In the present study, a sample of 520 mental health nurses was used to evaluate a cross-cultural Chinese adaptation of the PHASe. Initially, factor analysis yielded a scale with a seven-factor structure, which was substantially different from the original four-factor structure (Robson & Haddad, 2012). However, the main aim of this study was to develop a Chinese version of the PHASe for use in studies comparing mental health nurses’ attitudes towards physical healthcare across samples. After EFA was performed with the forced extraction of four factors with an eigenvalue of >1 and factor loading of >0.5, 17 items were loaded on the corresponding factors of the original PHASe. Furthermore, CFA results supported the four-factor, 17-item Chinese version of the PHASe.
EFA on our data confirmed the validity of the four-factor structure of the PHASe, which is similar to the structure of the original instrument. However, 11 items were removed in the Chinese version. The original version of the PHASe, developed in the United Kingdom, comprises 28 items, whereas the Canadian, Turkish, and Chinese versions comprise 15, 24, and 17 items, respectively. Siren et al. (2018) obtained a two-factor model for the Canadian version; the components of involvement and perceived barriers were combined, whereas the smoking component was removed. Ozaslan et al. (2020) obtained a four-factor model for their Turkish version of the PHASe; however, some items were loaded on different factors, and the name of factor 4 was changed because it combined two domains (attitudes to smoking and negative beliefs). These differences may be because mental health nurses in different cultures perceive their role in providing physical healthcare from differing perspectives.
The variance explained by the four-factor model in this study was relatively low (44.2%); however, this finding was consistent with the variance explained by the original version of the PHASe developed in the United Kingdom (42.1%) (Robson & Haddad, 2012) and the validated Canadian (46.8%) (Siren et al., 2018) and Turkish (51.3%) (Ozaslan et al., 2020) versions of the PHASe. These relatively low total variances in the Chinese versions of PHASe suggest that mental health nurses are a relatively homogeneous group, which restricts the range in the measures when performing EFA (Fabrigar et al., 1999). Mental health nurses in Taiwan implement nursing care following the national hospital accreditation standards. The consistent physical health care provision may result in a low total variance.
Both RMSEA and SRMR values supported the 4-factor 17-item Chinese version of the PHASe. Furthermore, each factor consisted of at least three items. All items were loaded on the same corresponding factors as those in the original PHASe (Robson & Haddad, 2012). The intercorrelation results among four factors also achieved the required discriminant validity, indicating that each factor reflected a specific subscale of the Chinese version of the PHASe. Therefore, the Chinese version of the PHASe with four factors and 17 items displayed suitable construct validity.
‘Involvement in physical healthcare’ was determined to be the factor accounting for the highest percentage (19.8%) of variance. This factor also accounted for the highest percentage of variance in the original version of the PHASe (15.5%) (Robson & Haddad, 2012) and the Turkish version of the PHASe (23.1%) (Ozaslan et al., 2020). However, item 1 (“Helping patients control their weight is a responsibility of psychiatric nurses”), item 2 (“Psychiatric nurses should be responsible for providing nutrition advice to patients”), item 4 (“Psychiatric nurses should not provide exercise-related advice to patients”), and item 11(“Psychiatric nurses should provide contraception advice to patients”) were removed from the aforementioned factor in the Chinese version of the PHASe because of low factor loadings (<0.5) in EFA, which is consistent with the findings for the Canadian version (Siren et al., 2018). In the Turkish version, item 1 displayed cross-loading on both “Nurses’ attitudes to involvement in physical health care” and “Nurses’ confidence in delivering physical health care,” and item 4 was removed from the PHASe (Ozaslan et al., 2020). Chee et al. (2018) reported no group difference in both items between generalist-prepared nurses and mental-health nurses in Australia. This finding may be because the PHASe was developed before the World Health Organization’s global recommendations regarding the minimum frequency, duration, intensity, type, and total amount of physical activity required for health (World Health Organization, 2010). Nurses have become aware of the importance of physical activity for noncommunicable disease prevention over the past decade. Therefore, these four items do not have sufficient discriminatory power to evaluate nurses’ attitude toward physical healthcare despite being a crucial contributor. This finding requires further investigation in future studies.
Our results demonstrated that factor 2 (attitude to smoke) was comparable with factor 4 of the original PHASe. Taiwan implemented the Tobacco Hazards Prevention Act in 2009 (Health Promotion Administration, 2019). Over the past decade, all hospitals have become smoke-free environments, and all hospital staff members are required to support the tobacco-free policy, and they have received training to provide smoking-cessation services. The majority of nurses in our study reported not using tobacco in any form. However, a study conducted in Taiwan revealed that mental health nurses had low self-efficacy and practical experience in providing smoking-cessation services for patients diagnosed with serious mental illness (Guo, Wang, & Shu, 2015). Therefore, four of the five items were retained to assess nurses’ attitude toward patients’ smoking cessation.
Four items, item 5 (“Patients with severe psychiatric problems are uninterested in improving their physical health”), item 13 (“Informing patients of the potential effects of medications on their physical health can increase their noncompliance”), item 23 (“My workload restricts me from administering any health-promotion measures to patients”), and item 27 (“Patients are worried about their physical health mostly because of their mental illness”) were removed from the ‘perception of obstacles to engagement in physical healthcare’ factor of the Chinese version of the PHASe, which is similar to the findings (items 13, 23, 27) of the Canadian version of PHASe (Siren et al., 2018). In the Turkish version, both items 13 and 27 were loaded in the “attitudes to smoking and negative beliefs” factor (Ozaslan et al., 2020). These results were not surprising because technology plays a crucial role in health education for patients diagnosed with serious mental illness. In addition, mental health nurses in Taiwan have used health information systems to perform and document health education based on patients’ health needs (Tseng, Liou, & Chiu, 2012).
The known-group validity was assessed, and four of the five hypotheses displayed moderate to small effect sizes, which indicated that the Chinese version of the PHASe and its subscales could discriminate between groups defined using high versus low characteristics affecting mental health nurses’ attitude. However, no significant differences were observed in the mean score of the ‘perception of obstacles to engagement in physical healthcare’ factor for nurses with differing personal and nursing backgrounds. A plausible explanation for this result is that all the items in this domain were negatively phrased items, which could have caused confusion in the participants because one negative phrase can have two types of inferences in Chinese (Chen, Huang, & Politzer-Ahles, 2018). Another possible reason is that the training of mental health nurses in Taiwan follows a system similar to that in the United States and Australia, where nurses qualify as registered nurses before choosing to specialise in mental health, whereas in the United Kingdom, nurses choose to specialise in mental health from the outset of their undergraduate programme and qualify as registered psychiatric nurses. Compared with the sample in the study by Robson et al. (2013), much more nurses with adult nursing care experience participating in our validation study perceived that they have experienced physical health care knowledge and skills. Nevertheless, although the known-group comparison hypothesis of perceived barriers was rejected, our finding provides evidence that nurses in Taiwan perceive the same levels of barriers.
Regarding reliability, the 17-item Chinese version of the PHASe had satisfactory internal consistency, with Cronbach’s α = 0.80 for the entire scale, is comparable to that of the original version (0.77) (Robson & Haddad, 2012) and a Turkish version (0.83) (Ozaslan et al., 2020). The reliability of the four subscales ranged from 0.70 to 0.80, which is comparable to the reliability obtained for samples of mental health nurses in the United Kingdom (0.61–0.86) (Robson & Haddad, 2012), Australia (0.60–0.83) (Chee et al., 2018), Hong Kong (0.66–0.85), Japan (0.65–0.76), and Qatar (0.36–0.77) (Bressington et al., 2018), and Turkish (0.64–0.88) (Ozaslan et al., 2020). The aforementioned results reveal that the Chinese version of the PHASe reliably assesses mental health nurses’ attitude toward physical health care.
This adaptation was performed on a sufficient sample size of mental health nurses from diverse nursing backgrounds. Therefore, the 4-factor structure of the Chinese version may be useful for future studies of culturally Chinese societies. Moreover, the Chinese version only comprises 17 items, which is practical for measuring mental health nurses’ attitudes toward physical healthcare. However, a model with different factors may be useful for improving the variability explained by the model in light of the low total variance in the 4-factor structure. The adaptation of the Chinese version of the PHASe should be further investigated using multiple analyses to test its validity and reliability; relevant parameters include convergent validity, criterion validity, and test–retest reliability.
Another limitation of this study is the limited generalisability of the findings. Although multisetting sampling was used to obtain adequate sample size, the results cannot be generalised to all mental health nurses because this study recruited nurses working in hospitals. Most of the participants were female and worked in acute inpatient psychiatric wards, which limits the generalisability of the results. To improve the generalisability of the results, additional cross-validated studies should be conducted using a diverse sample of nurses for confirming the four-factor structure of the Chinese version of the PHASe. Moreover, the data were obtained using self-report methods; thus, bias may occur in the results. Future research is needed to clarify the psychometric properties of the Chinese version developed in the current study.