Development and Testing of the Psychometric Properties of the Attitude Towards Medical Device-related Pressure Ulcers/Injuries Questionnaire

Medical devices such as endotracheal tubes, tracheostomy tubes, oxygen masks, nasogastric tubes, urinary catheters, cast, splints, and cervical collars are widely used in hospitals.¹ The skin beneath these devices can be damaged by pressure; this damage is called a medical device-related pressure ulcer/injury (MDRPU/I).² In addition to increasing costs, the occurrence of these wounds can cause pain, distress, impaired body image, increased risk of infection, increased length of hospital stay, and decreased quality of life.^3,4 Preventing MDRPU/Is is a hallmark of high-quality care.⁵ Although it is sometimes difficult, MDRPU/I prevention should be a goal for all health care team members.⁶

According to the theory of planned behavior, an individual’s attitude toward an issue can affect his or her behavior and performance.⁷ In recent years, this issue has drawn the attention of researchers to study health care team members’ attitude toward PU/Is. The results of a study conducted in 2019, which reviewed 20 studies on nurses’ attitudes toward PU/Is, demonstrated that nurses had a positive attitude toward prevention of these wounds.⁸ In a study conducted in the United Kingdom in 2019,⁹ the attitudes of 119 health care team members (including nurses, physiotherapists, speech therapists, hospital managers, occupational therapists, podiatrists, and health care and rehabilitation assistants) toward the prevention of PU/Is were investigated; the results showed that the team members exhibited positive attitudes toward preventing PU/Is. In another study, Simonetti et al¹⁰ examined the attitudes of 724 nursing students toward PU/Is and reported that the students had positive attitudes toward the care and prevention of these wounds. A study conducted in Iran in 2019 examined the attitudes of 214 nurses toward PU/Is and revealed that nurses had relatively positive attitudes toward PU/I prevention.¹¹ 

There has been a considerable increase in the number of studies conducted about the prevention and care of MDRPU/Is in the past decade.² One variable that can affect a health care team’s practices is their attitude toward PU/I prevention and care.¹² However, the authors were unable to find any studies in the literature regarding the attitudes of health care team members toward MDRPU/Is. A literature search for a valid and reliable instrument to measure attitudes also did not reveal any instruments specific to MDRPU/Is. The available instruments generally examine attitudes toward non-MDRPU/Is. Therefore, the current study was carried out to develop and assess psychometric testing of the Attitude Towards Medical Device-related Pressure Ulcers/Injuries Questionnaire, which was designed to measure nursing students’ attitudes about the care and prevention of MDRPU/Is.

The preliminary version of the questionnaire was generated after conducting a literature review. Articles published between 1990 and 2019 were searched for in several databases (ProQuest, Science Direct, PubMed, Scopus, Cumulative Index to Nursing and Allied Health Literature [CINAHL], and Google Scholar). The following keywords were used: bedsore, pressure ulcer, pressure injury, MDRPU/Is, attitude, questionnaire, psychometrics, validity, and reliability. The literature review was conducted with the following 3 goals in mind: 1) to ascertain if such a questionnaire already existed, 2) to be aware of all aspects of nursing prevention and care of MDRPU/Is, and 3) to use previous PU/I attitude questionnaire items to design the items of the present questionnaire. The preliminary version of the questionnaire contained 26 items and was reviewed by 10 faculty members and an expert in instrument development before the psychometric assessment took place. Both face and content validity of this 26-item questionnaire was assessed from March 2020 to August 2020. 

In Iran, nursing education is performed in nursing and midwifery schools through 8 semesters. The first semester usually contains theoretical lessons. After this semester, students enter hospital settings. Most of the clinical training is performed in the last 2 years, from semester 5 to semester 8. To measure face validity of the present questionnaire, 10 nursing students (studying in semesters 5, 6, 7, and 8) were asked to examine the items in terms of difficulty level, relevancy level, and ambiguity via internet and cell phone. Vague phrases or phrases that did not fit well were edited. In the next step, the item impact score was used to reduce the number of items, delete unsuitable phrases, and determine the importance of each item. To calculate the impact score, items were scored on a 5-point Likert scale (strongly agree to strongly disagree). Items with an impact score less than 1.5 were omitted.

Quantitative and qualitative phases of content validity of the questionnaire were then begun. In the qualitative phase, 10 faculty members who specialize in MDRPU/Is and instrument development were asked to assess items based on a 3-point Likert scale (“item is necessary,” “item is useful but not necessary,” and “item is not necessary”). In the quantitative phase, the modified Lawshe’s model was applied, and the content validity ratio (CVR) and content validity index (CVI) were calculated. According to Lawshe’s model, items with a CVI greater than 0.63 were retained. The minimum optimal CVI for the new instrument was 79%. 

Exploratory factor analysis was used to measure the construct validity. The required sample size for factor analysis is 5 to 10 cases per item. The sample of this part of the study consisted of 187 nursing students who were studying in semesters 5, 6, 7, or 8 and had access to the internet. A cell phone number and email address were given to them for further communication if needed. 

To assess construct validity of items, the authors used the Kaiser-Meyer-Olkin test of sampling adequacy; Bartlett’s test of sphericity was also performed. Following the analysis of the main components and the varimax rotation, the factor analysis of the questionnaire was determined. The authors used test-retest and intraclass correlation coefficient to assess reliability. For this reason, the questionnaire was distributed among 65 nursing students who were studying in semesters 5, 6, 7, or 8. Of these, 30 questionnaires were returned. The questionnaires were redistributed among them after 1 week, and the data were analyzed using SPSS v21 (IBM).

Ethical considerations. The present article is part of a larger study aimed to develop a MDRPU/Is attitude questionnaire and examine nursing students’ attitudes toward MDRPU/Is that was evaluated by the Yasouj University of Medical Sciences ethics committee (Code: IR.YUMS.REC.1398.156). Information about the questionnaire and its development process presented in this article and information about nursing students’ attitudes toward MDRPU/Is were published previously.¹³ Students were aware of the study objective and provided written informed consent. The researchers ensured the confidentiality of participants’ personal information through all stages of the study.

Of 187 participating students, 101 (54%) were female; 23, 50, 43, and 71 students were studying in semesters of 5, 6, 7, and 8, respectively. The mean age of the nursing students was 23.7 ± 3.9 years. 

The preliminary version of the questionnaire contained 26 items. In the quantitative section of face validity, 7 items were omitted because their impact scores were less than 1.5. After calculating CVR, 4 items were omitted due to a score less than 0.63. After calculating CVI, 4 items were omitted due to scores less than 0.79 (Table 1).

In the qualitative section of face validity, some items were changed in terms of grammar and language according to the opinions of the experts. In the quantitative section of face validity, after calculating the item impact score, 7 items had impact scores less than 1.5 and were omitted.

In the qualitative section of content validity, items were reviewed again and changes were made based on the opinions of the experts in instrument development. After calculating CVI and CVR for all items during the quantitative phase of content validity, 8 items did not achieve the desirable score. 

Finally, the questionnaire (which now had 11 items) was entered in construct validity analysis. After performing the exploratory factor analysis on these remaining 11 items, the Kaiser-Meyer-Olkin test’s value was 0.789, and the result of Bartlett’s test of sphericity was P < .0001, which was statistically significant (Table 2). In factor analysis, factor loads of 0.3 and higher were used. In other words, a correlation coefficient of 0.3 was determined as the minimum degree of acceptable correlation between each variable (item) and the extracted factors. Exploratory factor analysis suggested that the questions related to prevention and the questions related to care included 6 and 5 items, respectively (Table 3).

Internal consistency reliability. The Cronbach’s alpha coefficient was used to estimate the internal consistency of the 11-item questionnaire. Its value was calculated to be 0.77 for the whole instrument, 0.76 for the first factor (“attitude towards MDRPU/Is prevention”), and 0.7 for the second factor (“attitude towards MDRPU/Is care”). Because these values were more than 0.7, the questionnaire was considered optimal for internal consistency.

Reliability. The correlation coefficient between the scores of 30 nursing students was calculated twice, with an interval of 1 week, to assess the reliability of the retest. Of these 30 students, 21 were female; in addition, 5, 8, 7, and 10 students were studying in semesters of 5, 6, 7, and 8, respectively. The correlation coefficient was determined to be 0.86, which was significant at P < .005. The value of the intraclass correlation coefficient of the test-retest, with a 95% confidence interval, was 0.75 for the entire questionnaire, 0.75 for the first factor (“attitude toward MDRPU/I prevention”), and 0.60 for the second factor (“attitude toward MDRPU/I care”). This indicates acceptability and appropriateness of time reliability, or repeatability, of the questionnaire (Table 4).

Scoring. All items were scored as follows: 1 = strongly agree, 2 = agree, 3 = no opinion, 4 = disagree, and 5 = strongly disagree. The total score ranges between 11 and 55 (higher scores revealed a more positive attitude toward MDRPU/Is). A score of 11 to 25 indicated a negative attitude, 26 to 40 a neutral attitude, and 41 to 55 a positive attitude.

The authors sought to develop an instrument to measure nursing students’ attitudes toward MDRPU/I care and prevention. To the authors’ knowledge, this is the first study to develop a questionnaire to examine this factor. Existing instruments evaluate only the attitudes toward conventional PU/Is. 

A questionnaire used for any purpose should have acceptable validity and reliability.¹⁴ In this study, the basic steps related to instrument development were followed carefully. The preliminary version of the questionnaire contained 26 items; after psychometric assessment, the final version included 11 items. Face validity, content validity (using quantitative and qualitative phases), and structural validity were measured to determine the overall validity of the questionnaire. All had acceptable ranges of values, indicating the optimal validity of the final version of the questionnaire. 

The scientific literature has stated that 0.70 is an acceptable level of reliability.^15-17 The Cronbach’s alpha of the questionnaire was 0.77, indicating high consistency and confirming reliability. After performing exploratory factor analysis on the 11 items, the Kaiser-Meyer-Olkin test’s value was 0.789, and Bartlett’s test of sphericity was statistically significant (X² = 386.876E3; P < .001), indicating that the properties of the correlation matrix justified the conduction of a factor analysis. Two (2) factors that accounted for a total of 55% of the variance were accepted. These factors were “attitude towards MDRPU/Is prevention” and “attitude towards MDRPU/Is care.”

The items of the MDRPU/I questionnaire are different from items on the general PU/I attitude questionnaires designed by Moore and Price¹⁸ and Beeckman et al.¹⁹ The questionnaire designed by Beeckman et al¹⁹ consists of 13 items divided into 5 dimensions and includes PU/I prevention competency, PU/I prevention priority, PU/I impacts, responsibility in PU/I prevention, and confidence in the effectiveness of PU/I prevention, which are different from the dimensions of the MDRPU/Is questionnaire. The questionnaire designed by Moore and Price¹⁸ contains 11 questions that focused on the attitude toward prevention of conventional PU/I and that are different from the MDRPU/Is questionnaire. The differences between the items and dimensions of the present questionnaire and those designed by Beeckman et al¹⁹ and Moore and Price¹⁸ may be due to the differences in the nature of conventional PU/Is and MDRPU/Is. Unlike MDRPU/Is, PU/Is commonly form over bony prominences, such as on the sacrum and occiput, and are more common in older patients and those who are critically ill.^20,21 However, MDRPU/Is are caused by excessive pressure caused by the use of medical devices and can occur in patients in all hospital wards.²

Participation in this study was via an internet link, and communication with respondents was difficult. In addition, some students (about 5% of eligible participants) did not have internet access and were unable to participate. The authors believe that the questionnaire was useful for measuring nursing students’ attitudes toward MDRPU/Is. However, further testing among licensed and practicing nurses is needed.

A total of 187 nursing students and 10 faculty members participated in the development and testing of the Attitude Towards Medical-device Related Pressure Ulcers/Injuries Questionnaire. Following reliability and validity assessment, 11 of the original 26 items remained in the questionnaire. The CVR was 0.89 and the Cronbach’s alpha was 0.77 for the final 11-question instrument, showing acceptable validity and reliability. Studies to test this questionnaire and examine health care team members’ attitudes toward MDRPU/Is among licensed, practicing clinicians are needed.

Dr. Fereidouni is a nursing faculty member, Department of Medical Surgical Nursing, Nursing School, Fasa University of Medical Sciences, Fasa, Fars, Iran. Mr. Behnammoghadam is a nursing faculty member, Department of Nursing, Yasuj University of Medical Sciences, Yasuj, Iran. Dr. Rashvand and Mr. Rafiei are nursing faculty members, Social Determinants of Health Research Center, Research Institute for Prevention of Non-Communicable Diseases, Qazvin University of Medical Sciences, Qazvin, Iran. Address all correspondence to: Hossein Rafiei, MSc, Shahid Bahonar Blvd, Qazvin University of Medical Science, Qazvin, Iran 3419759811; email: Hosseinr21@gmail.com.