Translation, Cross-Cultural Adaptation, and Psychometric Testing of

YJPDN-01824; No of Pages 9 Journal of Pediatric Nursing xxx (2018) xxx–xxx

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Journal of Pediatric Nursing

Translation, Cross-Cultural Adaptation, and Psychometric Testing of Perception of Family-Centered Care Measurement Questionnaires in the Hospitalized Children in Iran Parvaneh Vasli ⁎ School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran

a r t i c l e

i n f o

Article history: Received 25 March 2018 Revised 3 August 2018 Accepted 3 August 2018 Available online xxxx

a b s t r a c t Purpose: This study aimed to offer a translation, cross-cultural adaptation, and psychometric testing of the Perception of Family-Centered Care-Staff (PFCC-S) and Perception of Family-Centered Care-Parents (PFCC-P) questionnaires for use in pediatric nursing in Iran. Design and Methods: The study was comprised of six steps. The first five steps included the preparation, forward translation, reconciliation, back translation, and back translation review of the translated questionnaires. In the sixth step, the content validity ratio, content validity index, confirmatory factor analysis, and reliability were estimated. Through the convenience sampling method, 456 nurses and mothers were included in the study for confirmatory factor analysis, while 40 nurses and mothers were selected to evaluate the reliability of the two questionnaires. Results: Harmonized versions of the Persian PFCC-S and PFCC-P questionnaires were developed (steps 1–5). The content validity ratio of all items of the questionnaires was N0.62. The content validity index for the PFCC-S and PFCC-P questionnaires was 0.81 and 0.83, respectively. One item was added to each questionnaire, which contained 21 items. The confirmatory factor analysis verified the three subscales of respect, collaboration, and support in the two questionnaires. The intraclass correlation and Cronbach's alpha coefficients for the PFCC-S questionnaire were 0.89 and 0.87, respectively, and 0.79 and 0.81, respectively, for the PFCC-P questionnaire. Conclusions: This study developed questionnaires that were compatible with the Iranian culture to measure the perception of family-centered care. Practice Implications: Nurses can use these questionnaires to measure and compare the perceptions of familycentered care by staff and parents. © 2018 Elsevier Inc. All rights reserved.

Introduction The provision of high quality care is a challenge for health care providers (Allen, Hutchinson, Brown, & Livingston, 2014). The Institute of Medicine identified the six indicators of high quality health care as safety, efficiency, equity, effectiveness, timeliness, and patient/familycenteredness (Allen et al., 2014; Gallo, Hill, Hoagwood, & Olin, 2016). Accordingly, family-centered care (FCC) has been acknowledged as the gold standard in the delivery of pediatric health care (Himuro, Miyagishima, Kozuka, Tsutsumi, & Mori, 2015; Smyth et al., 2017; Wang, Feng, Wang, & Chen, 2016). FCC dates back to the mid-nineteenth century and has become the central principle in child health care (Foster & Whitehead, 2017; Shields, 2010). FCC means providing care in partnership with the family ⁎ School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Vali Asr Street, Niayesh Cross Road, Tehran, Iran. E-mail address: [email protected].

and children (Al-Motlaq & Shields, 2017). In other words, FCC is a philosophy and a method for taking care of children and their families in health services in which the designed plan focuses on the entire family rather than just the child (Al-Motlaq & Shields, 2017; Smyth et al., 2017). The Institute for Patient- and Family-Centered Care (IPFCC) (2018) defines FCC as an approach in the planning, provision, and evaluation of health care that is based on a mutually beneficial partnership among health care providers, patients, and families. FCC may be associated with positive health care experiences, increased parental knowledge of health-promoting behaviors for children, a reduction in unmet health care needs, a reduced need for acute care, an increase in preventive care, decreased medical hospitalization costs, enhanced efficiency, a timely discharge, and an increase in the satisfaction of parents and health professionals (Alabdulaziz, Moss, & Copnell, 2017; Lindly et al., 2017; Wang et al., 2016). While literature demonstrates the benefits of FCC to care for children and their families in healthcare services, recent evidence suggests that understanding and implementing FCC remains challenging

https://doi.org/10.1016/j.pedn.2018.08.004 0882-5963/© 2018 Elsevier Inc. All rights reserved.

Please cite this article as: Vasli, P., Translation, Cross-Cultural Adaptation, and Psychometric Testing of Perception of Family-Centered Care Measurement Questionnaires ..., Journal of Pediatric Nursing (2018), https://doi.org/10.1016/j.pedn.2018.08.004

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P. Vasli / Journal of Pediatric Nursing xxx (2018) xxx–xxx

(Alabdulaziz et al., 2017; Al-Motlaq & Shields, 2017; Curley, Hunsberger, & Harris, 2013; Smith, Swallow, & Coyne, 2015; Smyth et al., 2017). Studies that have assessed nurses' perceptions and practices of FCC have consistently shown that despite their good perception of FCC as a concept, its implementation has been associated with some inconsistencies (Alabdulaziz et al., 2017). Differences in cultural contexts and healthcare systems, underlying beliefs regarding health care environments, and the attitudes of health care providers have caused challenges in the implementation of FCC (Feeg et al., 2016). Alternatively, health professionals may not know how to apply FCC principles to their daily activities, while patients and families may not appreciate FCC in their health care decisions. In other words, health professionals and parents may have different perceptions of the implementation of FCC. Such differences in expectations or goals may prevent the accurate implementation of FCC (Shields, 2015; Smyth et al., 2017). FCC cannot be implemented correctly unless it has been reviewed to achieve a more accurate understanding (Kuo et al., 2012). This necessitates measuring FCC in a way that includes all of its principles and components (Wells, Bronheim, Zyzanski, & Hoover, 2015). Since some researchers such as Hutchfield proposed the FCC, several instruments have been published and validated to measure its effectiveness (Wang et al., 2016). However, the use of inconsistent measurement approaches has provided little evidence of FCC implementation. The determination and use of valid measurement approaches may help to strengthen this evidence and encourage health systems to provide high quality care to children (Lindly et al., 2017). Measurements should be done with validated instruments that reflect both the families' and the health professionals' perspectives (Wells et al., 2015). The diversity of the population worldwide proposes a great need for cross-culturally validated research instruments that can be used by clinicians and researchers for various populations and languages and that the available instruments have to be localized for different cultures (Sousa & Rojjanasrirat, 2011). Shields and Tanner (2004) developed the Perception of Family-Centered Care–Staff (PFCC-S) and the Perception of Family-Centered Care–Parents (PFCC-P) questionnaires to measure and compare the perceptions of FCC by staff and parents/ caregivers on three subscales: respect, coordination, and support. The questionnaires underwent adaptations and psychometric testing for a number of languages, including Brazilian Portuguese and Chinese, and in various clinical environments, such as intensive care units (ICUs) (Mitchell, Burmeister, Chaboyer, & Shields, 2012; Silva et al., 2015; Wang et al., 2016). Some studies have been conducted to explain the concept and implementation challenges of FCC on pediatric nursing of Iranian children (Vasli, Dehghan-Nayeri, Borim-Nezhad, & Vedadhir, 2015; Vasli & Salsali, 2014; Vasli, Salsali, & Tatarpoor, 2012), however, the researcher could not find a study developed questionnaires to examine the perceptions of FCC by parents and health professionals. This study aimed to translate, cross-culturally adapt, and conduct a psychometric testing of PFCC-S and PFCC-P questionnaires in pediatric nursing of Iranian children.

Methods Design The process of translation, adaptation, and cross-cultural validation of an instrument for use in other cultures and languages requires careful planning and adoption of accurate and comprehensive methodological approaches (Sousa & Rojjanasrirat, 2011). In this study, the translation, cross-cultural adaptation, and psychometric testing of questionnaires were based on the internationally accepted and recommended guidelines of the International Society of Pharmacoeconomics and Outcome Research (Wild et al., 2005) and the World Health Organization's (2018) suggestions for translation and psychometric testing.

Instruments The items of the PFCC-S and PFCC-P questionnaires were completely homogenous and designed to measure the perceptions of FCC from two different groups (i.e., staff and parents). The responses were based on the Likert scale using never, sometimes, often, and always as responses. The subscales of the two questionnaires included respect, collaboration, and support (Shields & Tanner, 2004). A demographic information questionnaire containing 7 items was developed along with a 20-item PFCC-S questionnaire to evaluate the staff's perception of FCC. Additionally, a demographic information questionnaire with 15 items was developed with a 20-item PFCC-P to evaluate the parents' perception of FCC. The following six steps were taken to optimize the Persian versions of the PFCC-S and PFCC-P questionnaires: preparation; forward translation; reconciliation; back translation; back translation review; and cognitive debriefing and psychometric testing (see Fig 1.). Step 1: Preparation The first step involved the preparatory work, which included acquiring permission from the developers (Shields & Tanner, 2004) of the original questionnaire for translation and cross-cultural adaptation of the survey and inviting them to participate in the development of the instrument. They agreed to participate in the project. Step 2: Forward Translation In this step, two native English-speaking translators who were familiar with health care produced two independent forward translations of the PFCC-S, PFCC-P, and related demographic information questionnaires. In addition to remaining faithful to the English text, the translators tried to achieve a conceptual equivalence of words and sentences, rather than producing word-for-word translations from the original language to the target language (Persian). In addition, the principles of simplicity, clarity, and conciseness were considered at this step. Step 3: Reconciliation The third step aimed to identify and solve incomplete and vague translations and to remove inconsistencies between the forward translations and the original questionnaires. To this end, a consensus meeting between the two translators and the research team members was held in which the initial translated versions of the two questionnaires were studied and compared with the original versions. Step 4: Back Translation Back translations were provided by a native English speaking translator who had no information about the original versions of the questionnaires or the previous steps. At this stage, the principles of conceptual and cultural equivalence, simplicity, and clarity were also assessed in writing. Step 5: Back Translation Review The back-translated questionnaires into English were emailed to the developers who reviewed them and offered suggestions. The developers discussed the back translations, compared them with the forward translations, and finally reached a consensus on the Persian version of the questionnaires during a meeting attended by the native Englishspeaking translators and the research team members. Step 6: Cognitive Debriefing and Psychometric Testing A comprehensive analysis of the psychometric properties of the harmonized Persian versions of the PFCC-S and PFCC-P questionnaires was conducted to determine their intelligibility, validity, and reliability. This step involved determining the content validity, construct validity, and reliability. A) Content Validity. To determine the content validity, ten faculty members at three nursing and midwifery schools in Tehran, Iran, were asked



Step 1: Preparation

Step 2: Forward translations

Permission from the questionnaire developers for translation and crosscultural adaptation

Two independent forward translations of PFCC-S and PFCC-P by two native English speaking translators

Step 3: Reconciliation

First consensus meeting consisting of the two translators and the research team members

Step 4: Back-translation

Backward translations of the translated versions into English by another native English speaking translator

Step 5: Back-translation Review

Step 6: Cognitive Debriefing and

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Review of back-translation by developers Second consensus meeting Harmonized Iranian version

Expert panel team consisting 10 faculty members of School of Nursing and Midwifery Qualitative content validity and face validity Review and modification in number and content of demographic information and perception of FCC questions Adding question No 13 to “Participation” subscale CVR CVI Construct Validity Sample selection (n= 228 nurses, n= 228 mothers) CFA Reliability Fig. 1. The study process.

their opinions about the questionnaires. In this step, the number and content of the related items to the demographic information and the perceptions of FCC were reviewed and modified in both questionnaires. The expert panel was then asked to rate the PFCC-S and PFCC-P questionnaires in terms of the content validity ratio (CVR) and the content validity index (CVI). To measure the CVR, the expert panel was asked to rate the individual items based on three assessment options: unnecessary, useful but unnecessary, and necessary. The CVR was then calculated using in the following formula, CVR = (ne – N/2) / (N/2), where ne is the number of panel members indicating an item “essential” and N is the total panel members. Each item was scored between 1 (completely agree) and –1 (completely disagree), with the lower scores indicating the nonnecessity of an item. The CVR values of individual items were then compared with the Lawshe table, which is a table of critical values for the CVR, to determine whether to keep or discard specific items (Ayre & Scally, 2014). In the present study, values equal to or N0.62 were considered acceptable to verify each item's CVR according to the Lawshe table and the 10-member expert panel. The expert panel was also asked to rate the relevance of individual items of the two questionnaires to verify the CVI (Moule, Aveyard, &

Goodman, 2016). The CVI was first calculated as the item-level content validity index (I-CVI) and then as the scale-level content validity index (S-CVI). The I-CVI represents the expert panel's agreement ratio for each item and is scored from 0 to 1 (Zamanzadeh et al., 2015). To determine the I-CVI, the expert panel was asked to rate the relevance of individual items as 1 (not relevant), 2 (somewhat relevant), 3 (quite relevant), and 4 (very relevant). The researchers then classified the expert panel opinions into two categories: not relevant (scores 1 and 2) and relevant (scores 3 and 4). Finally, the ratio of experts who identified an item as relevant to the total number of experts was calculated for individual items. Items achieving scores N79%, between 70 and 79%, and b70% were regarded as appropriate, needs to be reviewed, and tobe-removed items, respectively. The S-CVI was the mean of the I-CVI (Vasli, Dehghan-Nayeri, & Khosravi, 2018). The questionnaires were revised according to the opinion of the expert panel and then reviewed again by the expert panel. Ten nurses working in pediatric wards and 10 mothers of children hospitalized in the wards, who were not included in the study, were asked to evaluate the items in the PFCC-S and PFCC-P questionnaires, respectively, in terms of simplicity, fluency, and conciseness to determine the content validity of the questionnaires more accurately.


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B) Construct Validity. Given the specificity of the subscales, confirmatory factor analysis (CFA) was used to evaluate the construct validity. Rather than using exploratory factor analysis to analyze the instrument with unspecified constructs, the researcher considered a priori specified theoretical model in CFA (Schumacker & Lomax, 2015). In this study, the structural equation modeling (SEM) technique was used in Amos software version 19 to conduct CFA and to examine the effects of the subscales on the PFCC-S and PFCC-P questionnaires. The goodness of fit was determined using the following indicators: comparative fit index (CFI), Tucker-Lewis index (TLI), root mean square error of approximation (RMSEA), standardized root mean square residual (SRMR), and goodness-of-fit statistic (GFI) (Hooper, Coughlan, & Mullen, 2008; Mueller, 2012). The acceptable CFI and TLI values were equal to or N0.95 and b1, respectively (Fan et al., 2016; Hayes, Slater, & Snyder, 2008). The RMSEA value should be b0.07; the closer it is to 0, the greater the model fitness will be. Similarly, the closer the SRMR value is to 0, the greater the model fitness will be, and well-fitting models obtain values b0.05 (Hooper et al., 2008). A model's goodness of fit is verified if the GFI value approaches 1 (Fan et al., 2016).

Data Collection and Participants for CFA. The participants included in the CFA step were the mothers of the hospitalized children and the nurses working in the pediatric wards of five hospitals affiliated with Shahid Beheshti University of Medical Sciences (SBMU) in Tehran, Iran. According to Harrington (2009), a sample size N200 would be excellent for CFA. Therefore, 228 mothers of children hospitalized in pediatric wards and 228 nurses working in the wards were included in the study through convenience sampling to conduct CFA for the PFCC-P and PFCC-S questionnaires, respectively. It should be noted that, according to Iranian law, only mothers are allowed to stay with their children in hospital so that they can freely breastfeed and take care of their infants in a comfortable environment without the presence of men. In this regard, only female nurses are employed in such wards. Therefore, all the nurses included in this study were female. The inclusion criteria for mothers were the hospitalization of their children for N2 days, proficiency in Persian, and the ability to read and write. The inclusion criteria for the nurses were having at least a bachelor's degree and a minimum of 1 year of nursing experience in the pediatric ward. The main researcher of this study was a woman and, thus, was allowed entry into the field and visited the pediatric departments various shifts works and days of the week. All eligible nurses and mothers who were willing to cooperate with the researcher were enrolled in the study. Additionally, an equal number of participants was allocated to the groups of mothers and nurses to more accurately compare the construct validity of the questionnaires.

C) Reliability. To determine the reliability, the PFCC-S questionnaires were completed by 20 nurses working in maternity and neonatal wards, and 20 mothers of hospitalized infants completed the PFCC-P questionnaires twice within 2 weeks. The researcher used the completed questionnaires to estimate the intraclass correlation. Furthermore, Cronbach's alpha coefficient for each questionnaire was calculated to determine the internal consistency. At this stage of the study, the questionnaires were completed by participants not previously included in the study.

Ethical Considerations This study was registered by the Ethics Committee of SBMU. Before the study, the participants received necessary information about the research objectives, anonymity of the questionnaires, voluntary nature of participation, and confidentiality of information. Participants then gave their informed consent to participate in the study.

Results The mean age and standard deviation (SD) of the nurses were 31 ± 3.3 years, 65.8% of the nurses were married, 48.7% did not have a child, 91.2% had bachelor's degrees in nursing, and 8.8% had master's degrees. Other demographic information is presented in Table 1. The mean age and SD of the mothers were 29 ± 2.8 years, 38.2% and 31.6% had high school and higher education, respectively, and 45.6% and 43.9% had 1 and 2 children, respectively. Other demographic information is given in Table 2. Steps 1–5 In the first and second steps, two independent and complete translations of the questionnaires were obtained after receiving permission

Table 1 Demographic characteristics participants for PFCC-S. Demographic characteristics

Frequency

Percent

Age 20–24 25–29 30–34 35–39 40–44 ≥45

15 55 58 50 27 24

6.6 24.1 25.0 21.9 11.8 10.5

Marital status Single Married Divorced Widow

74 150 3 1

32.5 65.8 1.3 0.4

Number of children No child One child Two children More than two children

111 62 50 5

48.7 27.2 21.9 2.2

Degree BSC MSC

208 20

91.2 8.8

Job title Head nurse Nurse

14 214

6.1 93.9

Employment status Official Contractual Conventional Projective

145 19 33 40

61.2 8 14 16.8

Work shift Day Night Rotating

33 23 172

14.5 10.1 75.4

Experience ≤5 6–10 11–15 16–20 ≥20

102 74 31 21 228

44.7 32.5 13.6 9.2 100.0

Wards Medical and infectious disease Neurology Nephrology Oncology Digestive disease Neonatal NICU

26 19 11 11 10 11 140

11.4 8.3 4.8 4.8 4.4 4.8 61.4

Education related to pediatric and neonatal nursing Yes 93 No 135

40.8 59.2


P. Vasli / Journal of Pediatric Nursing xxx (2018) xxx–xxx Table 2 Demographic characteristics of participants for PFCC-P. Demographic characteristics

Frequency

Percent

Age ≥20 21–25 26–30 31–35 ≥36

19 45 66 56 42

8.3 19.7 28.9 24.6 18.4

Level of education Illiterate and elementary education intermediate Education High school and diploma University

31 38 87 72

13.6 16.7 38.23 31.6

Number of children 1 Child 2 Children 3 Children ≥4 Children

104 100 18 6

45.6 43.9 7.9 2.6

How difficult is attending the hospital for family Not at all difficult 54 Minimal level of difficulty 67 Moderate level of difficulty 60 Severe level of difficulty 47

23.7 29.4 26.3 20.6

Main place of residence Metropolitan Regional/remote

93 6.6

212 16

Another person in home who helps mother care for the children Yes 77 No 47 Not applicable 104

33.8 20.6 45.6

The history of hospitalization of children Yes No

103 125

45.6 54.8

Age of hospitalized child ≤1 month 1 month–1 year 1–3 years 3–7 years ≤7 years

102 47 32 30 17

44.7 20.6 14 13.2 7.5

Hours which take to travel from home to the hospital ≤Half-hour 51 1–2 h 104 2–3 h 47 ≥3 h 26

22.3 45.6 20.6 11.4

Inpatient area Oncology Medical Surgical Mixed Neonate

4.4 15.8 12.7 22.4 11.7

10 36 29 51 102

from the developers of the questionnaire. A consensus was then reached over the initial translated versions of the questionnaires (third step). The principles of conceptual and cultural equivalence, simplicity, clarity, and conciseness were then confirmed in writing (fourth step). Finally, after reaching a consensus on the revised questionnaires, the harmonized Persian versions of the PFCC-S and PFCC-P questionnaires, which each contained 20 items, were achieved in the fifth step.

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health. In addition, each individual had experience with the use of psychometric instruments. After a review of the questionnaire, the number of demographic information items in the PFCC-S questionnaire was increased from 7 to 11. The modified version of the demographic information questionnaire included the following variables: sex, age, marital status, number of children, last academic degree, position, employment status, work shift, years of service, ward of service, and completion of a formal training course on pediatric nursing care. After review, the number of demographic information items of the PFCC-P questionnaire was reduced from 15 to 10. The items of this questionnaire included the following variables: sex, age, academic degree, number of children, difficulty in accompanying children in hospital, presence of a second person at home to attend to other children, history of hospitalization, the hospitalized child's age, the commute time from home to hospital, and the ward in which the child was hospitalized. The CVR value of all the PFCC-S and PFCC-P items was N0.62, which verified the necessity of all items. The S-CVI values for the PFCC-S and PFCC-P questionnaires were 0.81 and 0.83, respectively, which confirmed the relevance of all items in the questionnaires. During the review of the questionnaires, the expert panel pointed out the necessity of adding an item before item 14. After receiving permission from the developers, item 13 was added to the collaboration subscale of both questionnaires. This item was “Parents are provided with written educational material” in the PFCC-S questionnaire and “I am given written educational material” in the PFCC-P questionnaire. Thus, each questionnaire contained a total of 21 items: the respect subscale contained items 1–6, the collaboration subscale contained items 7–16, and the support subscale contained items 17–21. Item 14 was confirmed by the expert panel. After determining the CVR and CVI, the opinions of 10 nurses and 10 mothers were found to be similar in terms of the simplicity, fluency, and comprehensiveness of the PFCC-S and PFCC-P questionnaires. Most of these individuals reported insufficient fluency and simplicity in items 4, 16, and 20. Therefore, with the help of five experts on the panel, the researcher tried to simultaneously reconcile the views of both groups about the two questionnaires, while maintaining the similarities in the items of both surveys to achieve maximum simplicity and fluency. Construct Validity Figs. 2 and 3 show the CFA results for the three subscales (i.e., respect, collaboration, and support) of the PFCC-S and PFCC-P questionnaires in the standard estimation mode, respectively. Tables 3 and 5 represent the related indicators to the fitness of the models for the three subscales of the PFCC-S and PFCC-P questionnaires, respectively. As observed in Tables 3 and 5, the three subscales were confirmed in both questionnaires. However, it should be noted that the values of the TLI and RMSEA were obtained at the cut-off point for the support subscale. Nevertheless, the effectiveness of this subscale was approved for both questionnaires because of the acceptable levels of the other indices. Table 4 displays the regression weights of the PFCC-S items that affected each of the three subscales. The most effective factors were items 2 and 5 on the respect subscale, items 11 and 15 on the collaboration subscale, and item 18 on the support subscale. Table 6 displays the regression weights of the PFCC-P items that affected each of the three subscales. According to the findings, the most influential factors were items 1 and 6 on the respect subscale, items 14 and 16 on the collaboration subscale, and items 19 and 20 on the support subscale.

Step 6 Content Validity In this study, 80% of the expert panel members were female with a mean age and SD 45 ± 4.1 years. The majority (70%) of these individuals were associate professors with their PhD. Half of the members on the expert panel were active in pediatric health care, whereas the rest worked in health care areas, including adult health care and community

Reliability The mean ages and SD of the mothers and nurses were 29 ± 3.6 years and 30 ± 3.2 years, respectively. In terms of their level of education, all nurses had a BSc and were working rotating shifts with the exception of one individual, who was the head nurse and worked the morning shifts. In addition, the majority (63.2%) of mothers had high school diplomas or academic degrees; 40% of the mothers had infants


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Fig. 2. Structural equation modeling related to the Respect, Coordination and Support sub-scales (left to right respectively) for PFCC-S.

Fig. 3. Structural equation modeling related to the respect, coordination and support sub-scales (left to right respectively) for PFCC-P.


P. Vasli / Journal of Pediatric Nursing xxx (2018) xxx–xxx Table 3 Fitness indicators of PFCC-S.

Respect Collaboration Support

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Table 5 Fitness indicators of PFCC-P.

CFI

TLI

RMSEA

SRMR

GFI

Results

0.95 0.97 0.95

0.92 0.96 0.90

0.08 0.03 0.10

0.02 0.04 0.03

0.96 0.96 0.97

Confirmed Confirmed Confirmed

who were admitted to hospital. The intraclass correlation of the PFCC-S and PFCC-P questionnaires were 0.89 and 0.79, respectively, while the Cronbach's alpha coefficients of the PFCC-S and PFCC-P questionnaires were 0.87 and 0.81, respectively, which demonstrated the reliability and internal consistency of both questionnaires. Discussion The translation, cross-cultural adaptation, and psychometric testing of the PFCC-S and PFCC-P questionnaires were the final outcome of this study. There were a few properties that made this study unique and significant. This was the first time that matched questionnaires were introduced to measure the perceptions of FCC by staff and parents/ caregivers. This was important because the two distinct, yet matched, questionnaires provided the opportunity to measure and compare staff's and parents'/caregivers' perceptions of FCC implementation (Gill et al., 2014). Secondly, the questionnaires were developed in this study in accordance with standard translating and psychometric testing steps introduced by World Health Organization (2018). In addition to providing word-for-word (faithful) translations of the questionnaires into Persian, the principle of cross-cultural adaptation was also taken into account to achieve the maximum suitability within the context of pediatric nursing care for Iranian children. The cross-cultural adaptation of an instrument takes precedence over mere translation because the conceptual meaning of the linguistic source is also taken into account during the translation process (Waltz, Strickland, & Lenz, 2010). Moreover, in this study, the application of different approaches to psychometric testing, including content validity, construct validity, and reliability, contributed to the development of adequately valid questionnaires for the measurement of perceived FCC. The final property of this study was associated with construct validity verification using CFA and the SEM technique. SEM is an invaluable analytical method to conduct CFA for two reasons. First, basic statistical tests can only be used in the analysis of a limited number of dependent and independent variables and, therefore, cannot be used to test

Respect Collaboration Support

CFI

TLI

RMSEA

SRMR

GFI

Results

0.93 0.97 0.94

0.900 0.973 0.900

0.04 0.03 0.10

0.04 0.04 0.03

0.98 0.96 0.96

Confirmed Confirmed Confirmed

theoretical relationships among multiple variables. Secondly, SEM explicitly takes measurement error into account during the analysis (Schumacker & Lomax, 2015). In addition, various indicators, such as CFI, TLI, RMSEA, SRMR, and GFI, were applied to confirm the fitness of the models. In this way, the appropriate fitness of the models was approved and more accurate results were obtained. It should be noted that due to the health care rules in Iran about children, only mothers of hospitalized children and infants are permitted to be with their children, which makes FCC focused on mothers and not fathers or other family members. Therefore, in this study, the PFCC-P psychometric evaluation was performed on mothers. In practice, the Persian version of the PFCC-P questionnaire is used to measure the understanding and perception of mothers on FCC. Similar studies have been conducted on the PFCC-S and PFCC-P questionnaires. For example, Silva et al. (2015) conducted research to adapt the intercultural and psychometric properties of the PFCC-S and PFCC-P questionnaires in Brazil. During their study, Silva et al. made no change in the number and content of the items at the content validity stage. However, one item was added to the collaboration subscale of both questionnaires during the content validity stage of the current research. The psychometric properties of an English version of the questionnaires were assessed in a study by Aggarwal et al. (2009a); no change was made in the number of items at the content validity stage. Mitchell et al. (2012) only used the PFSS-P questionnaire and designed a new tool titled Family-Centered Care Survey – Adult Scale by rewording some of the items and maintaining the same number of items (20 items) and subscales (3 subscales). The researchers applied FCC to assess family perception of FCC. In research by Wang et al. (2016), which was based on the work by Mitchell et al. (2012), two factors of information and empowerment were added to the survey. The results of the CFA review verified the effect of the three subscales (i.e., respect, collaboration, and support) on both questionnaires. Similar results were obtained by Silva et al. (2015). However, two studies that conducted psychometric testing of the Family-Centered Care

Table 4 Factor loading and rating of items of PFCC-S. Sub-scale

No

Factors

Weight

Rating

Respect

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21

When parents come to hospital they feel welcome Other members of the child's family are welcome to attend with him/her at the hospital Parents are able to stay with their children during therapeutic and care procedures (e.g. venipuncture, blood sampling) Parents are able to question recommendations about their children's treatment if they are doubtful about them Parents are treated as parents (rather than mere visitors) when they come to the hospital Children's privacy and confidentiality are respected Parents get prepared for discharge/referral to other community services after their children's discharge Parents are provided with honest information about their children's care Parents know who to call after they get home if they need help or reassurance When decisions are made about their children's care, the parents get involved by staff Parents are taught what they need to know about their children's care Parents know the name of the doctor in charge of their children's care Parents are provided with written educational material Parents understand the written material that has been given to them Family members are included in their children's care Parents feel overwhelmed by the information given to them about their children The staff are familiar with the child's personal needs The staff listen to the parents' concerns The nursing staffs the parents see in the hospital are almost the same as before The staff know who supports the parents (e.g. friends, relatives, acquaintances, and other caregivers) The staff understand what parents and family members are going through

1.000 1.258 0.499 0.986 1.268 0.839 0.605 0.552 0.940 0.734 1.221 0.923 0.775 0.986 1.145 0.645 0.635 0.806 0.319 0.497 0.686

3 2 6 4 1 5 9 10 4 7 1 5 6 3 2 8 3 1 5 4 2

Collaboration

Support


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Table 6 Factor loading and rating of items of PFCC-P. Sub-scale

No

Factors

Weight

Rating

Respect

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21

When I come to hospital I feel welcome Other members of my family are welcome to attend with me at the hospital I am able to be with my child during therapeutic and care procedures (e.g. venipuncture, blood sampling) I am able to question recommendations about my child's treatment if I am doubtful about them I feel like a visitor (rather than a parent) when I come to the hospital My child's privacy and confidentiality are respected I get prepared for discharge/referral to other community services after my child's discharge I am given honest information about my child's care I know who to call after I get home if I need help or reassurance When decisions are made about my child's care, I get involved by the staff I am taught what I need to know about my child's care I know the name of the doctor in charge of my child's care I am given written educational material I understand the written material that has been given to me My family is included in my child's care I feel overwhelmed by the information given to me about the child The staff are familiar with my child's personal needs The staff listen to my concerns The nursing staffs I see in the hospital are almost the same as before The staff know who my support people are (e.g. friends, relatives, acquaintances, and other caregivers) The staff understand what my family and I are going through

0.732 0.314 0.342 0.381 −0.077 0.400 0.262 0.669 0.536 0.989 0.710 0.805 0.805 1.200 1.007 1.129 0.286 0.169 0.426 0.602 0.318

1 5 4 3 6 2 9 7 8 4 6 5 5 1 3 2 4 5 2 1 3

Collaboration

Support

Survey – Adult Scale showed inconsistent results. For example, Mitchell et al. (2012) showed that instrument did not have adequate validity in ICUs, while Wang et al. (2016) demonstrated the instrument's adequacy for the measurement of perception of FCC in ICUs through the verification of all dimensions using exploratory factor analysis. The results of this study confirmed the effect of the respect and support subscales on the PFCC-S and PFCC-P questionnaires. The overall content of the related items to these subscales revolved around the following points: the presence of parents alongside their children; the respectful behavior of the staff toward children and parents; and the consideration of the individual needs of children and family, as well as family concerns. The IPFCC (2018) introduced these components under the core concept of dignity and respect in which FCC underlines the value and role of families as essential mentors and partners in enhancing health care methods (Wells et al., 2015). In their review article based on the proposed principles of FCC, Kuo et al. (2012) verified that respect and honoring differences was a principle of FCC that signifies that working relationships should respect diversity, cultures, linguistic traditions, and care preferences. The findings of this study verified collaboration as the second subscale of the PFCC-S and PFCC-P questionnaires. Information sharing was regarded as an element of collaboration in the development of the PFCC-S and PFCC-P items. According to IPFCC (2018), information sharing, participation, and collaboration are components of FCC where information sharing corresponds to communicating and making information available to family members in a comprehensible way. Collaboration involves the inclusion of family members in decision-making and caring for children to the extent chosen by them. Drawing on their findings, Alabdulaziz et al. (2017) identified collaboration as the major element of FCC. The exchange of information without bias among families and health care providers has been recognized as a dimension of FCC in distinct conceptual analyses (Ramezani, Shirazi, Sarvestani, & Moattari, 2014; Vasli & Salsali, 2014). In this study, the reliability of the PFCC-S and PFCC-P questionnaires was confirmed in terms of repeatability and internal consistency. In similar studies, the reliability of the questionnaires was assessed only from the aspect of internal consistency. For instance, Aggarwal et al. (2009b) estimated the reliability of the English version of the PFCC-S and PFCC-P questionnaires using Cronbach's alpha coefficients of 0.79 and 0.72, respectively. Silva et al. (2015) obtained Cronbach's alpha coefficients of 0.78 and 0.72 for the Brazilian version of the PFCC-S and PFCC-P questionnaires, respectively. In Australia and China, Mitchell et al. (2012) and Wang et al. (2016) assessed the psychometric

properties of the Family-Centered Care Survey – Adult Scale and reported Cronbach's alpha coefficients of 0.81 and 0.94, respectively. Therefore, it could be concluded that the Persian version of PFCC-S and PFCC-P had sufficient reliability to be used for pediatric health care in Iran. Implications for Nursing and Clinical Practice We believe that the developed questionnaires can be used to adequately measure the perceptions of FCC by staff and parents who are caring for hospitalized Iranian children. Nurses and nurse managers can use these questionnaires to measure and study the dimensions, obstacles, and facilitators to implement FCC as a quality care principle. These questionnaires should be used in future studies to measure and compare the perceptions of FCC by staff and parents to draw the two groups closer together and overcome potential challenges. Conclusion The present study aimed to provide a translation, cross-cultural adaptation, and psychometric testing of questionnaires to measure perceptions of FCC by nursing staff and parents. Because the developed questionnaires were based on cross-cultural adaptation and psychometric testing, they were labeled as PFCC-P Persian version and PFCCS Persian version. The most important strength of the PFCC-S and PFCC-P questionnaires was to comprise all aspects of the definition of FCC. Attempts were made to produce translations, make cross-cultural adaptations, and conduct psychometric testing based on a standard procedure. This included using a sufficient number of participants from various pediatric wards and neonatal intensive care unit. Therefore, according to the authors, the findings have acceptable generalizability and the acquired questionnaires can be used to assess the understanding of FCC by the staff in pediatric wards and the mothers of children in those wards. Limitations Although attempts were made to provide questionnaires to participants who had the time and willingness to complete the questionnaires, the main limitation of the research might be the fatigue and concern of mothers about their ill infants and the fatigue of nurses due to high workload. These factors might have affected the accuracy of the results



to some extent. However, the research was conducted on an adequate number of subjects as previously noted. Acknowledgements We thank Professor Linda Shields, Ms. Ann Tanner, and Dr. Fenella Gill for permission to use the “Shields and Tanner” questionnaires, and for help with the back translation. References Aggarwal, S., Chadha, P., Kalia, S., Richardson, S., Winterbottom, L., & Shields, L. (2009a). Teaching research in paediatrics: a ‘hands on’ experience for medical students. Focus on Health Professional Education: A Multi-Disciplinary Journal, 10(3), 70. Aggarwal, S., Chadha, P., Kalia, S., Richardson, S., Winterbottom, L., & Shields, L. (2009b). Perceptions of family-centred care: A UK pilot study of the Shields and Tanner questionnaires. Neonatal, Paediatric and Child Health Nursing, 12(2), 25–29. Alabdulaziz, H., Moss, C., & Copnell, B. (2017). Paediatric nurses' perceptions and practices of family-centred care in Saudi hospitals: A mixed methods study. International Journal of Nursing Studies, 69, 66–77. https://doi.org/10.1016/j.ijnurstu.2017.01.011. Allen, J., Hutchinson, A. M., Brown, R., & Livingston, P. M. (2014). Quality care outcomes following transitional care interventions for older people from hospital to home: A systematic review. BMC Health Services Research, 14(1), 346. https://doi.org/10. 1186/1472-6963-14-346. Al-Motlaq, M. A., & Shields, L. (2017). Family-Centered Care as a western-centric model in developing countries: Luxury versus necessity. Holistic Nursing Practice, 31(5), 343–347. https://doi.org/10.1097/HNP.0000000000000228. Ayre, C., & Scally, A. J. (2014). Critical values for Lawshe's content validity ratio: Revisiting the original methods of calculation. Measurement and Evaluation in Counseling and Development, 47(1), 79–86. https://doi.org/10.1177/0748175613513808. Curley, M. A., Hunsberger, M., & Harris, S. K. (2013). Psychometric evaluation of the family-centered care scale for pediatric acute care nursing. Nursing Research, 62(3), 160–168. https://doi.org/10.1097/NNR.0b013e318286d64b. Fan, Y., Chen, J., Shirkey, G., John, R., Wu, S. R., Park, H., & Shao, C. (2016). Applications of structural equation modeling (SEM) in ecological studies: An updated review. Ecological Processes, 5(1), 19. https://doi.org/10.1186/s13717-016-0063-3. Feeg, V. D., Paraszczuk, A. M., Çavuşoğlu, H., Shields, L., Pars, H., & Al Mamun, A. (2016). How is family centered care perceived by healthcare providers from different countries? An international comparison study. Journal of Pediatric Nursing, 31(3), 267–276. https://doi.org/10.1016/j.pedn.2015.11.007. Foster, M., & Whitehead, L. (2017). Family centred care in the paediatric high dependency unit: Parents' and Staff's perceptions. Contemporary Nurse, 53(4), 489–502. https:// doi.org/10.1080/10376178.2017.1410067. Gallo, K. P., Hill, L. C., Hoagwood, K. E., & Olin, S. -C. (2016). A narrative synthesis of the components of and evidence for patient-and family-centered care. Clinical Pediatrics, 55(4), 333–346. https://doi.org/10.1177/0009922815591883. Gill, F. J., Pascoe, E., Monterosso, L., Young, J., Burr, C., Tanner, A., & Shields, L. (2014). Parent and staff perceptions of family-centered care in two Australian children's hospitals. European Journal for Person Centered Healthcare, 1(2), 317–325. https://doi.org/ 10.1080/10376178.2017.1410067. Harrington, D. (2009). Confirmatory factor analysis. Oxford University Press. Hayes, A. F., Slater, M. D., & Snyder, L. B. (2008). The Sage sourcebook of advanced data analysis methods for communication research. Sage. Himuro, N., Miyagishima, S., Kozuka, N., Tsutsumi, H., & Mori, M. (2015). Measurement of family-centered care in the neonatal intensive care unit and professional background. Journal of Perinatology, 35(4), 284–289. https://doi.org/10.1038/jp.2014.204. Hooper, D., Coughlan, J., & Mullen, M. (2008). Structural equation modelling: Guidelines for determining model fit. Articles, 2. Institute for Patient- and Family-Centered Care (2018). Patient- and family-centered care. Retrieved 6/16/2018, from http://www.ipfcc.org/about/pfcc.html. Kuo, D. Z., Houtrow, A. J., Arango, P., Kuhlthau, K. A., Simmons, J. M., & Neff, J. M. (2012). Family-centered care: Current applications and future directions in pediatric health care. Maternal and Child Health Journal, 16(2), 297–305. https://doi.org/10.1007/ s10995-011-0751-7. Lindly, O. J., Geldhof, G. J., Acock, A. C., Sakuma, K. -L. K., Zuckerman, K. E., & Thorburn, S. (2017). Family-centered care measurement and associations with unmet health care

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