Skip to main content
Download PDF

Cultural adaptation and psychometric evaluation of the Persian version of the Rushton Moral Resilience Scale (RMRS)

BMC Nursing volume 24, Article number: 372 (2025) Cite this article

Abstract

Background

Nurses frequently encounter complex ethical dilemmas and high-stress environments. Moral resilience, characterized by the ability to navigate these challenges with confidence and integrity, is essential for optimal patient care and personal well-being.

Aim

This study aimed to culturally adapt and validate the Persian version of the Rushton Moral Resilience Scale (RMRS) among Iranian nurses.

Method

This methodological study employed a convenience sample of 659 nurses working in clinical wards of public and private hospitals in Kermanshah City, Iran. The RMRS was translated into Persian using the forward-backward translation method proposed by Polit and Yang. To assess the psychometric properties of the Persian RMRS, exploratory factor analysis (EFA), confirmatory factor analysis (CFA), and reliability were conducted.

Results

Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) supported the factor structure of the Persian RMRS, identifying four factors comprising 15 items, which accounted for 50.98% of the total variance. The CFA model exhibited good fit indices: χ²/df = 2.35, RMSEA = 0.061, NNFI/TLI = 0.91, CFI = 0.94, GFI = 0.94, and SRMR = 0.049. The scale demonstrated satisfactory internal consistency, with a Macdonald Omega coefficient of 0.728 and an Intraclass Correlation Coefficient (ICC) of 0.715 (95% CI: 0.677–0.749).

Conclusion

The present study successfully adapted and validated the Persian version of the Rushton Moral Resilience Scale (RMRS) for Iranian nurses. The scale demonstrated sound psychometric properties, including acceptable reliability and validity. These findings suggest that the Persian RMRS can be a valuable tool for researchers and healthcare professionals to assess moral resilience among Iranian nurses, enabling a deeper understanding of this construct and its implications for patient care and well-being.

Clinical trial number

Not applicable.

Peer Review reports

Introduction

Healthcare professionals frequently encounter ethical challenges in their practice [1, 2]. Nurses, in particular, are uniquely susceptible to ethical conflicts due to the inherent nature of their role, involving direct patient care. As the largest group within the healthcare workforce [3, 4], nurses are disproportionately burdened by these ethical challenges. When faced with irresolvable ethical conflicts, healthcare professionals, especially nurses, may experience moral distress [5, 6]. This complex issue can have deleterious consequences, including diminished job satisfaction, increased turnover rates, and compromised patient care quality [7]. Therefore, mitigating moral distress among nurses is imperative to improve outcomes for both patients and healthcare providers.

Moral resilience, characterized as the capacity to maintain or restore integrity in the face of moral adversity [8, 9], is a crucial attribute for nurses confronting moral distress [10, 11]. This virtue not only safeguards nurses’ professional well-being and values but also enhances their ability to deliver high-quality patient care [5]. Empirical evidence suggests a correlation between elevated moral resilience and reduced burnout and turnover intentions among nurses [12, 13]. Therefore, having a standardized tool to assess moral resilience would enable nursing managers to analyze its impact on burnout and turnover rates. This knowledge could inform the development of targeted interventions to bolster nursing workforce stability, promote nurse well-being, and ultimately enhance patient care quality.

Numerous instruments have been developed to measure various dimensions of nursing ethics, including moral courage, moral distress, moral integrity, moral competence, moral intelligence, ethical awareness, ethical sensitivity, ethical caring competency, ethical reasoning, ethical conflict, and ethical behavior [14,15,16,17,18,19,20,21,22,23,24]. While these tools address concepts related to moral resilience, they do not specifically target moral resilience in nurses. To fill this gap, Heinze et al. (2021) developed the Rushton Moral Resilience Scale (RMRS) to assess moral resilience in healthcare interprofessionals, focusing on responses to moral adversity, personal integrity, moral efficacy, and relational integrity [8]. This comprehensive scale has demonstrated its utility in measuring moral resilience among healthcare professionals, including nurses. Furthermore, a Chinese adaptation of the RMRS by Tian et al. [5] has shown its cross-cultural applicability among Chinese registered nurses.

Moral resilience among nurses is significantly influenced by their ethical values and cultural background. These factors contribute to variations in the level, quality, and dimensions of moral resilience across different cultures. Adapting a tool developed in one cultural context to another necessitates careful consideration of the target population’s social norms and cultural nuances.

Iran, with its complex healthcare system, presents a context where nurses frequently encounter moral distress [25]. While research on resilience in Iran is growing, studies specifically focused on moral resilience are limited. For instance, a study conducted in Iran indicated that ICU nurses, when confronted with escalating moral distress, increasingly utilized coping mechanisms to maintain their professional commitment and engagement within the healthcare organization [26]. Additionally, Ghafouri et al. (2021) developed and validated a Persian version of the Moral Distress Scale for Iranian mental health nurses [27]. However, to date, no instrument has been developed or validated to comprehensively and specifically measure the moral resilience of Iranian nurses, considering the unique cultural context of the country. The absence of such a tool hinders the comprehensive and standardized assessment of this important phenomenon among Iranian nursing professionals. To address this gap, the current study aimed to translate, adapt, and validate the Persian version of the Rushton Moral Resilience Scale (RMRS) for use among Iranian nurses. The RMRS, with its focus on responses to moral adversity, personal integrity, moral efficacy, and relational integrity [8], offers a robust framework for assessing moral resilience in healthcare professionals. By developing a culturally adapted version of the RMRS, this study contributes to a better understanding of moral resilience among Iranian nurses and provides a valuable tool for future research and interventions.

Method

Design

This methodological study employed a psychometric approach to evaluate the Persian version of the Rushton Moral Resilience Scale (RMRS) between March and August 2024. The study involved two phases: (1) translation and cultural adaptation of the RMRS and (2) psychometric assessment of the adapted scale.

Participants and setting

A convenience sample of 659 nurses working in public and private hospitals in Kermanshah City participated in this methodological study. Inclusion criteria required at least six months of independent nursing experience and voluntary participation. Participants with more than 10% missing data were excluded [28].

To ensure adequate sample sizes for both exploratory factor analysis (EFA) and confirmatory factor analysis (CFA), participants were allocated accordingly. A sample size of 291 nurses was determined to be sufficient for EFA, following the recommended participant-to-item ratio of 2 to 20 [29]. The remaining 368 nurses were assigned to CFA, adhering to the recommended sample size range of 150 to 500 [30].

Rushton Moral Resilience Scale (RMRS)

This tool was developed and validated by Heinze et al. in the United States in 2021. It consists of 17 items and evaluates four key factors: responses to moral adversity, personal integrity, relational integrity, and moral efficacy [8]. Each item was rated on a 4-point Likert scale ranging from 1 (Disagree) to 4 (Agree). Participants are first asked about their responses to ethical challenges they have faced in their professional roles over the past three months [5]. The total score of the RMRS was calculated by averaging the scores across all 17 items. Higher scores reflect greater moral resilience. In the original development and validation study, the RMRS demonstrated good internal consistency with a reported Cronbach’s alpha coefficient of 0.84 [8].

Translation, back-translation, and cultural adaptation of the RMRS

The instrument was initially obtained from the designer for translation and psychometric evaluation in Iranian society. The translation and cultural adaptation process, based on the Polit and Yang model [31], was employed to develop the Persian version of the RMRS. Two independent forward translations were conducted by bilingual translators, followed by synthesis and back-translation by separate bilingual translators. A panel of experts reviewed and reconciled the translations to ensure conceptual and semantic equivalence. A final step involved a qualitative assessment of face validity through cognitive interviews with 15 nurses to evaluate item clarity, relevance, and potential ambiguity.

Psychometric evaluation

The second phase of the study focused on the psychometric evaluation of the Persian version of the RMRS. This assessment encompassed face validity, content validity, construct validity, and internal consistency reliability.

Face validity

Face validity was assessed quantitatively through a rating process. Fifteen nurses were asked to rate the importance of each item on a 5-point Likert scale. Items with an impact score above 1.5, calculated by multiplying the frequency of selection by the average importance rating, were retained for further analysis [32].

Content validity

Content validity was assessed using a mixed-methods approach. Qualitative content validity was established through expert review. A panel of 15 experts, including nursing faculty, managers, and clinical nurses, evaluated the scale for grammatical accuracy, word choice, item placement, clarity, scoring method, and cultural relevance to the Iranian context.

Two quantitative indices, the Content Validity Ratio (CVR) and the Content Validity Index (CVI), were calculated based on expert ratings. For CVR, experts rated each item’s necessity on a 3-point Likert scale [33, 34]. A CVR of 0.49 or higher was considered acceptable for a panel of 15 experts [35]. For CVI, each item’s relevance was rated on a 4-point Likert scale, with a CVI of 0.79 or higher indicating excellent content validity, regardless of the number of experts [33].

Construct validity

In this stage, both exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were implemented to ensure the measurement instrument accurately captured the target construct [34].

Considering translating the tool into Persian and using it in a different cultural context than the original version, as well as uncovering hidden variables based on Iranian society’s culture, we first conducted an exploratory factor analysis followed by a confirmatory factor analysis [36].

EFA, with Varimax rotation, was used to identify underlying factors. Factors were retained based on eigenvalues greater than one and factor loadings exceeding 0.5 [37, 38]. The Kaiser-Meyer-Olkin (KMO) measure and Bartlett’s test of sphericity were used to assess the sample’s suitability for factor analysis. A KMO value above 0.7 and a significant Bartlett’s test (p < 0.05) indicated a suitable sample size [39].

Confirmatory factor analysis (CFA) was employed to validate the proposed factor structure. Model fit was evaluated using several fit indices, including the chi-square test of model fit (χ²/df < 3), the root mean square error of approximation (RMSEA < 0.08) [40], the goodness-of-fit index (GFI > 0.90), the comparative fit index (CFI > 0.90), the Tucker-Lewis Index (TLI > 0.90), the incremental fit index (IFI > 0.90), and the adjusted goodness-of-fit index (AGFI > 0.80) [41, 42].

Reliability

Internal consistency reliability was assessed using Macdonald Omega, with values exceeding 0.70 indicating acceptable reliability [43, 44]. To assess test-retest reliability, the Intraclass Correlation Coefficient (ICC) was calculated on a 10% subsample (n = 65) over two separate sessions, 14 days apart [45]. An ICC value of 0.75 or higher indicates satisfactory test-retest reliability [46].

Data collection

Following ethical approval and informed consent, a random sample of nurses meeting the inclusion criteria was selected from public and private hospitals in Kermanshah City. Questionnaires were distributed directly to nurses at their workplaces during various shifts to minimize potential bias. Participants were instructed to complete the questionnaires independently and return them in sealed envelopes. Of the 697 distributed questionnaires, 659 were included in the analysis, with 38 excluded due to incomplete data.

Statistical analysis

Data analysis was performed using SPSS (version 26.0) and LISREL (version 8.0). Statistical techniques employed included Macdonald Omega, the Intraclass Correlation Coefficient (ICC), exploratory factor analysis (EFA), and confirmatory factor analysis (CFA). Statistical significance was set at the p < 0.05 level. To assess the normality of the data distribution, both skewness and kurtosis were analyzed. In the Persian version of The Rushton Moral Resilience Scale (RMRS), the skewness values for all statements ranged from − 2 to 2, while the kurtosis values also fell within the same range, indicating that the distribution of the statements is nearly symmetrical. Additionally, McDonald’s Omega [47] coefficients were utilized to evaluate the reliability of the instrument. Pearson’s correlation coefficient was employed to examine the internal correlations within the model.

Ethical considerations

This study was approved by the Ethics Committee of Kermanshah University of Medical Sciences (Ethics code: IR.KUMS.REC.1402.491). Written permission to use the scale was obtained from the tool’s developer. All participants provided written informed consent before participation. The study was conducted according to the Declaration of Helsinki and relevant ethical guidelines and regulations.

Results

Descriptive results

A total of 291 nurses, with a mean age of 31.06 years (SD = 3.81) and ages ranging from 25 to 47 years, participated in the exploratory factor analysis (EFA) phase. The sample consisted of 42.95% males, 47.8% unmarried individuals, and 83.5% bachelor’s degree holders (Table 1).

Table 1 Demographic characteristics of study participants
Full size table

A total of 368 nurses participated in the confirmatory factor analysis (CFA) phase. The mean age of participants was 30.31 years (SD = 4.36), with ages ranging from 25 to 48 years. The sample consisted of 47.3% males, 50.3% married individuals, and 82.1% bachelor’s degree holders (Table 1).

Face validity assessment

Based on qualitative feedback, one item was revised to improve clarity and understandability. The quantitative assessment of face validity revealed that all 17 items achieved an impact score greater than 1.5, indicating satisfactory face validity.

Content validity assessment

Following qualitative content analysis, items 2, 7, and 14 were revised to enhance clarity and comprehensibility, as recommended by a panel of experts.

Quantitative content validity was assessed using the Content Validity Ratio (CVR) and the Scale-level Content Validity Index (S-CVI). The CVR value of 0.92 fell within the acceptable range of 0.86 to 1, and all item-level CVI values were above 0.79. The S-CVI of 0.96 further indicated excellent content validity for the entire scale.

Construct validity

Exploratory factor analysis (EFA) with maximum likelihood extraction and Varimax rotation was conducted to identify the underlying factor structure (Table 2). The Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy (0.787) and Bartlett’s test of sphericity (p < 0.001) indicated the suitability of the data for factor analysis. The EFA revealed a four-factor solution, with eigenvalues greater than 1.0 and factor loadings exceeding 0.50, explaining 50.98% of the total variance. The scree plot further supported this four-factor structure (Fig. 1).

Table 2 Item factor loadings from exploratory factor analysis of the Rushton Moral Resilience Scale (RMRS) (N = 291)
Full size table
Fig. 1
figure 1

Scree plot of the extracted components of the Rushton Moral Resilience Scale (RMRS)

Full size image

Confirmatory factor analysis (CFA) supported the four-factor structure of the 17-item RMRS. Model fit indices, including χ²/df = 2.35, RMSEA = 0.061, NNFI/TLI = 0.91, CFI = 0.94, GFI = 0.94, and SRMR = 0.049, indicated acceptable model fit. The path diagram and factor loadings from the CFA are depicted in Fig. 2. Pearson’s correlation analysis revealed significant and positive relationships between the subscales and the overall scale, as shown in Table 3.

Fig. 2
figure 2

Final measurement model of the Rushton Moral Resilience Scale (RMRS) from confirmatory factor analysis (N = 368)

Full size image
Table 3 The correlation of the Rushton Moral Resilience Scale (RMRS) and sub-scales (N = 659)
Full size table

All first-order and second-order factor loadings were statistically significant at the 95% confidence level (|λ| > 1.96). Table 4 presents the Lambda coefficient, which represents the standardized factor loadings for each factor.

Table 4 T-value, pearson correlation coefficient, factor loadings, ICC, and Macdonald Omega of the Rushton moral resilience scale (RMRS) and sub-scales
Full size table

Given the critical value of 1.96, items 2 and 8 were excluded from the analysis. Consequently, the confirmatory factor analysis validated the scale model, which comprises 4 factors and a total of 15 items.

Reliability tests

Internal consistency

The Macdonald Omega coefficient for the entire scale was determined to be 0.728, which exceeds the generally accepted threshold of 0.7 for adequate internal consistency reliability (Table 4).

Test-retest reliability

The Intraclass Correlation Coefficient (ICC) for the total scale score was calculated to be 0.715 (95% CI: 0.677–0.749), suggesting substantial test-retest reliability (Table 4).

Discussion

The present study aimed to adapt and validate the Rushton Moral Resilience Scale (RMRS) (8) for use in a Persian-speaking population. The RMRS, a four-factor instrument assessing moral resilience, was translated and culturally adapted. The resulting Persian version comprised four subscales: Responses to Moral Adversity (4 items), Relational Integrity (5 items), Moral Efficacy (4 Items), and Personal Integrity (2 Items). To evaluate the scale’s psychometric properties, content validity was assessed. The Content Validity Ratio (CVR) and Scale-level Content Validity Index (S-CVI) were calculated as 0.92 and 0.96, respectively, indicating satisfactory content validity. These findings are consistent with those reported by Tian et al. [5], who adapted the RMRS into Chinese. Their study yielded I-CVI values ranging from 0.833 to 1.000 and an S-CVI of 0.92, further supporting the scale’s cross-cultural applicability.

Exploratory factor analysis (EFA) yielded a four-factor solution, consistent with the original RMRS (8). The identified factors were: Responses to Moral Adversity (5 items), Relational Integrity (5 items), Moral Efficacy (4 items), and Personal Integrity (3 items). The four-factor model explained 50.98% of the total variance, comparable to the 41.34% reported by Heinze et al. (8). These findings suggest that the Persian adaptation of the RMRS effectively captures the underlying construct of moral resilience.

Confirmatory factor analysis (CFA) supported a four-factor, 15-item structure. Items 2 and 8 were removed due to low factor loadings (< 1.96). The final model demonstrated excellent fit indices. While Tian et al. [5] also conducted CFA on a Chinese sample, their results diverged from the original RMRS [8]. The Chinese adaptation (Chi-RMRS) exhibited a three-factor structure: Ability to Respond Flexibly to Moral Adversity (5 items), Relationship Moral Soundness (6 items), and Moral Efficacy (6 items), explaining 53.08% of the variance. The Chi-RMRS demonstrated acceptable fit indices (χ²/df = 1.512, GFI = 0.907, CFI = 0.944, IFI = 0.946, TLI = 0.931, RMSEA = 0.054) (5).

The exclusion of the Personal Integrity factor from the Chinese version [5] underscores the influence of cultural differences, professional roles, and work environments on healthcare professionals’ moral experiences. Cultural variations can shape diverse perspectives on ethical responsibilities, significantly impacting moral resilience and the experiences of healthcare personnel when confronting ethical challenges. These findings emphasize the importance of considering cultural factors when selecting appropriate tools for measuring moral resilience.

The “Responses to Moral Adversity” factor emerged as the most salient component of the scale, explaining 19.31% of the total variance. This factor, characterized by buoyancy and self-regulation [8, 48], captures individuals’ abilities to maintain emotional stability and regulate their responses to ethical challenges. From an applied perspective, this factor offers valuable insights into nurses’ coping mechanisms in ethically complex situations. By identifying strengths and weaknesses in this area, healthcare organizations can tailor interventions to enhance moral resilience. This understanding can facilitate the design and implementation of targeted educational or support programs aimed at enhancing nurses’ moral resilience. Furthermore, leveraging this factor enables the identification of behavioral patterns and competencies associated with self-regulation and adaptability [8, 49, 50]. Ultimately, these efforts can contribute to improved patient care and reduced nurse burnout.

The “Relational Integrity” factor emerged as the second most significant component, explaining 13.32% of the total variance. This factor delves into individuals’ ethical decision-making in the context of interpersonal conflicts. The concept of “compromising one’s ethical values” highlights the challenges individuals face when balancing ethical principles with relational considerations [8, 48]. This factor underscores the complex nature of moral decision-making in healthcare settings.

The “Moral Efficacy” factor, accounting for 10.87% of the total variance, assesses individuals’ ability to effectively address ethical challenges. This factor is linked to the ability to voice concerns, manage moral dilemmas, and believe in one’s competence to handle ethical issues. It also underscores the importance of presenting ethical issues in a manner that ensures they are taken seriously by others. This is essential for cultivating an ethical culture in professional settings, such as healthcare [51, 52]. Generally, this factor underscores the importance of effective communication and advocacy in promoting ethical behavior and fostering ethical cultures in healthcare settings.

The “Personal Integrity” factor, contributing 7.46% to the total variance, emphasizes individuals’ commitment to ethical principles, even under pressure [8, 48]. Several studies have indicated that nurses may perceive a diminished sense of control over ethical decisions due to the supervision of other healthcare team members, which consequently limits their autonomy in decision-making [26, 53]. Developing personal integrity is essential for maintaining professional credibility and ethical practice in challenging healthcare environments.

The Persian version of the RMRS demonstrated acceptable internal consistency, with Macdonald Omega and ICC values of 0.728 and 0.715, respectively. Furthermore, all subscales of the instrument demonstrated Macdonald Omega coefficients above 0.50. These findings align with the results of Heinze et al. [8], where Cronbach’s alpha coefficients for each factor were reported as follows: Responses to moral adversity (α = 0.78), Relational integrity (α = 0.78), Moral efficacy (α = 0.69), Personal integrity (α = 0.50), and 0.84 for the entire instrument (8). However, the “Personal Integrity” subscale, with fewer items, exhibited lower reliability (α = 0.51), suggesting a need for further refinement in future studies. Overall, the RMRS appears to be a reliable instrument for measuring moral resilience in nursing contexts.

The RMRS is not a diagnostic tool but rather a tool to identify strengths and areas for development in moral resilience. While this scale focuses on individual-level moral resilience, it underscores that interventions aimed at enhancing individual moral resilience must be accompanied by organizational-level changes [54, 55]. Without organizational changes, transforming the healthcare culture from the bottom up will not be feasible.

Limitations

The present study, employing a cross-sectional design with a random sample of nurses from a western Iranian city, explored the psychometric properties of the Rushton Moral Resilience Scale (RMRS). Due to the limitations inherent in a cross-sectional design and the specific sample, the generalizability of the findings may be constrained. While the scale’s content and construct validity were assessed, criterion-related validity, such as concurrent and predictive validity, was not evaluated. Additionally, the interpretation of RMRS scores remains unclear, particularly regarding the absence of established cutoff values for categorizing scores into different levels. Furthermore, the influence of cultural and contextual factors on the scale’s responses cannot be fully ascertained. Future research is warranted to investigate the RMRS’s applicability and validity across diverse cultural contexts. To enhance the scale’s clinical utility, the establishment of categorized cutoff values and the calculation of clinically significant differences are recommended. Additionally, this study used convenience sampling, which may present a limitation.

Conclusion

The current study successfully adapted and validated the Rushton Moral Resilience Scale (RMRS) for the Iranian context. This reliable and valid instrument offers a comprehensive assessment of moral resilience in nursing, enabling a deeper understanding of this critical construct. By identifying strengths and weaknesses in moral resilience, this tool can inform targeted interventions to enhance nurses’ capacity to navigate ethical challenges. Furthermore, the RMRS can serve as a valuable research tool to explore the factors influencing moral resilience and to develop evidence-based strategies to promote ethical practice in nursing.

Data availability

The data analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

RMRS:

Rushton Moral Resilience Scale

CVI:

Content Validity Index

CVR:

Content Validity Ratio

KMO:

Kaiser Meyer Olkin

EFA:

Explorative factor analysis

CFA:

Confirmatory Factor Analysis

TLI:

Tucker-Lewis Index

NFI:

Normed Fit Index

GFI:

Goodness of Fit Index

RMSEA:

Root Mean Square Error of Approximation

PC:

Principal Components

SRMR:

Standardized Root Mean Square Residual

KUMS:

Kermanshah University of Medical Sciences

References

  1. Schürmann J, Reiter-Theil S. What factors contribute to ethical problems in patient care? A scoping review and case series of clinical ethics consultations. J Clin Ethics. 2024;35(2):119–35.

    Article  PubMed  Google Scholar 

  2. Juujärvi S, Nummela O, Sinervo T. Aspects of ethical conflicts and their implications for work-related well-being: a cross-sectional study among health and social care professionals. 2023.

  3. Wakefield M, Williams DR, Le Menestrel S. The future of nursing 2020–2030: charting a path to achieve health equity. National Academy of Sciences; 2021.

  4. Çatak T. Nursing and environmental sustainability: pioneers of green transformation in health. Sabuncuoglu Serefeddin Health Sci. 2024;6(1):51–62.

    Google Scholar 

  5. Tian X, He Q, Liu X, Gan X, Jiménez Herrera MF. Moral resilience in registered nurses: cultural adaption and validation study. Nurs Ethics. 2024;31(2–3):355–70.

    Article  PubMed  Google Scholar 

  6. Rushton CH. Transforming moral suffering by cultivating moral resilience and ethical practice. Am J Crit Care. 2023;32(4):238–48.

    Article  PubMed  Google Scholar 

  7. Ghazanfari MJ, Emami Zeydi A, Panahi R, Ghanbari R, Jafaraghaee F, Mortazavi H, et al. Moral distress in nurses: resources and constraints, consequences, and interventions. Clin Ethics. 2022;17(3):265–71.

    Article  Google Scholar 

  8. Heinze KE, Hanson G, Holtz H, Swoboda SM, Rushton CH. Measuring health care interprofessionals’ moral resilience: validation of the Rushton moral resilience scale. J Palliat Med. 2021;24(6):865–72.

    Article  PubMed  Google Scholar 

  9. Chen X, Zhang Y, Zheng R, Hong W, Zhang J. Latent profiles of nurses’ moral resilience and compassion fatigue. Nurs Ethics. 2024;31(4):635–51.

    Article  PubMed  Google Scholar 

  10. Galanis P, Moisoglou I, Katsiroumpa A, Vraka I, Siskou O, Konstantakopoulou O, et al. Moral resilience reduces levels of quiet quitting, job burnout, and turnover intention among nurses: evidence in the post COVID-19 era. Nurs Rep. 2024;14(1):254–66.

    Article  PubMed  PubMed Central  Google Scholar 

  11. Arries-Kleyenstüber EJ. Moral resilience in nursing education: exploring undergraduate nursing students perceptions of resilience in relation to ethical ideology. SAGE Open Nurs. 2021;7:23779608211017798.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Antonsdottir I, Rushton CH, Nelson KE, Heinze KE, Swoboda SM, Hanson GC. Burnout and moral resilience in interdisciplinary healthcare professionals. J Clin Nurs. 2022;31(1–2):196–208.

    Article  PubMed  Google Scholar 

  13. Yi L, Chen Z, Jiménez-Herrera MF, Gan X, Ren Y, Tian X. The impact of moral resilience on nurse turnover intentions: the mediating role of job burnout in a cross-sectional study. BMC Nurs. 2024;23(1):687.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Numminen O, Katajisto J, Leino-Kilpi H. Development and validation of nurses’ moral courage scale. Nurs Ethics. 2019;26(7–8):2438–55.

    Article  PubMed  Google Scholar 

  15. Eizenberg MM, Desivilya HS, Hirschfeld MJ. Moral distress questionnaire for clinical nurses: instrument development. J Adv Nurs. 2009;65(4):885–92.

    Article  PubMed  Google Scholar 

  16. Nunthawong J. A development of Thai moral integrity scale for professional nurses. 2017.

  17. Asahara K, Kobayashi M, Ono W. Moral competence questionnaire for public health nurses in J Apan: S Cale development and psychometric validation. Japan J Nurs Sci. 2015;12(1):18–26.

    Article  Google Scholar 

  18. Manzari Tavakoli H, Salajeghe S, Sheikhi A. Development and psychometric evaluation of nurses’ moral intelligence scale in Kerman university of medical sciences hospitals. J Health Promotion Manage. 2019;8(5):9–17.

    Google Scholar 

  19. Kolagari S, Moradi R, Milliken A, Khoddam H. Psychometric validation of the Persian version of the ethical awareness scale for nurses working in Iranian intensive care units. Nurs Open. 2024;11(6):e2168.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Joung M-Y, Seo JM. Development of an ethical sensitivity scale for clinical nurses. J Korean Acad Fundamentals Nurs. 2020;27(4):375–86.

    Article  Google Scholar 

  21. Katayama H, Muramatsu T, Aoki Y, Nagashima E. Psychometric evaluation of the ethical caring competency scale in nursing. BMC Nurs. 2022;21(1):103.

    Article  PubMed  PubMed Central  Google Scholar 

  22. McAlpine H, Kristjanson L, Poroch D. Development and testing of the ethical reasoning tool (ERT): an instrument to measure the ethical reasoning of nurses. J Adv Nurs. 1997;25(6):1151–61.

    Article  PubMed  CAS  Google Scholar 

  23. Çiriş Yıldız C, Yildirim D, Ergin E, Korkmaz I, Coşkun Z. Development of ethical conflict scale for nurses in extraordinary circumstances and psychometric testing. J Adv Nurs. 2024;80(3):1132–43.

    Article  PubMed  Google Scholar 

  24. Orathai P, Prapaipanich W, Arpanantikul M, Senadisai S. Development and psychometric evaluation of the ethical behavior for Thai nurses scale. Front Nurs. 2022;9(3):275–84.

    Article  Google Scholar 

  25. Tavakol N, Molazem Z, Rakhshan M, Asemani O. Moral distress in Iranian psychiatric nurses: a content analysis. Iran J Psychiatry Behav Sci. 2022;16(3).

  26. Talebian F, Hosseinnataj A, Yaghoubi T. The relationship between resilience and moral distress among Iranian critical care nurses: A cross-sectional correlational study. Ethiop J Health Sci. 2022;32(2).

  27. Ghafouri R, Lotfi-Bajestani S, Nasiri M, Ohnishi K, Atashzadeh-Shoorideh F. Psychometrics of the moral distress scale in Iranian mental health nurses. BMC Nurs. 2021;20:1–8.

    Article  Google Scholar 

  28. Nulty DD. The adequacy of response rates to online and paper surveys: what can be done? Assess Evaluation High Educ. 2008;33(3):301–14.

    Article  Google Scholar 

  29. Anthoine E, Moret L, Regnault A, Sébille V, Hardouin J-B. Sample size used to validate a scale: a review of publications on newly-developed patient reported outcomes measures. Health Qual Life Outcomes. 2014;12:1–10.

    Article  Google Scholar 

  30. Munro BH. Statistical methods for health care research. lippincott williams & wilkins; 2005.

  31. Polit-O’Hara D, Yang FM. Measurement and the measurement of change: a primer for the health professions. (No Title). 2016.

  32. Polit D, Beck C. Essentials of nursing research: appraising evidence for nursing practice. Lippincott Williams & Wilkins; 2020.

  33. Binti Hassan SA. Content validity of STEMTIP using CVR method. Int J Acad Res Bus Soc Sci. 2018;8:1118–25.

    Google Scholar 

  34. Lawshe C. A quantitative approach to content validity. Personnel psychology/Berrett-Koehler; 1975.

  35. Woo K. Polit & Beck Canadian essentials of nursing research. Lippincott Williams & Wilkins; 2017.

  36. Sharif-Nia H, Hanifi N. Psychometric properties of the Persian version of the second victim experience and support instrument. Nurs Open. 2023;10(7):4647–55.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Speziale HS, Streubert HJ, Carpenter DR. Qualitative research in nursing: advancing the humanistic imperative. Lippincott Williams & Wilkins; 2011.

  38. Jalali A, Sharifi A, Ezzati E, Babaei K, Chavoshani F, Rahmani S, et al. Cultural adaptation and psychometric evaluation of the Persian version of the motivation for nursing student scale (MNSS). BMC Med Educ. 2024;24(1):1117.

    Article  PubMed  PubMed Central  Google Scholar 

  39. Henson RK, Roberts JK. Use of exploratory factor analysis in published research: common errors and some comment on improved practice. Educ Psychol Meas. 2006;66(3):393–416.

    Article  Google Scholar 

  40. Byrne BM. Structural equation modeling with Mplus: basic concepts, applications, and programming. routledge; 2013.

  41. Floyd FJ, Widaman KF. Factor analysis in the development and refinement of clinical assessment instruments. Psychol Assess. 1995;7(3):286.

    Article  Google Scholar 

  42. Jalali A, Naghibzadeh A, Mohammadi MM, Rostami M, Kalhory P, Taghvostani NM, et al. Translation and validation of the Persian version of the nursing practice readiness scale (NPRS) for new graduate nurses. BMC Nurs. 2024;23(1):760.

    Article  PubMed  PubMed Central  Google Scholar 

  43. Okajima I, Komada Y, Inoue Y. A meta-analysis on the treatment effectiveness of cognitive behavioral therapy for primary insomnia. Sleep Biol Rhythms. 2011;9(1):24–34.

    Article  Google Scholar 

  44. McNeish D. Thanks coefficient alpha, we’ll take it from here. Psychol Methods. 2018;23(3):412.

    Article  PubMed  Google Scholar 

  45. Polit DF, Beck CT. Nursing research: generating and assessing evidence for nursing practice. Lippincott Williams & Wilkins; 2008.

  46. Koo TK, Li MY. A guideline of selecting and reporting intraclass correlation coefficients for reliability research. J Chiropr Med. 2016;15(2):155–63.

    Article  PubMed  PubMed Central  Google Scholar 

  47. Gravesande J, Richardson J, Griffith L, Scott F. Test-retest reliability, internal consistency, construct validity and factor structure of a falls risk perception questionnaire in older adults with type 2 diabetes mellitus: a prospective cohort study. Archives Physiotherapy. 2019;9:1–11.

    Article  Google Scholar 

  48. Holtz H, Heinze K, Rushton C. Interprofessionals’ definitions of moral resilience. J Clin Nurs. 2018;27(3–4):e488–94.

    PubMed  Google Scholar 

  49. O’Grady ET. An exploration of moral resilience. The Nurse Practitioner. 2024;49(11):12–5.

    Article  PubMed  Google Scholar 

  50. Wright E, D’Aoust R, Swoboda SM, Hughes V, Hudson K, Reller N, et al. Resilience and ethics in nursing education and practice: needs and opportunities. Nurse Educ. 2024;49(4):E218–22.

    Article  PubMed  Google Scholar 

  51. Grammatis V, Kouroutzis I, Apostolidi N, Vako I, Apostolidi T-P, Roka V et al. Moral distress and moral sensitivity and their correlation with safe nursing care. Med Res Archives. 2024;12(1).

  52. Ishihara I, Inagaki S, Osawa A, Umeda S, Hanafusa Y, Morita S, et al. Effects of an ethics education program on nurses’ moral efficacy in an acute health care facility. J Nurs Adm Manag. 2022;30(7):2207–15.

    Article  Google Scholar 

  53. Haahr A, Norlyk A, Martinsen B, Dreyer P. Nurses experiences of ethical dilemmas: A review. Nurs Ethics. 2020;27(1):258–72.

    Article  PubMed  Google Scholar 

  54. SMM H, SH E. Models and theories of health education and health promotion in physical activity interventions for women: a systematic review. J Educ Community Health. 2014;2(1):68–84.

    Google Scholar 

  55. Faraco MM, Gelbcke FL, Brehmer LCF, Ramos FRS, Schneider DG, Silveira LR. Moral distress and moral resilience of nurse managers. Nurs Ethics. 2022;29(5):1253–65.

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

The authors thank the faculty members of the Student Research Committee of Kermanshah University of Medical Sciences. This research project has been registered with code 4020971 at Kermanshah University of Medical Sciences, Iran.

Funding

No funding was received for this research.

Author information

Authors and Affiliations

  1. Substance Abuse Prevention Research Center, Research Institute for Health, Kermanshah University of Medical Sciences, Kermanshah, Iran

    Amir Jalali

  2. Department of Emergency and Critical Care Nursing, School of Nursing and Midwifery Kermanshah, University of Medical Sciences, Kermanshah, Iran

    Amir Jalali, Behrouz Soltany, Azam Sharifi & Khalil Moradi

  3. Student Research Committee, Kermanshah University of Medical Sciences, Kermanshah, Iran

    Amirhossein Naghibzadeh & Mohammad Moein Mohammadi

  4. Department of Islamic Studies, Kermanshah University of Medical Sciences, Kermanshah, Iran

    Mohammad Karami

Authors
  1. Amir Jalali
    View author publications

    You can also search for this author inPubMed Google Scholar

  2. Behrouz Soltany
    View author publications

    You can also search for this author inPubMed Google Scholar

  3. Azam Sharifi
    View author publications

    You can also search for this author inPubMed Google Scholar

  4. Amirhossein Naghibzadeh
    View author publications

    You can also search for this author inPubMed Google Scholar

  5. Mohammad Karami
    View author publications

    You can also search for this author inPubMed Google Scholar

  6. Mohammad Moein Mohammadi
    View author publications

    You can also search for this author inPubMed Google Scholar

  7. Khalil Moradi
    View author publications

    You can also search for this author inPubMed Google Scholar

Contributions

All authors participated and approved the study design. K, M; A, S and A, J contributed to designing the study, MM, M; M, K; B, S; and A, N collected the data, and data analyses were done by A, J and A, S and K, M. The final report and article were written by A, J; K, M; A, S; MM, M; M, K; A, N; and B, S; and all authors read and approved the final manuscript.

Corresponding author

Correspondence to Khalil Moradi.

Ethics declarations

Ethics approval and consent to participate

This study was approved by the Ethics Committee of Kermanshah University of Medical Sciences (Ethics code: IR.KUMS.REC.1402.491). Written permission to use the scale was obtained from the tool’s developer. All participants provided written informed consent before participation. The study was conducted according to the Declaration of Helsinki and relevant ethical guidelines and regulations.

Consent for publication

Not applicable.

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.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary Material 1

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

Jalali, A., Soltany, B., Sharifi, A. et al. Cultural adaptation and psychometric evaluation of the Persian version of the Rushton Moral Resilience Scale (RMRS). BMC Nurs 24, 372 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12912-025-03049-1

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12912-025-03049-1

Keywords

BMC Nursing

ISSN: 1472-6955

Contact us