Measuring Moral Courage for Interns and Residents

Scale Development and Initial Psychometrics

Published in: Academic Medicine, 2016

Posted on RAND.org on July 21, 2016

by William Martinez, Sigall K. Bell, Jason Michel Etchegaray, Lisa Soleymani Lehmann

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Research Question

  1. Can a survey measure moral courage for physicians in the context of patient care?

Purpose

To develop a practical and psychometrically sound set of survey items that measures moral courage for physicians in the context of patient care.

Method

In 2013, the 731 internal medicine and surgical interns and residents from two northeastern U.S. academic medical centers were invited to anonymously complete a survey about moral courage, empathy, and speaking up about patient safety breaches.

Results

Of the eligible participants, 352 (48%) responded. Principal components analysis of the moral courage items demonstrated a single, meaningful, nine-item factor labeled the Moral Courage Scale for Physicians (MCSP). All item-total score correlations were significant (P < .001) and ranged from 0.57 to 0.76. The Cronbach alpha for the MCSP was 0.90. Consistent with expectations based on theory, MCSP scores were negatively associated with being an intern versus resident (B = -4.17, P < .001), suggesting discriminant validity. MCSP scores were positively associated with respondents' Jefferson Scale of Physician Empathy perspective-taking score (B = 0.53, P < .001), a construct conceptually relevant to moral courage, suggesting convergent validity. Finally, MCSP scores were positively correlated with self-reported speaking up about patient safety breaches (r = 0.19, P = .008), an action that involves moral courage, suggesting concurrent validity.

Conclusions

The authors provided initial evidence for the reliability and validity of a measure of moral courage for physicians. The MCSP may help researchers and educators to tangibly measure physician moral courage as a concept, and track progress on a set of desired behaviors in response to curricular interventions.

Key Findings

  • The Moral Courage Scale for Physicians (MCSP) is a reliable and valid tool that can assess physician moral courage and help researchers and educators identify deficits, track progress in interventions, and better understand physician behavior.
  • Moral courage scores were positively associated with physician empathy and negatively associated with being an intern; they were also correlated with self-reports of speaking up about safety breaches.
  • Religiousness was not associated with moral courage.
  • Women physicians tended to have lower MCSP scores than men, consistent with gender-based differences in empowerment and confidence among physicians in training.

Recommendation

Future research should look at the relationships between MCSP scores and conceptually related measures, such as bravery and burnout, and situation-based measures, such as addressing an incompetent or impaired colleague.

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