As medical technology and information continue to advance rapidly, healthcare professionals are increasingly confronted with complex caregiving demands, often within the constraints of limited resources and the pressure for cost-efficiency. In such high-stakes environments, ethical ideals often collide with the complexities of real-world clinical environments (Topol, 2013). However, many institutions still lack standardized ethical guidelines to navigate these challenges, leaving caregivers feeling overwhelmed, helpless, and demoralized. As a result, healthcare providers often find themselves disoriented and emotionally distressed when making decisions in morally ambiguous situations (Austin et al., 2017; Hamric and Blackhall, 2007).

Jameton (1984) first introduced moral distress and described it as the psychological discomfort of knowing the morally appropriate course of action to take but failing to act on it because of external constraints. In examining the impacts of moral distress on neonatal intensive care unit nurses, Jameton (1984) highlighted how institutional or systemic barriers can hinder nurses from delivering optimal care but feel compelled to carry out actions they consider morally wrong. The definition of moral distress has been expanded over time to encompass a wider range of ethical challenges, including the psychological and physical tolls that result from such distress. Moral distress emerges when individuals are forced to act against their moral beliefs, preventing them from upholding their core values and resulting in a sense of powerlessness to alter the situation (Godshall, 2021; Jameton, 1993; Salari et al., 2022). In healthcare, moral distress arises primarily when professionals must administer treatments that they know are ineffective or do not serve the patient’s best interests, especially true in circumstances of futile medical care (Rice et al., 2008). This type of distress is prevalent among nurses working in high-pressure settings such as acute care units, obstetrics, pediatric wards, and acute psychiatric departments (Ferrell, 2006; Jansen et al., 2020). Compared to other healthcare professionals, nurses tend to experience moral distress both more frequently and intensely (Corley, 2002; Hamric and Blackhall, 2007; Sporrong et al., 2006).

Moral distress impacts not only nurses but also other healthcare providers, including doctors, physiotherapists, occupational therapists, speech therapists, pharmacists, dietitians, etc., (Brazil et al., 2010; Hamric, 2010; Ulrich and Grady, 2018). It presents a significant challenge for healthcare providers, particularly those working in high-pressure environments, such as emergency medical units, intensive care units, etc., (Lamiani et al., 2017), where they are frequently exposed to moral distress and psychological strain, especially during the pandemic. A meta-analysis of moral distress revealed that it is more frequently experienced by providers when they feel they are administering excessive care. It is less common when palliative care options are suggested (Prentice et al., 2016). ICU healthcare providers are more likely to suffer moral distress when faced with end-of-life situations, ethical dilemmas, and complicated family dynamics (Coughlin, 2021). Whitehead et al. (2015) noted that moral distress in ICU settings often comes from a lack of consistent care, pressure to follow family requests that conflict with the patient’s best interests, and adverse effects of ineffective communication. Additional challenges involve administering treatments that may be deemed inappropriate or ineffective, making life-or-death decisions, and withholding information from patients or their families–all of which can intensify moral distress (Corley, 1995; Ferrell, 2006; Fujii et al., 2021). Some other factors that may cause moral distress are poor teamwork, working with incompetent colleagues, fear of judgment from colleagues, improper allocation of medical resources, shortages of staff and resources, the continuation of treatments that merely prolong suffering, and the use of interventions deemed futile, which can cause unnecessary pain to the patient (Al-Humadi et al., 2021; Beltrão et al., 2023; Haghighinezhad et al., 2019).

If left unaddressed, moral distress may bring in a range of adverse emotional and psychological outcomes, such as anger, anxiety, shame, guilt, sadness, frustration, emotional numbness, cynicism, or self-criticism (Burston and Tuckett, 2012; Jameton, 1984, 2017; Jansen et al., 2020; Parker and Tavella, 2021; Rushton, 2018). Furthermore, they may emotionally disengage from their patients and distance themselves from others (Lamiani et al., 2017; Wilson et al., 2013). Physically, they may suffer from burnout, compassion fatigue, headaches, stomach issues, sleep disturbances, weight changes, palpitations, and medical errors (Delfrate et al., 2018; Rushton, 2018). Ultimately, unresolved moral distress may undermine healthcare quality, diminish patient satisfaction, and increase staff turnover (Burston and Tuckett, 2012; Huffman and Rittenmeyer, 2012; McCarthy and Gastmans, 2015).

Addressing the detrimental impacts of moral distress on healthcare personnel, organizations, and the overall healthcare system is an urgent concern (Aultman and Wurzel, 2014; Musto et al., 2015). Therefore, developing tools for early identification and accurate assessment of moral distress is essential, as this provides a foundation for designing effective intervention strategies (Lachman, 2016). Corley et al.’s (2001) Moral Distress Scale (MDS) is the pioneering instrument developed to measure moral distress, grounded in Jameton’s (1984) original conceptualization. The 38-item scale was initially developed to assess how often and severely nurses, especially those working in the ICU, experience moral distress (Corley et al., 2001). Despite its widespread use, the original MDS demonstrated acceptable internal consistency but lacked confirmatory factor analysis and was validated only in nurses. Hamric et al. (2012) modified the tool to 21 questions to assess moral distress. Today, the revised tool, MDS-Revised, remains the commonly employed measure to assess how often and how severely healthcare providers experience moral distress in diverse hospital settings (Hamric and Epstein, 2017). The MDS-R reduced the number of items but retained similar limitations regarding construct validity and generalizability. Different versions of the scale have been adapted to fit the unique needs of various healthcare practitioners, including Wocial and Weaver’s (2013) Moral Distress Thermometer (MDT) and Epstein et al.’s (2019) Measure of Moral Distress for Healthcare Practitioners (MMD-HP). These versions have shown robust validity and reliability across diverse healthcare professions but may require cultural adaptation.

Moreover, several challenges may emerge when considering direct adaptation of the MDS-R or MMD-HP into the Taiwanese context. First, moral distress varies depending on each individual’s cultural background and the unique circumstances of the healthcare setting (Horton et al., 2007). Additionally, the moral distress and ethical dilemmas embedded in these tools reflect Western healthcare systems and do not sufficiently resonate with the socio-cultural dynamics of the Taiwanese healthcare system, especially issues such as family authority and role-based power imbalances (Yeh et al., 2010). Given that environmental and cultural factors influence the experience and response to moral distress (Hamric et al., 2012; Tian et al., 2021), existing tools might not completely reflect the unique moral distress experienced by healthcare students and providers in Taiwanese culturally specific healthcare environments. Moreover, linguistic equivalence alone is insufficient to convey culturally embedded concepts, such as filial piety and collective decision-making, which profoundly shape clinical ethics in Taiwan (Yeh et al., 2010). These systemic, cultural, and linguistic differences make direct adaptation problematic and therefore justify the development of a culture-specific instrument (Picconi et al., 2023).

Hence, without cultural adaptation and validation, the use of these tools in Taiwan may result in incomplete or misleading assessments of moral distress. Consequently, to address this gap, the study intended to go through a systematic review to develop and validate a scale (MDS-HSP) for assessing moral distress in this population based on Taiwanese cultural contexts.

The objective of this research was to develop a medical distress scale (MDS-HSP Scale) to assess medical distress among medical students and providers in Taiwanese clinical and healthcare settings. The study validated the MDS-HSP Scale’s psychometric qualities using EFA to look at the hidden factor structure and CFA to make sure the dataset matched the model. A preliminary 42-item MDS-HSP Scale was initially developed by the researchers using the EFA. Six factors on this scale accounted for 79.268% of the variance: “acquiescence to patients’ rights violations” (8 items), “lack of professional competence” (9 items), “disrespect for patients’ autonomy” (10 items), “futile treatment” (5 items), “organizational and social climate” (6 items) and “not in patients’ best interest” (4 items).

The EFA findings showed that factor loadings are between 0.961 and 0.527, all higher than Hair et al.’s (2018) proposed threshold of 0.50. By analyzing the mean scores across six distinct factors, the researchers further investigated the diverse aspects of moral distress experienced by healthcare students and providers. Participants had the highest score on the “lack of professional competence” factor (Mean = 4.997 per item: 44.970÷9 = 4.997), followed by the “futile treatment” (Mean = 4.792), “organizational and social climate” (Mean = 4.789), “disrespect for patients’ autonomy” (4.771), and “not in patients’ best interest” (4.707). They gained the lowest scores on the “acquiescence to patients’ rights violations” (Mean = 4.600). This suggests that healthcare students and providers experience the most significant moral distress when they perceive themselves or others as lacking expertise and training to provide appropriate care. This finding corresponds with previous research by Epstein and Hamric (2009) and Oh and Gastmans (2015), indicating that moral distress frequently arises when healthcare providers feel inadequately prepared to manage complex clinical situations.

The second highest mean score was observed in the “futile treatment” factor, indicating significant distress associated with providing treatments perceived as non-beneficial. This is particularly evident in critical and end-of-life care settings, where providers may feel compelled to continue aggressive interventions despite ethical concerns. Hamric et al. (2012) noted that institutional pressures to prolong treatment can intensify moral conflict, especially when such interventions contradict a provider’s professional judgment. Close behind was the “organizational and social climate” factor. This highlights the impact of a negative or unsupportive workplace environment on moral distress. The finding corresponds with Hamric and Epstein’s (2017) study, emphasizing that a lack of open communication, ethical support, and collaborative decision-making within an organization significantly increases the likelihood of moral distress among healthcare providers. Moral distress was also notably associated with “disrespect for patient autonomy” (Mean = 4.771) and “not in patients’ best interest” (Mean = 4.600). Participants reported considerable distress when witnessing actions that undermined ethical principles or disregarded patient autonomy and rights. As Berlinger and Berlinger (2017) noted, excluding patients from decision-making or overriding their preferences can significantly contribute to moral distress. Similarly, some actions may raise moral concerns; however, their ambiguous nature makes it difficult to determine whether they harm patients or go against their best interests. As Johnstone and Hutchinson (2015) pointed out, determining what constitutes a patient’s best interest can be highly subjective, particularly in culturally diverse or ethically complex situations, which may contribute to the comparatively lower distress levels reported in this factor. The lowest mean score was associated with the “acquiescence to patients’ rights violations” factor (Mean = 4.600), still falling within the moderate range of moral distress. This may suggest that healthcare providers often feel powerless when institutional protocols or physician orders conflict with their ethical commitment to uphold patient dignity (Ulrich et al., 2010a).

To rigorously confirm the underlying factor structure, CFA was conducted, yielding the same 42 items with strong factor loadings, in the range of 0.609–0.906, surpassing the benchmark set by Hair et al. (2018). Based on multiple indices, the model’s overall fit was deemed robust and acceptable (Hu and Bentler, 1999). While the EFA-derived MDS-HSP scale already demonstrated acceptable fit indices, the CFA-derived model achieved even better fit. This was evidenced by notable improvements: the TLI and CFI rose by 0.12 and 0.11, respectively, while both the RMSEA and the χ²/df dropped significantly, by 0.06 and 1.304, respectively (p < 0.05). The MDS-HSP scale also met the criteria for convergent validity. Regarding convergent validity, findings indicated that the AVE values for constructs–such as “acquiescence to patients’ rights violations,” “lack of professional competence,” “disrespect for patients’ autonomy,” “futile treatment,” “organizational and social climate,” and “not in patients’ best interest”–were all above the suggested benchmark of 0.50 (Hair et al., 2018; Malhotra, 2008) and lower than their CR scores, exceeding. Therefore, because all AVEs exceeded 0.50 and were lower than their corresponding CRs, which all surpassed 0.60, the scale’s convergent validity is well established. Reliability testing also revealed excellent internal consistency in both the CFA-derived and EFA-derived versions of the scale. Across the full scale and all six factors, both the CR and Cronbach’s alphas ranged from 0.812 to 0.987, well exceeding the accepted minimum of 0.70 (Cunha et al., 2016; Hair et al., 2018), further confirming the scale’s robustness and trustworthiness.

Compared with the MDS and MDS-R, the MDS-HSP demonstrates higher overall reliability, with a Cronbach’s alpha of 0.974 and subscale values ranging from 0.832 to 0.957. By comparison, Corley et al.’s (2001) MDS reported an overall alpha of 0.96, with subscale alphas between 0.82 and 0.97, while Hamric et al.’s (2012) MDS-R showed an alpha of 0.89 for nurses and lower reliability for physicians, ranging from 0.67 in smaller samples to 0.88 in larger cohorts. These results indicate that the MDS-HSP provides robust reliability for measuring moral distress in healthcare settings. The results showed that both EFA and CFA supported the proposed factor structure and demonstrated adequate validity and reliability. Consequently, the scale can serve as a diagnostic and evaluative instrument in educational and clinical settings. Hence, it allows healthcare instructors and administrators to identify which aspects of moral distress are most pronounced and design targeted interventions accordingly. For example, educational interventions such as simulation-based training, clinical skills workshops, and mentorship programs may address distress related to lack of professional competence (Berger, 2014), while institutional policies, organizational cultures, and more straightforward guidelines on end-of-life care can mitigate distress associated with futile treatment (Dzeng et al., 2015; Eagle et al., 2015). Enhancing organizational communication, ethical support, and team-based decision-making may reduce distress linked to negative social climate (Hamric and Epstein, 2017), whereas structured communication, shared decision-making, and patient-centered care can help reduce distress associated with respecting patient autonomy or decisions not in patients’ best interest (Johnstone and Hutchinson, 2015; Zolnierek and DiMatteo, 2009). Reporting mechanisms can also help manage distress related to acquiescence to rights violations (Ulrich et al., 2010b).

Some factors of the MDS-HSP, such as organizational climate and futile treatment, reflect ethical challenges common across healthcare settings internationally and may be generalizable. Other factors–particularly “acquiescence to patients’ rights violations” and perceptions of “disrespect for patients’ autonomy”–are influenced by Taiwan’s cultural context, including hierarchical decision-making, family-centered care, and respect for authority, highlighting the scale’s culturally specific relevance (Ko et al., 2018; Kramer et al., 2002).

Overall, the MDS-HSP provides a framework to connect empirical assessment of moral distress with practical educational and institutional strategies, while acknowledging the cultural differences shaping healthcare providers’ experiences in Taiwan. It will help healthcare instructors and administrators identify ethical challenges and moral distress in clinical practice and design appropriate educational interventions, training programs, or institutional policies to reduce moral distress, thereby facilitating professional well-being and effective care delivery. This recognition can also foster broader cultural understanding of the moral complexities healthcare providers face. Nevertheless, this study has certain limitations. The sample was restricted to Taiwanese participants, limiting the generalizability of the findings to other cultural and clinical contexts. Cultural and contextual factors deeply impact moral distress, and differences in healthcare systems, professional roles, social values, and ethical standards across regions can shape how individuals perceive and respond to such distress. Consequently, the current scale may not fully reflect the complexities of moral distress in settings that differ significantly in cultural, ethical, or socioeconomic conditions. Future research should aim to validate the MDS-HSP scale in diverse healthcare systems and cultural contexts, including adaptations for cross-cultural use. Future research may also focus on longitudinal validation, cross-cultural application, and the effects of targeted interventions on moral distress levels over time.

This study offers empirical support for the MDS-HSP, confirming its validity and reliability for measuring moral distress in healthcare students and providers within the Taiwanese cultural context. Both exploratory and confirmatory factor analyses demonstrated its strong psychometric properties, establishing the MDS-HSP as a dependable assessment tool. Use of this instrument may guide the development of educational programs, institutional policies, and ethical support frameworks in both healthcare and academic settings.