Development and psychometric evaluation of a scale on nursing students’ perceptions of hospital caring environment (PHCE) in China

Background : Caring is a basic tenet of nursing and an essential trait a competent nurse. In China, nursing students spend 8-12 months on clinical rotation in hospitals after the completion of theoretical component of the program in their fourth year. The hospital then becomes the focus of nursing clinical education. However, there is no culturally-specific tool to assess nursing students’ perceptions of hospital caring environment (PHCE). The aim of this study was to develop a valid assessment tool to measure nursing students’ perceptions of hospital caring environment. Methods: A two-phase study was conducted to develop a PHCE scale and to test its psychometric properties. In phase one, the items of the PHCE scale were developed from a qualitative study, a literature review and expert validation. The second phase tested the factor structure, construct validity and reliability through a convenience sample of 383 final year nursing students recruited from two teaching hospitals in China (response rate 95.75%). Results: The final PHCE scale consists of 41 items, was internally consistent (Cronbach’s α = 0.98) and had satisfactory test-retest reliability (intra-class correlation coefficient = 0.87). The exploratory factor analysis revealed that the scale contained four subscales, accounting for 63.69% variance. Conclusions: The 41-item NSPHCE is a reliable tool to assess the Chinese nursing students’ perceptions of the hospital caring environment in China.

The first phase of the study was to develop the instrument item pool. An exploratory qualitative approach using face-to-face interviews was adopted to explore nursing students' perceptions, experiences, feelings of caring and the most unforgettable caring events they had observed during nursing clinical practice in hospitals. A total of 14 nursing students were interviewed using an open- Three round consultations were conducted for consensus, and a total of a 62-item PHCE was established after the initial round.
A panel of seven content experts, including two nursing educators, three nurse managers and two clinical nurse teachers, were then recruited to evaluate the content validity of the PHCE scale for content relevance. Using a 4-point Likert scale: 1 = not relevant, 2 = somewhat relevant, 3 = relevant and 4 = very relevant, the content experts rated whether each item was clear, appropriate, accurate and content-relevant. A plausible method of estimating the content validity of a new scale is using the content validity Index (CVI) []. In the first course of content validity testing, four items with item-CVI < 0.75 were removed as the CVI suggested that they were similar to the other items. Two other items were revised to minimize confusion. The revised instrument was then sent to the content experts for another course of content validation. After removing four items due to low item-level CVI, a 58-item PHCE scale was developed as shown in Table 1. The total CVI of the 58-item PHCE scale was 0.93.
Insert Table 1 58-item of PHCE here Psychometric Testing Procedure To evaluate the psychometric properties of the PHCE scale, namely, the factor structure, internal consistency and test-retest reliability, a convenience sample of 400 final-year nursing students were recruited from two teaching hospitals at the end of their transition to practice. The sample size was determined by the ratio of 5-10 subjects per item as suggested by Everitt []. To examine the testretest reliability, another 60 students were recruited to test the PHCE scale and did it again after two weeks.

Data analysis
Descriptive statistics, such as mean and standard deviation, were used to report sample characteristics and the responses for the items on the PHCE. Exploratory factor analysis (EFA) was performed to examine the factor structure of the PHCE scale. Cronbach's alpha and item-to-total correlation were also used to examine the internal consistency of the scale, while intra-class correlation coefficient (ICC) was used to test the stability of the scale. A p-value of <0.05 was considered statistically significant. SPSS Version 20 was used to analyse the data (SPSS Inc., Chicago, IL, USA).

Ethical considerations
Approval for the study was obtained from the university research ethics committee. Before interviewing and conducting the survey, the researcher explained the purpose and nature of the study. Students were assured that their participation was voluntary and anonymous and that they could withdraw from the study at any time. The return of the questionnaire was considered their consent to participate in the study.

Sample characteristics
Four hundred nursing students were recruited and invited to complete the questionnaire; 383 students returned the completed questionnaires, which resulted in a response rate of 95.75%. The nursing students were aged 16-25 years (mean = 21.00). The majority of them (n = 368, 96.08%) were female. More than half of them (n = 200, 52.22%) were undergraduate nursing students, 137 (35.77%) were diploma nursing students and 46 (12.01%) were secondary nursing students.   Insert Table 3 Internal consistency and test-retest reliability In the study of first-year nursing students, it was found that caring was not what they expected [19]. However, nursing students learned from their experiences and vowed to provide caring behaviours toward their patients. Therefore, it is important that clinical teachers model caring behaviours not only to the patients and their families, but also to students [19,24].
The results of the psychometric testing in our study indicated that the 41-item PHCE scale is a fourfactor structure. The EFA showed good construct validity as each item was sufficiently loaded to its own domain with item loading of more than 0.

Limitations Of The Study
The use of convenience sampling may limit the generalisability of the results. Future studies with random sampling may add support to the validity and reliability of the instrument.

Conclusions
The role of nursing education is paramount for the acquisition and refinement of students' caring attributes [22]. When the teaching atmosphere is perceived as caring, nursing students []. Moreover, nursing is a practice-based profession, thus, the internship, which is the transition from theory to practice, would be the most important stage to form students' nursing values. Currently, there is no culture-specific caring tool to assess the hospital caring environment in mainland China. The results of this study showed that our newly developed 41-item PHCE scale is a valid and reliable tool to assess

Ethics approval and consent to participate
The study was approved by the research ethics committee of Hubei University of Medicine. The participants were informed of the purpose and nature of the study. They were assured that their participation was voluntary and anonymous and that they could withdraw from the study at anytime.
The return of the questionnaire was considered as their consent to participate in the study.

Consent to publish statement
The authors give consent for this article to be published in BMC Medical Education.

Availability of data and materials section
The datasets supporting the conclusions of this article are included within the article. The questionnaires used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Competing Interest
The authors declare that they have no competing interest Funding None.

Authors' contributions
All the below authors have approved the final version of the article.
CL has contributed to the: i) conception design of the study, ii) acquisition of data, iii) analysis and interpretation of the data, iv) drafting the article and v) critical revision of the article LYL has contributed to the: i) conception design of the study, ii) critical revision of the article.
WW has contributed to the i) conception design of the study, ii) acquisition of data, iii) analysis and interpretation of the data and iv) critical revision of the article 4.
always smile and be kind and patient, 6.
answer quickly when patients call for them, 8. explain in simple words, 9.
hope to get support from the patients' families, 11. encourage patients to share experiences, 12.
understand patients when they are angry, 13. make patients physically or emotionally comfortable, 14.
give treatments on time, 16.
explain preventive actions to patients and their families, and 17.
are grateful for patients' cooperation. PART 2: The clinical teachers: 18.
sincerely want to see students succeed, 19.
praise students when they perform well, 20.
recognize when students have problems, 21.
believe students will do their best to take care of patients, 22.
listen to students' problems or concerns seriously, 23.
deal with students fairly, 24.
care about students' daily lives, 26.
give students reasons for decisions that affect them,

27.
encourage an open exchange of ideas among clinical instructors and students, 28.
tell students when they are doing something wrong and give them some advice, 29.
encourage students to state their ideas or opinions to the clinical instructors, 30.
take time to make sure students understand what they are learning, 31.
understand how it feels to be a student, 32.
do not make students feel stupid when asking questions, 33.
provide uplifting encouragement to their students, 34.
help students do a better job of taking care of patients, 35.
help students problem solve difficult patient situations, and 36.
tell students how to deal with relationships. PART 3: The students' peers: 37.
help fellow classmates with reasonable needs, 38.
help classmates who encounter difficulties, 39.
are concerned about one another's health, 40.
accompany a classmate who is sick to get medical help, 41.
smooth things over when there is a conflict between classmates, 42.
give suggestions to a classmate who encounters difficulties with school assignments, 43.
provide company when a classmate is lonely, 45.
respect the different opinions of other classmates, 46.
listen to one another's troubles and problems, 47.
talk to one another about problems, 49.
share experiences and feelings in the patient setting, and 50.
share notes, books or articles with one another. PART 4: The other health care workers: 51.
help students with difficulties, 53.
think students are learners, instead of people who do the chores, 54.
tell students what their mistakes are, rather than laughing at or blaming them, 55.
talk to students with a smile, 56.
tell students their experiences, and 58. cooperate with students.   Figure 1 Scree plot for PHCE