2.1 Design
The fundamental research will be divided into four stages. (1) Literature search: A comprehensive search of relevant databases, such as PubMed, Cochrane, Embase, CNKI, WANFANG, and National Guideline Clearinghouse (NGC), was performed by using the select keywords “renal transplant patients”, “postoperative”, “nursing quality evaluation indicators”, and “nursing quality”. The Johns Hopkins Nursing Evidence-based Practice Rating Scale was used to assess the quality of the retrieved literature [12]. (2) Setting up the first draft of nursing quality evaluation indicators for renal transplant patients: the outline of the semi-structured interview was developed through literature analysis [13], and the data were sorted out following the interviews to construct a pool of itemized indicators. (3) Delphi method: Delphi method is two or more rounds of expert correspondence with feedback and opinions[14]. In this study, two rounds of expert correspondence were conducted via email to determine the final pool of indicator entries from February to May 2022. (4) Analytic hierarchy process: A hierarchical structure model was established, a judgment matrix of the model was constructed, and the weights of each level of indicators and the consistency test were calculated to understand the importance of each entry of the nursing quality evaluation indicators for kidney transplant patients as it relates to the whole system. [15].
2.2 Inclusion criteria of experts
We use the purposive sampling method to screen experts both in the interview and Delphi consultation stages [16]. The specific inclusion criteria were as follows: (1) Education: bachelor's degree or above; (2) Title: intermediate or above; (3) Working experience: 5 years or above of relevant experience in the field of renal transplantation; (4) Voluntary participation in this study.
From October 2021 to January 2022, we included 7 experts from 4 provinces for interviews. The size of the interview group was determined by data saturation [17]. The information was saturated by the 5th expert interviewed. We also interviewed two other experts to ensure no new content emerged. From February 2022 to May 2022, Delphi expert correspondence mailings were prepared based on interviews, 23 experts from 11 provinces and municipalities were selected, and data saturation was achieved at 19th expert [18]. To ensure the study's validity, experts who had participated in interviews were not allowed to enter Delphi [19]. There were 24 people in the first round of Delphi, and one person dropped out in the second round, leaving 23 people in total. The specific information is presented in Tables 1 and 2.
Table 1
Participant demographic data (interviews)
Participant | Section | Professional title | Position | Educational background | Age | Working years |
1 | Organ Transplant | co-chief superintendent nurse | head nurse | Bachelor | 45 | 23 |
2 | Organ Transplant | co-chief superintendent nurse | head nurse | Bachelor | 42 | 22 |
3 | Organ Transplant | chief superintendent nurse | head nurse | Bachelor | 52 | 32 |
4 | Organ Transplant | co-chief superintendent nurse | head nurse | Bachelor | 39 | 18 |
5 | Organ Transplant | co-chief superintendent nurse | head nurse | Bachelor | 41 | 15 |
6 | Organ Transplant | co-chief superintendent nurse | head nurse | Bachelor | 45 | 23 |
7 | Organ Transplant | supervisor nurse | head nurse | Bachelor | 43 | 19 |
Table 2
Participant demographic data (Delphi)
Items | Category | Round 1(n = 24) | Round 2(n = 23) |
n (%) | n (%) |
Age(years) | 31ཞ40 | 8 (33.3) | 8 (34.8) |
| 41ཞ50 | 14 (58.3) | 13 (56.6) |
| > 50 | 2 (8.4) | 2 (8.6) |
Educational background | Bachelor | 16 (66.7) | 15 (65.2) |
| Master and above | 8 (33.3) | 8 (34.8) |
Professional title | intermediate | 11 (45.8) | 10 (43.5) |
| Sub-high | 11 (45.8) | 11 (47.8) |
| Senior | 2 (8.4) | 2 (8.7) |
Position | Head nurse | 12 (50.0) | 11 (47.8) |
| head of the nursing department | 1 (4.2) | 1 (4.4) |
| nurse | 8 (33.3) | 8 (34.8) |
| doctor | 3 (12.5) | 3 (13.0) |
Working years | 5ཞ10 | 1 (4.2) | 1 (4.4) |
(years) | 11ཞ20 | 14 (58.3) | 14 (60.9) |
| 21ཞ30 | 7 (29.2) | 6 (26.1) |
| > 30 | 2 (8.3) | 2 (8.6) |
Work areas | Clinical nursing care | 7 (29.2) | 7 (30.4) |
| Nursing management | 13 (54.1) | 12 (52.2) |
| Nursing education | 1 (4.2) | 1 (4.4) |
| Clinical medicine | 3 (12.5) | 3 (13.0) |
Postgraduate advisor | Yes | 5 (20.8) | 4 (17.4) |
| No | 19 (79.2) | 19 (82.6) |
Years working in Organ Transplant Section (years) | > 5 | 24 (100.0) | 23 (100.0) |
2.3 Information, Data Collection, and Analysis
Literature retrieval stage: There are two trained researchers, including articles that meet the research content, and the third researcher resolved any disagreements through arbitration. Finally, 67 specific indicators were determined.
During the interview stage, research group was asked to (1) Repeatedly and carefully reading the text transcribed from the interviews until there was a sense of integrity; (2) disassembling the material and analyzing it line by line to identify significant statements; (3) coding and categorizing recurring statements and phenomena to generate themes; (4) finding connections in different themes to form thematic clusters; (5) the above procedures are cycled until no more new themes and sub-themes are presented [20]. These tasks were completed within 48 hours after completing the interview. Three expert interviews were conducted as face-to-face interviews, and the remaining four were conducted as online conference connections.
Delphi method stage: (1) Two rounds of expert consultations were sent by email. For the information returned by the experts, the team members connected with experts through email when there were any information-related questions. (2) Two rounds of questionnaires contain three contents: the introduction of the questionnaire, the theme text, and the expert self-evaluation table. Firstly, the part of introduction explains the background and purpose of this study. Secondly, the theme text includes a Likert 5 rating scale to score the importance of each indicator (5, very important; 4, Important; 3, generally important; 2, not too important; 1, not important), and experts ' opinions on the indicator, in which experts can also make any recommendations for this study. Finally, experts should explain the familiarity and decision-making basis of this study. (3) Determining the final index system: After the two rounds of expert consultation, the research team members used Excel 2016 and SPSS21.0 software for statistical analysis. Descriptive statistics were used to incorporate each indicator according to the criteria of importance mean > 4, coefficient of variation (CV) ༜0.25, and score rate > 0.2. At the same time, the indicators were also modified, combined, deleted, or added with expert opinions. Finally, the Kendall coefficient and expert authority coefficient are calculated.
2.3.1 Interviews
Before the interview began, the research group formed 67 specific indicators based on the results of the literature evaluation and discussed the interview outline[21]. (Example: With your rich experience in the renal transplant department, what should be the focus of nursing quality indicators for renal transplant patients?) Based on the results of expert interviews, a total of three themes were obtained by combining content analysis: (1) The indicators' characteristics must be highly targeted to renal transplant patients and must emphasize the specialty. However, the comprehensiveness of the indicators should also be considered. (2) Hierarchical structure of indicators: indicators should be classified according to the “structure-process-result” three-dimensional quality structure model, which can make users clear and better grasp the application methods of various indicators. (3) Specific modification of indicators: According to the interview content of experts, the research team revised 3 indicators, added 14 indicators, and deleted 1 indicator.
2.3.2 Round 1
Based on the results of the interviews, a nursing quality evaluation index system for renal transplant patients was developed, including 3 first-level indicators, 10 second-level indicators, and 67 third-level indicators. The questionnaire was sent out by email, and the team reminded the experts who did not respond after two weeks. The first round of consultation took more than one month. At the end of this round, the research group deleted 9 indicators. Four indicators did not meet the requirements, namely, “Lower leg circumference”, “Pulsation of foot dorsal artery”, “Incidence of immune rejection”, and “Incidence of bladder spasm”. Five repeated indicators were “Incision bleeding”, “oozing blood”, “Implementation rate of physical therapy to prevent DVT”, “Psychological state”, “Implementation rate of early postoperative activity guidance”, and “Implementation rate of prevention of DVT-related knowledge guidance”. The number of experts recommending deletion of these duplicate indicators was higher than 70%. Eight indicators were added, and 1 indicator was modified. It is worth noting that 3 newly added indicators, “renal transplant function”, “self-management ability”, and “quality of survival”, were unanimously agreed to be classified under a newly established secondary indicator named “patient-related functional status" through telephone consultation with experts, which is an outcome indicator. So far, the index system has a total of 3 primary indicators, 11 secondary indicators, and 66 tertiary indicators. The details are as follows:
Nurse quit rate (%)
This indicator reflects the nursing team's stability, and the nurse turnover rate can affect patient outcomes.
Cardiovascular status
Kidney transplantation can affect the original cardiovascular disease or cause new cardiovascular disease. Screening and evaluation of cardiovascular disease risk factors should be carried out before renal transplantation, and corresponding nursing prevention measures and treatment methods should be given to reduce cardiovascular complications after transplantation.
The implementation rate of the correct application of immunosuppressive agents
The nurse must deliver the medication to the patient on time and supervise its timely administration. The requirements for medication administration, precautions, and contraindications vary among kidney transplant patients and are individualized, requiring the nurse to understand the patient's individualized treatment plan and avoid risks.
Incidence of psychiatric abnormalities after renal transplantation
Renal transplant patients can have abnormal mental states due to surgical, treatment, environmental, and psychological factors. When patients have abnormal mental symptoms, it can result in a lower success rate of surgery, longer treatment time for patients, and a higher incidence of rejection.
Disease Guidance Awareness Rate
Patients must understand the progression of their disease, master the initial symptoms of rejection, and comprehend the purpose and normal value of routine examinations.
Transplant kidney function
Transplant kidney function is a vital outcome indicator for patients with kidney failure, closely related to the transplantation's success and the patient's quality of life.
Self-management ability
Postoperative medication, diet management, regular blood pressure, blood glucose monitoring, and regular follow-ups are all aspects that require long-term adherence in kidney transplant patients. Good self-management is an important contributor to kidney transplant recipients' long-term survival.
Quality of life
Outcome indicators should include the quality of life of the patients.
Awareness rate of medication guidance
The indicator "medication adherence" was renamed "knowledge of medication instructions". Experts believe it is too simple to focus only on patients' medication compliance and does not fully reflect the complexity of postoperative medication in kidney transplant patients. This indicator is defined as the patient's mastery of medication time, medication type, dosage, drug effects, and side effects.
2.3.3 Round 2
At the end of the second round of consultation, the expert included the indicator ' perinephric drainage ' into the indicator ' Implementation rate of standardized nursing of perinephric drainage tube ', because these two indicators are inclusive. So far, the index system has 3 first-level indicators, 11 second-level indicators, and 65 third-level indicators.
2.4 Analytic hierarchy process
According to the hierarchical structure model constructed by Yaaph software, the indicators at all levels in this study were divided into the target layer, criterion layer, and program layer [22]. The target layer is the construction of a nursing quality evaluation index system for kidney transplant patients. The criterion layer refers to the specific influencing factors to achieve this goal. The first-level and second-level indicators are used as the criterion layer. The program layer is the specific implementation steps to achieve the goal, and the three-lever indicators are used as the program layer.
2.4.1 Construction of the judgment matrix
The Delphi method was combined with the hierarchical analysis process. The importance of each indicator at each level was derived by comparing the indicators according to the constructed hierarchical model. This process is the formation of the judgment matrix. The judgment matrix can be established based on the Saaty1-9 scale method.
2.4.2 Determination of the weight of each layer and performing the consistency test
After determining the Saaty scale, the Saaty scale values of each level of indicators were entered into the yaahp10.1 software to calculate the weights of the index system and the Consistency Ratio (CR value). It is generally considered that when CR < 0.1, the importance score of the judgment matrix meets the logic requirements, and the weight of each factor is reasonable.
2.4.3 Determination of the combined weight of indicators at all levels
The combined weight refers to the relative importance of all factors at the same level to the target layer. The original weight of the second- or third-level index is compared with its corresponding superior index by using the multiplication method to obtain the combined weight.