Assessing ethical competence and ethical climate: development and psychometric testing of the Clinical Ethics Support Measurement Instrument (CES-MI)

Abstract

Abstract Background Clinical ethics support (CES) is increasingly recognised as essential in healthcare, yet its evaluation remains challenging due to the complexity of CES practices and the latent, psychosocial nature of relevant outcomes. The European Moral Case Deliberation Outcomes Instruments (Euro-MCD original and 2.0) represents important steps in operationalising CES outcomes. However, there remains a need for a further theoretically grounded and psychometrically robust instrument. This study aimed to revise the Euro-MCD 2.0 and to develop and psychometrically test a new measurement instrument for CES. Methods A sequential mixed-methods instrument redevelopment and validation design was used, guided by an abductive, theory-driven approach. Content validity processes involved conceptual framing, item revision, item development, and cognitive evaluation. Construct validity processes involved psychometric testing using survey data, incorporating principal component analysis and complementary item-level assessments. Results The revision of Euro-MCD 2.0 resulted in the Clinical Ethics Support Measurement Instrument (CES-MI), assessing ethical competence and ethical climate. Ethical competence comprises holding moral judgement, being responsive, and acting with moral courage (9 items, using a 5-point scale assessing perceived difficulty). Ethical climate comprises permissive dialogue, supportive relationships, and managing ethical concerns together (7 items, using a 4-point scale assessing perceived extent). Measurement properties were generally strong: targeting was appropriate, response categories functioned as intended, and only minor issues, such as limited local dependencies were observed. Reliability indices were high, unidimensionality was supported across the constructs, and no differential item functioning was detected by sex or intervention groups. Conclusions The CES-MI is a coherent, theoretically grounded, and psychometrically robust instrument for measurement, suitable for both clinical practice and research. The strong validity likely reflects the extensive qualitative and psychometric work underpinning the CES-MI, together with a user-friendly response format that supports reflective and authentic self-assessment. Next steps include examining the instrument’s sensitivity to change over time for example by exploring whether open-ended follow-up questions could deepen understanding of concrete changes, as well as, assessing applicability across diverse healthcare settings.