Introduction
Moral distress is experienced when experts know how to do the right things but cannot act ethically because of factors beyond their control [1]. Three possible reasons for moral distress have been identified: the problematic clinical situation, internal constraints such as feelings of helplessness, and external constraints such as insufficient resources [2]. Moral distress has negative impacts on health care professionals [3] and detrimental effects on the quality of patient care [4]. Moral distress causes frustration, anger, guilt, anxiety, helplessness, and even physical symptoms [5]. The distress is associated with job burnout and increased health care costs [3]. Organizations face new challenges for their continuity and establishment [6]. Work-related stress has negative impacts on organizational performance [7]. The efficiency of any organization is a direct function of the efficiency of its human resources, affected by their physical and mental health [8]. Job burnout is also associated with mental disorders and physical illnesses [9]. Human resources are the fundamental capital and the source of change and innovation in organizations [10]. Despite patient-centered care In the current situation, there are a lack of health professionals and increasing hospital accidents. So, we cannot be indifferent to moral distress [11]. The type and severity of moral distress vary according to position and profession [12]. Rehabilitation is one of the most important pillars related to community health [13]. The field of rehabilitation is full of moral issues, some of which are specific to this field [14]. However, moral distress has recently been considered in occupational therapy [3].
Studies on moral issues in the field of occupational therapy are limited [15]. Evidence suggests that occupational therapists experience moral distress, so researchers need a tool to measure the effectiveness of strategies designed to reduce distress and prevent job burnout [1]. The Moral Distress Scale (MDS) was first developed for the field of nursing [16, 17], and in 2012, the revised scale (MDS-R) was designed for use in various areas and disciplines of health care [11]. However, its scenarios were more appropriate for nurses [1, 2]. Penny et al. modified a version of MDS-R for measuring moral distress in occupational therapists (MDS-R-OT [A]) that was appropriate for occupational therapists (MDS-R-OT [A]) working in the field of the elderly or adults with physical disabilities [1]. In Iran, several qualitative studies have been conducted to explain occupational therapists’ moral issues and distress in the field of mental health [18] in adults and children [19, 20]. The findings of these studies can be used to design tools since no means has been designed to measure moral distress that covers different areas of occupational therapy. This study was conducted to develop a moral distress questionnaire and evaluate its validity among occupational therapists. 
Materials and Methods
This descriptive-analytical study was conducted in Tehran City, Iran, in two steps.
Step 1 consists of determining the items of the moral distress questionnaire in occupational therapists.
Based on Waltz et al.’s tool design, the first step is to provide a conceptual definition of what the tool is intended to measure. Therefore, a clear definition of moral distress was initially introduced. Then, the assessment goals and more specific areas of moral distress are identified [21]. The deductive method was used to produce items. This method is suitable when the structure of conceptual basis and domains have been well defined [22]. Studies on the moral issues of occupational therapists have been reviewed in various databases to obtain conditions that create moral distress in occupational therapy. Then, the questionnaire items were extracted from the study’s codes, sentences, and phrases.
Step 2 consists of performing face and content validities of the designed tool.
Examination of face validity
To evaluate the face validity of the questionnaire, we asked the target group, i.e., occupational therapists, to comment on the importance of the items using the 5-point Likert scale and make suggestions for improving sentence structure, clarity, and editing. The available sampling method and the study population were occupational therapists working in various occupational therapy fields and had at least 1 year of experience in the occupational therapy profession. The exclusion criteria were incomplete completion of questionnaires. Fifty questionnaires were distributed among occupational therapists working in private clinics, hospitals, and other government centers. Finally, 30 complete questionnaires were provided to the researcher. Quantitative face validity was assessed by determining the item impact coefficient. If the impact score of the item is more than 1.5, the item is suitable for further analysis [23].
Content validity review
To perform quality content validity, we invited 7 experts in teaching ethics in occupational therapy and familiar with tool design to review the questionnaire and exchange views to conduct content validity. At this meeting, the participants were first told that this tool was designed to assess the moral distress among occupational therapists working in clinical settings. After carefully studying the tool, they were asked to express their corrective views on grammar, proper use of words, placing items in the right place, and proper scoring. Also, they comment on the four criteria of clarity, simplicity, transparency, and relevance of items to moral distress [22]. Content Validity Ratio (CVR) and Content Validity Index (CVI) were measured to assess the quantitative content validity of the questionnaire. For this purpose, a questionnaire was distributed among 35 occupational therapy professors with doctoral degrees. Finally, 20 completed questionnaires were collected. CVR above 0.42 and CVI above 0.78 was considered acceptable [24, 25].
Results
First, 93 items were extracted deductively and provided to the research team for discussion and editing. According to the research team, changes were made in the spelling of the items; items with the same meaning were merged, and unrelated items were removed. Finally, 50 items were selected. A number of items were related to the therapist himself, for example, the impact of the therapist’s personal issues on the quality of patient care. The rest was related to external factors. Most of the external factors were related to the client, such as the difference between the client’s goals and the treatment goals, the client’s unreasonable expectations from the treatment results, the client’s lack of cooperation in providing treatment, and the client’s caregivers mistreated. Some of the distress was related to the organization, such as the reduction in the quality and quantity of interventions due to work pressure and a large number of clients, limited facilities in the workplace, limited workforce, and early discharge. To perform quality content validity, the opinions and suggestions of experts were collected. According to them, some items were removed due to inconsistency with the definition of moral distress, a number of items were merged, and some items’ editing was changed again. After being reviewed by the research team and applying their proposed revisions, the final questionnaire had 22 items. It was also decided to use a high [4], medium [3], low [2], and not at all [1] ranking scale for scoring items. Thus, a higher score is a sign of more moral distress. Then, this revision was again emailed to experts attending the meeting and approved by them.
During quantitative face validity, the impact of items was obtained between 2.85 and 4.83, and thus none of the items were deleted. At this stage, occupational therapists had suggestions about a number of items and questionnaire. These suggestions were collected and reviewed, and after re-examination by the research team, changes were made to the questionnaire and items. During the quantitative content validity assessment, the CVR and CVI of each questionnaire item were obtained. CVR of at least 0.42 is acceptable based on the Lawshe table for 20 experts, which in the present study was in the acceptable range of 0.5 to 1 with a mean of 0.7. The total content validity of the questionnaire (S-CVI) was calculated to be 0.93. The results of calculating the impact of item and CVR and CVI of each item of the questionnaire are presented in Table 1.


Discussion and Conclusion
This study was conducted to design and evaluate the face and content validities of the moral distress questionnaire in occupational therapists. The study results showed that the moral distress questionnaire in occupational therapists with 22 items has a good CVR (0.93) and CVI (0.5 to 1). 
In the last three decades, there has been a strong interest in studying the field of moral distress in nursing as well as in other fields. Moral distress is also a growing concern in the health profession. The type and severity of moral distress vary depending on the situation and the profession. Thus, moral distress is increasingly being studied worldwide due to cultural differences and various perceptions of professional roles [5, 12]. 
The present study is the only study that has designed and examined the psychometrics of the moral distress questionnaire for occupational therapists in all clinical areas. Another study was conducted in the United States on the elderly and adults with physical disabilities for occupational therapists [1]. It is the only study to develop tools for measuring moral distress in occupational therapy. Therefore, it is in line with the present study. However, there are some differences. First, the study in the United States included only occupational therapists working in the field of the elderly or adults with physical disabilities. In contrast, the present study included occupational therapists working in various fields. Second, the scale of the study (MDS-R-0T [A]) was obtained by changing the version of MDS-R-OHPA. However, the questionnaire items in the present study are the result of the themes obtained from the interviews with occupational therapists working in different areas of occupational therapy. These interviews were conducted in three previous qualitative studies [18, 19, 20]. Comparing the questionnaire items from the present study with the distress issues in other studies, in the current questionnaire, the most distressful matters, including financial issues and repayment pressures, discharge schedule, disagreement in setting goals, patient/family refusal of medical advice, and patient privacy issues [26,  27 ] have been addressed in items 1, 3, 7, 9, 10, 11, 14 and 18.
Also, in another study conducted in Canada using MDS-R-OT [A], the 10 cases of the most distressful issues occupational therapists face in working with the elderly were categorized according to priority [28]. The themes of some of these distressful issues are in line with the themes of items 9, 17-20 of the present questionnaire.
Regarding the problems and limitations of the study, we can point to a lack of motivation or partial response from some occupational therapists, which prolongs the sampling process. Also, in the face validity stage, some occupational therapists were not familiar with the concept of moral distress due to the lack of basic training in the field of ethics in occupational therapy. Despite the brief explanation of moral distress at the beginning of the questionnaire, in some cases, the researcher inevitably has to provide an oral explanation of this concept to the respondent to make it more understandable and familiar.
Because this study was the first step in preparing the tool, it is suggested that in future studies, the construct validity and reliability of the moral distress questionnaire in occupational therapists be examined. Also, if the psychometric process is completed, it should evaluate the frequency, severity, and type of experience of moral distress in occupational therapists according to gender, work history, the field of work, and work environment.
Conclusion
The study results showed that the 22-item moral distress questionnaire in occupational therapists has an appropriate face and content validity. This study was the first step in preparing this tool. By completing the psychometric process and checking the validity of the structure and the reliability of the questionnaire, it will be possible to use it to measure moral distress in occupational therapists. Therefore, it is suggested that the validity of the structure and its reliability be investigated in future research. The strength of the present study is the specificity of the questionnaire in the field of occupational therapy and attention to moral distress in all areas of clinical work in this field.

Ethical Considerations
Compliance with ethical guidelines
The Ethics Committee of Shahid Beheshti University of Medical Sciences approved the present study with the ethical ID IR.SBMU.REC.1398.105. The principle of scientific honesty and recording the participants’ answers were considered. The utmost fidelity and honesty were done while collecting data and reviewing available references.

Funding
The paper was extracted from the MSc. thesis of Masoumeh Khaleghi, Department of Occupational Therapy, School of Rehabilitation, Shahid Beheshti University of Medical Sciences.

Authors' contributions
Conceptualization and Supervision: Minoo Kalantari; Methodology: Minoo Kalantari, Mehdi Rezaee; Data collection: Masoumeh Khalegh; Data analysis: Alireza Akbarzadeh Bagheban; Writing – original draft, and Writing – review & editing: All authors.

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
We would like to thank all professors and colleagues who helped us in this research and the Faculty of Rehabilitation Sciences of Shahid Beheshti University of Medical Sciences.


 
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