четверг, 4 октября 2012 г.

Psychometric instrument evaluation: the Pediatric Family Satisfaction Questionnaire. (Continuing Education Series). - Pediatric Nursing

Patient satisfaction, also called satisfaction or client satisfaction, has received increased attention in the last decade as a reliable and valid measurement of quality of care. This is also believed to be true among the pediatric patient population. Due to the stature of children, parents are seen as the consumers or patients in proxy. Parents are the child's advocates within the health care system and, therefore, represent the patient point of view. The importance of parental satisfaction studies is supported by research findings that indicate that parental perception does not always equal health care professional perception of various phenomena in the health care setting (Bournaki, 1987; Bradford, 1991; Graves & Hayes, 1996; Graves & Ware, 1990; Horner, Rawlins, & Giles, 1987; Thornton, 1996; Tughan, 1992). Parental satisfaction studies indicate that health care providers often under or overestimate parental needs and satisfaction (Bradford, 1991; Thornton, 1996), presumably inhibiting improvement of quality of care.

In preparation for studying parental satisfaction with hospital care in general inpatient pediatric units, the existing literature on parents in hospitals was searched and analyzed to identify an instrument suitable for the purpose of the study. The search resulted in the selection of the Pediatric Family Satisfaction Questionnaire (PFSQ) (Budreau & Chase, 1994) as the most suitable instrument. There were three broad steps used in the selection process: (a) selecting satisfaction as the indicator of quality of care that would be measured, (b) identifying the criteria for selecting an instrument to measure the concept, and (c) verifying that an instrument meets all the criteria for selection. The process engaged in each step will be presented, but it was the third step that proved to be the most time-consuming, particularly identifying the psychometric properties of the instrument. To determine if the instrument selected met the criterion of having satisfactory psychometric properties, it was necessary to test the instrument ourselves with data made available to us.

Selecting Satisfaction as Quality of Care Outcome Measure

Although satisfaction measurements are but one method of measuring outcomes, they are considered by many to be one of the most important ones in improving quality of care. Patients' points of view add a new dimension to quality, the personal value, the degree to which health care satisfies patients, which Palmer, Donabedian, and Povar (1991) choose to call 'the acceptability of care' (p. 58). According to Vuori (1989), the term quality can refer to effectiveness, efficiency, equity, acceptability, accessibility, adequacy, and scientific-technical quality of care. In this context, Vuori (1987) identified three possible functions for patient satisfaction. It can serve as an attribute for quality care indicating that care can not be of high quality unless the patient is satisfied. Patient satisfaction can be an indicator for quality care reflecting the patient's views of the received care. Or, patient satisfaction can function as a precondition for quality care assuming that the more satisfied patients will cooperate more effectively and show a greater compliance to treatment and, thus, will more likely return to the services again.

Patient satisfaction measurements can and should improve quality of care by providing important marketing data and by helping to improve the quality of risk management programs (Scott & Smith, 1994). They can be used in goal-setting programs, to improve employee performance, or to recognize high-performance employees (Strasser & Davis, 1991). Patient satisfaction can serve to assess consultations and patterns of communication within the health care system and as feedback on alternative treatment choices (Fitzpatrick, 1991).

Patient satisfaction has been defined as 'judgment made by a recipient of care as to whether his or her expectations for that care have been fulfilled' (Palmer et al., 1991, p. 56). It is a means of measuring acceptability of care, where acceptability is the degree to which health care satisfies the patient (Palmer et al., 1991). To explain the inextricable links of patient satisfaction and quality of care, quality of health care has further been defined as 'the production of improved health and satisfaction of a population within the constraints of existing technology, resources, and consumer circumstances' (Palmer et al., 1991, p. 58). Thus, to be able to interpret the quality of care, the degree of acceptability and the expectations of the patient must be known (Allanach & Golden, 1988; Scardina, 1994; Scott & Smith, 1994) and 'care cannot be of high quality unless the patient is satisfied' (Vuori, 1987, p. 107).

Identifying the Criteria for Instrument Selection

It was decided that the instrument needed to meet two broad criteria. One of these was consistency with the theoretical framework of the study and with the empirical findings related to that theoretical framework. The second was the instrument had to have adequate psychometric properties. However, these distinctive criteria are interconnected, as a study's theoretical framework must be kept in mind when assessing the psychometrics of an instrument (Ferketich & Muller, 1990; Giuffre, 1995; Nunnally, 1978).

The theoretical framework of the proposed study on parental satisfaction is based on: (a) Donabedian's (1980; 1982; 1988) structure, process, and outcome approach to quality care; (b) Price's (1993) preliminary theory on quality nursing care; and (c) empirical findings on the needs of parents whose children are hospitalized.

For quality assessment, Donabedian (1988) categorized quality indicating information into: (a) structure, (b) process, and (c) outcome. Structure refers to the setting where the care is carried out. Process refers to what is actually done when giving and receiving care. Outcome refers to the effects of the care on the patient's health status. Donabedian's framework is based on the assumption that good structure increases the likelihood of good process, and good process increases the likelihood of good outcome. According to Donabedian (1988), appropriate management of interpersonal relationships to carry out the necessary technical care in each case is the key to successful outcomes. The quality of health care is the optimal intertwining of technical care and the management of the interpersonal relationships between the health care provider and the patient (Donabedian, 1982).

In a qualitative study on parents' perceptions of the meaning of quality nursing care, Price's (1993) findings indicated that parents experienced quality nursing care as a four-stage process. The process included: (a) maneuvering or getting in touch with the parents and the child; (b) getting to know the parents and the child; (c) establishing a positive relationship between the nurse and the parents and child; and (d) meeting the biopsychosocial needs of the parents and child, which was described by the parents as quality nursing care.

Several empirical studies have indicated basic parental needs related to their child's hospitalization. These needs refer to: (a) information, (b) being able to stay with the child and take care of the child, (c) being trusted, (d) trusting health care providers, (e) support and guidance, (f) human and physical resources, (g) financial assistance, (h) other family members, (i) hope, (j) the child's development and education, and (k) coordination of care (Bragadottir, 1999; Farrell & Frost, 1992; Fisher, 1994; Kasper & Nyamathi, 1988; Kirschbaum, 1990; Kristjansdottir, 1991; 1995; Terry, 1987).

The key role of nurses and physicians in providing care to hospitalized children and their parents is reflected in parental self-perceived needs, where parents expressed the need to be able to trust nurses and physicians and to be trusted by nurses and physicians (Bragadottir, 1999; Kristjansdottir, 1991, 1995; Terry, 1987). In Terry's (1987) study, parents chose physicians and nurses as the persons most likely to meet their needs. These findings support the proposition that nursing care, with medical care, is of most importance in meeting parental needs in hospitals and, therefore, is most important for parental satisfaction. This indicates that parental satisfaction questionnaires must be nursing sensitive to be of true value as outcome measurements.

Instrument Evaluation

Whether developing a new instrument or evaluating an existing one, the instrument needs to be psychometrically sound and feasible. The usefulness of an instrument as an outcome measure depends on its reliability, validity, sensitivity, feasibility, and clinical practicability (Abdellah & Levine, 1965; Aday, Begley, Lairson, & Slater, 1993). The following questions were used to evaluate existing parental satisfaction instruments identified in the literature:

1. What was the purpose of the instrument?

2. What is the theoretical and empirical framework of the instrument?

3. Does it reflect the conceptual definition of the variables in the proposed study?

4. Was the instrument developed for the same population and setting as it is intended to be used in the proposed study?

5. Is the readability level of the instrument appropriate for the population?

6. How long and complex is the instrument?

7. What evidence is available related to the instruments reliability and validity? (Burns & Grove, 1993; McDowell & Newell, 1987; Radosevich, 1997; Waltz, Strickland, & Lenz, 1991).

Consistency with the theoretical framework and related empirical findings. To identify publications on parental satisfaction CINAHL 1982-1999, Medline 1985-1999, and PsycINFO 1984-1999 computerized databases were searched using a number of keywords. The articles identified from the literature reporting satisfaction studies among parents of hospitalized children were few and varied in perspective and methodology. Bergman's (1995) point about how little had been done in patient-centered areas of satisfaction, especially for children seemed more than true. Table 1 gives an overview of identified general parental satisfaction instruments for inpatient pediatric units.

Based on the available information, the PFSQ (Budreau & Chase, 1994) instrument seemed to best serve the purpose of the proposed parental satisfaction study. It was developed to ensure a family-centered approach in general pediatric health care settings. The instruments content validity had been established, but its psychometric soundness was still in question.

For further investigation on the value of the PFSQ, its authors provided data for psychometric analysis from several years of parent satisfaction surveys at a large Midwest hospital and clinics. Information on the readability and complexity of the PFSQ was not available.

Several procedures are used to estimate reliability (Burns & Grove, 1993; Carmines & Zeller, 1979; Crocker & Algina, 1986; Krowinski & Steiber, 1996). The most common method of internal consistency testing is Cronbach's coefficient alpha (Cronbach, 1951). Homogeneous or internally consistent items measure the same thing, and the closer the Cronbach's coefficient alpha is to 1.0, the higher the internal consistency. For new instruments under development, Cronbach's coefficient alpha of .70 is considered satisfactory but should preferably be at least .80 for well established instruments (Carmines & Zeller, 1979; Nunnally, 1978).

Construct validity involves three steps: (a) specifying the theoretical relationship between concepts, (b) examining the empirical relationship between the measures of the concepts, and (c) interpreting the empirical evidence as to how it clarifies the construct validity of the particular measure (Carmines G Zeller, 1979; Nunnally, 1978). Factor analysis is the most common statistical analysis used for construct validity testing (Kim & Muller, 1978a; 1978b; Krowinski & Steiber, 1996; Nunnally, 1978). It involves testing the interrelationship among items that measure the same concept or factor. This clustering of related items through correlation is called factor loading. Higher factor loading indicates a strong interrelationship among items, indicating an instrument's validity (Burns & Grove, 1993; Cronbach, 1951; Kim & Mueller, 1978a). Factor loading of .30 or more is desirable (Kim & Mueller, 1978b; Nunnally, 1978).

Adequacy of the psychometric properties of the PFSQ. The SPSS statistical software package was used for testing the reliability and construct validity of the PFSQ. The instruments' content validity was already established to some extent (Budreau & Chase, 1994), but no statistical tests had been done to assess its psychometric soundness.

Cronbach's coefficient alpha (Cronbach, 1951) was used to estimate the internal consistency reliability. It was computed for the total scale and for each of the four subscales: (a) hospital services and accommodations, (b) nursing care, (c) medical care, and (d) child life therapy. Treating each subscale as a separate scale is especially important with satisfaction measures, as they usually include several diverse factors (Krowinski & Steiber, 1996). When interpreting the results of internal consistency, the number of items and their nature need to be considered. A higher number of items, greater test variance, and approximation to normal distribution increase the alpha level (Ferketich, 1990; Nunnally, 1978; Waltz et al., 1991).

The construct validity of the PFSQ was tested with factor analysis. Factor analysis includes several mathematical procedures involving a series of multiple regression analyses (Kim & Mueller, 1978a; 1978b). There are two types of factor analysis: exploratory factor analysis and confirmatory factor analysis. Both include three steps: (a) the development of the covariance matrix, (b) the extraction of the initial factors, and (c) the rotation to a terminal solution (Burns & Grove, 1993; Crocker & Algina, 1986; Kim & Mueller, 1978b). The initial step involves exploring the interdependence among the items. The core difference between exploratory factor analysis and confirmatory factor analysis is that a hypotheses on the number of the common factors guides the assessment of the rotated factor solution in the latter procedure (Kim & Mueller, 1978a; 1978b). For the factor analysis of the PFSQ, varimax rotation was used for an orthogonal solution (Kim & Mueller, 1978a). The formerly identified four factors of the PFSQ served as the hypothesis guiding the interpretation of the factor analysis.

Results

The analyzed data were collected from October 1994 through March 1997 with the bulk of the cases from 1995 (45%) and 1996 (36%). The total sample consisted of 848 cases. The majority of the participants were mothers (83%). In some instances, mothers and fathers had answered jointly, mothers and patients jointly, or fathers only. Most of the children had been hospitalized in a pediatric medical or surgical unit (92%) with a minority (8%) being hospitalized in a specialty unit such as the pediatric bone marrow transplant unit, the pediatric intensive care unit, or the neonatal intensive care unit.

Cronbach's alpha. The results of the Cronbach's alpha internal consistency testing are presented in Table 2. The alpha for the total instrument including all 35 items was .83. Due to missing data, only 327 cases were included in the reliability testing of the total scale. The subscales of nursing care (scale II) had an alpha of .92, and the subscale of medical care (scale III) an alpha of .83, indicating high internal consistency. The subscale of hospital services and accommodation (scale I) and the child life therapy subscale (scale IV) showed low internal consistency with an alpha of .65 and .53, respectively.

Due to substantial missing data in the child life therapy subscale and the relatively low internal consistency of that subscale, Cronbach's alpha was also computed without the child life therapy subscale to obtain a more reliable estimate of the internal consistency. The alpha for the total instrument, omitting subscale IV, was .90, based on 675 cases and 30 items.

The alpha for each subscale if an item was deleted showed significant difference in two instances. For the subscale of medical care, the alpha increased to .92 if the item 'the doctors were caring and concerned' was deleted, and in the subscale of child life therapy, the alpha increased to .90 if the item 'the child life therapist recognized the patient's individual needs' was deleted.

For the total instrument no significant changes in alpha were identified when items were deleted. In turn, however, when the subscale IV of child life therapy was deleted entirely, the alpha for the total instrument increased substantially.

Factor analysis. Due to substantial missing data, low internal consistency, and low loading in earlier stages of the factor analysis, subscale IV was excluded from the final stages of the factor analysis for construct validity testing. The guiding hypothesis of four main factors was not supported. Solutions of three and four factor rotation showed a secondary loading of most items. The rotation of the axis showed a terminal solution of two main factors as indicated by the factor matrix in Table 3, with a fairly distinct clustering of items. A scree plot supported this interpretation suggesting two main factors.

For factor I, 18 items showed a loading of [greater than or equal to] .30, and for factor II, 10 items showed a loading of [greater than or equal to] .30. However, three of these items showed secondary loading: (a) overall satisfaction, (b) doctors information about test results and changes in patient's condition, and (c) doctors including parents in decision making and care planning. Two of the items had a loading of < .30, 'the unit and patient rooms were clean' and 'the patient was not disturbed by noise,' and two items did not have trivial loading on either factor, 'the admission procedure went smoothly' and 'the doctors were caring and concerned.'

Discussion

Reliability. The Cronbach's alpha reliability tested satisfactory internal consistency for the total PFSQ instrument, its alpha being above .80 (Carmines & Zeller, 1979; Nunnally, 1978). Two of the four subscales showed a satisfactory alpha coefficient, scale II of nursing care and scale III of medical care. These subscales have significantly more items, 12 and 11, than subscale I of hospital services and accommodation and subscale IV of child life therapy, which have 7 and 5 items, respectively. A scale with few items may show a low alpha, and adding items to a scale may raise the alpha (Ferketich, 1990, 1991; Nunnally, 1978). Another reason for a low alpha may be that the interim items in subscales I and IV are not measuring the same concept. Low alpha indicates that a scale needs improvement by adding, dropping, or changing items. In the case of subscales I and IV, the reason for a low alpha may well be high divergence of interim items or few items. However, adding items to a scale increases the burden on participants, making administration of the instrument less feasible. To this author's knowledge no studies have been done on the burden of the PFSQ. Asking participants about how well they understand the questionnaire and how long it takes them to answer it may shed a light on what changes are appropriate for increasing the reliability of the instrument, especially subscales I and IV. The divergent nature of parental needs and their numbers makes it difficult to keep the instrument short and still measure all the indicators of parental satisfaction. It may even be true that Cronbach's alpha is not the best test for reliability in this case (Ferketich, 1990). Theta and omega are other statistical tests of internal consistency not used as commonly as Cronbach's alpha, yet they may better suit the testing of instruments with diverse interim items (Carmines & Zeller, 1979; Ferketich, 1990).

Construct validity. The construct validity testing with factor analysis indicated that changes need to be made on the PFSQ. The hypothesis of four factors was not supported. The factor analysis indicated two main factors, nursing care and medical care. These results are in concordance with empirical findings indicating nursing care and medical care are the core indicators of parental satisfaction (Knafl, Cavallari & Dixon, 1988; Terry, 1987). The lack of loading or low factor weights of some of the items raises questions about whether they are of any clinical value and should, therefore, be deleted (Burns & Grove, 1993). Few responses for subscale IV, child life therapy, and subjective evaluation of parents' comments to the open ended questions indicated that child life therapy is not of concern to many parents although it may be of importance to some (Bragadottir, 1999; Kasper & Nyamathi, 1988). Items on accommodation showed none or low factor weight indicating little contribution to parental satisfaction as a whole. The item of teamwork among health care providers and the item of discharge preparation loaded more heavily on factor I indicating their consistency with the nursing care items. The item of doctors caring and concern loaded on neither factor, indicating no contribution to the overall parental satisfaction. A factor loading of .30 or more is desirable (Kim & Mueller, 1978b; Nunnally, 1978). At a cutting point of .30, three items had a secondary loading. To avoid this the cut-off point can be set higher (Burns & Grove, 1993), which, however, was not done in this case. Setting the cutting point higher and deleting items loading under the cutting point may strengthen the instrument psychometrically.

Conclusion

It should be noted here that the different types of validity are interrelated as are reliability and construct validity. Any factorial composition of measures plays a part in all three types of validity: content validity, criterion-related validity, and construct validity (Nunnally, 1978). Reliability and validity are matters of degree rather than all-or-none properties (Waltz et al., 1991). Instrument validity and reliability are situation bound and can vary from one sample to another. Tests of reliability and validity do not really assess an instrument in itself, but rather the use of it in certain populations and settings (Carmines & Zeller, 1979).

Although not discussed here, reliability can be tested with factor analysis (Burns & Grove, 1993; Carmines & Zeller, 1979). Deleting items that have low factor weights increases an instrument's reliability (Burns & Grove, 1993). Also, the reliability increases the more items loading high on the same concept (Kim & Mueller, 1978b). As pointed out by Ferketich (1991) 'the argument for achieving the goal of similarity among items is central to the estimates of both reliability and validity' (p. 167). The theoretical framework balanced with the mathematical criteria must, however, always lead the development of an instrument (Ferketich & Muller, 1990). What Giuffre (1995) calls 'healthy dose of judgment' (p. 36) must be mixed with statistical tests when evaluating an instrument's soundness. As Nunnally (1978) puts it, in judging the usefulness of a particular method of analysis, the researcher needs to question how much it helps the program of research.

Based on the content analysis and statistical testing reported here, the PFSQ is considered a promising instrument for evaluating parental satisfaction in general inpatient pediatric units. Reliability for the total instrument was satisfactory. Based on the factor analysis, construct validity tested satisfactory to some extent, indicating two main factors showing relatively high loading of most items.

For the development of the PFSQ, a two-step initial procedure is suggested. Led by the theoretical and empirical framework of the proposed study, the first step should be to evaluate the importance of items, especially the ones in subscales I and IV, to identify whether they need rewording, additional items, or deletion of items. This could be done by analyzing parents' comments to each of the factors and by further use of the instrument where parents are asked about the importance of each item, how well they understand the questions, and how long it takes to answer the questionnaire. The second step should be to test the revised instrument statistically repeating the procedures reported in this paper. It is suggested that items not loading on a factor nor explaining any of the variance be deleted. A reliable and valid shorter version of the PFSQ may make it a feasible instrument for nurse clinicians and nurse managers to use for ongoing quality control in pediatric units. However, further development of the instrument is suggested. The psychometric strengths of the PFSQ support its further development.

 Table 1. Studies on Parental Satisfaction in the Hospital      Author         Instrument          Purpose          Framework  Bradford, 1991   The Survey of     To investigate    Not reported                  Parental          whether pedi-                  Satisfaction      atric staff                  (SPS) (Dare &     accurately                  Hemsley, 1986),   estimated the                  a 35-item         concerns of                  scale.            parents and                                    assess the role                                    of staff level                                    of contact with                                    parents on                                    their subse-                                    quent accuracy.  Budreau &        The Pediatric     To develop a      Family-centered Chase, 1994      Family            family-centered   approach influ-                  Satisfaction      parental          enced by                  Questionnaire     satisfaction      Risser's (1975)                  (PFSQ), a 35-     questionnaire.    conceptual                  item, 5-point,                      framework and                  Likert-type                         the modified                  questionnaire                       Caring Beha-                  offering parti-                     viors Assess-                  cipants com-                        ment (Cronin &                  ments to each                       Harris, 1988,                  of the factors.                     Henry, 1992).  Thornton, 1996   Risser's          To determine      The enabling                  25-item,          the level of      and empowering                  self-report       congruence bet-   model of                  instrument,       ween parents'     helping rela-                  revised and       satisfaction      tionships                  adapted. A        with nursing      (Dunst, Tri-                  25-item,          care in a pedi-   vette, Davis, &                  5-point,          atric neuro-      Cornwell,                  Likert-type       science setting   1988).                  questionnaire.    and the nurses'                                    perceptions of                                    parents'                                    satisfaction.  Vandvik,         10-cm visual      To identify       Not reported Hoyeral,         analog scales.    areas of & Fagertum,                        parental dis- 1990                               satisfaction                                    with the                                    hospital care                                    of rheumatic                                    children.      Author            Factors         Reliability  Bradford, 1991   * Information        Not reported                  * Emotional sup-                    port                  * Discussion of                    outlook/prog-                    nosis,                  * Discussion of                    impact on daily                    life                  * Financial                    problems                  * Marital tension                  * Sibling                    problems                  * Contact with                    other families  Budreau &        * Hospital service   Not reported Chase, 1994        and accommo-                    dation                  * Nursing care                  * Medical care                  * Child life                    therapy  Thornton, 1996   * Professional       Not reported                    items                  * Educational                    items                  * Trust items  Vandvik,         * Reception to       Not reported Hoyeral,           the ward & Fagertum,      * Patient exami- 1990               nation by the                    physician                  * Ward atmos-                    phere and set-                    up                  * Patient exami-                    nation/treat-                    ment by the                    physiotherapist                  * School/                    preschool                  * Information                    (regarding dis-                    ease/treatment)  Table 2. Reliability of the PFSQ                                                N of                                               Cases      Alpha                                                for        for Factors and Items                            Subscale   Subscale  I. Hospital Service and Accommodation          772       .6538  1.  The admission procedure went smoothly. 2.  The unit and patient rooms were clean. 3.  The decor and furnishings were     suitable. 4.  The patient was not disturbed by     noise. 5.  The hospital staff worked together as     a team. 6.  We were adequately prepared for     discharge. 7.  Overall, we were satisfied with the     care we received at UIHC.  II. Nursing Care                               775       .9205  The nurses: 8.  were caring and concerned. 9.  were gentle with the patient. 10. checked the patient's condition     closely. 11. notified the doctor when necessary. 12. were aware of changes in the treatment     plan. 13. gave treatment and medication on time. 14. were skillful with procedures and     equipment. 15. kept us informed. 16. answered our questions clearly. 17. explained the patient's condition and     care in terms we understood. 18. listened to what we had to say. 19. included us in making decisions and     planning care.  III. Medical Care                              770       .8326  The doctors: 20. were caring and concerned. 21. were familiar with the medical     history. 22. were knowledgeable and skillful. 23. were available when needed or called. 24. responded promptly to changes in the     patient's condition. 25. had clear, honest communication with     us. 26. gave us information about treatments     and tests before they were done. 27. kept us informed of test results an of     changes in the patient's condition. 28. gave us complete explanations. 29. answered our questions clearly. 30. included us in making decisions and     planning care.  IV. Child Life Therapy                         371       .5290  The child life therapists: 31. introduced themselves and explained     their function. 32. were caring and supportive. 33. provided assistance to make the pa-     tient's hospital stay less stressful. 34. recognized the patient's individual     needs. 35. provided age-appropriate toys, games,     playrooms, and activities.                                                            * Total                                              Alpha for   Instrument                                              Subscale      Alpha                                               if Item     if Item Factors and Items                             Deleted     Deleted  I. Hospital Service and Accommodation  1.  The admission procedure went smoothly.     .6546       .8290 2.  The unit and patient rooms were clean.     .6398       .8281 3.  The decor and furnishings were     suitable.                                  .6205       .8264 4.  The patient was not disturbed by     noise.                                     .6546       .8246 5.  The hospital staff worked together as     a team.                                    .5744       .8223 6.  We were adequately prepared for     discharge.                                 .5998       .8283 7.  Overall, we were satisfied with the     care we received at UIHC.                  .5835       .8240  II. Nursing Care  The nurses: 8.  were caring and concerned.                 .9136       .8268 9.  were gentle with the patient.              .9158       .8272 10. checked the patient's condition     closely.                                   .9160       .8261 11. notified the doctor when necessary.        .9154       .8253 12. were aware of changes in the treatment     plan.                                      .9205       .8271 13. gave treatment and medication on time.     .9184       .8230 14. were skillful with procedures and     equipment.                                 .9149       .8261 15. kept us informed.                          .9112       .8231 16. answered our questions clearly.            .9085       .8230 17. explained the patient's condition and     care in terms we understood.               .9119       .8229 18. listened to what we had to say.            .9105       .8238 19. included us in making decisions and     planning care.                             .9089       .8228  III. Medical Care  The doctors: 20. were caring and concerned.                 .9221       .8758 21. were familiar with the medical     history.                                   .8197       .8223 22. were knowledgeable and skillful.           .8183       .8234 23. were available when needed or called.      .8127       .8219 24. responded promptly to changes in the     patient's condition.                       .8154       .8243 25. had clear, honest communication with     us.                                        .8018       .8177 26. gave us information about treatments     and tests before they were done.           .8066       .8179 27. kept us informed of test results an of     changes in the patient's condition.        .8018       .8153 28. gave us complete explanations.             .8013       .8165 29. answered our questions clearly.            .8048       .8173 30. included us in making decisions and     planning care.                             .8042       .8167  IV. Child Life Therapy  The child life therapists: 31. introduced themselves and explained     their function.                            .4582       .8270 32. were caring and supportive.                .4167       .8227 33. provided assistance to make the pa-     tient's hospital stay less stressful.      .4098       .8226 34. recognized the patient's individual     needs.                                     .8992       .8734 35. provided age-appropriate toys, games,     playrooms, and activities.                 .4300       .8257                                               ** Instru-                                              ment Alpha                                                if Item                                                Deleted                                              (Subscales Factors and Items                            I, II, III)  I. Hospital Service and Accommodation  1.  The admission procedure went smoothly.      .8980 2.  The unit and patient rooms were clean.      .8967 3.  The decor and furnishings were     suitable.                                   .8959 4.  The patient was not disturbed by     noise.                                      .8993 5.  The hospital staff worked together as     a team.                                     .8921 6.  We were adequately prepared for     discharge.                                  .8946 7.  Overall, we were satisfied with the     care we received at UIHC.                   .8919  II. Nursing Care  The nurses: 8.  were caring and concerned.                  .8942 9.  were gentle with the patient.               .8945 10. checked the patient's condition     closely.                                    .8936 11. notified the doctor when necessary.         .8937 12. were aware of changes in the treatment     plan.                                       .8930 13. gave treatment and medication on time.      .8932 14. were skillful with procedures and     equipment.                                  .8939 15. kept us informed.                           .8920 16. answered our questions clearly.             .8918 17. explained the patient's condition and     care in terms we understood.                .8925 18. listened to what we had to say.             .8915 19. included us in making decisions and     planning care.                              .8907  III. Medical Care  The doctors: 20. were caring and concerned.                  .9274 21. were familiar with the medical     history.                                    .8949 22. were knowledgeable and skillful.            .8936 23. were available when needed or called.       .8922 24. responded promptly to changes in the     patient's condition.                        .8929 25. had clear, honest communication with     us.                                         .8902 26. gave us information about treatments     and tests before they were done.            .8919 27. kept us informed of test results an of     changes in the patient's condition.         .8899 28. gave us complete explanations.              .8909 29. answered our questions clearly.             .8909 30. included us in making decisions and     planning care.                              .8900  IV. Child Life Therapy  The child life therapists: 31. introduced themselves and explained     their function. 32. were caring and supportive. 33. provided assistance to make the pa-     tient's hospital stay less stressful. 34. recognized the patient's individual     needs. 35. provided age-appropriate toys, games,     playrooms, and activities.  * N of cases = 327, alpha for total instrument with 35 items = .8303  ** N of cases = 675, alpha for total instrument with 30 items = .8974  Table 3. Factor Matrix                                                      Fac-     Fac- Items                                               tor I   tor II  1.  The admission procedure went smoothly. 2.  The unit and patient rooms were clean.                   .228 3.  The decor and furnishings were suitable.         .313 4.  The patient was not disturbed by noise.          .294 5.  The hospital staff worked together as a team.    .450 6.  We were adequately prepared for discharge.       .442 7.  Overall, we were satisfied with the care we     received at UIHC.                                .588    .383  The nurses: 8.  were caring and concerned.                       .717 9.  were gentle with the patient.                    .677 10. checked the patient's condition closely.         .635 11. notified the doctor when necessary.              .656 12. were aware of changes in the treatment plan.     .570 13. gave treatment and medication on time.           .577 14. were skillful with procedures and equipment.     .609 15. kept us informed.                                .719    .201 16. answered our questions clearly.                  .835 17. explained the patient's condition and care in     terms we understood.                             .758    .248 18. listened to what we had to say.                  .820 19. included us in making decisions and planning     care.                                            .802    .207  The doctors: 20. were caring and concerned. 21. were familiar with the medical history.                  .638 22. were knowledgeable and skillful.                         .735 23. were available when needed or called.            .254    .605 24. responded promptly to changes in the     patient's condition.                             .204    .624 25. had clear, honest communication with us.         .263    .813 26. gave us information about treatments and     tests before they were done.                     .209    .694 27. kept us informed of test results and of                  .702     changes in the patient's condition.              .315    .836 28. gave us complete explanations.                   .221    .838 29. answered our questions clearly. 30. included us in making decisions and planning     care.                                            .334    .691 

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SPECIAL RESEARCH ISSUE ON PARENTS

The purpose of this continuing education series is to foster the pediatric nurse's understanding of parents of children undergoing health care experiences.

Providing quality care to children who are ill, disabled, or hospitalized includes giving attention to the needs, concerns, and wisdom of the parents. Nurses with a greater understanding of parents' experiences when their children are acutely or chronically ill are better prepared to provide the support and knowledge parents need to care for their children as well as the skills needed to cope with the stressors that accompany these experiences.

This continuing education series features three research articles on parent issues. The first article presents the results of research that compared satisfaction with social support received, perception of the impact of the child's illness, and coping behaviors of parents of children with life threatening and non-life threatening chronic illness. The second article discusses findings of a study that compared outcomes for parents who participated in empowering and traditional approaches to asthma education. The third article reports on the psychometric testing of the Pediatric Family Satisfaction Questionnaire (PFSQ).

ASSIGNMENT

Katz, S. (2002). Severity of child's chronic illness and parents' social support, perception, and coping behaviors. Pediatric Nursing, 28(5), 453-463.

McCarthy, M., Herbert, R., Brimacombe, M., Hansen, J., Wong, D., & Zelman, M. Empowering parents through asthma education. Pediatric Nursing, 28(5), 465-473.

Bragadottir, H., & Reed, D. (2002). Psychometric instrument evaluation: The Pediatric Family Satisfaction Questionnaire. Pediatric Nursing, 28(5), 475-482.

 Earn 3.0 Contact Hours  Questions  1.  In Katz's study, the least frequently used     coping behavior of parents of children with     life threatening illnesses was      a. keeping close contact with the medical        services.     b. distancing oneself from the family.     c. involvement in the care of the child.     d. use of emotional coping behaviors.     e. use of family integration coping behaviors.  2.  The likely reason that parents of children     with non-life threatening illnesses generally     used fewer coping behaviors than parents     of children with life threatening illnesses     was      a. the higher frequency of hospital visits of        the parents of children with non-life        threatening illness.     b. parents of children with non-life threatening        illnesses use more family coping        behaviors.     c. the chronic fatigue of parents whose        children had non-life threatening illnesses.     d. parents of children with non-life threatening        illnesses have less compelling        reasons to use a wide array of coping        behaviors.     e. parents of children with non-life threatening        illnesses use their social support        system to a greater extent.  3.  Katz proposes that fathers of children with     life threatening illnesses expressed satisfaction     with the social support received     from the medical team because      a. they received more informal support        from significant others.     b. they were less involved in the care of the        child.     c. they had more frequent contact with        their children and increased decision        making than fathers in the past.     d. the family participated in medical consultations.     e. the medical team discussed the illness        only with fathers.  4.  The lack of significant differences between     fathers and mothers of children with life     threatening and non-life threatening illnesses     in the perception of the child's illness     was most likely influenced by      a. the cultural factor that encouraged        fathers to participate in the care of the        child.     b. the economic factor--the parents' concerns        about the financial situation.     c. the high cost of medical care for chronic        illnesses in Israel.     d. the fact that fathers and mothers shared        identical concerns regarding the child's        illness.     e. similar personality traits of parents influenced        their perception of the illness.  5.  Recommendations for clinical nursing     included      a. discouragement of the use of too many        coping behaviors.     b. encouragement of families to be self-supportive.     c. discouragement of expression of frustration        and denial.     d. referral of parents to spiritual guidance        and help.     e. provision of relevant illness-related        information to the parents.  6.  During the past two decades asthma rates     have increased more dramatically in adults     than in children.      a. True.     b. False.  7.  Which of the following is considered to be     the 'cornerstone of asthma management?'      a. Individualized pharmacotherapy.     b. Patient education.     c. Exercise program.     d. Environmental control.  8.  Which of the following factors have been     documented as consequences of empowerment?      a. A partnership between clients and professionals.     b. Mutual respect and trust.     c. Mutual decision making.     d. All of the above.     e. None of the above.  9.  Educational programs are more likely to     have empowering outcomes for participants     when      a. the educator uses an authoritarian        approach to deliver the educational program.     b. expert professionals provide the educational        sessions.     c. content is based on the educator's and        participants' perceptions of learning        needs.     d. the nurse educator is positioned as the        expert, and parents' expertise is not promoted.     e. the focus of the program is on provision of        information.  10. McCarthy and colleagues compared outcomes     for parents who participated in     empowering and traditional approaches to     asthma education. Which of the following     outcomes showed comparable results     between the two groups of parents?      a. Knowledge.     b. Sense of control.     c. Ability to make decisions.     d. Ability to provide care.  11. The most common method for tesing the     internal consistency of an instrument is     Cronbach's coefficient alpha. For new instruments     under developent, what is considered     a satisfactory Cronbach's coefficient alpha?      a. .10.     b. .30.     c. .50.     d. .70.     e. .90.  12. For well-established instruments, what is     considered a satisfactory Cronbach's coefficient     alpha?      a. .20.     b. .40.     c. .60.     d. .80.     e. 1.00.  13. Factor analysis is the most common statistical     analysis for construct validity testing.     What does this test involve?      a. Testing the interrelationship among        items that measure different concepts.     b. Testing the interrelationship among        items that measure the same concept or        factor.     c. Testing the relationship between the        items of an instrument and the theoretical        framework of a study.     d. Testing an instrument for a given setting        and population.     e. Testing the relationship between the reliability        and the validity of an instrument.  14. The results of the reliability testing of the     PFSQ showed a Cronbach's coefficient     alpha of .83. What does this indicate?      a. High internal consistency between        items.     b. Low internal consistency between        items.     c. High factor loading of items.     d. Low factor loading of items.     e. None of the above.  15. The construct validity testing of the PFSQ     in this study indicated that changes need     to be made on the instrument. The factor     analysis indicated      a. four main factors: hospital services and        accommodation, nursing care, medical        care, and child life therapy.     b. three main factors: nursing care, medical        care, and child life therapy.     c. three main factors: hospital services and        accommodation, nursing care, and        medical care.     d. two main factors: nursing care and medical        care.     e. one main factor: nursing care 

Objectives:

1. Discuss the importance of pediatric nurses assuming a family-centered approach to patient care.

2. Discuss examples of issues facing parents of ill, disabled, or hospitalized children.

3. List three features of an empowering approach to asthma education.

4. Describe the steps needed to select an instrument to measure parent satisfaction.

5. Identify additional opportunities pediatric nurses may have to learn more about the parents' perspective.

This activity for 3.0 contact hours is provided by Anthony J. Jannetti, Inc., which is accreditted as a provider of continuing education in nursing by the American Nurses Credentialing Center's Commission on Accreditation (ANCC-COA). Anthony J. Jannetti, Inc. is an approved provider of continuing education by the California Board of Registered Nursing, CEP No. 5387.

Articles accepted for publication in the continuing education series are refereed manuscripts that are reviewed in the standard Pediatric Nursing review process with other articles appearing in the journal.

This test was reviewed and edited by Judy A. Rollins, MS, RN, Pediatric Nursing associate editor; Veronica D. Feeg, PhD, RN, FAAN, Pediatric Nursing editor; and Marion E. Broome, PhD, RN, a Pediatric Nursing Editorial Board member.

[ILLUSTRATION OMITTED]

Helga Bragadottir, PhD(c), MSN, RN, is Nursing Director, Landspitali-University Hospital, Reykjavik, Iceland, and Doctoral Student, The University of Iowa College of Nursing, Iowa City, IA.

David Reed, PhD, is Assistant Research Scientist, The University of Iowa College of Nursing, Iowa City, IA.