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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Moral distress &#40;MD&#41; is the psychological consequence that occurs when healthcare professionals &#40;HCPs&#41; cannot carry on what they believe is the ethically correct action&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> This serious problem threats the integrity not only of HCPs but of healthcare organizations as well&#46; MD has been associated with risk of burnout&#44; employee attrition&#44; propensity to leave a position and decreased quality of care&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2&#8211;6</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In order to precise and study MD&#44; valid and reliable tools to measure its impact are needed&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> In this sense Epstein et al&#46;&#44; in 2019&#44; developed and validated the most recent instrument to explore MD&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> The Measure of Moral Distress for Healthcare Professionals &#40;MMD-HP&#41; is a 27-item scale that captures the five key components of MD directly and indirectly&#58; complicity in wrongdoing&#44; lack of voice&#44; wrongdoing associated with professional &#40;not personal&#41; values&#44; repeated experiences&#44; and three levels of etiologies &#40;patient&#44; unit&#44; system&#41;&#46; This tool is a self-administered questionnaire&#44; the participants rate each item on a Likert scale for how often it occurs in their practice &#40;frequency&#58; 0<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>never&#44; 4<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>very frequently&#41; and for how distressing it is when it occurs &#40;distress&#58; 0<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>none&#44; 4<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>very distressing&#41;&#46; The frequency score &#40;<span class="elsevierStyleItalic">f</span>&#41; is multiplied by the distress score &#40;<span class="elsevierStyleItalic">d</span>&#41; to create a composite score &#40;&#8220;<span class="elsevierStyleItalic">f</span>&#215;<span class="elsevierStyleItalic">d</span>&#44;&#8221; range 0&#8211;16&#41; for each item&#46; These composite item scores are summed to create an overall MMD-HP score &#40;range 0&#8211;432&#41;&#44; with higher scores indicating higher levels of MD&#46; Additionally&#44; two open boxes were created for respondents to add other situations that cause MD in their particular practice in order to gain further data on root causes&#46; Write-in items are not included in the composite score&#46; In the original study&#44; the MMD-HP had an excellent reliability&#44; with Cronbach&#39;s <span class="elsevierStyleItalic">&#945;</span> ranging from 0&#46;90 to 0&#46;93&#44; depending on professional group&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">To the best of our knowledge&#44; no prior instruments to measure MD has been validated in Spanish&#46; Therefore&#44; as part of the <span class="elsevierStyleItalic">Desasosiego Moral en la Unidad de Cuidados Intensivos</span> &#40;DEMOUCI&#41; research project&#44; we aim to develop and validate the Spanish version of the MMD-HP &#40;MMD-HP-SPA&#41; &#40;<a class="elsevierStyleCrossRef" href="#sec0030">Appendix B</a>&#41;&#46; Firstly&#44; a structured 10-step cultural adaptation and translation process<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> was carried out as it follows&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8226;</span><p id="par0020" class="elsevierStylePara elsevierViewall">Step 1 involved preparation by the researchers working with the instrument developer&#46; Written permissions to use the MMD-HP was obtained from Prof&#46; Ann B&#46; Hamric&#44; who developed this tool &#40;written permissions received by e-mail in August 2019&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0025" class="elsevierStylePara elsevierViewall">Step 2 was the initial forward translation of the MMD-HP from English to Spanish provided by two bilingual expert researchers who work in ICU&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8226;</span><p id="par0030" class="elsevierStylePara elsevierViewall">Step 3 was ensuring that this translation was appropriate for the Spanish critical care setting&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8226;</span><p id="par0035" class="elsevierStylePara elsevierViewall">Step 4 was back translation from Spanish to English by two professional translators who can understand and speak both languages &#40;English and Spanish&#41;&#44; and who had not seen the original scales&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8226;</span><p id="par0040" class="elsevierStylePara elsevierViewall">Step 5&#44; the authors compared the back translation of the scales with the original scales in order to verify the equivalence in terms of grammar between the two versions&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#8226;</span><p id="par0045" class="elsevierStylePara elsevierViewall">Step 6&#44; harmonization included reaching consensus among the research team&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#8226;</span><p id="par0050" class="elsevierStylePara elsevierViewall">Step 7&#44; the scales were then pilot tested on two physicians and three nurses to resolve ambiguous expressions that could lead to item misunderstanding&#46; A supporting text was included in order to collect any doubts that could be raised with any question regarding comprehension and writing&#44; and to prove the overall assessment of the questionnaire by the HCPs&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#8226;</span><p id="par0055" class="elsevierStylePara elsevierViewall">Step 8 was to analyze the results of the pilot test and to complete the translation by the research team&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">&#8226;</span><p id="par0060" class="elsevierStylePara elsevierViewall">Step 9 was to edit the questionnaires&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">&#8226;</span><p id="par0065" class="elsevierStylePara elsevierViewall">Step 10 is the final report of the research team&#46;</p></li></ul></p><p id="par0070" class="elsevierStylePara elsevierViewall">Afterwards&#44; we conducted a cross-sectional study across Spanish ICUs&#46; The study population included intensivists and critical care nurses directly involved in critically ill patient care&#46; The questionnaire was electronically distributed via <span class="elsevierStyleItalic">Sociedad Espa&#241;ola de Medicina Intensiva&#44; Cr&#237;tica y Unidades Coronarias</span> &#40;SEMICYUC&#41;&#44; <span class="elsevierStyleItalic">Sociedad Galega de Medicina Intensiva y Unidades Coronarias</span> &#40;SOGAMIUC&#41;&#44; <span class="elsevierStyleItalic">Sociedad Espa&#241;ola de Enfermer&#237;a Intensiva y Unidades Coronarias</span> &#40;SEEIUC&#41;&#44; and <span class="elsevierStyleItalic">Sociedad Espa&#241;ola de Cuidados Intensivos Pedi&#225;tricos</span> &#40;SECIP&#41; mailing lists&#46; A total of 1065 HCPs&#44; 608 critical care nurses and 457 intensivists&#44; completed the questionnaire between October and December 2019&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Cronbach&#39;s <span class="elsevierStyleItalic">&#945;</span> computations suggested good reliability of the MMD-HP-SPA for the overall sample &#40;Cronbach&#39;s <span class="elsevierStyleItalic">&#945;</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;97&#41; and for each provider group&#59; nurse Cronbach&#39;s <span class="elsevierStyleItalic">&#945;</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;97 and physician Cronbach&#39;s <span class="elsevierStyleItalic">&#945;</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;94&#46; Item-to-item correlations and changes in alpha calculations if particular items were deleted were evaluated and no problematic items were identified&#46; In addition&#44; ordinal alpha calculation also showed good reliability of the MMD-HP-SPA for the overall sample &#40;ordinal alpha<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;98&#41; and for each provider group&#59; nurse ordinal alpha<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;98 and physician ordinal alpha<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;98&#46; To evaluate construct validity&#44; we tested four hypotheses&#46; Each hypothesis is supported by previous studies&#46; First&#44; we hypothesized that physicians would have lower levels of MD than nurses&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5&#44;7&#44;9</span></a> Second&#44; we hypothesized that healthcare professionals who were considering leaving their position due to MD would have higher MMD-HP-SPA scores than those not considering leaving&#46; Third&#44; based on previous studies&#44;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> we hypothesized that higher MMD-HP scores would be associated with poorer provider perceptions of their Unit&#39;s ethical climate&#46; Finally&#44; we hypothesized that the MMD-HP-SPA would have a three-level structure &#40;patient&#44; team&#44; and system&#41;&#44; reflective of the levels of MD identified from MD consultation&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> The MMD-HP-SPA proved to be a valid instrument to measure MD as three of the four validity hypotheses were supported&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">In conclusion&#44; the MMD-HP-SPA is a valid and reliable instrument that will assist in the assessment of specific MD root causes&#46; We hope it can be of help for future studies in ICUs located both in Spain and Latin-American countries in order to target interventions for particular units&#44; teams&#44; and professionals&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Ethics approval and consent to participate</span><p id="par0085" class="elsevierStylePara elsevierViewall">The local Research Ethics Committee approved the study &#40;ref&#46; CAEIG 2019&#47;471&#41;&#46; Participation was on a voluntary anonymous basis and informed consent was assumed by return of completed survey&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Authors&#8217; contributions</span><p id="par0090" class="elsevierStylePara elsevierViewall">ERR and MCI wrote and prepared the manuscript&#46; AEG and ABH performed statistical analysis&#46; MSRC and ARN supervised and approved the final version of the manuscript&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Funding</span><p id="par0095" class="elsevierStylePara elsevierViewall">This research did not receive any specific grant from funding agencies in the public&#44; commercial&#44; or not-for-profit sectors&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conflict of interest</span><p id="par0100" class="elsevierStylePara elsevierViewall">The authors have no conflict of interest to declare regarding this article&#46;</p></span></span>"
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Scientific letter
Validation and psychometric properties of the Spanish version of the Measure of Moral Distress for Health Care Professionals (MMD-HP-SPA)
Validación y propiedades psicométricas de la versión en español de la medida de desasosiego moral para profesionales sanitarios (MMD-HP-SPA)
E. Rodriguez-Ruiza,b,c,
Autor para correspondencia
r.ruizemilio@gmail.com

Corresponding author.
, M. Campelo-Izquierdod, A. Estany-Gestale, A.B. Hortase, M.S. Rodríguez-Calvof, A. Rodríguez-Núñezb,c,g
a Intensive Care Medicine Department, University Clinic Hospital of Santiago de Compostela (CHUS), Galician Public Health System (SERGAS), Santiago de Compostela, Spain
b Life Support and Medical Simulation Research Group, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
c CLINURSID Research Group, University of Santiago de Compostela, Santiago de Compostela, Spain
d Division of Nursing, Intensive Care Medicine Department, University Clinic Hospital of Santiago de Compostela (CHUS), Galician Public Health System (SERGAS), Santiago de Compostela, Spain
e Epidemiology and Clinical Research Unit, Health Research Institute of Santiago (IDIS), Santiago de Compostela, Spain
f Institute of Forensic Sciences, University of Santiago de Compostela, Spain
g Paediatric Intensive Care Unit, Department of Pediatrics, University Clinic Hospital of Santiago de Compostela (CHUS), Galician Public Health System (SERGAS), Santiago de Compostela, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Moral distress &#40;MD&#41; is the psychological consequence that occurs when healthcare professionals &#40;HCPs&#41; cannot carry on what they believe is the ethically correct action&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> This serious problem threats the integrity not only of HCPs but of healthcare organizations as well&#46; MD has been associated with risk of burnout&#44; employee attrition&#44; propensity to leave a position and decreased quality of care&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2&#8211;6</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In order to precise and study MD&#44; valid and reliable tools to measure its impact are needed&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> In this sense Epstein et al&#46;&#44; in 2019&#44; developed and validated the most recent instrument to explore MD&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> The Measure of Moral Distress for Healthcare Professionals &#40;MMD-HP&#41; is a 27-item scale that captures the five key components of MD directly and indirectly&#58; complicity in wrongdoing&#44; lack of voice&#44; wrongdoing associated with professional &#40;not personal&#41; values&#44; repeated experiences&#44; and three levels of etiologies &#40;patient&#44; unit&#44; system&#41;&#46; This tool is a self-administered questionnaire&#44; the participants rate each item on a Likert scale for how often it occurs in their practice &#40;frequency&#58; 0<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>never&#44; 4<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>very frequently&#41; and for how distressing it is when it occurs &#40;distress&#58; 0<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>none&#44; 4<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>very distressing&#41;&#46; The frequency score &#40;<span class="elsevierStyleItalic">f</span>&#41; is multiplied by the distress score &#40;<span class="elsevierStyleItalic">d</span>&#41; to create a composite score &#40;&#8220;<span class="elsevierStyleItalic">f</span>&#215;<span class="elsevierStyleItalic">d</span>&#44;&#8221; range 0&#8211;16&#41; for each item&#46; These composite item scores are summed to create an overall MMD-HP score &#40;range 0&#8211;432&#41;&#44; with higher scores indicating higher levels of MD&#46; Additionally&#44; two open boxes were created for respondents to add other situations that cause MD in their particular practice in order to gain further data on root causes&#46; Write-in items are not included in the composite score&#46; In the original study&#44; the MMD-HP had an excellent reliability&#44; with Cronbach&#39;s <span class="elsevierStyleItalic">&#945;</span> ranging from 0&#46;90 to 0&#46;93&#44; depending on professional group&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">To the best of our knowledge&#44; no prior instruments to measure MD has been validated in Spanish&#46; Therefore&#44; as part of the <span class="elsevierStyleItalic">Desasosiego Moral en la Unidad de Cuidados Intensivos</span> &#40;DEMOUCI&#41; research project&#44; we aim to develop and validate the Spanish version of the MMD-HP &#40;MMD-HP-SPA&#41; &#40;<a class="elsevierStyleCrossRef" href="#sec0030">Appendix B</a>&#41;&#46; Firstly&#44; a structured 10-step cultural adaptation and translation process<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> was carried out as it follows&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8226;</span><p id="par0020" class="elsevierStylePara elsevierViewall">Step 1 involved preparation by the researchers working with the instrument developer&#46; Written permissions to use the MMD-HP was obtained from Prof&#46; Ann B&#46; Hamric&#44; who developed this tool &#40;written permissions received by e-mail in August 2019&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0025" class="elsevierStylePara elsevierViewall">Step 2 was the initial forward translation of the MMD-HP from English to Spanish provided by two bilingual expert researchers who work in ICU&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8226;</span><p id="par0030" class="elsevierStylePara elsevierViewall">Step 3 was ensuring that this translation was appropriate for the Spanish critical care setting&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8226;</span><p id="par0035" class="elsevierStylePara elsevierViewall">Step 4 was back translation from Spanish to English by two professional translators who can understand and speak both languages &#40;English and Spanish&#41;&#44; and who had not seen the original scales&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8226;</span><p id="par0040" class="elsevierStylePara elsevierViewall">Step 5&#44; the authors compared the back translation of the scales with the original scales in order to verify the equivalence in terms of grammar between the two versions&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#8226;</span><p id="par0045" class="elsevierStylePara elsevierViewall">Step 6&#44; harmonization included reaching consensus among the research team&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#8226;</span><p id="par0050" class="elsevierStylePara elsevierViewall">Step 7&#44; the scales were then pilot tested on two physicians and three nurses to resolve ambiguous expressions that could lead to item misunderstanding&#46; A supporting text was included in order to collect any doubts that could be raised with any question regarding comprehension and writing&#44; and to prove the overall assessment of the questionnaire by the HCPs&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#8226;</span><p id="par0055" class="elsevierStylePara elsevierViewall">Step 8 was to analyze the results of the pilot test and to complete the translation by the research team&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">&#8226;</span><p id="par0060" class="elsevierStylePara elsevierViewall">Step 9 was to edit the questionnaires&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">&#8226;</span><p id="par0065" class="elsevierStylePara elsevierViewall">Step 10 is the final report of the research team&#46;</p></li></ul></p><p id="par0070" class="elsevierStylePara elsevierViewall">Afterwards&#44; we conducted a cross-sectional study across Spanish ICUs&#46; The study population included intensivists and critical care nurses directly involved in critically ill patient care&#46; The questionnaire was electronically distributed via <span class="elsevierStyleItalic">Sociedad Espa&#241;ola de Medicina Intensiva&#44; Cr&#237;tica y Unidades Coronarias</span> &#40;SEMICYUC&#41;&#44; <span class="elsevierStyleItalic">Sociedad Galega de Medicina Intensiva y Unidades Coronarias</span> &#40;SOGAMIUC&#41;&#44; <span class="elsevierStyleItalic">Sociedad Espa&#241;ola de Enfermer&#237;a Intensiva y Unidades Coronarias</span> &#40;SEEIUC&#41;&#44; and <span class="elsevierStyleItalic">Sociedad Espa&#241;ola de Cuidados Intensivos Pedi&#225;tricos</span> &#40;SECIP&#41; mailing lists&#46; A total of 1065 HCPs&#44; 608 critical care nurses and 457 intensivists&#44; completed the questionnaire between October and December 2019&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Cronbach&#39;s <span class="elsevierStyleItalic">&#945;</span> computations suggested good reliability of the MMD-HP-SPA for the overall sample &#40;Cronbach&#39;s <span class="elsevierStyleItalic">&#945;</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;97&#41; and for each provider group&#59; nurse Cronbach&#39;s <span class="elsevierStyleItalic">&#945;</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;97 and physician Cronbach&#39;s <span class="elsevierStyleItalic">&#945;</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;94&#46; Item-to-item correlations and changes in alpha calculations if particular items were deleted were evaluated and no problematic items were identified&#46; In addition&#44; ordinal alpha calculation also showed good reliability of the MMD-HP-SPA for the overall sample &#40;ordinal alpha<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;98&#41; and for each provider group&#59; nurse ordinal alpha<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;98 and physician ordinal alpha<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;98&#46; To evaluate construct validity&#44; we tested four hypotheses&#46; Each hypothesis is supported by previous studies&#46; First&#44; we hypothesized that physicians would have lower levels of MD than nurses&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5&#44;7&#44;9</span></a> Second&#44; we hypothesized that healthcare professionals who were considering leaving their position due to MD would have higher MMD-HP-SPA scores than those not considering leaving&#46; Third&#44; based on previous studies&#44;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> we hypothesized that higher MMD-HP scores would be associated with poorer provider perceptions of their Unit&#39;s ethical climate&#46; Finally&#44; we hypothesized that the MMD-HP-SPA would have a three-level structure &#40;patient&#44; team&#44; and system&#41;&#44; reflective of the levels of MD identified from MD consultation&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> The MMD-HP-SPA proved to be a valid instrument to measure MD as three of the four validity hypotheses were supported&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">In conclusion&#44; the MMD-HP-SPA is a valid and reliable instrument that will assist in the assessment of specific MD root causes&#46; We hope it can be of help for future studies in ICUs located both in Spain and Latin-American countries in order to target interventions for particular units&#44; teams&#44; and professionals&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Ethics approval and consent to participate</span><p id="par0085" class="elsevierStylePara elsevierViewall">The local Research Ethics Committee approved the study &#40;ref&#46; CAEIG 2019&#47;471&#41;&#46; Participation was on a voluntary anonymous basis and informed consent was assumed by return of completed survey&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Authors&#8217; contributions</span><p id="par0090" class="elsevierStylePara elsevierViewall">ERR and MCI wrote and prepared the manuscript&#46; AEG and ABH performed statistical analysis&#46; MSRC and ARN supervised and approved the final version of the manuscript&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Funding</span><p id="par0095" class="elsevierStylePara elsevierViewall">This research did not receive any specific grant from funding agencies in the public&#44; commercial&#44; or not-for-profit sectors&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conflict of interest</span><p id="par0100" class="elsevierStylePara elsevierViewall">The authors have no conflict of interest to declare regarding this article&#46;</p></span></span>"
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