Participants
Participants were recruited from seven hospitals with registered nurses. The surveys were conducted by the authors of the present study in Shanghai, Hangzhou, and Nanjing, China (samples 1-2; ZhB), and in Shanghai (sample 3; HJ). Participants in sample 1 were invited to complete the initial 33-item NPPBQ; participants in sample 2 were invited to complete the final 17-item NPPBQ; and participants in sample 3 were invited to complete the 17-item NPPBQ and the Maslach Burnout Inventory (MBI) to evaluate the concurrent validity of the NPPBQ. Participants in samples 1-3 provided written informed consent to complete the 33-item NPPBQ, the 17-item NPPBQ, and the MBI and to supply their demographic characteristics (gender, years working, education, and marital status). Data for three samples were shared with all authors of the present study through data use agreements. The detailed demographic characteristics are listed in Table 1.
Instruments
The survey consisted of a demographic information form, the NPPBQ and the MBI. The MBI [11] is a self-evaluation tool that uses the 7-point Likert rating method. It has a total of 22 items in three domains: emotional exhaustion; depersonalization; and reduced personal accomplishment. The MBI has been translated into a variety of languages and is currently a universal tool for measuring job burnout in various occupational groups. It is also widely used in the field of nursing with high reliability and validity.
Steps
Step 1: item generation
The development of the items on the pilot and final versions of the NPPBQ occurred in four steps described as follows.
Concept definition:
First, the definition of preceptors’ perceived professional benefits, the 5-dimension NPPB conceptual framework developed by Hu and Liu [12], existing measures, interviews with 23 nurses, and the empirical literature discussing professional benefits or rewards were reviewed and evaluated to provide the definition and to generate items. Considering the impact of understanding and support from the medical team, society, family and patients on the perceived benefits of the nursing profession, NPPB was defined as the gains and benefits nurses perceived that they received from their profession in the process of employment and the belief that engaging in the nursing profession can promote their all-round growth and development. Specifically, five dimensions were distinguished as follows: (1) positive occupational perception; (2) good nurse-patient relationship; (3) recognition from family, relatives, and friends; (4) sense of belonging to a team; and (5), and self-growth (see Supplementary Table 1).
Initial pool of items:
Thereafter, thirty-seven potential items were created to reflect the NPPB construct. The criterion for including an item in the pool of potential items was that the item should fit one of the five potential dimensions (positive occupational perception, good nurse-patient relationship, recognition from others, sense of belonging to a team, and self-growth) and/or relate to the benefits perceived by the nurse as a nurse.
Content validity:
A panel of experts (independent) and judges (five associate nursing professors, two clinical psychology professors, and 14 clinical nurses with more than five years of experience) discussed, evaluated, and modified these potential items based on the following three principles: (1) whether the items were in accordance with the content of the nurses’ professional benefits; (2) whether the items were suitable and consistent with the NPPB definition and conceptual components; and (3) whether the wording of the items was concise and accurate. Following the above procedure, the first pool of items was reduced to 33 items after the examination and assessment by the judges.
Creation of the pilot version:
Following the recommendations by Jing Hu and Xiaohong Liu [10], who stated that the measurement of NPPB is more suitable using a five-level Likert scale, 5 response categories ranging from 1 (strongly disagree) to 5 (strongly agree) were used. The following instructions were given: “Nurses’ perceived professional benefits are the gains and benefits that nurses perceive that the profession brings to them in the process of practice and the belief that the nursing profession can promote the overall growth of the self. What benefits and gains do you feel you have experienced from your career? Please read the following statements carefully, consider how well each statement fits your real idea or situation, and click “√” according to your personal experience (1=Strongly disagree, 2=Disagree, 3=Not sure, 4=Agree, 5=Strongly agree). There are no “wrong” answers. Please choose only one answer for each statement”.
Step 2: item reduction (exploratory factor analysis)
For this step, IBM Statistics SPSS version 22.0 was used for the sample 1 data analysis to carry out the preliminary psychometric validation of the NPPBQ. The primary aim of this analysis was to examine the hypothesized factor structure and reduce the 33-item questionnaire to a smaller set of high-performing items to create the final version of the NPPBQ. Therefore, the fixed factor method was used as the criterion to decide the number of dimensions, and an EFA was conducted to test whether the items were consistent with the pre-defined sub-dimensions of the questionnaire (item homogeneity). Based on the results, inconsistent items were removed [13] (items were inconsistent with the pre-defined sub-dimensions; low factor loadings, i.e., <0.70; low total Cronbach’s alpha if the item was deleted; and low item-questionnaire correlations, i.e., <0.40), and those items that best reflected the definition and theoretical dimensions of the perceived professional benefits described above were retained. The subsequent items were re-rotated after the removal of items following the factor analysis. Each time an item was deleted, it was re-rotated. The main axis factor rotation method was used for each rotation. Sixteen items were removed during the initial screen, and the items with factor loadings greater than 0.70 were retained. Finally, the 17 items retained in this step were used to create a pilot questionnaire (see Supplementary Table 1).
Step 3: verification
The analysis in step 3 was conducted to further verify the NPPBQ using a different sample from similar groups. A confirmatory factor analysis with maximum likelihood estimation was conducted to test the underlying factor structure of the NPPBQ. First, the loading values of the first item of each factor were fixed to zero, i.e., the loading values of items A1_7, A2_3, A3_4, A4_5, and A5_7 (see Figure 1) were set to zero. Second, the inter-factor correlations were not set as fixed zero values because the oblique rotation method was used. There are clear predictions regarding the dimension structure of the measure analyzed. Regarding the CFA analyses, the following multiple indices of fit were considered: the ratio of the χ2 to its degrees of freedom (df), the standardized root mean square residual (SRMR), the root mean square error of approximation (RMSEA), the comparative fit index (CFI), the normed fit index (NFI), the Tucker-Lewis index (TLI), and the goodness of fit index (GFI). Amos 24.0 was used to analyze the data of sample 3 in step 3. RMSEA and RMR values of 0.06 or below are indicative of a good fit, and values >0.06 to 0.08 are considered an acceptable fit. For the GFI, CFI, NFI, and TLI, values ≥0.90 are considered a good fit.
Step 4: further validation (concurrent validation)
The primary objective of this step was to assess the stability of the NPPBQ (Guttman split-half coefficient) and to examine its validity in terms of the relationship of the 17-item, five-dimension NPPBQ with the MBI [11]: emotional exhaustion, depersonalization, and reduced personal accomplishment.