In this study, the instrument of nurses' compassionate care measurement was designed and its psychometric properties were evaluated. In the first stage, individual and focus group interviews were conducted to explain the concept of compassionate nursing care with nurses, nurse instructors, patients and family caregivers. Qualitative findings were presented in three themes of effective interaction, professionalism and continuous comprehensive care. At the end of the qualitative phase, items were extracted based on the operational definitions and a review of literature. Next, the questionnaire was assessed for psychometric properties.
One of the important steps of questionnaire’s design is the process item generation. In the present study, item generation was made using a combination of inductive and deductive approaches. While in some available instruments, the production of items has been solely generated through a review of literature and based on dictionary definitions (deductive approach) [19, 35, 36]. Also, due to the influence of social and cultural factors around the concept, there is a need to incorporate a deep understanding of related experiences of nurses, patients and family caregivers, assessment of which was performed in this study.
Compared to the present study, the Schwartz center compassionate care scale [16] and the Fogarty Compassion Scale (1999) were designed for physicians. It should be noted that physicians and nurses have a different understanding of the needs of patients due to their different professional roles. Also, the nature of nursing care is different and over a more sustained timeframe than medicine.
Some definitions of compassion that are based on dictionary classifications or literature reviews include aspects of empathy or sympathy [10], while compassionate care is conceptually broader than these concepts. In compassionate care is emphasized to interventions for relieving suffering. 2 In some instruments, the word "compassion" itself is used in the scale instead of the use of descriptive variable for compassion [16, 35, 36].
In the study by Lee and Simon (2017), the concept of compassion competence was developed through analyzing the hybrid concept and indicated specific nursing behaviors for measuring the effects of compassion. In this study, only nurses in special wards were interviewed [37], but in the present study, experiences of nurses, patients and family caregivers in specialized units (CCU, ICU, hemodialysis, emergency and burn), surgical and internal medicine were used to explain the concept. Therefore, the present study contained richer information about the concept of compassionate care.
Compared to the present study, in most previous studies, face and content validity was assessed using a qualitative method. In the study by Fogarty (1999) [35], face and content validity was not carried out. The calculation of the item impact score, deletion of inappropriate items and determination of the importance of each item were carried out [20]. Also, calculating the content validity ratio in the present study helped identify those items that were necessary for measuring the concept [21]. Calculating the content validity index helped with identifying related concepts based on the opinions of experts [24]. The Kappa score of the questionnaire was excellent, indicating an agreement between evaluators on the relevance of items.
In the present study, before making construct validity, item analysis was performed. The results of the exploratory factor analysis indicated the adequacy of the sample size for performing construct validity assessment. Varimax rotation led to assignment of 28 items to 4 factors as professional performance (9 items), continuous follow up (6 items), surrogacy (7 items) and empathic communication (6 items). For convergent validity, the questionnaire of Wolf et al.’s (1998) was used, that showed a moderate correlation with our questionnaire.
Compared to the present study, the construct validity of the 18-item scale of Lee and Simon entitled The Compassionate Competence Scale (2016) was assessed by exploratory factor analysis on 660 nurses. It led to placing 17 individual items within one of the three factors found; communication, sensitivity or insight. The convergent validity of the questionnaire showed a high correlation coefficient, but item analysis was not performed for identifying items affecting initial reliability.
In the Grimani's study (2017) the way of extracting factors and determining the factor structure in construct validity was not clear [38].
In a study of Burnell & Agan (2013), exploratory factor analysis with a sample size of 250 hospitalized patients was conducted. Twenty-four items were fitted into four factors of meaningful relationship, patient expectations, care characteristics, and competent specialist. However, information on the adequacy of sampling was unavailable. Also, the method of extracting factors and determining the factor structure had not been reported [36]. In some of available tools, construct validity has not been conducted [19].
In most existing tools, item analysis has not been performed for identifying items that affect reliability. In this study, reliability was assessed through internal consistency and stability (test-re test method) within a two-week interval. Similar to the current study, reliability of the scale was assessed through an examination of internal consistency and test-retest [37]. In this study, a half split technique was also used to examine reliability. The linear correlation between the first and second half of questionnaire items indicated appropriate reliability of the questionnaire.
In most existing tools, stability has not been reported [18, 19, 35, 36]. The high stability of this questionnaire showed that the individual score of the test would remain constant over time, so this could not be compared with other questionnaires.
In this study, the effect of ceiling and floor on the sample size of 420 nurses was studied. One of the factors influencing the reliability of a tool was the effect of ceiling and floor. If there was no such an effect, individuals with the highest and lowest scores were not intelligible and could not be differentiated, and reliability decreased. 6 No information on the effect of ceiling and floor has been reported in any of available tools.
In the present study, a broad spectrum of participants was considered through selecting a sample of nurses, nurse educators, patients and family caregivers with a maximum variability and a comprehensive psychometric assessment.