RESEARCH ARTICLE


Assessment of Reliability and Validity of a Nursing Tool Used to Examine Knowledge, Attitude, and Practices of Professional Nurses in Writing Nursing Care Plans at a Teaching Hospital in Gauteng Province, South Africa



Louisa M. Lodi1, Moreoagae B. Randa2, Samuel T. Ntuli3, *, Sogo F. Matlala4
1 Department of Nursing, School of Health Care Sciences, Sefako Makgatho Health Sciences University, Pretoria, South Africa
2 Department of Public Health, Sefako Makgatho Health Sciences University, Pretoria, South Africa
3 Department of Statistical Sciences, School of Science and Technology, Sefako Makgatho Health Sciences University, Pretoria, South Africa
4 Department of Public Health, School of Health Care Sciences, University of Limpopo, Limpopo, South Africa

Article Information


Identifiers and Pagination:

Year: 2023
Volume: 17
E-location ID: e187443462306060
Publisher ID: e187443462306060
DOI: 10.2174/18744346-v17-e230711-2022-195

Article History:

Received Date: 15/12/2022
Revision Received Date: 06/05/2023
Acceptance Date: 19/05/2023
Electronic publication date: 07/08/2023
Collection year: 2023

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Creative Commons License
© 2023 Lodi et al.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: https://creativecommons.org/licenses/by/4.0/legalcode. This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

* Address correspondence to this author at the Department of Statistical Sciences, School of Science and Technology, Sefako Makgatho Health Sciences University, Pretoria, South Africa; Tel: (012) 521 4111; E-mail: tsntuli@hotmail.com


Abstract

Background:

A nursing care plan is a guideline developed for a patient's needs. A well-documented care plan provides holistic patient-centred care and includes assessing, evaluating, and administering a variety of interventions as well as teaching patients and families. There are existing tools to measure nurses' knowledge, attitude, and practices in writing nursing care plans in many countries. However, cultural differences and most of the tools do not cover region-specific aspects of diseases, making it challenging to be used between countries.

Objective:

Thisstudy aimed to develop and validate a tool for determining the knowledge, attitudes, and practices of nurses in writing nursing care plans at a teaching hospital in Gauteng province, South Africa.

Methods:

A cross-sectional study was conducted among 218 registered nurses in selected hospital wards. Reliability was examined using Cronbach alpha and item-total correlation, while validity was assessed using Exploratory Factor Analysis (EFA EFA) and convergent validity. SPSS for Windows (version 10.0; SPSS, Inc., Chicago, IL, USA) was used to analyze data.

Results

Cronbach's alpha was 0.75 for knowledge, 0.74 for attitude, and 0.77 for practices. The item-total correlation values ranged from -0.203 to 0.742. Kaiser-Meyer-Olkin was 0.877, 0.793, and 0.797 for the three dimensions, respectively and the Bartlett test was significant (p< 0.0001). The EFA showed that all the items had loadings ≥0.5 except for item A1. Knowledge and practice had a good convergent validity.

Implications for Nursing

Efforts to develop, validate and implement a new instrument to assess nursing knowledge, attitudes, and practice in writing nursing care plans improve communication between nursing staff, and involve patients more in their care, resulting in fewer medical errors and improving the quality of patient care.

Conclusion:

This study indicates that the tool has satisfactory reliability, and the use of EFA for the investigation of validity is adequate, but one item in the attitude dimension has a lower threshold value. Further confirmatory factor analysis studies with a larger sample size are needed to support construct validity.

Keywords: Exploratory factor analysis, Nursing care plan, Registered nurses, Validation, Questionnaire, Patient care.

1. INTRODUCTION

Nursing has been essential in delivering nursing care to patients, families, and communities for many years [1-3]. The primary role of a nurse is to provide holistic and patient-centred care, which includes assessing, evaluating, and administering a variety of interventions as well as empowering patients and families to become active participants in their care [4, 5]. A nursing care plan is written documentation outlining the steps the nurse takes to provide care to a patient. The care plan details the direction of the nursing care an individual patient may need and records the intervention's effectiveness. A well-documented nursing care plan provides standardized, evidence-based, holistic, and patient-centred care. Professional/registered nurses are responsible for planning and delivering nursing care plans [6]. A nursing care plan is a safe, ethical, and effective source of patient condition, diagnosis, and treatment, so it should fulfill the legal requirements of nursing care documentation [7].

A nursing care plan is essential in communication among nursing team members. Nursing errors are a common phenomenon in healthcare settings, and poor communication among the nursing team is one of the leading causes [8-11]. Studies assessing challenges to implementing the nursing care plan reveal many issues. The problems that make it challenging to implement nursing care include high patient workload, lack of equipment, and shortage of nursing staff. Other challenges include inadequate follow-up by nursing managers, insufficient time to apply the nursing care planned, poorly documented nursing records, low educational qualifications, and lack of in-service training [12-15].

Several studies have been conducted in Ethiopia [7], Kenya [16], and Uganda [17] to evaluate nurses’ knowledge, attitude, and practices in writing nursing care plans. These show that existing instruments are already developed and validated in various countries, which researchers could use to measure the nurse's knowledge, attitude, and practices in writing nursing care plans. However, cultural differences and some of these tools developed do not cover all aspects of nursing care plans for many countries, including South Africa, due to differences in disease profile, implying the need to establish a new, regionally specific, and generic tool.

Validity indicates the extent to which a research tool is accurately measuring what it is intended to measure, while reliability is concerned with the degree to which a tool produces consistent findings when used repeatedly. Validity is categorized into three criteria: content validity, construct validity, and criterion validity. Reliability also has three attributes, of which the most common use is internal consistency, assessed using item-total correlation, split-half reliability, Kuder-Richardson coefficient, and Cronbach alpha. A new tool should have been completed using a representative sample to be valid and reliable. Thus, this study aimed to develop and validate a questionnaire used to gather data to examine nurse's knowledge, attitude and practices in writing nursing care plans at a teaching hospital in South Africa.

2. MATERIALS AND METHODS

2.1. Study Design, Setting, and Population

A cross-sectional study was conducted at a teaching hospital for three months, from April to June 2021. The hospital is a teaching hospital for one of the universities in South Africa. It has more than 500 patient beds and approximately 931 nurses working the day shift in the selected wards for the study. The study population was registered nurses chosen in the following wards: General Surgery, Paediatrics, Specialist, Psychiatric, Medical, as well as Obstetrics and Gynaecology.

2.2. Inclusion and Exclusion Criteria

All registered nurses permanently employed, working a day shift in the selected wards, and registered with the South African Nursing Council were considered for the study. Registered nurses not permanently employed and those placed by nursing agencies were excluded.

2.3. Sample Size and Sampling Technique

The minimum required sample size was 273. The sample size was calculated using the Rao-Soft online sample size calculator with the following assumptions: approximately 931 registered nurses working the day shift in the selected wards; a 95% confidence interval; with a 5% margin of error; 50% response distribution. A convenient sampling method was used to select the six wards and a simple random sampling technique was used to select registered nurses after proportional allocation within each of the six selected wards in the hospital.

2.4. Data Collection

Researchers collected data using a self-administered questionnaire which they developed by reviewing relevant literature [7, 16-18]. Most of these tools were standardized, reflecting the environment and culture of the patients they were initially developed for, which shows that these tools may not be appropriate for use in other countries whose backgrounds and cultures are different. Therefore, this study's nursing care plan questions were created and developed based on the SA national guideline.

The questionnaire has two sections: Section A is about participants' demographics, which relate to their age, gender, level of qualification, years of experience as a nurse, and current working unit. Section B consists of three domains that contain a total of 26 items which cover knowledge, attitude, and practice questions for writing nursing care plans (Table 1).

The knowledge and attitude domain has ten questions each, while the practice has six questions. All were measured using a 5-point Likert scale (Strongly disagree, Disagree, Neither agree nor do not agree, Agree, Strongly agree) [17, 18], and the correct responses scored “1”, and incorrect answers scored “0” in each domain. Three trained research assistants administered the tool and piloted it before data collection commenced. The instrument was piloted on five registered nurses for clarity and comprehension, and the research team improved the wording.

Table 1. Domain named according to the question distribution.
Knowledge K1. The nursing care plan is an important tool to assist in the provision of quality patient care
K2. History taking is very important in drawing up a nursing care plan
K3. Assessment of a patient allows the nurse to identify problems that might have been missed from history taking
K4. The patient's history and assessment assist in formulating the nursing diagnosis of the patient
K5. It is difficult to draw a nursing diagnosis of a patient for a nursing care plan
K6. Patient care is compromised if a patient is not given a proper nursing diagnosis
K7. A nursing care plan allows proper planning of activities to be done for /with the patient
K8. Nursing interventions should be specific to the problems identified
K9. Evaluation should be done continuously to ensure quality patient care
10. Every step of nursing care should be recorded to ensure continuous patient care
Attitude A1. Formulation of the Nursing care plan is time-consuming
A2. It is difficult to draw a Nursing care plan
A3. Nursing care plan steps are not clear
A4. Other categories of Nursing personnel should write the nursing care plan
A5. There are no resources for writing a nursing care plan
A6. There should be a standardized nursing care plan to refer to when writing a nursing care plan
A7. I would not write a Nursing care plan for a patient
A8. A patient can be given quality patient care without a drawn nursing care plan
A9. Other patient-related activities are very important than drawing a nursing care plan
A10. A nursing care plan should be cancelled
Practice P1. In the ward, every patient has a nursing care plan
P2. I draw a nursing care plan for every problem identified by the patient
P3. I would follow every step involved in writing a nursing care plan
P4. The nursing care plans are written in an accessible and easy-to-use format
P5. I review the nursing care plan twice daily for each patient
P6. When I draft a nursing care plan, I write an expected outcome statement in measurable terms

2.5. Data Analysis

Data were analyzed using the statistical programme STATA version 16.0 (StataCorp., USA). The demographic characteristics of the participants were presented using frequencies and percentages. The distribution of items was evaluated using mean, standard deviation (SD), skewness, and kurtosis. The internal consistency reliability was assessed using Cronbach alpha coefficients and item-total correlation. The Cronbach alpha coefficients are considered satisfactory if a cutoff value is greater than 0.7 [19-21], while the item-total correlation with a threshold value greater than 0.20 is considered satisfactory [22-24].

The validity of the tool was evaluated using content and construct validity. The content validity was assessed by giving the questionnaire to a panel of experienced nurses to evaluate its face and content validity (i.e. appearance, clearness, and comprehensibility of the questions). The construct validity was evaluated using convergent validity and Exploratory factor analysis (EFA). Convergent validity was investigated by calculating ' 'Spearman's correlation coefficients (r) classified as low (r<0.30), moderate (0.30 < r <0.60), and high (r > 0.60) [25]. The EFA used the maximum likelihood method with varimax rotation. The Kaiser-Meyer-Olkin measure (KMO) of sampling adequacy >0.60 and Bartlett's test of sphericity with a p-value < 0.05 determined the suitability of the data for factor analysis [26-28]. To run a principal component analysis, it is suggested that multiple techniques be used for factor extraction [29]. Thus, this study used the following techniques for factor extraction: the Cattell scree plot, Kaiser criteria of an eigenvalue >1, and the cumulative percentage of variance. The principal component analysis model retained items in each factor with loading values greater than 0.5 [30].

2.6. Ethical Considerations

Ethical clearance to conduct the study was obtained from a university Research Ethics Committee (REF: SMUREC/H /205/2020: G) while permission to access participants was sought from the management of the hospital. All participants were informed about the aim and objectives of the study before completing an informed concern form.

3. RESULTS

3.1. Sociodemographic Characteristics

Two hundred and eighteen registered nurses participated in this study, with a response rate of 79.9%. Seventy-two percent of the nurses were 50 years and younger, and 93% were females. Over two-thirds (72%) of the participants had a diploma as the highest qualification. More than half (58%) had five or more years of work experience as nurses and 29% were working in the medical ward followed by 20% in the specialist and 20% in Obstetrics and Gynaecology wards.

Table 2. Demographic Information.
- No. %
Age - -
≤30 46 21
31-40 65 30
41-50 45 21
60+ 62 28
Sex - -
Male 15 7
Female 203 93
Level of Education - -
Diploma 157 72
Bachelors 49 23
Postgraduate 10 4
Unspecified 2 1
Years of Nursing Experience - -
≤5 91 42
>5 127 58
Current Workstation/unit/ward - -
Medical 63 29
Specialist 43 20
Surgical 31 14
Psychiatry 18 8
O&G 44 20
Paediatrics 19 9
Diploma: a 3-year post-matric nursing qualification leading to registration with the South African Nursing Council

3.2. Items Analysis

The summary statistics for each item of the domain are presented in Table 3. All items in the domain of knowledge have a mean greater than 2, while all items in the attitude and practice domain have a mean below 2. With the exception of items K3, K5, and K10, the skewness statistics for all the items of the knowledge domain are not within the range of ±2, whereas for an attitude domain, all the values are within the range of ±2 except item A10. All the items in the domain of practice are within the range of ±2.

3.3. Reliability Analysis

Cronbach alpha and item-total correlation were used to evaluate internal consistency. As shown in Table 3, Cronbach's alpha gave values of 0.75, 0.74, and 0.77 for the domain of knowledge, attitude, and practices, respectively. The item-total correlation analysis in each domain showed that, except for items A7 and P5, all items had a positive and statistically significant correlation (p<0.05). The correlation coefficient ranged from -0.203 to 0.742.

3.4. Validity Analysis

3.4.1. Content and Face Validity

The first step to validating the tool was to test the face and content validity meant to identify the questions' clearness, comprehensibility, and appearance. This was performed by five nursing experts selected according to their field of expertise. Suggestions were made, and related items were restructured according to the expert's opinions. Subsequently, a pilot study was conducted to examine the study methods' feasibility and the questionnaire's clarity. The pilot study results indicated that nurses understood the questions; thus, the need for changes was ruled out.

3.4.1.1. Construct Validity

The second step for validation was to calculate the KMO to determine how suitable the data is for EFA. The KMO value of 0.877 and the Bartlett test of sphericity gave a chi-squared value of 928.9 (df=45, p < 0.001) for the knowledge domain, while for the attitude domain, KMO was 0.793 with a Bartlett test of sphericity 402.1 ((df=45, p < 0.001). For the practice domain, the KMO was 0.797 with a Bartlett test of sphericity of 295.9 ((df=15, p < 0.001). These findings showed that the EFA was suitable for the three domains [26-29].

The EFA was conducted for individual domains and is shown in Table 4. Two factors were extracted using varimax rotation with an eigenvalue of >1, which explained 59.0% of the total variance for knowledge. Three factors were extracted for the attitude dimension after varimax rotation extracted with an eigenvalue >1.0 and explained 56.0% of the total variance. For the practice dimension, one factor was extracted by varimax rotation with an eigenvalue of >1.0, which explained 46.4% of the total variance. An analysis of individual factor loadings shows that except for item A1, all had a loading of ≥0.5, indicating each item's existence power [30].

3.4.1.2. Convergence Validity

Lastly, the convergent validity was examined using Spearman's correlation coefficient and shown in Table 5. The findings revealed that the majority of scores for items of knowledge and practice domains were classified as moderate (0.30 < r <0.60), while for attitude dimension was classified as low (r<0.30).

Table 3. Summary statistics of each item .
Items Mean (SD.) Skewness Kurtosis Item-total Correlation Cronbach's Alpha
Knowledge K1. 4.74(0.63) -3.17 14.62 0.699 0.75
K2. 4.87(0.35) -2.47 8.13 0.583
K3. 4.83(0.37) -1.85 4.41 0.641
K4. 4.83(0.40) -2.18 6.92 0.609
K5. 3.41(1.47) -0.25 1.52 0.465
K6. 4.45(1.04) -2.09 6.59 0.648
K7. 4.71(0.55) -2.11 8.27 0.665
K8. 4.73(0.54) -2.42 10.55 0.643
K9. 4.75(0.49) -2.25 9.99 0.684
K10. 4.76(0.46) -1.64 4.68 0.720
Attitude A1. 0.51(0.50) -0.07 1.00 0.585 0.74
A2. 0.77(0.42) -1.29 2.66 0.549
A3. 0.77(0.42) -1.26 2.58 0.577
A4. 0.23(0.42) 1.29 2.66 0.434
A5. 0.41(0.49) 0.37 1.14 0.553
A6. 0.33(0.47) 0.74 1.55 0.444
A7. 0.15(0.35) 1.99 4.98 -0.299
A8. 0.53(0.50) -0.11 1.01 0.689
A9. 0.49(0.50) 0.04 1.00 0.613
A10. 0.93(0.26) -3.27 11.70 0.476
Practice P1. 0.42(0.49) 0.32 1.09 0.587 0.77
P2. 0.57(0.49) -0.29 1.09 0.715
P3. 0.83(0.38) -1.72 3.94 0.682
P4. 0.67(0.47) -0.72 1.52 0.742
P5. 0.71(0.45) -0.93 1.87 -0.203
P6. 0.62(0.48) -0.53 1.28 0.668
Table 4. Factor loading of the original items of knowledge, attitude, and practices.
- Knowledge Attitude Practice
F1 F2 Items F1 F2 F3 Items F1
% of Variance 48.1 10.9 - 31.5 13.1 11.4 - 46.4
Eigenvalues 4.8 1.1 - 3.2 1.3 1.1 - 2.78
K6 0.741 - A9 0.811 - - P1 0.606
K9 0.739 - A8 0.775 - - P2 0.749
K10 0.736 - A5 0.581 - - P3 0.675
K8 0.732 - A7 -0.529 - - P4 0.766
K3 0.618 - A1 0.408 - - P5 -0.620
K7 0.605 - A3 - 0.764 - P6 0.655
K1 0.542 - A2 - 0.691 - - -
K2 - 0.830 A6 - 0.616 - - -
K4 - 0.784 A10 - 0.533 - - -
K5 - 0.511 A4 - - 0.856 - -
Table 5. Spearman's correlation coefficient for the items of the three dimensions.
- K1 K2 K3 K4 K5 K6 K7 K8 K9 K10 A1 A2 A3 A4 A5 A6 A7 A8 A9 A10 P1 P2 P3 P4 P5
K2 0,51+ 1,00 - - - - - - - - - - - - - - - - - - - - - - -
K3 0,53+ 0,47+ 1,00 - - - - - - - - - - - - - - - - - - - - - -
K4 0,50+ 0,65+ 0,57+ 1,00 - - - - - - - - - - - - - - - - - - - - -
K5 0,14* 0,18+ 0,02 0,14* 1,00 - - - - - - - - - - - - - - - - - - - -
K6 0,45+ 0,20+ 0,47+ 0,22+ 0,11 1,00 - - - - - - - - - - - - - - - - - - -
K7 0,56+ 0,50+ 0,46+ 0,52+ 0,07 0,37+ 1,00 - - - - - - - - - - - - - - - - - -
K8 0,46+ 0,30+ 0,49+ 0,37+ 0,07 0,42+ 0,50+ 1,00 - - - - - - - - - - - - - - - - -
K9 0,45+ 0,36+ 0,46+ 0,43+ 0,10 0,45+ 0,50+ 0,51+ 1,00 - - - - - - - - - - - - - - - -
K10 0,45+ 0,46+ 0,48+ 0,48+ 0,10 0,46+ 0,63+ 0,53+ 0,71+ 1,00 - - - - - - - - - - - - - - -
A1 0,26+ 0,18+ 0,30+ 0,23+ 0,16+ 0,23+ 0,31+ 0,33+ 0,37+ 0,34+ 1,00 - - - - - - - - - - - - - -
A2 0,35+ 0,23+ 0,30+ 0,23+ 0,16* 0,25+ 0,22+ 0,24+ 0,19+ 0,25+ 2,38+ 1,00 - - - - - - - - - - - - -
A3 0,39+ 0,19+ 0,29+ 0,23+ 0,17+ 0,24+ 0,25+ 0,32+ 0,25+ 0,26+ 0,27+ 0,42+ 1,00 - - - - - - - - - - - -
A4 -0,05 0,02 0,15* -0,01 0,03 0,03 0,00 0,09 0,10 0,00 0,13* 0,04 0,04 1,00 - - - - - - - - - - -
A5 0,11 0,05 0,19+ 0,07 0,07 0,10 0,01 0,09 0,16+ 0,11 0,15* 0,21+ 0,15* 0,26+ 1,00 - - - - - - - - - -
A6 0,13* 0,12* 0,14* 0,12* 0,26+ 0,14* 0,09 0,06 0,12* 0,11 0,14* 0.24+ 0,32+ 0,23+ 0,04 1,00 - - - - - - - - -
A7 -0,36+ -0,10 -0,31+ -0,12* -0,07 -0,38+ -0,17+ -0,28+ -0,31+ -2,93+ -1,97+ -0,30+ -0,32+ -0,10 -0,21+ -0,09 1,00 - - - - - - - -
A8 0,26+ 0,19+ 0,26+ 0,13* 0,04 0,24+ 0,27+ 0,24+ 0,36+ 0,33+ 0,30+ 0,27+ 0,30+ 0,23+ 0,38+ 0,09 -0,39+ 1,00 - - - - - - -
A9 0,22+ 0,14* 0,23+ 0,19+ -0,04 0,17+ 0,18+ 0,11 0,31+ 0,31+ 0,34+ 0,19+ 0,22+ 0,14* 0,32 0,00 -0,36+ 0,58+ 1,00 - - - - - -
A10 0,44+ 0,39+ 0,26+ 0,32+ 0,10 0,21+ 0,31+ 0,19+ 0,18+ 0,31+ 0,26+ 0,31+ 0,34+ 0,03 0,16+ 0,12* -0,23+ 0,30+ 0,24+ 1,00 - - - - -
P1 0,03 0,11 -0,11 0,06 0,09 -0,05 0,14* -0,02 0,02 0,01 -0,05 0,09 0,10 0,18+ 0,14* -0,06 -0,04 0,25+ 0,15* 0,13* 1,00 - - - -
P2 0,16+ 0,15* 0,10 0,03 0,01 0,18+ 0,16+ 0,13* 0,20+ 0,14* 0,12* 0,21+ 0,16+ 0,18+ 0,19+ -0,01 -0,35+ 0,41+ 0,35+ 0,11* 0,44+ 1,00 - - -
P3 0,35+ 0,17+ 0,26+ 0,14* 0,12* 0,39+ 0,25+ 0,28+ 0,28+ 0,29+ 0,14* 0,29+ 0,29+ -0,01 0,19+ 0,11* -0,36+ 0,29+ 0,21+ 0,33+ 0,17+ 0,41+ 1,00 - -
P4 0,27+ 0,12* 0,20+ 0,17+ 0,13* 0,31+ 0,32+ 0,32+ 0,44+ 0,34+ 0,22+ 0,27+ 0,23+ 0,13* 0,21+ 0,11* -0,29+ 0,39+ 0,28+ 0,14* 0,34+ 0,44+ 0,50+ 1,00 -
P5 -0,04 0,05 0,00 -0,04 -0,11* -0,01 -0,11 -0,11 -0,08 -0,09 -0,07 -0,08 -0,11* -0,18+ -0,07 -0,12* 0,15* -0,08 0,00 0,05 0,38+ -0,39+ -0,21+ -0,34+ 1,00
P6 0,24+ 0,14* 0,16* 0,15* 0,01 0,19+ 0,17+ 0,23+ 0,32+ 0,21+ 0,15* 0,30+ 0,23+ -0,01 0,19+ 0,09 -0,30+ 0,28+ 0,22+ 0,26+ 0,22+ 0,34+ 0,42+ 0,43+ -0,28+
Note: +Correlation is significant at 0.01 level (1-tailed); * Correlation is significant at 0.01 level (1-tailed)

4. DISCUSSION

This study investigated the validity and reliability of a questionnaire developed to measure registered nurses' knowledge, attitude, and practice in writing nursing care plans. The instrument was a 26-item questionnaire, and most items, except for items in the knowledge domain, were within the range of ±2 to show that items were reasonably normally distributed [31]. The possible reason for the items in the knowledge domain not being normally distributed could be that a different measurement scale was used.

The reliability of the three domains assessed using Cronbach alpha equalled 0.75 for knowledge, 0.74 for attitude, and 0.77 for practice. Andualem et al., in their study in Ethiopia, found Cronbach's Alpha value of 0.912, 0.784, and 0.713 for knowledge, attitude, and practice questions, respectively [18]. A value greater than 0.7 is considered acceptable [20-22] and indicates that items in the current study had relatively high internal consistency. The study used an inter-total correlation coefficient to evaluate the reliability and found it to be above the acceptable threshold of 0.2 [23-25], indicating that items in the tool belonged to the same construct and that the overall scale was stable and reliable.

Following the internal consistency, EFA was performed to assess the construct validity of the different domains of the questionnaire. The KMO measure of the sampling values were 0.877, 0.793, and 0.797 for knowledge, attitude, and practice, more than the 0.60 thresholds [26-28], demonstrating that the data was sufficient to implement EFA. The Bartlett test of sphericity for all the domains was statistically significant, allowing the EFA to be conducted. Regarding factor loading, except for A1 under the attitude domain with a loading value of 0.408, the results showed that all items obtained loading values >0.5, which is considered ideal and satisfactory [30]. Because other authors recommended a loading factor of ≥0.3 [31] or ≥0.4 [32], item A1 (i.e. Formulation of the Nursing care plan is time-consuming) was retained irrespective of its loading below 0.5, after a brainstorming session with three experienced nurses at the hospital: psychiatric nurse, midwife, and general nurse.

Subsequently, convergent validity was evaluated using the correlation matrix, and it found that items of knowledge and practice showed significant and moderate correlations (0.30 < r <0.60), indicating good convergent validity [25]. Attitude items, however, had low correlations (r<0.30). Most studies that develop a questionnaire to examine nurses' knowledge, attitude, and practices in writing nursing care plans did not assess convergent validity [7, 16-18]. However, one study that tested the instrument validity found three items had total-item correlation coefficient values less than 0.3, and the authors decided not to exclude these items in the revised version of the tool [33, 34].

The study limitation should be considered; participants were registered nurses from one hospital affiliated with a medical university in the Gauteng province of South Africa (SA). Gauteng is the smallest of the nine provinces of SA but highly urbanized and shares the largest (26%) of the country's population. Hence, further study is needed to validate this tool and should include rural hospitals and those not allied with medical schools. The research team selected only six disciplines for the study - adding other fields to a further investigation is essential.

5. IMPLICATIONS FOR NURSING

This instrument will likely assist in and ensure the routine quality of patient care. Furthermore, the excellent and reliable tool will help policymakers in knowing the level of nurses' knowledge, attitude, and practice regarding the drawing of nursing care plans and relevant interventions developed and implemented.

CONCLUSION

This study developed and examined the reliability and validity of the questionnaire used to evaluate registered nurses' knowledge, attitude, and practice in writing nursing care plans. The results indicated that the tool had satisfactory internal consistency and reliability. The researchers found the use of EFA for the investigation of validity to be adequate; however, one item in the attitude domain had a lower threshold value. Further confirmatory factor analysis studies with a larger sample size are needed to support construct validity analysis.

ETHICS APPROVAL AND CONSENT TO PARTICIPATE

A Research Ethics Committee gave Ethical clearance (REF: SMUREC/H/205/2020: G) while the hospital's management permitted access to participants. All participants gave informed consent after getting full information about the study from the researchers.

HUMAN AND ANIMAL RIGHTS

No animals were used in this research. All procedures performed in studies involving human participants were in accordance with the ethical standards of institutional and/or research committees and with the 1975 Declaration of Helsinki, as revised in 2013.

CONSENT FOR PUBLICATION

Informed consent was obtained from all participants.

STANDARDS OF REPORTING

STROBE guidelines were followed.

AVAILABILITY OF DATA AND MATERIALS

The corresponding author [T.S.N] can provide the data sets upon reasonable request.

FUNDING

None.

CONFLICT OF INTEREST

The authors declare no conflict of interest, financial or otherwise.

ACKNOWLEDGEMENTS

The authors would like to thank the Gauteng Department of Health, the National Department of Health, and the hospital's management for granting permission to conduct this study in the hospital. They also thanked all the registered nurses who participated in the study.

REFERENCES

[1] López M, Mirón-González R, Castro MJ, Jiménez JM. Training of volunteer nurses during the Spanish Civil War (1936-1939): A historical study. PLoS One 2021; 16(12): e0261787.
[2] Cardillo A, Pancheri ML, La Torre A. [The participation of italian nurses in the spanish civil war (1936-1939): Identity, ideals and motivations]. Assist Inferm Ric 2019; 38(1): 15-22.
[3] Wildman S, Hewison A. Rediscovering a history of nursing management: From Nightingale to the modern matron. Int J Nurs Stud 2009; 46(12): 1650-61.
[4] Lewis B. Medical-Surgical Nursing: Assessment and Management of Clinical Problems In: Mosby 2017.
[5] Reynolds A. Patient-centered Care. Radiol Technol 2009; 81(2): 133-47.
[6] Urquhart C, Currell R, Grant MJ, Hardiker NR. Nursing record systems: effects on nursing practice and healthcare outcomes. Cochrane Libr 2009; 1(1): CD002099.
[7] Tasew H, Mariye T, Teklay G. Nursing documentation practice and associated factors among nurses in public hospitals, Tigray, Ethiopia. BMC Res Notes 2019; 12(1): 612.
[8] von Laue NC, Schwappach DLB, Koeck CM. The epidemiology of medical errors: A review of the literature. Wien Klin Wochenschr 2003; 115(10): 318-25.
[9] Ente C, Oyewumi A, Mpora OB. Healthcare professionals’ understanding and awareness of patient safety and quality of care in Africa: A survey study. Int J Risk Saf Med 2010; 22(2): 103-10.
[10] Oyebode F. Clinical errors and medical negligence. Med Princ Pract 2013; 22(4): 323-33.
[11] Miziara ID, Miziara CSMG. Medical errors, medical negligence and defensive medicine: A narrative review. Clinics 2022; 77: 100053.
[12] Zeleke S, Kefale D, Necho W. Barriers to implementation of nursing process in South Gondar Zone Governmental hospitals, Ethiopia. Heliyon 2021; 7(3): e06341.
[13] Adraro Z, Mengistu D. Implementation and factors affecting the nursing process among nurses working in selected government hospitals in Southwest Ethiopia. BMC Nurs 2020; 19(1): 105.
[14] Julie NK, Simon IK, Irène KU, et al. Barriers to the implementation of the nursing approach in public hospitals in Lubumbashi in the Democratic Republic of Congo: A cross-sectional descriptive study. OAlib 2017; 4(7): 1-14.
[15] Manal HMM, Hala MBB. Barriers and facilitators for execution of nursing process from nurses’ perspective. Int J Adv Res (Indore) 2014; 2: 300-15.
[16] Mwangi C, Lucy W, Mbugua RG. Utilisation of the Nursing Process among Nurses Working at a Level 5 Hospital, Kenya. Int J Nurs Sci 2019; 9(1): 1-11.
[17] Nakate G, Dahl D, Drake KB, Petrucka P. Knowledge and attitudes of select Ugandan nurses towards documentation of patient care. Afr J Nurs Midwifery 2015; 2(1): 056-65.
[18] Andualem A, Asmamaw T, Sintayehu M, et al. Knowledge, attitude, practice and associated factors towards nursing care documentation among nurses in West Gojjam Zone public hospitals, Amhara Ethiopia, 2018. Clin J Nurs Care Prac 2019; 3: 001-13.
[19] Heale R, Twycross A. Validity and reliability in quantitative studies. Evid Based Nurs 2015; 18(3): 66-7.
[20] Clark LA, Watson D. Constructing validity: Basic issues in objective scale development. Psychol Assess 1995; 7(3): 309-19.
[21] Lance CE, Butts MM, Michels LC. The sources of four commonly reported cutoff criteria. Organ Res Methods 2006; 9(2): 202-20.
[22] Lindahl J, Elmqvist C, Thulesius H, Edvardsson D. Psychometric evaluation of the Swedish language Person-centred Climate Questionnaire-Family version. Scand J Caring Sci 2015; 29(4): 859-64.
[23] Kline P. Computing test-reliability A Handbook of Test Construction: Introduction to Psychometric Design. New York, NY: Methuen & Co 1986; pp. 118-32.
[24] Piedmont RL. Inter-item Correlations.Encyclopedia of Quality of Life and Well-Being Research. Dordrecht: Springer 2014; pp. 3303-04.
[25] Streiner DL, Norman RG. Health Measurement Scales: A Practical Guide to Their Development and Use. 3rd ed. Oxford: Oxford University Press 2003.
[26] Kaiser HF. An index of factorial simplicity. Psychometrika 1974; 39(1): 31-6.
[27] Pallant JF. Development and validation of a scale to measure perceived control of internal states. J Pers Assess 2000; 75(2): 308-37.
[28] Hair JF, Black B, Babin B, Anderson RE, Tatham RI. Multivariate analysis: A global perspective. New Jersey: Person Education Inc, Upper Saddle River 2010.
[29] Williams B, Onsman A, Brown T. Exploratory factor analysis: A five-step guide for novices. Australasian Journal of Paramedicine 2010; 8: 1-13.
[30] Comrey A, Lee H. A first course in factor analysis. 2nd ed. Hillsdale: Erlbaum 1992.
[31] Tabachnick BG, Fidell LS. Using Multivariate Statistics. 5th ed. Boston, MA: Pearson Education. Inc. 2007.
[32] Garson GD. Testing statistical assumptions. Asheboro, NC: Statistical Associates Publishing 2012.
[33] Jardien-Baboo S, Van Rooyen D, Ricks E, Jordan P, Ten Ham-Baloyi W. Best practice guideline for patient-centred care in South African public hospitals. Afr J Nurs Midwifery 2019; 21(2): 1-20.
[34] Tsogbadrakh B, Kunaviktikul W, Akkadechanunt T, et al. Development and psychometric testing of quality nursing care scale in Mongolia. BMC Nurs 2021; 20(1): 68.