Measuring Health Care Interprofessionals' Moral Resilience: Validation of the Rushton Moral Resilience Scale

Abstract

Background:

Health care interprofessionals face competing obligations to their patients, employers, and themselves. When ethical conflicts ensue and competing obligations cannot be resolved, health care interprofessionals have reported experiencing symptoms of burnout, moral distress, and other types of moral suffering. Recently, moral resilience or “the capacity of an individual to sustain or restore their integrity in response to moral adversity,” has been proposed as a resource to address moral suffering while contributing to well-being.

Objectives:

Develop and validate an instrument to measure moral resilience.

Design:

Phase one: item development and expert review. Phase two: focus groups with health care interprofessionals to refine items. Phase three: psychometric testing.

Setting/Subjects:

Seven hundred twenty-three health care interprofessionals participated; inclusion criteria included being a chaplain, nurse, physician, or social worker, and having practiced at least 1 year. Participants were recruited from seven academic and community hospitals in the Eastern United States.

Results:

One hundred items were created for expert review. Following focus groups to refine items, 35 items remained for psychometric testing. Eighteen items were removed following item analysis. Exploratory factor analysis (EFA) of the remaining items suggested a four-factor solution, titled Responses to Moral Adversity, Personal Integrity, Moral Efficacy, and Relational Integrity, respectively. Overall reliability was α = 0.84. The Rushton Moral Resilience Scale (RMRS) demonstrated convergent validity with the Connor Davidson Resilience Scale-10 and criterion validity with the Maslach Burnout Inventory–Human Services Survey.

Conclusion:

The RMRS demonstrated acceptable validity and reliability. Examining the factor structure of moral resilience contributes to burgeoning moral resilience science and enables future research. Moral Resilience offers a promising pathway to support interprofessionals' integrity even when faced with ethical challenges.

Introduction and Background

It is inevitable that health care interprofessionals will face ethical challenges as they conduct their work.¹ As health care technology advances, increasing diversity ensures a plurality of values and new challenges surface, disagreement about the “right thing to do” is inevitable.² Daily, clinicians must balance competing obligations and commitments to patients, families, health care institutions, and themselves. These factors have only intensified in the recent COVID-19 pandemic, revealing the need to equip health care interprofessionals to face these challenges in a way that preserves their integrity and well-being.

When values clash and there is no consensus on the appropriate action to take, or competing obligations cannot be reconciled, health care interprofessionals may feel as though their integrity is threatened in response to various types of moral adversity.^3–5 Moral adversity “occurs when internal or external circumstances or actions produce morally objectionable, troublesome, or unfortunate results that can imperil integrity and well-being—individually or collectively.”⁶ Moral adversity may lead to various forms of moral suffering, including moral distress and injury, moral residue, and contribute to burnout.^7,8 Moral distress is the most commonly studied form of moral suffering among health care interprofessionals; it is prevalent particularly among those who work in critical settings and with patients at the end of life, such as neonatal/pediatrics, oncology, and the emergency department.^9,10 Palliative care professionals are also more likely to experience moral distress because of factors such as proximity to suffering, and responsibility to facilitate end-of-life decisions¹¹

Burnout is another concern in the health care workforce.^12–17 It is estimated that 35%–45% of nurses^18,19 and 40%–45% of physicians²⁰ experience burnout, which is a concerning statistic, but this statistic also leads to the conclusion that the majority of sampled nurses and physicians do not experience burnout. A better understanding of the constructs that lead a health care professional to develop protective behaviors and positive coping mechanisms may be instrumental in helping health care interprofessionals to meet ethical challenges with less personal and professional damage.

Recently, the concept of moral resilience has emerged as a potential pathway to health care interprofessional well-being. Moral resilience, “the capacity of an individual to sustain or restore their integrity in response to moral adversity,” has the potential to guide health care interprofessionals who seek to maintain integrity in the face of everyday ethical challenges.⁶

Very little empirical research focused on moral resilience has been conducted. A concept analysis of moral resilience found the known antecedents of moral resilience include ethics education; creating meaning in life; understanding a diversity of human values; moral adversity; and reducing ethical complexity.²¹ The same concept analysis also revealed the following attributes of moral resilience: enables a person to navigate morally complex situations; reduces moral distress; and supports a person to have integrity by being true to one's values and convictions.²¹ Sala Defilippis et al. conceptualized moral resilience as a moral virtue, with the associated vices of faintheartedness and rigidity.²² Furthermore, Holtz et al.²³ published six domains of moral resilience derived from qualitative analysis of interprofessionals' definitions of moral resilience (Table 1).

Table 1.

Descriptions of Previously Identified Domains of Moral Resilience

Domains of moral resilience	Description
Personal integrity	• Moral wholeness • A “state of balance, harmony, and solidarity” • Staying true to one's values in the midst of adversity
Relational integrity	• Distinguishing one's own values, views, and interests from others • Reflects the interplay between upholding one's personal values and professional commitments to prioritize the interests of those being served • Maintaining one's own beliefs while remaining open and flexible to the beliefs and values of others
Buoyancy	• Ability to withstand threats to one's integrity • Gaining new perspectives while facing ethical challenges • Being courageous while facing ethical challenges
Self-regulation	• Noticing one's own mental, emotional, and somatic state • Observing what is happening without being overwhelmed or distracted • Shifting from upset and anxiety to balance and insight
Self-stewardship	• Acknowledging one's needs and limitations • Giving sufficient attention to one's own well-being • Serving others while keeping others' needs in proportion
Moral efficacy	• Confidence in one's capacity to respond to ethical challenges effectively • Communicating what one believes is the right thing to do even in the face of resistance • Navigating moral conflict in a way that reflects one's values

One of the primary hindrances to furthering the study of moral resilience is the lack of a valid and reliable instrument to measure moral resilience. Such an instrument would allow researchers to describe moral resilience among health care interprofessionals, and test interventions designed to effect moral resilience.²¹

Therefore, the purpose of this study was to develop and validate a measure of moral resilience among a sample of health care interprofessionals, including chaplains, nurses, physicians, and social workers.

Materials and Methods

This study was carried out in three phases: (1) item development, (2) item refinement, and (3) psychometric testing.

Phase one: Item development

Literature review²¹ informed the overall conceptualization of moral resilience. A previously published work established six constructs of moral resilience (Table 1),²³ and these constructs formed the basis for items included in the Rushton Moral Resilience Scale (RMRS). Items were created a priori, and related scales were hand-searched to ensure established themes related to resilience were represented.

To establish content validity, six experts in resilience and ethics (three philosophers, two physicians, and one nurse) reviewed the items and provided written feedback related to (1) the relevance of each item to the concept of moral resilience, (2) the wording of the items, and (3) concepts related to moral resilience that were not captured in the items of the RMRS (see Fig. 1 for recruitment diagram).

FIG. 1.

Participant flow diagram.

Phase two: Item refinement

To further refine items and strengthen content validity, practicing health care interprofessionals participated in focus groups. Study procedures were approved by the Johns Hopkins University Institutional Review Board. Participants were recruited by invitation of the study team and word-of-mouth, with the goal of including at least two of each: chaplains, nurses, physicians, and social workers. Focus groups were recorded and transcribed verbatim by a Health Insurance Portability and Accountability Act (HIPAA) compliant transcription company.

Focus group participants completed both the RMRS and demographic information, and then were invited by the interviewers (K.E.H. and C.H.R.) to comment on each question. The interviewers used cognitive interviewing techniques^24,25 to help participants elucidate thought processes. Participants also identified which items they thought were the most and least clear in representing the constructs and meaning of moral resilience.

The authors read the interview transcripts and compared texts across groups to discern common themes. Items were refined and/or removed iteratively until the RMRS was finalized for psychometric testing.

Phase three: Psychometric testing

Recruitment

Practicing chaplains, nurses (registered nurses and advanced practice nurses), physicians, and social workers were recruited via email from five hospitals: Johns Hopkins All Children's Hospital (St. Petersburg, FL), Allegheny Medical Center (Pittsburgh, PA), Ann Arundel Medical Center (Annapolis, MD), Inova Health System (Falls Church, VA), and Reading Hospital–Tower Health (West Reading, PA). Allegheny Medical Center, Ann Arundel Medical Center, and Reading Hospital participated via the Johns Hopkins Clinical Research Network. Survey participation was voluntary and anonymous, but participants did have the option to enter a drawing for one of five $100 gift cards. Each study site sent the recruitment email three times. The target sample size was 340 participants (10 per RMRS item), and at least two participants from each profession.

Study measures

Participants completed the RMRS, Connor Davidson Resilience Scale-10 (CD RISC-10), Maslach Burnout Inventory–Human Services Survey (MBI–HSS), and a demographic form created by the authors.

Rushton Moral Resilience Scale

The RMRS had 34 items scored on a 4-point Likert scale (1 Disagree, 2 Somewhat Disagree, 3, Somewhat Agree, or 4 Agree). Higher scores indicate higher moral resilience. A priori the items were designed to represent the six domains of moral resilience.^21,23 See Supplementary Appendix A1 for a list of RMRS items.

Connor Davidson Resilience Scale-10

The CD RISC-10 is a 10-item version of the CD RISC, which measures general resilience²⁶; items are scored on a 5-point Likert scale (0 Not true at all, 1 Rarely true, 2 Sometimes true, 3 Often true, or 4 True nearly all the time).

Maslach Burnout Inventory–Human Services Survey

The MBI–HSS is a widely used burnout scale adapted specifically for human service professionals. The MBI–HSS comprises three subscales: Emotional Exhaustion, Depersonalization, and Personal Accomplishment.²⁷ Responses were given on the following scale: 0 (never); 1 (a few times a year or less); 2 (once a month or less); 3 (a few times a month); 4 (once a week); 5 (a few times a week); and 6 (every day).

Analysis

Descriptive statistics were used to describe the sample. Several item analysis tools were used, including item means, item standard deviations, item-total correlations, and interitem correlations to examine the functioning of individual items. Items that had little variability or low correlations were omitted. Exploratory factor analysis with iterative principle axis factoring was used to examine the factor structure. Factors with an Eigenvalue >1 were considered for retention, and the item loading threshold was set at 0.4. Correlations between the subscales of moral resilience, resilience, and burnout were examined. Finally, one-way analysis of variances (ANOVAs) with Bonferroni follow-up tests was used to examine differences between the subscales of moral resilience by profession and practice setting.

Results

Phase one: Item development

Each of the six recruited experts agreed to provide item feedback. The authors created 100 items for review. Following expert review, 7 items were removed, 93 items were edited for content and clarity, and 2 items were added.

Phase two: Item refinement

Twenty-two health care interprofessionals attended one of seven focus groups between March 13 and April 5, 2018. After the first two focus groups, the study team met to review the transcripts. Twenty-two items were removed from the scale and the remaining 73 items were revised.

After focus group five, 27 items were removed, 2 items were added, and the remaining 48 items were revised. After focus group seven, 17 items were removed and 3 items were added, resulting in 34 items.

Phase three: Psychometric testing

A total of 702 participants were recruited for the validation study between August 30, 2018 and October 31, 2018. Average time to complete all survey measures was 57 minutes. See Table 2 for descriptions of study participants.

Table 2.

Demographic Characteristics

	Mean (SD)
Age	45.6 (12.3)
Years worked in professional role	17.7 (12.2)
	n (%)^a
Race
American Indian/Alaskan Native	3 (0.5)
Asian/Pacific Islander	36 (6)
Black/African American	19 (3)
Caucasian/White	534 (84)
Multiple races	17 (3)
Other	23 (4)
Religious or spiritual preference
Buddhist	5 (1)
Christian	423 (66)
Hindu	7 (1)
Jewish	17 (3)
Muslim	6 (1)
No religious preference/atheist	68 (11)
Spiritual not religious	95 (15)
Other	18 (3)
Professional role
Chaplain	18 (3)
Nurse	485 (75)
Physician	106 (17)
Social worker	30 (4)
Level of education
Associate degree	69 (11)
Bachelor's degree	307 (48)
Master's degree	151 (24)
Doctorate	112 (18)
Primary practice location
Inpatient—acute care	192 (30)
Inpatient—critical care	127 (20)
Outpatient/ambulatory	141 (22)
Emergency department	51 (8)
Operating room	48 (8)
Multiple practice locations	74 (12)
Primary specialty
Administration	23 (4)
Critical care	111 (19)
Emergency medicine	45 (7)
General medicine/pediatrics	88 (14)
OB/GYN	35 (6)
Oncology	48 (8)
Psychiatry	29 (5)
Specialty	74 (12)
Surgery/anesthesia	98 (15)
Other	64 (10)
Primary patient population
Adult patients	361 (57)
Pediatric/adolescent patients	276 (43)
Number of ethical challenges faced at work in the past month
None	95 (16)
1–8	451 (76)
9–16	31 (5)
17+	18 (3)

Declined to answer = 63.

OB/GYN, obstetrics and gynecology; SD, standard deviation.

The variability of each item of the RMRS was analyzed using the mean, standard deviation, frequency distribution, and bivariate correlations among items. At the preliminary subscale level, we also looked at the item total correlation and alpha if item dropped. Items were dropped if they had a standard deviation of <1, no bivariate correlations of 0.3 or greater, an item total correlation ≤0.5, or if dropping the item would notably increase alpha. Based on these criteria, 18 of the original 34 items were retained.

Factor analysis

A common factor analysis using iterative principle axis factoring was used to explore the factor structure of the remaining 18 items. Oblique rotation was used, because subscales were expected to be correlated. The analysis resulted in four factors with Eigenvalue >1, and four factors explaining at least 5% of the variability in the items, supporting a four-factor solution. In the pattern matrix, nearly all items demonstrated simple structure loading at 0.4 or above and at least 0.2 higher on one factor than the other factors. Two items had factor loadings that were below 0.4: (1) “I am reluctant to take an unpopular position,” factor loading = 0.35 and; (2) “I voice my ethical concerns in a way that others take seriously,” factor loading = 0.39. The first item was omitted because of its low factor loading and its redundancy with the other items. The second item was retained because its factor loading was nearly 0.4, and it captured a unique aspect of moral resilience that other items did not. The final factor analysis explained 41.34% of the variability.

Items that had a factor loading of 0.39 or above on one factor were interpreted as part of that factor (Table 3). The five items that loaded on factor 1 were mainly made up of items developed to measure buoyancy and self-regulation. These items had in common a person's reaction to ethical challenges, thus we named this factor Responses to Moral Adversity. The second factor was made up of three items that were intended to measure personal integrity, thus we named it Personal Integrity. The third factor included moral efficacy items, thus we named this factor Moral Efficacy. The fourth factor was made up of items from relational integrity and self-stewardship domains about compromising one's ethical values when facing conflict with others, thus we named this factor Relational Integrity.

Table 3.

Factor Loadings for the Four-Factor Moral Resilience Scale (N = 689; Missing = 13)

	Factor
	Responses to moral adversity	Personal integrity	Moral efficacy	Relational integrity
1. Difficult ethical situations leave me feeling powerless (R)	0.72
2. When a challenging ethical situation can't be resolved, I find myself “going through the motions” in my job (R)	0.63
3. I am overwhelmed by persistent ethical conflicts (R)	0.63
4. After facing a challenging ethical situation, lingering distress weighs me down (R)	0.59
5. When confronted with an ethical challenge, I push myself beyond what is healthy for me (R)	0.54
6. No matter the situation I do what is consistent with my values		0.62
7. In my professional role, my choices and behaviors consistently reflect my values		0.52
8. I find it challenging to implement the decisions of others when it threatens my values (R)		0.41
9. When I am confronted by an ethical challenge, I am able to articulate the ethical conflict			−0.67
10. I am confident in my ability to reason through ethical challenges in my professional role			−0.64
11. I can think clearly when confronting an ethical challenge, even when I feel pressured			−0.45
12. I voice my ethical concerns in a way that others take seriously			−0.39
13. When others criticize my opinions, I compromise my values (R)				−0.83
14. When faced with a difficult ethical challenge, I find myself doing or saying things that I later regret (R)				−0.50
15. I would rather avoid conflict with those who have more authority than I do than act in accordance with my values (R)				−0.45
16. I tend to be distracted by others strong emotions when ethical conflicts occur (R)				−0.43
17. My fear can cause me to act in a way that compromises my values (R)				−0.43

Note: (R) These items were reverse coded. All items were coded so that higher scores indicated higher moral resilience.

Convergent validity

Correlations were assessed between the subscales of the RMRS and other related scales, specifically the CD RISC-10 and MBI–HSS (Table 4). As theorized, the RMRS was positively correlated with the CD RISC-10 and negatively correlated with the MBI–HSS. The majority of the correlations were moderate, but the Personal integrity factor was weakly correlated with the CD RISC-10 and the MBI HSS. Overall, these results demonstrate the convergent validity of the RMRS.

Table 4.

Correlations of the Moral Resilience Scale

	Total moral resilience scale	Responses to moral adversity	Personal integrity	Moral efficacy	Relational integrity
	(N = 699)	(N = 698)	(N = 689)	(N = 699)	(N = 701)
Connor Davidson Resilience Scale (N = 657; α = 0.84)	0.50^**	0.41^**	0.06	0.48^**	0.43^**
Maslach Burnout Inventory
Depersonalization (N = 640; α = 0.92)	−0.38^**	−0.41^**	−0.11^*	−0.23^**	−0.27^**
Emotional Exhaustion (N = 642; α = 0.75)	−0.33^**	−0.42^**	−0.02	−0.20^**	−0.21^**
Personal Accomplishment (N = 643; α = 0.76)	0.45^**	0.38^**	0.14^*	0.40^**	0.35^**

p < 0.01, ^**p < 0.001.

The Connor Davidson Resilience Scale ranged from 0 to 40 where high scores indicate greater resilience. Depersonalization ranged from 0 to 35 where higher scores indicate higher depersonalization. Emotional exhaustion ranged from 0 to 63 where higher scores indicate higher emotional exhaustion. Personal accomplishment ranged from 0 to 56 where higher scores indicate higher emotional exhaustion. Factor 1, personal integrity, moral efficacy, and factor all range from 1 to 4 where higher scores indicate greater moral resilience.

The reliability for the overall RMRS was α = 0.84. The reliability for the four factors are as follows: factor 1 α = 0.78, factor 2 α = 0.50, factor 3 α = 0.69, and factor 4 α = 0.78.

Differences by professional role and primary practice location

One-way ANOVAs with Bonferroni follow-up tests were used to examine differences in each of the moral resilience subscales by professional role and primary practice setting. Differences by professional role were found in Responses to Moral Adversity (F = 5.82, p = 0.001) and Moral Efficacy (F = 5.81, p = 0.001), but not in Personal Integrity or Relational Integrity. Specifically, chaplains scored higher in Responses to Moral Adversity than both nurses and physicians (Table 5). Nurses had lower Moral Efficacy than both chaplains and physicians. Differences by primary practice setting were found only in Personal Integrity (F = 3.14, p = 0.008); outpatient/ambulatory employees rated their personal integrity as higher than employees in inpatient-critical care.

Table 5.

Differences on Moral Resilience Subscales by Professional Role and Setting

	Responses to moral adversity		Personal integrity		Moral efficacy		Relational integrity
	M	SD	M	SD	M	SD	M	SD
Professional role
Chaplain	3.38^a,b	0.49	3.11	0.55	3.65^c	0.34	3.31	0.54
Nurse	2.74^a	0.67	3.10	0.59	3.32^c,d	0.49	3.17	0.61
Physician	2.82^b	0.74	3.21	0.54	3.45^d	0.47	3.16	0.59
Social worker	2.91	0.63	3.03	0.70	3.50	0.40	3.39	0.43
Primary practice location
Emergency department	2.75	0.60	3.06	0.56	3.41	0.51	3.14	0.60
Inpatient—acute care	2.72	0.67	3.13	0.60	3.35	0.50	3.13	0.58
Inpatient—critical care	2.66	0.71	2.95^e	0.63	3.30	0.49	3.22	0.60
Outpatient/ambulatory	2.90	0.60	3.21^e	0.46	3.32	0.40	3.22	0.53
Operating room	2.82	0.70	3.20	0.58	3.40	0.45	3.21	0.60
Multiple practice locations	2.96	0.75	3.19	0.50	3.40	0.48	3.21	0.66

Means with the same superscript letter are statistically different at the p < 0.05 level using one-way analysis of variance with Bonferroni follow-up tests.

Discussion

Main findings

To our knowledge, the RMRS is the first scale developed to measure Moral Resilience among health care interprofessionals. Because the construct of moral resilience has only recently emerged in health care literature, it was necessary to establish construct validity. To this end, we based item development on existing published literature, including a concept analysis of moral resilience²¹ and a content analysis of interprofessionals' definitions of moral resilience.²³ We then sought expert input to ensure the items adequately addressed to known domains of moral resilience. Finally, we recruited end-users into a series of focus groups to test and refine the items.

Once these steps to establish construct validity were complete, 702 health care interprofessionals participated in a larger study designed for psychometric testing. Study measures included demographic information, the RMRS, CD RISC-10, and the MBI–HSS. Factor analysis suggested a solution with 17 items and 4 factors, which explained 41% of the variation. Scale items were developed using the six previously described domains of moral resilience (Personal Integrity, Relational Integrity, Buoyancy, Self-Regulation, Self-Stewardship, and Moral Efficacy), and we therefore theorized that EFA would reveal a six-factor solution. However, when we examined the four factors suggested by EFA, items from all six of the original domains were retained, which satisfied us that construct validity was intact. With further use and testing of the scale, confirmatory factor analysis and other psychometric methods will further strengthen the theoretical factor structure of the RMRS.

The RMRS had an overall reliability of α = 0.84, indicating acceptable reliability. The factors, titled Responses to Moral Adversity (five items, α = 0.78); Personal Integrity (three items, α = 0.50); Moral Efficacy (four items, α = 0.69); and Relational Integrity (five items, α = 0.78), demonstrated acceptable reliability except for Personal Integrity, which had the fewest items. Reliability may be improved by testing additional items in future studies.

As theorized, convergent validity was demonstrated with a moderate positive correlation to general resilience, and criterion validity was demonstrated with a moderate negative correlation to burnout. Taken together, we feel these psychometric tests demonstrate that the RMRS is a valid and reliable measure of moral resilience.

Chaplains scored higher on Responses to Moral Adversity than both nurses and physicians. This result is in line with other reports that chaplains as a group report high resilience,²⁸ and may stem from a greater repertoire of skills to handle moral adversity or from training in the chaplaincy to cultivate inner capacities. Nurses had lower Moral Efficacy than both chaplains and physicians. One possible explanation is that nurses may feel that they have less control over moral decisions as they are often subject to oversight by other members of the care team, and thus have less decisional latitude.²⁹ Outpatient/ambulatory employees rated their personal integrity as higher than employees did in inpatient critical care; it is possible that this finding is due to the lower acuity and higher predictability of the outpatient setting, but further research is warranted. The different patterns of results by subdomain provide further evidence that these subdomains are meaningfully distinct.

Strengths and weaknesses of the study

A multistep process was used to establish validity of the RMRS, demonstrating the rigor of the scale. The contributions of theoretical experts, methodological experts, researchers, and clinicians strengthened the RMRS, from item development to psychometric testing. Furthermore, utilizing the Johns Hopkins Clinical Research Network enabled us to recruit a large sample for psychometric testing.

Although we used a rigorous process to establish scale validity, it is possible that there are constructs related to moral resilience not included in the RMRS. Demographic information for all participants—the demographic form was placed last among the surveys, and not all participants chose to fill out the form. In addition, participants' gender and ethnicity were not assessed, which may limit the generalizability of the results. Finally, the goal of the RMRS is not to “diagnose” moral resilience, or lack thereof, but to provide insights about capacities that can be amplified and strengthened to confront inevitable ethical challenges in health care; individual moral resilience scores should not be used to determine a cutoff for adequate moral resilience.

What this study adds

This study's investigation of the factor structure of moral resilience as a construct contributes to the science of moral resilience in health care interprofessionals. The four identified factors—Responses to Moral Adversity, Personal Integrity, Moral Efficacy, and Relational Integrity—provide guidance for future scientific inquiry. This scale will enable interventional research to aid health care interprofessionals to address ethically challenging situations in their clinical practice. With the new moral challenges of COVID-19,³⁰ research and interventions designed to understand and promote moral resilience may be critical to support health care interprofessionals.

Finally, while this scale focuses on moral resilience at the individual level, it is of the utmost importance that interventions designed to foster individual moral resilience are accompanied by changes at the institutional level. Without institutional change, it will be nearly impossible for individuals to change health care culture from the bottom up.⁶

Conclusion

The RMRS is a valid and reliable measure of moral resilience. Future studies designed to test moral resilience interventions will continue to shape the science of moral resilience.

Authors' Contributions

K.E.H. managed the three phases of the study and drafted the article; G.H. completed all statistical analyses, drafted portions of the article related to statistical analysis, and contributed to the interpretation of analysis; S.S. and H.H. contributed substantively to the design and completion of the study, and reviewed the article; C.H.R. conceptualized the study, cofacilitated focus groups, contributed to data interpretation, guided its completion, and contributed to every portion of the article.

Footnotes

Acknowledgments

Research recruitment partially completed through The Johns Hopkins Clinical Research Network, under the Johns Hopkins Institute for Clinical and Translational Research (ICTR), which is funded, in part, by Grant Number UL1 TR 001079 from the National Center for Advancing Translational Sciences (NCATS) a component of the National Institutes of Health (NIH), and NIH Roadmap for Medical Research.

Disclaimer

The contents are solely the responsibility of the authors and do not necessarily represent the official view of the Johns Hopkins ICTR, JHCRN, NCATS, or NIH.

Funding Information

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The Dorothy Evens Lynn Fund at the Johns Hopkins School of Nursing.

Author Disclosure Statement

No competing financial interests exist.

Supplementary Material

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