Design and psychometric properties of a tool to assess Adherence to the Code of Ethics in Midwifery

Abstract Introduction Ethics is an important aspect of midwifery care. A code of ethics in midwifery can provide a general framework for ethical behavior among midwives and enhance the quality of midwifery services. However, there is no tool to assess adherence to codes of ethics in midwifery. This study aims to design and evaluate the psychometric properties of a tool to measure Adherence to the Code of Ethics in Midwifery (ACEM). Methodology This was a methodologic study based on the steps described by Waltz for tool development. The concept of ethics and the codes of ethics were used to design the preliminary tool. Then qualitative and quantitative face and validity assessments were performed. The construct validity was assessed using Exploratory Factor Analysis (EFA) on 200 samples through a cross-sectional study. The reliability was evaluated by stability and internal consistency assessment using the test re-test method and by intra-cluster correlation coefficient (ICC) calculation. Absolute reliability was also measured by calculating the standard error of measurement (SEm) and minimum detectable change (MDC) indexes. Finally, Confirmatory Factor Analysis (CFA) was implemented by another cross-sectional study on 200 samples using Structural Equation Modelling (SEM) and calculating the fit indexes of the model. Sampling was conducted using a convenience sampling method among midwives working in various departments (public hospitals, private hospitals, health centers, university faculty members, university staff, research centers, headquarters, and private offices) across four regions of Iran: North, South, East, and West. The sampling was carried out electronically via Google Forms, and the questionnaire link was distributed to eligible individuals through the university of medical sciences, the deputy of health and medical services, and medical council of the Islamic republic of Iran. Results The preliminary tool was developed with 92 items. After the face and content validity assessment, the items were reduced to 55. The validity assessment showed S-CVI = 0.94, I-CVR ranges > 0.88, Kappa *>0.6. These values ​​indicate that the tool has appropriate content validity. The EFA resulted in the design of the ACEM with 42 items in 4 factors including; “Professional commitment (17 items)”, “client-centered service (11 items)”, “Professional management (7 items)”, and “Standard services (7 items)”. These four factors explained 65.912% of the variance of ACEM. Intra-class correlation coefficient (ICC) of the entire tool was 0.98 (CI 95%: 0.97–0.99) and Internal consistency with α-Cronbach calculation for the entire questionnaire was 0.98 Considering that it is above 0.8, it is very good reliability. The standard error of measurement) SEM (for the entire instrument is 0.74. This means that an individual’s score on the instrument may vary by ± 0.74 upon repeated testing. The minimum detectable change (MDC (for the entire instrument is 2.05, indicating that a change of at least 2.05 points is needed to be considered a true change beyond measurement error. Since the percentage of minimum detectable changes for each dimension and the entire instrument is less than 30%, this level of sensitivity is acceptable. The findings of the CFA were completely consistent with EFA and Structural Equation Modelling (SEM) showed all fit indexes in the acceptable levels. Conclusion The ACEM-42 is a valid and reliable tool to assess adherence to codes of ethics in midwifery practice. ACEM-42 can show the ethics-related gaps in midwifery services and so it can be used for improving ethics and quality of midwifery services. It could be integrated into routine practice or training programs and used to evaluate midwifery personnel.