Participants
The provided data in this study are a part of the data of a PhD. Thesis entitled “Designing and Validation of the Questionnaire for the Assessment of Spiritual Needs of Hospitalized Patients.” Participants were selected by random sampling from nine general hospital wards of two public hospitals in Shiraz, Iran. The inclusion criteria were hospitalization in general settings, speaking and understanding the Persian language, age range of 18-60 years, and ability to answer the questionnaire. The exclusion criteria were acute mental or physical disorders, patients at the end stages of life, or patients with AIDS or cancer. Overall, 301 hospitalized patients with a mean age of 42.09 (SD =11.96) years participated in this study; 163 (54.2%) of patients were female, 200 (66.4%) were married, 83 (27.6 %) were single, and others were either widows, widowers or divorced. The mean duration of hospitalization was 9.26±6.28. 15 patients (5%) were illiterate, while the education level of 80 (26.6%) was primary school, 82 (27.2%) was high school, 76 (25.2%) was bachelor’s degree, and 48 (15.9%) was MSc or PhD. 105 (35.9%) of participants were self-employed, 51 (16.9%) had governmental jobs, 88 (29.2%) were housewives, 17 (5.6%) were students, and 14 (14.7%) were unemployed. The hospital ward of 36 (12%) was surgery, 43 (14.3%) was neurology, 27 (9%) was rheumatology, 21 (7%) was nephrology, 46 (15.3%) was internal, 41 (13.6%) was gastrointestinal, 25 (8.3%) was obstetric, 43 (14.3%) was orthopedic and 19 (6.3%) was urology.
The Ethical and Research Committee of Shiraz University of Medical Sciences confirmed this study (No. IR.SUMS.REC.1395.S872). In this study, we followed ethical research principles such as obtaining informed consent, confidentiality, and having the right of withdrawal from research in any step of the study without any impact on the treatment or care procedures.
Instrument
The HPSNQ questionnaire contains 43 items that are divided into 4 subscales and are according to a 5-point Likert scale (1 = No, 2 = Low, 3 = Average, 4 = High, 5= Very high). The questionnaire subscales were "the interconnection with people” (15 items), “relationship with God” (10 items), “transcendence” (10 items), and “peaceful environment” (8 items). According to the pervious study, the HPSNQ questionnaire is of the required validity and reliability for assessing the patients’ spiritual needs in general hospital settings.
In the previous study exploratory sequential design was used. In the qualitative study, data collection was conducted by 16 in-depth and semi-structured interviews with 16 patients. The conventional content analysis introduced by Yan Zhang and Barbara M. Wildemuth (2009) [15] was used for data analysis. According to the data obtained in the qualitative phase and a literature review covering spirituality, spiritual needs and related questionnaires, the questionnaire was designed and could be used for the quantitative phase. So, a pool of 73 items was generated using the inductive and deductive method. Then in the item reduction phase, after face and content validity and item analysis, 43 items remained. Exploratory factor analysis led to extraction of a four-factor structure (interpersonal connectedness, relationship with God, transcendence, and peaceful environment) with 43 items of which 58.35% of the total variance was explained. The confirmatory factor analysis (CFA) was in line with the result of the exploratory factor analysis. A total of 80 patients participated in this study in the stage of convergent validity of the questionnaire. convergent validity was estimated by identifying the correlation between the HPSNQ and the cancer patients’ spiritual needs questionnaire (a valid and reliable tool in Iranian society) scores. The patients completed these questionnaires at the same time. In assessing convergent validity, the correlation coefficient between the scores of the designed questionnaire and the cancer patients’ spiritual needs questionnaire was acceptable (r=0.76, p<0.001). To assess the reliability of the scale using internal consistency (Cronbach’s alpha coefficient) and Test re test (interclass correlation coefficient), 301 and 34 hospitalized patients completed the questionnaire, respectively. The Cronbach’s alpha of the scale and factors was between 0.83 and 0.95. The interclass correlation coefficient of scale and factors was between 0.89 and 0.96. The data analysis was conducted by the SPSS software (version 19) in the exploratory factor analysis (EFA), convergent validity and reliability stages. The MPLUS software (version 5.1) was used for data analysis in the CFA stage.
Procedures
This study was carried out from June to September 2018, with the patients hospitalized in seven general wards of two public hospitals in Shiraz, Iran. After coordination with the hospitals authorities, a researcher distributed the questionnaires among the hospitalized patients in the general wards who were selected randomly based on the inclusion criteria.
The HPSNQ was originally created as a self-administered tool. Nevertheless, in the present study, patients who had low education, were assisted to use the tool. After reading to the patient each item of the questionnaire as well as its answer, patients could select an answer. This intervention allowed the tool to be used by individuals who had low education.
Patients were given enough time to fill out the HPSNQ. At first, a researcher explained the questionnaire purpose and the instructions for answering. Items meanings were further explained when needed. After completing the questionnaire, if there was any missing data the researcher asked the patients to answer the related items.
Data analysis
Instrument analysis using IRT included: dimensionality assessment, estimation or calibration of the items parameters, and structure of the scale.
Before conducting these analyses, the unidimentionality and concordance of the items in the four subscales were assessed. There is another assumption in IRT that says the answers to items are independent of each other, This is known as local independence [18, 19], meaning that excluding the underlying characteristic, there is no link between the items [19]. The unidimensional latent characteristic is evaluated using a scale (level of patients’ spiritual need in the present study).Unidimensionality was evaluated by item-to-total correlations, Cronbach’s alpha, and factor analysis [18, 20]. The local items independence can be determined by factor analysis since locally dependent items presented as detached factors in the factor analysis [18].
Samejima’s (1969) graded response model (GRM) [21] was used in this study, and all of the analyses were applied using MPLUS. At present, several IRT models are available. Compared to other factors, the response format of items is crucial to selecting which IRT model to use [18]. The two-parameter logistic model [18] is an example of a dichotomous responses model, which offers threshold and discrimination parameters for items. Since the responses format of HPSNQ with the graded response options, is an appropriate IRT model for this response format, which considers an item in terms of a series of k - 1, where k shows the response options number [22]. Samejima’s (1969) graded responses model (GRM) [21].
The item threshold (difficulty) and discrimination parameters are estimated in GRM. The thresholds number is the response options number minus 1. In this study, there were 5 response options resulting in 4 thresholds. Item difficulty is a concept in the education field that shows the difficulty of achieving a 0.5 probability of a true answer for a particular item considering the respondent’s level of latent variable (theta). However the concept of “location parameter” might be more related compared with the “Item difficulty” concept in the health field [17].
The item discrimination parameter specifies how well items determine patients at various levels of each latent trait. The item discrimination parameter or the slope parameter at a special theta level, has steeper slopes demonstrating better discrimination than others with less steep slopes illustrated in the Item Characteristic Curve (ICC).
In this study, In addition to estimating the item threshold (difficulty) and discrimination parameters we also assess ICCs as the graphical functions for showing the probability of endorsing the item in the specific categories as a function of the latent trait of the respondents [23]. Then, according to the ICCs, item information curves (IICs) were presented, IICs in a mathematical way referring to the how much information can be provided by every ICC. Finally, all of the IICs together provided the test information function (TIF), that shows how well a person’s locations can be estimated by the questionnaire. The psychometric information at each point in the range of a latent trait can be identified by the information plots [24].