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Psychometric properties of the Malay version of the Measure of Moral Distress for Healthcare Professionals (MMD-HP): a cross-cultural adaptation study in Malaysia

Year: 2026

Type: article

Abstract: Moral distress (MD) among healthcare workers (HCWs) has been linked to burnout, job dissatisfaction, and a diminished quality of patient care. Although the Measure of Moral Distress for Healthcare Professionals (MMD-HP) is widely used and validated in multiple languages to assess MD, a culturally adapted Malay version for Malaysia has not been developed despite the detrimental consequences of MD among HCWs. Therefore, our present study aims to address this gap by conducting a cross-cultural adaptation (CCA) and psychometric validation of the MMD-HP in the Malay language to be utilised in Malaysia. Subsequently, the validated Malay MMD-HP is intended to facilitate the assessment of MD levels and sources among HCWs across diverse disciplines in a Malaysian tertiary hospital, thereby supporting the development of targeted strategies to mitigate MD and improve the healthcare workforce’s well-being. The MMD-HP questionnaire was translated into Malay language and culturally adapted for the Malaysian healthcare setting. The translated MMD-HP was administered to HCWs across 18 departments at Sarawak General Hospital (SGH) to evaluate construct validity and reliability and to assess the level and distribution of MD among HCWs from diverse disciplines at both the organizational and departmental levels. Construct validity was examined using factor analysis with promax rotation, while reliability was assessed through internal consistency using Cronbach’s alpha. Convergent and discriminant validity were assessed using composite reliability (CR), average variance extracted (AVE), the Fornell–Larcker criterion, and the heterotrait–monotrait (HTMT) ratio. The Malay version of the MMD-HP demonstrated excellent psychometric properties with high internal consistency (Cronbach’s alpha = 0.974). Convergent validity was supported, with composite reliability values ranging from 0.928 to 0.963 (threshold > 0.70) and average variance extracted between 0.624 and 0.684 (threshold > 0.50). Discriminant validity was confirmed using the Fornell–Larcker criterion and heterotrait–monotrait ratios < 0.85. Exploratory factor analysis revealed a three-factor structure (Clinical, Team, System), explaining 71.6% of the total variance, which was further evaluated by confirmatory factor analysis, indicating marginal model fit, with CFI = 0.875, TLI = 0.863, RMSEA = 0.101 (90% CI = 0.096–0.105), and SRMR = 0.053. System-level factors were the prominent source of MD among 527 HCWs in SGH, with doctors reporting higher adjusted total MD scores compared with nurses and other HCWs. The Malay MMD-HP demonstrates strong reliability and evidence of construct validity as an instrument for assessing MD among Malaysian HCWs, capturing experiences across clinical, team, and system levels, with system-level factors contributing most to MD.

Source: BMC Medical Ethics

DOI: 10.1186/s12910-026-01617-x