The Italian Moral Distress Scale-Revised is a valid and reliable instrument to assess moral distress among critical care clinicians and develop tailored interventions addressing its different components. Further research could test the generalizability of its factorial structure in other cultures.

Of 874 eligible clinicians, 635 responded to the survey (75% response rate), and 612 correctly completed the survey. Clinicians were 74% female; 66% nurses and 34% physicians; and 51% had between 6 and 20 years of experience from graduation. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS:Clinicians completed the "Italian Moral Distress Scale-Revised, " the "Connor-Davidson Resilience Scale, " and a sociodemographic questionnaire inquiring about sex, profession, years of experience, and spiritual/religious belief. PICU organizational characteristics were also collected (e.g., number of admissions, mortality rate, nurse-patient ratio, presence of parents in PICU, presence of parents during physical examination). To identify individual predictors of moral distress, we used stepwise linear regression. To determine the impact of organizational factors on moral distress, we used analysis of covariance, controlling for those individual factors that emerged as significant in the regression model. Moral distress was associated with being a nurse (B = -0.094; p < 0.05) and not having spiritual/religious belief (B = 0.130; p < 0.01), but not with resilience. Clinicians working in PICUs with a medium number of admissions per year (between 264 and 468), a lower nurse:patient ratio (1:3), and where parents' presence during physical examination were never allowed experienced higher moral distress even controlling for profession and spiritual/religious belief. CONCLUSIONS:Organizational factors (medium number of admissions, lower nurse:patient ratio, and parental exclusion from physical examination) played a stronger role than individual factors in increasing moral distress. To decrease moral distress, attention should be paid also to organizational aspects.

Introduction: It is important for HIV positive patients to be engaged in their care and be adherent to treatment in order to reduce disease progression and mortality. Studies found that illness representations influence adherence through the mediating role of coping behaviors. However, no study has ever tested if patient engagement to the visits mediate the relationship between illness perceptions and adherence. This study aimed to explore illness representations of HIV positive patients and test the hypothesis that illness representations predict adherence through the mediating role of a component of behavioral engagement.Methods: HIV-positive patients treated with highly active antiretroviral therapy (HAART) for at least one year and presenting to a check-up visit were eligible to participate in the study. Patients completed the Illness Perception Questionnaire-Revised. Behavioral engagement was measured based on the patients’ clinical attendance to the check-up visits; adherence to HAART was measured by viral load. Undetectable viral load or HIV-RNA < 40 copies/ml were considered indexes of virologic success.Results: A total of 161 patients participated in the study. Most of them coherently attributed the experienced symptoms to HIV/HAART; perceived their condition as chronic, stable, coherent, judged the therapy as effective, and attributed their disease to the HIV virus and to their behavior or bad luck. The majority of patients (80.1%) regularly attended check-up visits and 88.5% of them reached virologic success. The mediation model did not show good fit indexes. However, a significant direct effect of two independent variables on virologic success was found. Specifically, the perception that the disease does not have serious consequences on patient’s life and the prevalence of negative emotions toward HIV were associated with virologic success. On the contrary, the patient’s perception that the disease has serious consequences on his/her life and the prevalence of positive emotions were associated with virologic failure. This model showed good fit indexes (CFI = 1; TLI = 1; RMSEA = 0.00; and WRMSR = 0.309).Discussion: Results do not support the mediating role of behavioral engagement in the relationship between illness representations and adherence. As perception of serious consequences coupled with positive emotions are directly associated with virologic failure, clinicians should take them into account to promote treatment adherence.