Development and Validation of An Elderly Care Capacity Needs Questionnaire in Elderly Care Institutions with the Model of Combination of Medical and Health Care

Background China's elderly population is growing rapidly. As the primary provider of geriatric care services, the expertise and care competencies of nursing staff directly affect the quality of services provided by elderly care institutions. To develop a geriatric care capacity needs questionnaire to provide an assessment tool for the implementation of geriatric care quality improvement and staff capacity building programs in elderly care institutions. item pool was was by interviewing staff and a pilot survey. by and

Five nursing staff with more than ve years of working experience in medical and health elderly care institutions were selected for a structured interview. Questions were reviewed by them to remove duplicates, combine concepts, and remove nonrelevant or outdated items. Finally, the ECCNQ is summarized into 12 dimensions, making the questions concise and quick to answer. The 12 dimensions include emergency care, health assessment, safety protection, knowledge of nosocomial infection, rehabilitation care, communication skills, cognitive impairment care, diet care, professional ethics, specialized care, hospice care, organizational skills.

Participants
The Human Research Ethics Committee of the First A liated Hospital of Changde Vocational Technical College approved pilot research and large sample research.
Inclusion criteria: working years of elderly care for the aged ≥ 2 years; voluntary participation, informed consent of the study, and signing of informed consent. 10 nursing staff who met the inclusion criteria were selected to participate in the pilot survey to test the initial version of the questionnaire's surface validity.
A strati ed random sampling method was used to draw nursing staff from eight local medical and health care institutions.
Participants were recruited from nursing staff in elderly care institutions via social media such as WeChat and email. The ECCNQ uses a 5-point Likert scale from " not at all" to "daily needs" on a scale of 1-5. The higher the score, the higher the need.

Data Analysis
SPSS software (version 26) was used to analyze the data. The critical ratio value was used to analyze the items. Exploratory Factor Analysis was used to investigate the construct validity of the ECCNQ. The reliability of the ECCNQ was evaluated by internal consistency reliability test and test-retest reliability. Cronbach's Alpha coe cient is used to measure internal consistency and reliability, which is related to the homogeneity of items in the scale and their relationship. Cronbach's Alpha coe cients between 0.70 and 0.90 are considered acceptable internal consistency [14][15] . Spearman-Brown coe cient and Guttman split-half coe cient were used to test the test-retest reliability.

Results
The results of the pilot survey showed that nursing staff in elderly care institutions were able to understand the items of the questionnaire better. Their feedback was that ECCNQ is easy to understand and applicable to the assessment of nurses' capacity needs in medical and health care institutions. The average time to ll out the questionnaire was about 10 minutes.161 questionnaires were collected, and the recovery rate was 100%. Among the 161 elderly nursing staff, there were 65 from Fushou Yikang nursing home, 14 from Jiayuan nursing home, 14 from Heshengyuan nursing home, 16 from Kangfulai nursing home, 7 in Yongfeng nursing home, 16 in Fuhai nursing home, 18 in Xiyanghong nursing home and 11 from Elderly care service center in Zou town. The scores for the capacity needs of nursing staff in medical and health care institutions are shown in Table 1.

Item Analysis
The rst 27% was de ned as the low group, and the last 27% was the high group. The independent-sample t-test was used to compare the difference between the two groups. The absolute value of CR < 3.000 and not signi cant (P > 0.05) was taken as the deletion standard [16] . The data collected from 161 valid questionnaires showed that each item's scores were signi cantly different (P = 0.000), and the CR was above 3.000, as shown in Table 2.

Construct validity
After item analysis, Exploratory Factor Analysis was used to test the construct validity. Kaiser Meyer Olkin measure of sampling adequacy test (KMO) and Bartlett's spherical test are needed to test whether exploratory factor analysis is suitable [17] . KMO value ≥ 0.6 and the spherical test has a statistical difference (P < 0.05) is suitable for exploratory factor analysis [18] . The analysis results of 161 questionnaires showed that the KMO value was 0.762. Bartlett's sphericity test showed a signi cant difference (p = 0.000), suitable for factor analysis, as shown in Table 3. These 12 dimensions have common factors and can be subjected to principal component factor analysis. The results of in nite extraction factor rotation, factor loading matrix and commonality are shown in Table 4. The results of the analysis showed that the loadings of the 12 dimensions exceeded the signi cance of 0.45. The results of the contribution and eigenvalue of each dimension are shown in Table 5. The correlation coe cient between each dimension and the total questionnaire was 0.472-0.737, as shown in Table 6.

Reliability Analysis
The Cronbach's Alpha coe cient of the total questionnaire was 0.860. The spearman-Brown coe cient was 0.832, Guttman split-half coe cient was 0.83, as shown in Table 7.

Acceptability of the questionnaire
In this study, the questionnaire's recovery rate reached 100%, and the effective rate was 100%. It took an average of 10 minutes for the elderly nursing staff to ll in the questionnaire. Participants' feedback was that the questionnaire items' design was simple, easy to read and write, and the length of the items was acceptable.

Discussions
This study found the structure of the staff of the combined health and nursing care facilities. Most managers were women in their 30s who were not nursing majors and had college degrees. The skills required of them by the institutions were pro ciency in the use of computers for documentation and organization and management. The nursing staff, on the other hand, is the group that directly cares for the elderly and is between 45 and 60 years old; they are poorly educated, poorly paid, and highly mobile, with few working for more than ve years. In addition, nursing staff of nursing institutions cannot participate in the professional title of nursing.
Moreover, different from clinical nursing, the elderly nursing staff in combined medical and health care institutions need life nursing skills and clinical professional nursing skills. Therefore, the staff who have worked in elderly care institutions with the mode of combination of medical and health care for more than ve years were consulted due to the lack of local theoretical experts with rich practical experience in elderly care institutions, after the preliminary formulation of the item pool of this questionnaire [20] . Finally, the 40 item pools were summarized into 12 dimensions more suitable for actual work needs than Delphi expert consultation.
Item analysis of 161 valid questionnaires showed a signi cant difference between each item and the total score of the ECCNQ, and the CR was above 3.000, which was statistically signi cant. The ECCNQ construction procedure was reasonable. Although there is a nurse capacity needs assessment tool, there is a lack of speci c questionnaire tools for health care integrated geriatric care institutions.
There are 40 items in the ECCNQ. The average time taken for the participants to ll in the ECCNQ is 10 minutes. The participants' feedback is that the content of the items is easy to read, easy to ll in, and takes a short time. Compared with the existing assessment tools, the ECCNQ has reliability and validity and provides a scienti c tool for evaluating nursing staff in elderly care institutions.
The reliability of the ECCNQ is evaluated by the internal consistency test and test-retest reliability. The Cronbach's Alpha coe cient of the total questionnaire was 0.860, indicating that the ECCNQ has good internal consistency, and all items can measure the topic of nurses' capacity needs in elderly care institutions. The spearman-Brown coe cient was 0.832, and the Guttman split-half coe cient was 0.83, indicating that the ECCNQ was stable.
In terms of construct validity, only Exploratory Factor Analysis was conducted in this study. The KMO was 0.762, and Bartlett's sphericity test showed a signi cant difference (p = 0.000). Factor analysis was appropriate. In nite decimation factor analysis was performed. The minimum factor load is 0.529, and the load of 12 dimensions is more than 0.4, indicating that the dimensions were representative [19] . The commonality of communication skills was 0.311, lower than 0.4, which should be deleted. However, after consulting nursing staff in elderly care institutions many times, it was found that the demands for this ability were undeniable, and the application of communication skills ranked rst in daily work. Therefore, combined with the actual situation of nursing work, this dimension should be retained. Besides, there are only two dimensions with factor eigenvalue ≥ 1, and the cumulative contribution rate of variance contribution rate reaches 54%. The rst two-factor rotational analysis found the lowest contribution of organizational capacity at 1.298%, which should be removed. However, the nursing staff has applied organizational skills every day, including organizing and carrying out various nursing work. Generally, the nursing staff was assigned to serve 7 to 8 older adults. Therefore, the research group decided that the questionnaire dimension should not be divided into two modules, and no factor extraction analysis was carried out. Pearson correlation analysis showed that the correlation coe cient between each dimension and the total questionnaire was 0.472-0.737 (all P ≤ 0.01). Except for the correlation coe cient of communication skills was 0.472, the other dimensions were above 0.5, indicating that each dimension's measurement contents belong to the same subject. This result also shows that the dimensions are different but cannot replace each other.
Due to time and sample limitations, con rmatory factor analysis and calibration validity evaluation were not carried out in this study. Future research can expand the sample to con rmatory factor analysis and use predictive validity to test the questionnaire's calibration validity in the case of su cient time. Participants in this study were 161 nursing staff from 8 local elderly care institutions, with insu cient coverage and poor representation. Therefore, further research will use the ECCNQ to carry out large sample measurements of multiregional cooperation to test the reliability and validity to increase the popularization of the ECCNQ.

Conclusions
The results indicated that the ECCNQ has good reliability, validity and comprehensive items, which is the result of strict adherence to the questionnaire development procedures. Therefore, the ECCNQ can be used as a tool to measure the nursing capacity needs of nursing staff in elderly care institutions and provide a basis for developing a geriatric care training curriculum and improving the quality of geriatric care. Consent for publication: Written informed consent for publication was obtained from all participants.

Abbreviations
Availability of data and materials: All data generated or analyzed during this study are included in this published article.
Funding Statement: This study was supported by grants from the Education Department of Hunan Province (ZJGB2019226).
Authors' contributions: YYF and ZLP are joint rst authors. ZLP, YYF, XX and SYH obtained funding. ZLP, YYF and TSY were responsible for the design of the study, and organized and coordinated all aspects of the research. ZLP, XX and SYH collected and analyzed the data. ZLP and YYF was responsible for drafting the article and TSY revised it critically for important intellectual content. All authors have read and approved the nal manuscript.