instruments mentioned above that evaluated one of the four components, tools were developed to assess all four components. For instance, the Ethical Caring Competency Scale developed by Katayama et al. for nurses [25] and the Ethical Decision-making Competence Scale developed by Pai et al. for nursing students [19]. Furthermore, the content of the measurement tool and the application population were not identical to our study; EDMAS was developed based on Cooper’s ethical decision-making model [28] and Rest’s four-component model [46]. The utilization of both theories offers a comprehensive framework that encompasses theoretical and practical components, enabling EDMAS to encapsulate the intricacies of ethical decision-making by combining fundamental ethical competencies with implementable strategies.

Our study indicated that nurses in China possess superior ethical decision-making abilities. Several studies have demonstrated that suitable educational methods can significantly enhance nursing ethical decision-making and mitigate the adverse effects of ethical dilemmas. Kim et al. [47] reported that utilizing frequent ethical dilemmas in clinical practice as subjects for debate significantly enhances the ethical judgment skills of trainees compared to conventional didactic teaching methods. The interprofessional ethics course created by Sedgwick et al. [48] offers significant insights on nursing ethics for continuing education programs in China. Gazarian et al. [49] recommended employing digital storytelling methods—including computer-generated stories, music, video clips, and text—to enhance nurses’ awareness of their advocacy roles. Wheeler et al. [50] reported that developing reflective practice storytelling guidelines helped nursing students better understand reflective professional practice, thereby improving their communication, teamwork, and ethical skills. In the future, additional measures should be taken to improve the ethical decision-making ability of nurses.

Limitations

First, we used convenience sampling to recruit the participants, which may limit the generalizability of the findings. This sampling method may introduce selection bias, as participants may have different characteristics than those who do not, potentially compromising the external validity of the results.

Conclusion

Our study developed a unique tool to assess the ethical decision-making ability of nurses in China and evaluated the psychometric characteristics of EDMAS. The scale quantitatively evaluates nursing decision-making ability across four aspects: ethical sensitivity, motivation, judgment, and action. The instrument demonstrates satisfactory internal consistency, reliability, robust content, and construct validity. Employing EDMAS to investigate nurses’ ethical decision-making ability could reveal the lack of vulnerable abilities in their decision-making processes regarding ethical dilemmas. Nursing educators and administrators can utilize the findings to perform focused ethical training.

Data availability

All the data will be available from the corresponding author upon reasonable request.

Abbreviations

EDMAS:

Ethical Decision-making Ability Scale

EFA:

Exploratory Factor Analysis

CFA:

Confirmatory Factor Analysis

CR:

Composite Reliability

AVE:

Average Variance Extracted

MSV:

Maximum Shared Variance

RMSEA:

Root Mean Square Error of Approximation

CFI:

Comparative Fit Index

TLI:

Tucker-Lewis Index

NFI:

Normalized Fit Index

IFI:

Incremental Fit Index

I-CVI:

Content Validity Index for the Scale Items

S-CVI/ave:

Average Scale Content Validity Index

ICC:

Intraclass Correlation Coefficient

KMO:

Kaiser–Meyer–Olkin

References

  1. Haahr A, Norlyk A, Martinsen B, Dreyer P. Nurses experiences of ethical dilemmas: A review. Nurs Ethics. 2020;27(1):258–72. https://doiorg.publicaciones.saludcastillayleon.es/10.1177/0969733019832941.

    Article  Google Scholar 

  2. Alba B. Factors that impact on emergency nurses’ ethical decision-making ability. Nurs Ethics. 2018;25(7):855–66. https://doiorg.publicaciones.saludcastillayleon.es/10.1177/0969733016674769.

    Article  Google Scholar 

  3. Luo Z, Tao L, Wang CC, Zheng N, Ma X, Quan Y, et al. Correlations between moral courage, moral sensitivity, and ethical decision-making by nurse interns: a cross-sectional study. BMC Nurs. 2023;22(1):260. https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12912-023-01428-0.

    Article  Google Scholar 

  4. Huffman DM, Rittenmeyer L. How professional nurses working in hospital environments experience moral distress: a systematic review. Crit Care Nurs Clin North Am. 2012;24(1):91–100. https://doiorg.publicaciones.saludcastillayleon.es/10.1016/j.ccell.2012.01.004.

    Article  Google Scholar 

  5. Mealer M, Moss M. Moral distress in ICU nurses. Intensive Care Med. 2016;42(10):1615–7. https://doiorg.publicaciones.saludcastillayleon.es/10.1007/s00134-016-4441-1.

    Article  Google Scholar 

  6. Ramos FRS, Barth PO, Brehmer LCF, Dalmolin GL, Vargas MA, Schneider DG. Intensity and frequency of moral distress in Brazilian nurses. Rev Esc Enferm U S P. 2020;54:e035578. https://doiorg.publicaciones.saludcastillayleon.es/10.1590/s1980-220x2018020703578.

    Article  Google Scholar 

  7. Molaei Tavani F, Behshid M, Rahmani A, Mousavi S, Seif-Farshad M, Rahmani P. Relationships between ethical decision-making and professional behavior in Iranian nursing students. J Med Ethics History Med. 2022;15:4. https://doiorg.publicaciones.saludcastillayleon.es/10.18502/jmehm.v15i4.10190.

    Article  Google Scholar 

  8. Rushton CH, Swoboda SM, Reller N, Skarupski KA, Prizzi M, Young PD, et al. Mindful Ethical Practice and Resilience Academy: Equipping Nurses to Address Ethical Challenges. American J Crit care. 2021;30(1):e1–11. https://doiorg.publicaciones.saludcastillayleon.es/10.4037/ajcc2021359.

    Article  Google Scholar 

  9. Kovanci MS, Atli ÖA. Moral distress and moral sensitivity in clinical nurses. Res Nurs Health. 2023. https://doiorg.publicaciones.saludcastillayleon.es/10.1002/nur.22366.

    Article  Google Scholar 

  10. Arafat R, Tahir T, Harisa A. Moral distress among nurses in caring COVID-19 patients. Clinical ethics. 2023;18(1):62–6. https://doiorg.publicaciones.saludcastillayleon.es/10.1177/14777509211057251.

    Article  Google Scholar 

  11. Du J, Huang S, Lu Q, Ma L, Lai K, Li K. Influence of empathy and professional values on ethical decision-making of emergency nurses: A cross sectional study. Int Emerg Nurs. 2022;63:101186. https://doiorg.publicaciones.saludcastillayleon.es/10.1016/j.ienj.2022.101186.

    Article  Google Scholar 

  12. Kim S. Development and Initial Psychometric Evaluation of Nurses’ Ethical Decision Making Around End-of-Life-Care Scale in Korea. J Hosp Palliat Nurs. 2011;13(2):97–105. https://doiorg.publicaciones.saludcastillayleon.es/10.1097/NJH.0b013e31820611a4.

    Article  Google Scholar 

  13. Lim A, Kim S. Nurses’ ethical decision-making during end of life care in South Korea: a cross-sectional descriptive survey. BMC Med Ethics. 2021;22(1):94. https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12910-021-00665-9.

    Article  Google Scholar 

  14. Alzghoul MM, Jones-Bonofiglio K. Nurses’ tension-based ethical decision making in rural acute care settings. Nurs Ethics. 2020;27(4):1032–43. https://doiorg.publicaciones.saludcastillayleon.es/10.1177/0969733020906594.

    Article  Google Scholar 

  15. Numminen OH, Leino-Kilpi H. Nursing students’ ethical decision-making: a review of the literature. Nurse Educ Today. 2007;27(7):796–807. https://doiorg.publicaciones.saludcastillayleon.es/10.1016/j.nedt.2006.10.013.

    Article  Google Scholar 

  16. Crisham P. Measuring moral judgment in nursing dilemmas. Nurs Res. 1981;30(2):104–10.

    Article  Google Scholar 

  17. Rest J, Thoma S, Edwards L. Designing and validating a measure of moral judgment: Stage preference and stage consistency approaches. J Educ Psychol. 1997;89(1):5–28. https://doiorg.publicaciones.saludcastillayleon.es/10.1037/0022-0663.89.1.5.

    Article  Google Scholar 

  18. Hébert PC, Meslin EM, Dunn EV. Measuring the ethical sensitivity of medical students: a study at the University of Toronto. J Med Ethics. 1992;18(3):142–7. https://doiorg.publicaciones.saludcastillayleon.es/10.1136/jme.18.3.142.

    Article  Google Scholar 

  19. Pai HC, Hwu LJ. Development of the ethical decision-making competence scale. Nurs Ethics. 2025;32(1):88–98. https://doiorg.publicaciones.saludcastillayleon.es/10.1177/09697330241235300.

    Article  Google Scholar 

  20. Ketefian S. Tool development in nursing: construction of a scale to measure moral behavior. J N Y State Nurses Assoc. 1982;13(2):13–8.

    Google Scholar 

  21. Mohammadi A, Vanaki Z, Memarian R, Fallahrafie RA. Islamic and Western Ethical Values in Health Services Management: A Comparative Study. Int J Nurs Knowl. 2019;30(4):239–50. https://doiorg.publicaciones.saludcastillayleon.es/10.1111/2047-3095.12244.

    Article  Google Scholar 

  22. Derpmann S. Ethical reasoning in pandemic preparedness plans: Southeast Asia and the Western Pacific. Bioethics. 2011;25(8):445–50. https://doiorg.publicaciones.saludcastillayleon.es/10.1111/j.1467-8519.2011.01922.x.

    Article  Google Scholar 

  23. Robichaux C, Grace P, Bartlett J, Stokes F, Saulo Lewis M, Turner M. Ethics Education for Nurses: Foundations for an Integrated Curriculum. J Nurs Educ. 2022;61(3):123–30. https://doiorg.publicaciones.saludcastillayleon.es/10.3928/01484834-20220109-02.

    Article  Google Scholar 

  24. Rest JR. Moral development: Advances in research and theory. 1986.

  25. Katayama H, Muramatsu T, Aoki Y, Nagashima E. Psychometric evaluation of the Ethical Caring Competency Scale in nursing. BMC Nurs. 2022;21(1):103. https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12912-022-00886-2.

    Article  Google Scholar 

  26. Kulju K, Stolt M, Suhonen R, Leino-Kilpi H. Ethical competence: A concept analysis. Nurs Ethics. 2016;23(4):401–12. https://doiorg.publicaciones.saludcastillayleon.es/10.1177/0969733014567025.

    Article  Google Scholar 

  27. Jormsri P, Kunaviktikul W, Ketefian S, Chaowalit A. Moral competence in nursing practice. Nurs Ethics. 2005;12(6):582–94. https://doiorg.publicaciones.saludcastillayleon.es/10.1191/0969733005ne828oa.

    Article  Google Scholar 

  28. Cooper TL. The responsible administrator: An approach to ethics for the administrative role. Hoboken: John Wiley & Sons; 2012.

  29. Palermo J, Evans A. Relationships between personal values and reported behavior on ethical scenarios for law students. Behav Sci Law. 2007;25(1):121–36. https://doiorg.publicaciones.saludcastillayleon.es/10.1002/bsl.712.

    Article  Google Scholar 

  30. Yarahmadi S, Khademi M, Ebrahimzadeh F, Cheraghian T, Shahidi DE. Development and psychometric properties of health care workers’ concerns in infectious outbreaks scale. Front Psychol. 2022;13:1108835. https://doiorg.publicaciones.saludcastillayleon.es/10.3389/fpsyg.2022.1108835.

    Article  Google Scholar 

  31. Sabo A, Kuan G, Sarimah A, Kuay HS, Kueh YC. Psychometric properties of the newly developed self-report environmental determinants of health questionnaire (EDH-Q): development and validation. BMC psychology. 2024;12(1):438. https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s40359-024-01782-x.

    Article  Google Scholar 

  32. Nayak M, Narayan K. Strengths and weaknesses of online surveys. Technology. 2019;6(7):0837–2405053138.

    Google Scholar 

  33. Han C, Zhang L, Liu J. Development and Reliability Testing of the Stroke Patient Protection Motivation Scale. Neuropsychiatr Dis Treat. 2022;18:1341–9. https://doiorg.publicaciones.saludcastillayleon.es/10.2147/ndt.S353111.

    Article  Google Scholar 

  34. Kline RB. Principles and practice of structural equation modeling. New York: Guilford publications; 2023.

  35. Galiana L, Moreno-Mulet C, Carrero-Planells A, López-Deflory C, García-Pazo P, Nadal-Servera M, et al. Spanish psychometric properties of the moral distress scale-revised: a study in healthcare professionals treating COVID-19 patients. BMC Med Ethics. 2023;24(1):30. https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12910-023-00911-2.

    Article  Google Scholar 

  36. Sabo A, Kuan G, Abdullah S, Kuay HS, Goni MD, Kueh YC. Psychometric properties of the social determinants of health questionnaire (SDH-Q): development and validation. BMC Public Health. 2024;24(1):2507. https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12889-024-19990-w.

    Article  Google Scholar 

  37. Hosseini M, Heydari A, Reihani H, Kareshki H. Development and psychometric properties of teamwork scale in resuscitation: A sequential exploratory mixed-method study. J Educ Health Promotion. 2023;12:10. https://doiorg.publicaciones.saludcastillayleon.es/10.4103/jehp.jehp_139_22.

    Article  Google Scholar 

  38. Izadi-Avanji FS, Zamani N, Azizi-Fini I, Mohammadnejad E. Development and psychometric testing of the Aesthetics of Everyday Life Scale in Aging (AELSA). BMC Geriatr. 2024;24(1):259. https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12877-024-04874-w.

    Article  Google Scholar 

  39. Chen Q, Su X, Liu S, Miao K, Fang H. The relationship between moral sensitivity and professional values and ethical decision-making in nursing students. Nurse Educ Today. 2021;105:105056. https://doiorg.publicaciones.saludcastillayleon.es/10.1016/j.nedt.2021.105056.

    Article  Google Scholar 

  40. Chang YL. Medical Ethics Calls for Cultural Confidence. Chinese Med Ethics. 2017;30(04):440–1.

    Google Scholar 

  41. Chen XL, Fei Huang F, Zhang J, Li J, Ye BY, Chen YX, et al. Tertiary hospital nurses’ ethical sensitivity and its influencing factors: A cross-sectional study. Nurs Ethics. 2022;29(1):104–13. https://doiorg.publicaciones.saludcastillayleon.es/10.1177/09697330211005103.

    Article  Google Scholar 

  42. Milliken A. Nurse ethical sensitivity: An integrative review. Nurs Ethics. 2018;25(3):278–303. https://doiorg.publicaciones.saludcastillayleon.es/10.1177/0969733016646155.

    Article  Google Scholar 

  43. Huang FF, Yang Q, Zhang J, Khoshnood K, Zhang JP. Chinese nurses’ perceived barriers and facilitators of ethical sensitivity. Nurs Ethics. 2016;23(5):507–22. https://doiorg.publicaciones.saludcastillayleon.es/10.1177/0969733015574925.

    Article  Google Scholar 

  44. El-Gazar HE, Zoromba MA. Ethical Leadership, Flourishing, and Extra-Role Behavior Among Nurses. SAGE open nursing. 2021;7:23779608211062669. https://doiorg.publicaciones.saludcastillayleon.es/10.1177/23779608211062669.

    Article  Google Scholar 

  45. Şahin Ş, Alpar Ş. Development of the ethical behavior scale in nursing. BMC Nurs. 2024;23(1):857. https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12912-024-02529-0.

    Article  Google Scholar 

  46. Chambers DW. Developing a Self-Scoring Comprehensive Instrument to Measure Rest’s Four-Component Model of Moral Behavior: The Moral Skills Inventory. J Dent Educ. 2011;75(1):23–35.

    Article  Google Scholar 

  47. Kim WJ, Park JH. The effects of debate-based ethics education on the moral sensitivity and judgment of nursing students: a quasi-experimental study. Nurse Educ Today. 2019;83:104200. https://doiorg.publicaciones.saludcastillayleon.es/10.1016/j.nedt.2019.08.018.

    Article  Google Scholar 

  48. Sedgwick M, Yanicki S, Pijl EM. Analysis of Undergraduate Nursing Students’ Sensitivity to Microethical Dilemmas During Simulation. J Nurs Educ. 2020;59(2):88–92. https://doiorg.publicaciones.saludcastillayleon.es/10.3928/01484834-20200122-06.

    Article  Google Scholar 

  49. Gazarian PK, Fernberg LM, Sheehan KD. Effectiveness of narrative pedagogy in developing student nurses’ advocacy role. Nurs Ethics. 2016;23(2):132–41. https://doiorg.publicaciones.saludcastillayleon.es/10.1177/0969733014557718.

    Article  Google Scholar 

  50. Wheeler PL, Butell SS, Epeneter BJ, Langford CA, Taylor JD. Storytelling: A Guided Reflection Activity. J Nurs Educ. 2016;55(3):172–6. https://doiorg.publicaciones.saludcastillayleon.es/10.3928/01484834-20160216-10.

    Article  Google Scholar 

Download references

Acknowledgements

None.

Funding

This study was approved by the Medical Technology Project of Health Commission of Sichuan Province, China (21PJ109) and the Sichuan Provincial Philosophy and Social Science Key Base Project, China (YF23-Y02).

Author information

Author notes

  1. Xinyu Chen, Chenxi Wu and Wenting Ji contributed equally to this work.

Authors and Affiliations

  1. College of Nursing, Chengdu University of Traditional Chinese Medicine, No. 1166, Liutai Avenue, Wenjiang District, Chengdu, Sichuan Province, 611137, China

    Xinyu Chen, Chenxi Wu, Wenting Ji, Dingxi Bai, Huan Chen, Chaoming Hou & Jing Gao

Authors
  1. Xinyu Chen
    View author publications

    You can also search for this author inPubMed Google Scholar

  2. Chenxi Wu
    View author publications

    You can also search for this author inPubMed Google Scholar

  3. Wenting Ji
    View author publications

    You can also search for this author inPubMed Google Scholar

  4. Dingxi Bai
    View author publications

    You can also search for this author inPubMed Google Scholar

  5. Huan Chen
    View author publications

    You can also search for this author inPubMed Google Scholar

  6. Chaoming Hou
    View author publications

    You can also search for this author inPubMed Google Scholar

  7. Jing Gao
    View author publications

    You can also search for this author inPubMed Google Scholar

Contributions

J G and C H were responsible for the study conception and design. X C, C W, and W J were responsible for project implementation, data collection, data analysis and drafting of the manuscript, and they contributed equally to this article. D B and H C made critical revisions to the paper for important intellectual content. X C, C W, and W J made the equal contribution to this article.

Corresponding authors

Correspondence to Chaoming Hou or Jing Gao.

Ethics declarations

Ethics approval and consent to participate

This study was approved by the ethics committee of Jinniu District People’s Hospital of Chengdu with approval number (QYYLL-2024–13). All aims and methods of this study were explained to all the participants. The methods were performed in accordance with the applicable guidelines and regulations (Helsinki Declaration), and all participants provided written informed consent.

Consent for publication

All the participants and patients in our study gave written informed consent for their personal and clinical details along with any identifying images to be published in this study.

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Chen, X., Wu, C., Ji, W. et al. Development and psychometric properties of the nursing ethical decision-making ability scale. BMC Med Ethics 26, 35 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12910-025-01190-9

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12910-025-01190-9

Keywords

BMC Medical Ethics

ISSN: 1472-6939

Contact us