Luppo Kuillman

Re-assessing the validity of the Moral Sensitivity Questionnaire 39 2 Confirmation of the latent MSQ dimensions The Velicer’s Minimum Average Partial (MAP) test yielded three factors to be retained (MAP squared: 0.017) for consecutive analysis (Courtney & Gordon, 2013). This test was followed by EFA, which was also based on a polychoric correlation matrix (Olsson, 1979) using principal axis factoring and oblimin-quartimin-Q rotation (Basto & Pereira, 2012). A three-factor model converged well, detecting 16 items with loadings exceeding 0.40 and having no cross-loadings exceeding 0.20 on any other factors (Costello, 2009). CFA was used to assess the model fit of the three-factor solution retained from the MSQ item pool. At first glance, the model fit parameters for the CFA appeared to indicate an acceptable model fit. Upon closer examination, however, five items (all of which were clustered in one factor) had standardized loadings well below 0.40. These items were therefore eliminated from the model. Finally, a two-factor solution demonstrated a very good model fit, with χ2/df = 1.168 and a significance of p = 0.223, RMSEA = 0.033 (CI 90% lower bound = 0.000 and CI 90% upper bound = 0.069), SRM R = 0.0622, CFI = 0.965, and GFI = 0.951. The lower AIC value (101.218) that was found for the two- factor solution, as compared with the AIC of the initially anticipated three-factor solution model (203.371), provided evidence that eliminating the weak items was necessary in order to establish a good model with two latent constructs. Despite this good model fit, three items in Factor 1 continued to exhibit standardized regression weights less than 0.40: Item 4 (“When I need to make a decision contrary to the will of a patient, I do so according to my opinion about what is good care”), Item 12 (“If I am unacquainted with the case history of a patient, I follow the rules that are available”), and Item 16 (“I think that good care often includes making decisions for the patient”). Additional CFA, in which the three items with factor loadings less than 0.40 were separately excluded from the analysis, indicated deterioration in the model fit parameters. Once all of the items with factor loadings less than 0.40 were excluded from the analysis, the model became unidentifiable. For that reason, these three items were not included in Factor 1. As in the feasibility study, the results of this study indicate that the MSQ item pool represents two dimensions. In light of these findings, we conducted a meticulous recheck of the content of the factors retained from the MSQ items. This led to the conclusion that the findings were congruent with the content of the moral deliberation andpaternalismof thephysician-patient relationshipmodelshypothesizedby Emanuel and Emanuel (Emanuel & Emanuel, 1992) and empirically tested by Falkum and Førde