Preparing research instruments for use with different cultures

The Finnish versions of food allergy quality of life questionnaires including parent form 10

AIM

Examining health-related quality of life (HRQoL) is important to improve patient care. In this study, we translate and evaluate the Finnish versions of the Food Allergy Specific Quality of Life Questionnaires (FAQLQs) from a Finnish perspective and undertake a detailed evaluation of the 10-question Parent Form Questionnaire (FAQLQ-PF10).

METHODS

This validation study was performed to evaluate the Finnish versions of the FAQLQs. Validation was performed by analysing clinical characteristics, factor loadings and Cronbach's α reliability estimates. The inclusion criteria for participants in this study were having a doctor-diagnosed food allergy or being a parent of a child with a doctor-diagnosed food allergy and being able to answer the questionnaire in Finnish.

RESULTS

Altogether, 247 questionnaires were completed in this study. Most of the respondents had multiple food allergies (77%, 189/247). Spearman's correlations related to the 10-question parent form (FAQLQ-PF10), the 30-question parent form (FAQLQ-PF) and the Food Allergy Severity Measurement-Parent Form (FAIM-PF) were statistically significant (p value = 0.000-0.007). The reliability of the Finnish versions of the FAQLQs measured by Cronbach's α was overall good (0.75-0.981).

CONCLUSION

The Finnish versions of the FAQLQs are reliable and suitable to use, and the FAQLQ-PF10 has good usability.

Psychometric testing of a Danish version of the empowerment of parents in the intensive care - Neonatology questionnaire has confirmed validity

AIM

Investigating parent satisfaction with care is important to guide quality development. In this study, we translated and validated a Danish version of the empowerment of parents in the intensive care - neonatology (EMPATHIC-N) questionnaire to determine validity in Danish contexts.

METHOD

A psychometric study design was applied. Translation was performed according to recommended international standards. Confirmatory factor analyses including standardised factor loadings, Cronbach's α reliability estimates, congruent validity and non-differential validity testing were applied. The study was performed from June 2017 to November 2019 at a 33-bed level IV neonatal intensive care unit.

RESULTS

Participants were 311 parents (response rate = 42,8%). Confirmative factor analyses disclosed a moderate model fit of the instrument with Comparative Fit Index (CFI) values of 0.83-0.92. Cronbach's α showed good reliability (0.82-0.93). Congruent validity showed good positive correlations (0.48-0.71) between the instrument domains and four overall satisfaction indicators. In search of improved model fit, a version including 27 items was tested. This version showed a better model fit with CFI values of 0.92-0.99 and satisfactory Cronbach's α values.

CONCLUSIONS

Model fit for the Danish full EMPATIC-N was moderate. The shorter version showed better psychometric properties.

End-of-life decisions and practices as viewed by health professionals in pediatric critical care: A European survey study

BACKGROUND AND AIM

End-of-Life (EOL) decision-making in paediatric critical care can be complex and heterogeneous, reflecting national culture and law as well as the relative resources provided for healthcare. This study aimed to identify similarities and differences in the experiences and attitudes of European paediatric intensive care doctors, nurses and allied health professionals about end-of-life decision-making and care.

METHODS

This was a cross-sectional observational study in which we distributed an electronic survey to the European Society of Paediatric and Neonatal Intensive Care (ESPNIC) members by email and social media. The survey had three sections: (i) 16 items about attitudes to EOL care, (ii) 14 items about EOL decisions, and (iii) 18 items about EOL care in practice. We used a 5-point Likert scale and performed descriptive statistical analysis.

RESULTS

Overall, 198 questionnaires were completed by physicians (62%), nurses (34%) and allied health professionals (4%). Nurses reported less active involvement in decision-making processes than doctors (64% vs. 95%; p < 0.001). As viewed by the child and family, the child's expected future quality of life was recognised as one of the most critical considerations in EOL decision-making. Sub-analysis of Northern, Central and Southern European regions revealed differences in the optimal timing of EOL decisions. Most respondents (n = 179; 90%) supported discussing organ donation with parents during EOL planning. In the sub-region analysis, differences were observed in the provision of deep sedation and nutritional support during EOL care.

CONCLUSIONS

This study has shown similar attitudes and experiences of EOL care among paediatric critical care professionals within European regions, but differences persist between European regions. Nurses are less involved in EOL decision-making than physicians. Further research should identify the key cultural, religious, legal and resource differences underlying these discrepancies. We recommend multi-professional ethics education to improve EOL care in European Paediatric Intensive Care.

Is paediatric endotracheal suctioning by nurses' evidence based? An International Survey

BACKGROUND

Endotracheal suction (ETS) is essential in intubated patients to prevent tube occlusion and is one of the most common nursing interventions performed in intensive care.

AIMS AND OBJECTIVES

To explore how paediatric ETS practices reflect evidence-based practice (EBP) recommendations in paediatric intensive care units (PICU) worldwide.

STUDY DESIGN AND METHODS

A cross-sectional electronic survey linked to a real patient suction episode. Nurses completed the survey following a recent ETS episode. Evidence-based practice (EBP) was defined based on four of the American Association for Respiratory Care (AARC) best evidence recommendations: pre-oxygenation before suction, use of a suction catheter no more than half the diameter of the tracheal tube, shallow depth of suction, and the continuous suction applied upon withdrawal of the catheter. Participants included PICU nurses who performed ETS in children (0-17 years) excluding preterm neonates.

RESULTS

Four hundred forty-six complete surveys were received from 20 countries. Most nurses (80%, 367/446) reported that their units had local guidelines for ETS. The most common reason for suctioning (44%) was audible/visible secretions. Over half of ETS episodes (57%) used closed suction. When exploring the individual components of suction, 63% (282/446) of nurses pre-oxygenated their patient prior to suction, 71% (319/446) suctioned no further than 0.5 cm past end of the endotracheal tube (ETT), 59% (261/446) used a catheter no more than half the diameter of the ETT, and 78% (348/446) used continuous negative pressure. 24% of nurses gave patients an additional bolus of sedative, analgesic, and/or muscle-relaxant medication prior to suction; this decision was not related to the child's history of instability with suction, as there was no significant difference in those who reported patients had a history of being unstable with suction (P = .80). 26% (117/446) of nurses complied with all four EBP components in the reported suctioning episode.

CONCLUSIONS

Considerable variation in paediatric endotracheal suctioning practices exists internationally. Although most nurses applied single components of evidence-based recommendations during ETT suctioning, just a quarter applied all four elements.

RELEVANCE TO CLINICAL PRACTICE

Nurses' need to consider and strive to apply EBP principles to common nursing interventions such as ETS.

Barriers to Delivery of Enteral Nutrition in Pediatric Intensive Care: A World Survey

OBJECTIVES

To explore the perceived barriers by pediatric intensive care healthcare professionals (nurses, dieticians, and physicians) in delivering enteral nutrition to critically ill children across the world.

DESIGN

Cross-sectional international online survey adapted for use in pediatric settings.

SETTING

PICUs across the world.

SUBJECTS

PICU nurses, physicians, and dietitians.

INTERVENTIONS

The 20-item adult intensive care "Barriers to delivery of enteral nutrition" survey was modified for pediatric settings, tested, and translated into 10 languages. The survey was distributed online to pediatric intensive care nurses, physicians, and dieticians via professional networks in March 2019 to June 2019. Professionals were asked to rate each item indicating the degree to which they perceived it hinders the provision of enteral nutrition in their PICUs with a 7-point Likert scale from 0 "not at all a barrier" to 6 "an extreme amount."

MEASUREMENT AND MAIN RESULTS

Nine-hundred twenty pediatric intensive care professionals responded from 57 countries; 477 of 920 nurses (52%), 407 of 920 physicians (44%), and 36 of 920 dieticians (4%). Sixty-two percent had more than 5 years PICU experience and 49% worked in general PICUs, with 35% working in combined cardiac and general PICUs. The top three perceived barriers across all professional groups were as follows: 1) enteral feeds being withheld in advance of procedures or operating department visits, 2) none or not enough dietitian coverage on weekends or evenings, and 3) not enough time dedicated to education and training on how to optimally feed patients.

CONCLUSIONS

This is the largest survey that has explored perceived barriers to the delivery of enteral nutrition across the world by physicians, nurses, and dietitians. There were some similarities with adult intensive care barriers. In all professional groups, the perception of barriers reduced with years PICU experience. This survey highlights implications for PICU practice around more focused nutrition education for all PICU professional groups.

Perceived language proficiency and pain assessment by registered and student nurses in native English-speaking and EAL children aged 4-7 years

AIMS AND OBJECTIVES

To identify the factors that influence decisions made by health professionals when assessing the pain of native English speaking and children whose English is an additional language.

BACKGROUND

Pain assessment in children is often poorly executed following acute injury. Whilst a range of pain assessment tools have been developed, little guidance is provided for assessing pain in children with English as an additional language.

DESIGN

Factorial survey design.

METHODS

Twenty minor injuries unit nurses and 20 children's nursing students participated in an electronic survey to make judgements on 12 scenarios describing a child attending a minor injuries unit following an incident, accompanied by a parent. Respondents had to decide the most important form of pain assessment, and whether they would ask a parent or an interpreter to assess the pain of the child. An open-ended question asked about the difficulties found in making a judgement.

RESULTS

Observation of the child's behaviour was the most common pain assessment reported. The visual analogue scale was significantly associated with children with proficient English. Respondents were significantly more likely to involve parents in the assessment if they could speak English well compared to parents with poor English skills. Moreover, nursing students were significantly more likely than registered nurses to call for support from an interpreter. Thematic analysis identified three themes related to difficulties with pain assessment: contrasting approaches, differing perceptions of pain and overcoming challenges.

CONCLUSIONS

The reduced ability to communicate between child, parent and healthcare professional highlights the need to identify forms of assessment based on individual cases.

RELEVANCE TO CLINICAL PRACTICE

The number of children with English as an additional language has seen a marked rise over the last decade. In situations where communication ability is reduced, assessment of pain should be tailored to meet the needs of the child. This may require timely access to interpreter services.

Comparison of the Center for Epidemiology Studies Depression Scale and Beck Depression Inventory for Research with Latinas

U.S. Latino farmworkers face multiple potential stressors. Research on the mental health status of this U.S. Latino subgroup has suggested high prevalence of stress, anxiety, and depressive symptoms when compared to other groups. Latina farmworkers may be at greater risk than their male counterparts for poor mental health because they confront many of the same stressors but may experience additional difficulties including domestic violence, taking on new roles and responsibilities on top of traditional ones, and being expected to maintain the health and integrity of their families at the expense of their own needs. Most of the research on Latino/Latina farmworker mental health has focused on identifying prevalence of mental health symptoms and the vulnerabilities that predict these symptoms. A variety of instruments with English and Spanish versions have been employed to measure depressive symptoms in U.S. Latinos. Two such instruments, the Center for Epidemiology Studies Depression Scale and the Beck Depression Inventory, are evaluated in this article to determine which is more valid, reliable, relevant, and useful for a proposed study on stress, social support, coping, and depression in U.S. Latina farmworkers and which is more congruent with the study's conceptual framework, Lazarus and Folkman's transactional model of stress, appraisal, and coping. Though each instrument is shown to have certain advantages over the other, neither is definitively judged to be more appropriate for this largely unexplored subgroup. What is proposed instead is to conduct a mixed methods study to further evaluate the potential applicability of each instrument.

Measurement of parent satisfaction in the paediatric intensive care unit - Translation, cultural adaptation and psychometric equivalence for the French-speaking version of the EMPATHIC-65 questionnaire

INTRODUCTION

Within paediatric intensive care units (PICUs), only a few parent satisfaction instruments are validated and none are available for French-speaking parents. The aims of the study were to translate and culturally adapt the Dutch EMPATHIC-65 questionnaire into a French version and to test its psychometric equivalence.

METHODS

Two French-speaking PICUs in Switzerland and France participated. The questionnaire was translated using a standardised method and parents with PICU experience were interviewed to assess clarity of the translated version. Secondly, parents of children hospitalised for at least 24 hours and who were fluent in French, were invited to complete the French translated version of the EMPATHIC-65 questionnaire. Reliability and validity measures were used to examine its psychometric equivalence.

RESULTS

The overall mean clarity agreement reached 90.2% by 17 French-speaking parents. Eight unclear items have subsequently been reworded. One hundred seventy-two parents completed the French version questionnaire. Reliability and convergent validity have been confirmed by an adequate internal consistency (0.59-0.89) and convergent validity (r_s 0.25-0.63, p<0.01).

CONCLUSION

Psychometric equivalence of the French EMPATHIC-65 questionnaire highlights the appropriateness of relying on available valid instrument to expand the availability of health instrument measure in French.

Development and psychometric testing of ventilator bundle questionnaire and observation schedule

BACKGROUND

There is a current lack of valid and reliable instruments that can be used to examine critical care nurses' knowledge and skills in adhering to ventilator bundles. The aim of this study was to develop and psychometrically test a ventilator bundle questionnaire (VBQ) and ventilator bundle observation schedule (VBOS).

METHODS

The VBQ and VBOS consisted of a list of pharmacologic and nonpharmacologic nurse-led interventions taken from the literature and supported by various levels of evidence. After content validation, stability and equivalence reliabilities of the VBOS were determined in a randomly selected sample of critical care nurses from a single academic center in Finland.

RESULTS

The final VBQ contained 49 multiple-choice questions, and the VBOS had 86 dichotomous items, whose overall content validity ranged from 0.99 to 1.0. The overall intraclass correlation coefficient of the VBOS ranged from 0.93 to 1.0.

CONCLUSIONS

The VBQ and VBOS have acceptable psychometric properties and could be used to objectively assess whether evidence-based guidelines regarding ventilator bundles are being used in clinical practice. Further testing with diverse samples is needed to strengthen the validity and reliability of these instruments.

Cross-cultural validation of the revised temperament and character inventory in the Bulgarian language

RATIONALE, AIMS AND OBJECTIVES

Health-care professions have long been considered prone to work-related stress, yet recent research in Bulgaria indicates alarmingly high levels of burnout. Cloninger's inventory is used to analyse and evaluate correlation between personality characteristics and degree of burnout syndrome manifestation among the risk categories of health-care professionals. The primary goal of this study was to test the conceptual validity and cross-cultural applicability of the revised TCI (TCI-R), developed in the United States, in a culturally, socially and economically diverse setting.

METHODS

Linguistic validation, test-retest studies, statistical and expert analyses were performed to assess cross-cultural applicability of the revised Cloninger's temperament and character inventory in Bulgarian, its reliability and internal consistency and construct validity.

RESULTS

The overall internal consistency of TCI-R and its scales as well as the interscale and test-retest correlations prove that the translated version of the questionnaire is acceptable and cross-culturally applicable for the purposes of studying organizational stress and burnout risk in health-care professionals.

CONCLUSIONS

In general the cross-cultural adaptation process, even if carried out in a rigorous way, does not always lead to the best target version and suggests it would be useful to develop new scales specific to each culture and, at the same time, to think about the trans-cultural adaptation.

Development and validation of a neonatal intensive care parent satisfaction instrument

OBJECTIVE

To develop and test the psychometric properties of the EMPATHIC-N (EMpowerment of PArents in THe Intensive Care-Neonatology) questionnaire measuring parent satisfaction.

DESIGN

A psychometric study testing the reliability and validity of a parent satisfaction questionnaire by applying confirmatory factor analysis including standardized factor loadings and subsequently Cronbach's α reliability estimates across time, congruent validity, and nondifferential validity testing.

SETTING

A 30-bed neonatal intensive care unit in a university hospital.

PATIENTS

Two cohorts with a total of 441 parents whose child was admitted to the neonatal intensive care unit, January to December 2009.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

In the first cohort, 220 of 339 (65%) parents responded; in the second cohort, 59 of 102 (58%) parents responded. Structural equation modeling and confirmatory factor analysis resulted in a sufficient model fit of 57 statements within five domains: Information, Care & Treatment, Organization, Parental Participation, and Professional Attitude. Standardized factor loading of these statements were between 0.58 and 0.91. Reliability measures, Cronbach's α, of the domains ranged from 0.82 to 0.95. Reliability across time showed no evidence of statistically significant differences between the domains. Congruent validity was confirmed by a good correlation (p = .01) between the domains and four general satisfaction questions. Nondifferential validity showed no significant effect sizes between the infants' characteristics and the domains, except between ventilated infants and parent participation statements and infants ≥30 wks gestational age and organizational statements.

CONCLUSIONS

The EMPATHIC-N questionnaire is a valid quality performance indicator to measure the delivered care as perceived by parents.

The impact of language on the expression and assessment of pain in children

This paper focuses on the importance of language in the expression of pain. Variation in definitions of pain is presented, together with a review of the evidence examining the impact language may have on the way pain is expressed linguistically. The implications for conducting research with children who speak different languages are explored. Strategies such as using non-linguistic methods of communication, additional time required for conducting interviews and the inclusion of research team members from the same ethnic or linguistic background are presented.

Construction and psychometric testing of the EMPATHIC questionnaire measuring parent satisfaction in the pediatric intensive care unit

Purpose

To construct and test the reliability and validity of the EMpowerment of PArents in THe Intensive Care (EMPATHIC) questionnaire measuring parent satisfaction in the pediatric intensive care unit (PICU).

Methods

Structured development and psychometric testing of a parent satisfaction-with-care instrument with the results of two cohorts of parents (n = 2,046) from eight PICUs in the Netherlands.

Results

In the first cohort, 667/1,055 (63%) parents participated followed by 551/991 (56%) parents in the second cohort. The empirical structure of the instrument was established by confirmatory factor analysis with the first sample of parents confirming 65 statements within five theoretically conceptualized domains: information, care and cure, organization, parental participation, and professional attitude. The standardized factor loadings were greater than 0.40 in 63 statements. Cronbach’s α, a measure of reliability, per domain ranged from 0.73 to 0.93 in both cohorts with no significant difference documenting the reliability over time. Beside rigorous content and face validity, the congruent validity of the instrument showed adequate correlation with four gold standard questions measuring overall satisfaction. The non-differential validity was confirmed with no significant differences between the population characteristics and the domains, except that parents with a child for a surgical admission were more satisfied on information issues.

Conclusions

The final EMPATHIC questionnaire incorporates 65 statements. The empirical structure of the satisfaction statements and domains was satisfactory. The reliability and validity proved to be adequate. The EMPATHIC questionnaire is a valid quality performance indicator to measure quality of care as perceived by parents.

Practical problems of doing research across different cultures: experiences from the RACHEL study

For many nurses the thought of conducting a research study, even one based in one centre, is daunting but coordinating a multi-centred study across different countries with different cultures can seem overwhelming. Some of the practical problems of doing research across different cultures are predictable and can be planned for, while others may surface as the study is started and need to be reacted to as they happen. Clear lines of communication are therefore essential. This article discusses some of the issues and problems that can occur using examples from a large multi-national nursing study by the RACHEL group.