Abstract
Background
Patient satisfaction and health status improve with person-centered care. It also reduces hospital stays and medical costs.
Aim
The purpose of this methodological study was to assess the validity and reliability of the “Person-Centered Perioperative Nursing Scale” in Turkey.
Methods
This online study was conducted between March and September 2021, and 185 nurses worked in the operating rooms of fourteen private hospitals, five state hospitals, and one university hospital in Gaziantep, Turkey. Scale validity analysis, language equivalence, content validity, exploratory and confirmatory factor analysis, reliability analysis, internal consistency, item-total correlations, and retest method were used. The STARD checklist organized the study setting.
Results
The scale’s item-total correlation values were 0.519–0.804, and the Cronbach’s alpha coefficient was 0.939. The scale has a five-factor structure, and according to the confirmatory factor analysis, the fit indices were χ2 (Cmin/df) 2.065; CFI 0.957; IFI: 0.958; Excellent agreement with TLI: 0.944; and RMR: 0.051, RMSEA 0.076; and it was found to be in acceptable agreement with NFI 0.921 and AGFI 0.836 ( p = 0.000). The scale’s discriminant validity was AVE: 0.59, CR: 0.88, and there were high congruent validity correlations.
Conclusion
The Person-Centered Preoperative Nursing Scale, which can be used to evaluate the quality of perioperative care, has enough validity and reliability indicators to be considered a measurement tool.
1
Introduction
The use of modern devices in surgery together with the developing technology not only reduces the complications that may occur in the patient after the surgery but also accelerates wound healing . However, perioperative nurses are becoming less involved in providing direct patient care because of improvements in surgical procedures and equipment . Perioperative care has always been challenging, but the modern surgical environment is highly diverse due to the complexity of procedures, the presence of highly variable patient comorbidities, and the high-tech environment in which these procedures are performed . The perioperative staff is made up of individuals who play a crucial role in addressing the clinical needs of patients undergoing surgery. This team possesses specialized clinical skills and knowledge. The hospital staff working in the operating theater includes registered nurses, nurse anesthetists, allied health professionals, and operating room assistants . In Turkey, operating room nurses are responsible for all perioperative care except for the administration of anesthesia and other medications. Anesthesiologists administer anesthesia, and anesthesia technicians assist them during surgery . Nursing education in Turkey is different from the US and European countries. Until 2014, nurses who graduated from high school were working as operating room nurses by obtaining an operating room nursing certificate. With the legal regulation made in 2014, only nurses who graduated from university undergraduate programs were allowed to work in operating rooms. However, high school graduate nurses who started working before 2014 continued to work in operating rooms .
The idea of “person-centered care” in nursing has long been recognized as crucial. According to Nightingale, person-centered care is founded on nursing’s respect of human dignity and individuality and prioritizes individuals above illnesses , . Nurses that practice “person-centered care” may interact with patients, sympathize with them, and include them in their own treatment , . A modern method for delivering individualized treatment is called “person-centered care” . This method supports the patient socially, mentally, and spiritually while also providing active care for the person.
The Perioperative Patient Focused Model (PPFM) for perioperative nursing was put out by Rothrock and Smith . Patient safety, behavioral reaction, physiological response, and the health system are the four components of this approach . The AORN (Association of perioperative Registered Nurses) supported the delivery of person-centered perioperative care that would develop perioperative nursing standards based on PPFM .
2
Background
According to Olsson et al. , person-centered care provides benefits including shorter hospital stays, cutting medical costs, and speeding up patient satisfaction and recovery. Implementing person-centered care can have a number of beneficial effects, including a decrease in surgical site infections and a shorter hospital stay . Studies attempting to bring person-centered care to the clinic have been conducted in several domains including intensive care, oncological care, dementia care, and perioperative care, according to an analysis of the literature .
There is a need for measurement tools with proven validity and reliable instruments to assess person-centred care for the perioperative nursing role. This study was designed to translate the Person-Centred Perioperative Nursing Scale into Turkish and assess its reliability and validity.
Research Questions
- •
Is the Person-Centered Perioperative Nursing Scale a valid measurement tool for Turkish society?
- •
Is the Person-Centered Perioperative Nursing Scale a reliable measurement tool for Turkish society?
3
Methods
This research was conducted in five state hospitals, one university hospital, and fourteen private hospitals in Gaziantep, Turkey. Operating room nurses with at least six months of experience who worked in operating rooms between March and September 2021 and consented to participate in the study provided the data for the study online. The STARD checklist was used to arrange the study.
Participants
The sample size for scale research is recommended to be at least five or perhaps 10 times the number of items , . Therefore, 185 operating room nurses, who are around nine times as many items as the Person-Centered Perioperative Nursing Scale’s 20 total, made up the sample for the research’s validity and reliability study in Turkey.
3.1
Data collection tools
Data for the study were gathered using the person-centered perioperative nursing scale and the nurse identification form.
3.1.1
Nurse identification form
This form asks questions on the nurses’ age, gender, marital status, educational background, place of employment, length of nursing career, and number of years working as operating room nurses.
3.1.2
Person-Centered perioperative nursing scale
Shin and Kang’s Development and Validation of a Person-Centered Perioperative Nursing Scale has a total of 20 items and 5 subscales. The scale is a five-point Likert (never/always) type, with always equaling 5 points and never equaling 1 point to calculate the scale score. The scale includes five subscales, five items for affectionate interaction, six items for respect, and three items for comfort, knowledge sharing, and expertise. In the original scale, Cronbach’s alpha values for these subscales were 0.88, 0.86, 0.78, 0.76, and 0.83, respectively.
3.2
Ethical permissions
The scale’s creators, Soyeung Shin and Jiyeon Kang, were contacted through email, and the appropriate approvals were secured before the scale could be modified. The study was approved by the hospitals where the research would be conducted (E-87,825,162–774.99, E-91,786,782–900–18,462, and 584/2021), as well as clinical research ethics committee of the Gaziantep University (2020/386). The operating room nurses who would participate in the study were informed of its objectives, and their verbal and written consent was secured before they could begin.
3.3
Data analysis
The SPSS 25® package application (IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY: IBM Corp) was used to analyze the data collected for the study. For quantitative variables, mean, median (minimum-maximum), and standard deviation values were employed, while for qualitative variables, number and percentage calculations were used. Reliability assessments were conducted using invariance and internal consistency analysis techniques. The adequacy of the data for factor analysis was assessed using the Kaiser-Meyer-Olkin (KMO) value and Barlett’s test. The scale’s content validity was assessed using the Content Validity Index (CVI), and the validity of the factor structure was assessed using confirmatory factor analysis. Cronbach’s alpha was used to assess homogeneity, item-total score correlation to assess item reliability, and test-retest to assess the scale’s temporal invariance. At a 95% confidence level, p < -0.05 was recognized as the statistical significance threshold.
Language adaptation of the scale
The linguistic adaption of the scale was done using the translation-back translation technique. Three separate experts—a translator and a professor with expertise in surgical nursing—translated it from English into Turkish. An specialist with a solid understanding of English translated the Turkish scale’s final form into English. The translation’s compatibility with the original scale was determined after comparison. As a result, the scale’s linguistic translation into Turkish was made available.
3.4
Expert opinions
Eleven faculty members with expertise in operating room nursing were contacted for the intelligibility of the scale items and the assessment of cultural appropriateness for the scale’s content validity. All statements on the scale were examined and any required modifications were made in accordance with professional judgments. When assessing expert opinion, the Davis method was applied. The scale items were evaluated according to a four-point scale, which was prepared as “not suitable” (1), “needs to be adjusted” (2), “appropriate but needs minor changes” (3), “very appropriate” (4) for each of the items. The “content validity index” for the question was calculated using the Davis approach by dividing the proportion of experts who selected choices (3) and (4) by the total number of experts. The whole of the scale items’ CVI value was found to be.081. According to professional judgments, nothing was added or removed.
Pre-application
Twenty operating room nurses took part in the pre-application to assess the comprehension of the scale’s elements. The nurses who work in operating rooms did not have any unfavorable comments about the scale’s components. The research did not include the data of the operating room nurses who received pre-treatment.
4
Results
4.1
Results on the descriptive characteristics of the participants
In the study, 185 operating room nurses took part. The majority (77.3%) of the operating room nurses who took part in the study were scrub nurses, with 78.9% of them being female and 55.1% holding bachelor’s degrees, 38.4% having 0 to 5 years of professional experience, and 38.9% having more than 11 years of experience ( Table 1 ).
| Number | Percentage | ||
|---|---|---|---|
| Gender | Female | 146 | 78.9 |
| Male | 39 | 21.1 | |
| Marital Status | Married | 113 | 61.1 |
| Single | 72 | 38.9 | |
| Age | Between 18 and 21 years old | 6 | 3.2 |
| Between 22 and 25 years old | 32 | 17.3 | |
| Between 26 and 30 years old | 16 | 8.6 | |
| Between 31 and 35 years old | 67 | 36.2 | |
| 36 years old or older | 64 | 34.6 | |
| Educational Level | Vocational High School of Health | 44 | 23.8 |
| Associate’s degree | 29 | 15.7 | |
| Bachelor’s degree | 102 | 55.1 | |
| Master’s degree | 10 | 5.4 | |
| How many years have you been nursing? | Between 0 and 5 years | 71 | 38.4 |
| Between 6 and 10 years | 35 | 18.9 | |
| Between 11 and 15 years | 38 | 20.5 | |
| Between 16 and 20 years | 3 | 1.6 | |
| 20 years or longer | 38 | 20.5 | |
| How many years have you been working in the operating room? | Less than 1 year | 19 | 10.3 |
| Between 1 and 5 years | 65 | 35.1 | |
| Between 6 and 10 years | 29 | 15.7 | |
| 11 years or longer | 72 | 38.9 | |
| What is your operating room duty? | Chief nurse of the operating room | 16 | 8.6 |
| Scrub nurse | 143 | 77.3 | |
| Circulating nurse | 22 | 11.9 | |
| Circulating and scrub nurse | 4 | 2.2 | |
| Are you satisfied with your duty in the operating room? | Yes | 180 | 97.3 |
| No | 5 | 2.7 | |
| Are you willingly doing operating room nursing? | Yes | 178 | 96.2 |
| No | 7 | 3.7 |
4.2
Results on the validity of the scale
4.2.1
Item analysis
The item-total correlations of the scale are satisfactory ( Table 2 ) since they are more than 0.30 (0.505 and.801).
| Mean of the scale when the item is deleted | Variance of the scale when the item is deleted | Item-total score correlations | Square of the multiple correlations | Internal consistency coefficient when the item is deleted | |
|---|---|---|---|---|---|
| 1. I empathize when the patient expresses emotions. | 79.1322 | 223.607 | .600 | .530 | .950 |
| 2. I actively listen to the patient. | 79.0920 | 219.529 | .744 | .710 | .948 |
| 3. I attempt nonverbal communication with patients who cannot speak. | 79.5115 | 214.679 | .688 | .603 | .949 |
| 4. I try to reduce the anxiety of the patient through words or actions. | 79.1207 | 219.020 | .755 | .639 | .948 |
| 5. I use terms that patients can understand. | 78.8908 | 221.971 | .753 | .700 | .949 |
| 6. I often check the patient’s for needs (e.g., breathing, voiding). | 79.3276 | 212.256 | .801 | .720 | .947 |
| 7. I use honorific words for the patient. | 78.6322 | 225.737 | .695 | .826 | .950 |
| 8. I call the patient by a proper title. | 78.6149 | 224.793 | .713 | .852 | .949 |
| 9. I avoid unnecessary body exposure of the patient. | 78.5575 | 228.422 | .572 | .583 | .951 |
| 10. I respond quickly to the patient’s needs or questions. | 78.9655 | 222.010 | .729 | .653 | .949 |
| 11. I look at the patient’s preoperative history. | 79.5230 | 213.072 | .764 | .717 | .948 |
| 12. I identify the patient’s discomfort from the surgical position and take appropriate action. | 79.0057 | 215.428 | .816 | .741 | .947 |
| 13. I check if the patient is feeling cold and take appropriate action. | 78.9598 | 219.495 | .753 | .666 | .948 |
| 14. If the patient complains of pain, I take appropriate action. | 79.4138 | 210.429 | .730 | .623 | .949 |
| 15. I explain the procedure to the patient before surgery. | 79.4310 | 213.437 | .755 | .730 | .948 |
| 16. I explain the reason for a delay in the operation to the patient. | 79.2701 | 214.776 | .749 | .686 | .948 |
| 17. I provide the patient with an explanation before taking any nursing action. | 79.0287 | 215.878 | .769 | .642 | .948 |
| 18. I regularly attend perioperative nursing training. | 79.6782 | 220.370 | .524 | .770 | .952 |
| 19. I participate in quality improvement activities on perioperative nursing. | 79.7644 | 220.262 | .505 | .757 | .953 |
| 20. I cooperate with other departments to treat patients. | 79.3046 | 219.704 | .598 | .470 | .951 |
4.2.2
Internal consistency
The scale has a 0.939 internal consistency reliability rating (Cronbach’s alpha), which indicated that it’s a very reliable scale. The scale’s subscale of the Compassionate Interaction was calculated as 0.880; the scale’s subscale of the Respect was calculated as 0.910; the scale’s subscale of the Comfort was calculated as 0.910; the scale’s subscale of the Information Sharing was calculated as 0.832; the scale’s subscale of the Expertise was calculated as 0.918. The subscales’ reliabilities likewise fall into the category of being extremely reliable ( Table 3 ).
| n | Min | Max | Mean | SD | Cronbach’s alpha | |
|---|---|---|---|---|---|---|
| Total Scale | 185 | 1.00 | 5.00 | 4.17 | 0.77 | 0.939 |
| Compassionate Interaction | 185 | 1.00 | 5.00 | 4.10 | 0.87 | 0.880 |
| Respect | 185 | 1.00 | 5.00 | 4.70 | 0.70 | 0.910 |
| Comfort | 185 | 1.00 | 5.00 | 4.21 | 0.97 | 0.832 |
| Information Sharing | 185 | 1.00 | 5.00 | 4.08 | 1.01 | 0.861 |
| Expertise | 185 | 1.00 | 5.00 | 3.65 | 1.23 | 0.918 |
The total mean score in our study ranges from a minimum of 1 point to a maximum of 5 points, which is the range from which the total mean score must be calculated. Positive perceptions of person-centered perioperative nursing grow as the scale’s mean score rises. The mean score and scale’s standard deviation in our study were 4.17 and 0.77, respectively. The nurses’ judgments on this matter were found to be more positive, as seen by the mean scores of the “respect” and “comfort” subscales, which were 4.21 and 4.70, respectively. Even while the other subscales’ mean scores (compassionate interaction=4.100.87, information sharing=4.081.01, and Expertise=3.651.23) are close, they fall short of the scale’s mean score.
In terms of compassionate interaction, information sharing, and expertise, it was discovered that the operating room nurses had a poor opinion of person-centered perioperative nursing ( Table 3 ).
4.3
Results on the validity of the scale
Both the KMO and Barlett’s tests were used to evaluate if the sample was big enough for factor analysis. The scale’s KMO value was 0.934 and Barlett’s test value was χ2=2830.484 with a significance level of 0.0001.
The scale’s suitability for Turkish culture was assessed using the AMOS (IBM SPSS Amos for Windows, Version 24.0. Chicago, IL: IBM Software Group) licensed program’s confirmatory factor analysis ( Fig. 1 ). The simulation has been altered. The factors that affected the fit were identified during the application of the adjustments, and a new covariance was constructed for those that had a high degree of covariance among the residual values (e1-e2, e15–17). The research revealed that all of the scale’s items had factor loadings that were more than 0.30 ( Fig. 2 ).
To enhance the model, the scale’s fifth, tenth, eleventh, and twenty-first items were dropped from the confirmatory factor analysis. Removed items were determined as “I use terms that patients can understand.”, “I respond quickly to the patient’s needs or questions.”, “I look at the patient’s preoperative history.”, “I cooperate with other departments to treat patients.”.
All scale items were found to be significant when the t statistics of the scale items were analyzed. No item on the scale had a factor loading below 0.30, and the factor loadings were found to be within acceptable bounds when the factor loads of the scale were reviewed ( Table 4 ).
| Items | Factor Loads | Standard Deviation | t Values | p Values | |
|---|---|---|---|---|---|
| Standardized | Modified | ||||
| I1 | 0.627 | 1000 | *** | ||
| I2 | 0.800 | 1283 | 0.117 | 10.930 | *** |
| I3 | 0.760 | 1595 | 0.186 | 8567 | *** |
| I4 | 0.801 | 1297 | 0.146 | 8904 | *** |
| I6 | 0.830 | 1649 | 0.181 | 9131 | *** |
| I7 | 0.915 | 1000 | *** | ||
| I8 | 0.969 | 1094 | 0.049 | 22.462 | *** |
| I9 | 0.763 | 0,865 | 0.063 | 13.789 | *** |
| I12 | 0.861 | 1000 | *** | ||
| I13 | 0.802 | 0.847 | 0.063 | 13.395 | *** |
| I14 | 0.761 | 1165 | 0.094 | 12.331 | *** |
| I15 | 0.879 | 1000 | *** | ||
| I16 | 0.822 | 0.905 | 0.068 | 13.353 | *** |
| I17 | 0.842 | 0.875 | 0.073 | 12.021 | *** |
| I18 | 0.929 | 1000 | *** | ||
| I19 | 0.914 | 1022 | 0.087 | 11.738 | *** |
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