Nurses play an essential role in providing palliative care to improve the quality of life of people with chronic diseases. The Willingness of nurses to engage in this cares is a necessary issue. Therefore, the evaluation of their willingness requires the use of valid, reliable, and suitable tools in the health system of Iran. This study was conducted to translate and validate the psychometric properties of the Persian version of the nurses' willingness to engage in the palliative care scale.
Methods
This methodological study was conducted in 2023. 440 nurses were included using the convenience sampling in Baqiyatallah Hospital in Tehran. The translation was done using the forward–backward method. Face validity was done with a cognitive interview with 15 clinical nurses. Content validity was done using the opinions of 15 palliative expert nurses, and construct validity was done using exploratory factor analysis (n = 240) and confirmatory factor analysis (n = 200). The reliability was done using internal consistency and assessment of stability. The data were analyzed using SPSS v.25 and LISREL v.8.8.
Results
In the face validity assessment, the items did not change. Brief changes were made in items 8 and 18, in the content validity assessment. In the exploratory factor analysis, 4 factors same as the original version were extracted with a cumulative variance of 59.52%. The results of confirmatory factor analysis showed that the 4-factor model was fit (RMSEA = 0.062, CFI = 0.97, NFI = 0.93, IFI = 0.97, GFI = 0.88). The internal consistency using Cronbach's alpha was 0.9 also the stability was 0.79.
Conclusion
The Persian version of nurses' willingness to engage in palliative care scale has sufficient validity and reliability for nurses in the Iranian population. Therefore, this tool can be used to measure nurses' willingness to engage in the palliative care and identify effective strategies. This tool can be used in clinical trials and research in order to improve the ability of nurses in palliative care in Iranian society.
Hinweise
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Abkürzungen
PC
Palliative Care
TPB
Theory of Planned Behavior
COSMIN
Consensus-based Standards for the selection of health Measurement Instruments
CVI
Content Validity Index
S-CVI /Ave
Scale-level content validity index/Average
EFA
Exploratory Factor Analysis
KMO
Kaiser-Meyer-Olkin Index
CFA
Confirmatory Factor Analysis
ICC
Intraclass Correlation Coefficient
Introduction
Palliative care (PC) is an approach to improve the quality of life of seriously ill patients and their families facing a life-threatening illness; which includes physical, psychological, social, and spiritual aspects [1]. PC plays an essential role in comprehensive and patient-centered services, which means healthcare professionals should play their role in providing this care in the health systems of different countries [2]. PC In Iran, has received more attention but has not developed significantly [3]. So that, PC is provided in a scattered manner in limited centers [4]. According to the quality of death index in 2015, Iran was at the end of this scale [5]. In 2020, the World Atlas of PC classified Iran in A3 group [6].
The high quality of PC can be ensured by a multidisciplinary team. At the same time, a nurse is the core of this team, and their tasks are coordination of all specialists, integration of all recommendations, and adaptation to a particular patient [7]. Nurses have more frequent contact with patients than other healthcare teams and spend more time at the patient's bedside [8]. So that, they spend 20 to 86% of their time with patients [9‐11]. Nurses’ tasks and their behaviors in the field of PC include; defining a patient’s problems, principles of general care, psychological support not only for a patient but also for their relatives, and symptom management [12].
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Despite of importance of PC in Iran, the results of Khanali-Mojen et al.’s study showed that Iranian nurses and physicians have a moderate level of knowledge and attitude towards PC [13]. Also in the study of Dehghannezhad et al., the home care nurses' attitude towards and knowledge of home PC were found to be negative and limited [14]. Studies show that nurses with a negative attitude towards PC avoid dealing with dying patients [15, 16]. On the contrary, a positive attitude can improve the quality of these care services, while a negative attitude can prevent the provision of these services [17].
The willingness of nurses to engage in the PC discussion is very challenging so some nurses consider that physicians have the authority to make end-of-life decisions [18] and some report uncertainty about having to administer treatment dictated by physicians, regardless of the nurses’ own beliefs [19]. The results of studies show that nurses do not prefer care that causes anxiety, helplessness, anger, distress, and fear of failure [14, 20, 21]. Some nurses even express reluctance to provide patients with end-of-life information for fear of being reprimanded by physicians. Previous studies showed that nurses experienced serious challenges and frustrations in communicating with family members and physicians about end-of-life care [18]. However, it is desirable that nurses should be involved in such discussions, as different aspects of the situation must be considered to determine the wishes of patients and their families [22] and their roles involved in patient care and relationships with patients and their families [23].
It seems necessary to investigate nurses' willingness to engage in palliative care. According to the theory of planned behavior(TPB), willingness is a specific measure of intention that describes a person's tendency to behave in a certain situation [24]. The willingness to engage in PC not only affects the quality of services provided, but can also help improve the experience of patients and families [25]. Therefore A valid tool is needed to assess nurses' willingness to engage in palliative care. By reviewing the literature, there are 2 major challenges to find an valid and reliable tool. One is that researchers have investigated nurses' willingness indirectly with other tools, which are mainly assess the knowledge [26, 27], and attitude [28, 29] of nurses towards palliative care. For example, in the study of Masharipova et al., they investigated the readiness of nurses by using two tools the palliative care quiz for nurses (PCQN) (knowledge) and the Frommelt attitudes towards care of the dying (FATCOD) (attitude) [8]. The second challenge is to examine the willingness of nurses based on the researcher's tools [25, 30], in which the psychometric characteristics of the tools have not been fully investigated and the validity of the tool is challenged.
According to studies, nurses' willingness to engage in PC has been measured indirectly by various tools. Most of the tools have focused on the knowledge [31, 32] and attitude [28, 29] of nurses towards PC. Also in Iran, many studies have been conducted regarding the status of knowledge [26, 27] and attitudes [33, 34] of nurses regarding PC [14, 13, 35].
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These tools are not related to how nurses' behavior and willingness to engage in PC are formed. Also, they are not a specific tool to measure nurses' willingness to engage in PC. Zhu et al. developed a scale in 2022 to assess nurses' willingness to engage in PC. This scale developed base on TPB and focused on behavioral intention, attitudes, perceived behavioral control, and subjective norms [36].
Considering the importance of nurses' willingness to engage in PC and the lack of a specialized tool to measure this willingness, this study was conducted with the aim of translating and validating the Persian version of nurses' willingness to engage in palliative care. The following primary research question will be addressed by the study:
Is the nurses’ willingness to engage in the palliative care scale a valid measurement tool in the nursing population?
Methods
Study design
This methodological study was carried out in 2023 to translate and psychometric assessment of nurses' willingness to engage in palliative care scale in Baqiyatallah Hospital in Tehran, Iran. This study was done to provide a culturally relevant, validated instrument that can enhance the understanding of nurses' willingness to engage in PC.
Study participants
The participants were included in the study by convenience sampling at Baqiyatallah Hospital in Tehran. In exploratory factor analysis (EFA), the minimum sample size is 3 to 10 samples per item of the scale [37]. Also, in conducting confirmatory factor analysis (CFA), the sample size should not be less than 200 [38]. 440 nurses participated in the study which 240 nurses participated in EFA and 200 nurses participated in CFA. Nurses for the EFA phase were recruited from various hospital departments during different work shifts. The selection was based on convenience sampling, ensuring a diverse representation across different departments. Similarly, nurses for the CFA phase were selected using convenience sampling, but with an emphasis on different participants from those in the EFA phase to avoid overlap. The inclusion criteria included willingness to participate in the study, speaking Persian, not having a history of psychological disorder based on his/her self-report, and completing the informed consent to participate in the study. Also, novice nurses with less than 1 year of experience were not included in the study because new graduate nurses usually undergo a dynamic transition and crisis in their role as a nurse [38]. Exclusion criteria included not returning the questionnaire and incomplete completion of the scale.
Data collection
After receiving the required ethical approval and permissions and coordinating with the hospital's president and manager, the researcher referred to the director of nursing. In the nursing office of the hospital, a list of nurses qualified for the study was prepared. Then the researcher visited the specified departments of the hospital during different work shifts. The researcher approached potential participants, explained the study's purpose and methodology, and invited those who met the inclusion criteria to participate. The researcher clearly explained the study's purpose and methodology to the nurses in each department. Nurses who agreed to participate and met the inclusion criteria were given the questionnaire. The researcher was available to assist if they had any difficulties understanding the questionnaire. Ultimately, the researcher collected the completed questionnaires from the nurses ensuring proper documentation and adherence to the research protocol. To prevent data contamination in the study, several strategies were employed. First strict inclusion criteria was used so that only nurses who met the inclusion criteria participated to maintain sample relevance. Also, clear instructions were used. For this purpose, we provided detailed guidance to minimize the risk of misinterpretation. In the end, data collection was done separately. Data were collected individually during different shifts to avoid peer influence.
Study instruments
Socio-demographic information
Socio-demographic information was including gender, age, work experience, education, workplace ward, marital status, income satisfaction, and religiosity (Do you consider yourself a religious person?). Also, three bellow questions were asked; “Do you have a history of participating in PC workshops?”, “Do you have a history of caring for a dying person in the family?”, and “Do you have a history of caring for a dying patient in a hospital?”.
Nurses’ willingness to engage in palliative care scale
This scale was developed by Zhu et al. in 2022 with the aim of measuring nurses' willingness to engage in PC. This tool is a self-report scale that is completed by nurses. The scale has 20 items and includes four sub-dimensions: behavioral intention (8 items), attitude toward the behavior (6 items), perceived behavioral control (3 items), and subjective norms (3 items). Responses are based on the 5-point Likert (1 = unimportant, 2 = not particularly important, 3 = moderately important, 4 = relatively important and 5 = very important). Scale scores range is from 20 to 100. Higher scores indicate a higher willingness of nurses to engage in PC. The item-level content validity index (CVI) for the items varied between 0.85 and 1.0, and the scale-level CVI was 0.97. The final EFA had a Kaiser–Meyer–Olkin (KMO) value of 0.91, and Bartlett's test statistic for sphericity was 2632.18 (P < 0.001). Four common factors with eigenvalues greater than 1 were extracted and the cumulative variance explained was 63.20%. Cronbach's alpha coefficient for the internal consistency of the original version of the scale was 0.89 [36] (Fig. 1).
Fig. 1
Scree plot of exploratory factor analysis for Persian version of nurses' willingness to engage in palliative care scale
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Translation process of the scale
The translation process was performed using the Brislin double translation-back translation model [39]. At first, the researchers have obtained permission to translate and psychometric assessment of the scale into Farsi from its developer, Yichang Zhu. In the Forward stage, two bilingual translators (expert professors fluent in English and nurses with sufficient familiarity with the concepts of PC) translated the tool into Farsi. Then, the translated transcripts were created by the translators in the form of a questionnaire and reviewed, edited, and approved in a meeting by nursing and English language experts. In the backward stage, the Farsi translation of the tool was translated into English using two native speakers who were fluent in Farsi and English and were unaware of the original version of the scale. The final English version was sent to the scale developer and approved. The final Farsi version was presented in Fig. 2.
Fig. 2
Persian version of nurses’ willingness to engage in palliative care scale
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Psychometric assessment of the scale
The psychometric properties of the scale including face validity, content validity, construct validity (EFA and CFA) and reliability (internal consistency and stability) were evaluated. This evaluation was done using the Consensus-based Standards for the selection of health measurement instruments (COSMIN) [40].
Face validity
The best people to evaluate a tool's relevance to a given concept are its actual users. In other words, the participation of users of a tool in its psychometric evaluation process can increase its relevance and quality. Therefore, the face validity of the scale was evaluated by potential users of nurses [41].
Qualitative face validity
After completing the translation process, cognitive interviews were used to evaluate the qualitative face validity. Cognitive interviewing is conducted to identify the source of error in the scale by focusing on the cognitive process of the respondents when completing the scale [42]. A face-to-face interview was conducted with 15 nurses to determine the difficulty, appropriateness, and relevance of the items of scale.
Quantitative face validity
To assess the quantitative face validity, the same nurses were asked to indicate the ability to understand each item of the scale with a 5-point Likert scale (1 = not at all understandable to 5 = completely understandable). For quantitative face validity, the impact score was calculated [42]. The impact of the items was calculated with the formula; Impact Score = Frequency (%) × Comprehensiveness. Frequency is the number of people who gave 4 and 5 scores to each item. Comprehensiveness is also the scores obtained from people's responses to that item based on the Likert scale. Items whose score is equal or greater than 1.5 are kept and other items were removed [43].
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Content validity
The content validation was assessed to explore all important aspects of the intended concept of the instrument as well as acceptance of execution and totality of the instrument by experts [44].
Qualitative content validity
The scale was presented to 15 nursing professionals (10 Ph.D. and 5 a master's degree in nursing). They were asked to evaluate the items of the scale in terms of grammar, phrasing, comprehensibility and, adaptation to Iranian culture and express their opinion to each item.
Quantitative content validity
To check the content validity index (CVI), the modified version of the scale was presented again to the same 15 nurses. They were asked to score each item based on simplicity, clarity and, relevance by a four-point Likert scale (1 = not relevant to 4 = completely relevant) [37, 45]. Then the CVI of each item and the entire scale was calculated. The CVI above 0.8 was considered appropriate [46].
$$CVI=n/N$$
CVI = content validity index.
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n = the number of experts who rated an item 3 and 4.
N = the total number of experts who answered the item.
The ceiling and floor effects
If more than 15% of respondents score the lowest or highest possible score, there is a floor or ceiling effect, respectively [47]. The presence of these effects suggests that there may be extreme cases at the high or low end of the scale and indicate insufficient content validity [4].
Construct validity
Construct validity refers to the extent to which a test measures what it is intended to measure. It can be examined by examining the instrument's correlation with other variables that are known or expected to be theoretically related to the construct it purports to measure [48].
EFA is used to discover the underlying structure of a relatively large set of variables. In examining construct validity, we seek to answer the question of whether the instrument can measure theoretical and unobservable constructs [49, 50]. Establishing construct validity for interpretations derived from a measure is critical to high-quality evaluation and subsequent research that uses data from that measure's results [51].
Exploratory Factor Analysis
EFA is used to discover the underlying structure of a relatively large set of variables [38]. The minimum sample size required for EFA is 3–10 participants per item [37]. In this study, achieving initial communality values higher than 1 and factor loading higher than 0.42 were considered. Also, the adequacy of the samples was evaluated using the KMO and Bartlett's test. The KMO value greater than 0.5 is acceptable and greater than 0.7 is more appropriate [52]; Also, the value of Bartlett's test should be less than 0.05 (p < 0.05) [43]. If the factor load of an item was less than 0.4, should be removed from the questionnaire. In this study, 12 nurses were considered for each item, and thus 240 nurses included in EFA. Given that the factor loading for item 11 was below 0.4, it was deemed necessary to exclude it from the analysis. To extract and interpret factors in EFA, the Promax rotation method was used [53].
Confirmatory Factor Analysis (CFA)
Factors extracted in EFA were evaluated with CFA [45]. CFA is a method to determine the maximum likelihood in evaluating construct validity [54]. In this phase, we included 200 nurses (other than the participants in EFA). Analysis was performed using LISREL (v. 8.8) and several indicators were used to measure the usefulness of the model. Model fit indices in CFA are classified into three general categories: Absolute Fit included Root Mean Square Error of Approximation (RMSEA), Standardized Root Mean Square Residual (SRMR), Goodness of Fit Index (GFI), and Chi-square. Comparative Fit included Comparative Fit Index (CFI), Incremental Fit Index (IFI), Relative Fit Index (RFI), Normed Fit Index (NFI) and, Tucker–Lewis index (TLI). Parsimonious Fit included Parsimonious Comparative Fit Index (PCFI), Parsimonious Normed Fit Index (PNFI), Adjusted Goodness of Fit Index (AGFI), and Akaike Information Criterion (AIC).
Reliability
Reliability indicates the level of confidence of the test scores in terms of accuracy and lack of measurement error [55]. The reliability of nurses' willingness to engage in PC scale was measured using the internal consistency method (Cronbach's alpha coefficient) and stability measurement test-retest. Cronbach's alpha coefficient greater than 0.7 was considered acceptable [56]. These participants were selected through convenience sampling from various hospital departments, ensuring a representative sample for this measurement. In order to measure the stability by test–retest method, the intraclass Correlation Coefficient (ICC) was calculated by collecting the data of 30 working nurses with an interval of two weeks [57]. These 30 nurses were a subset of the initial 240 participants involved in the EFA phase, ensuring stability in the sample used for reliability testing.
Data analysis
Data analysis was done using SPSS software (version 25). Descriptive statistics included frequency/percentage, mean ± standard deviation and analytical statistics included factor analysis rotation, correlation, Cronbach's alpha coefficient, and ICC were used. Also, a significance level of 0.05 considered.
Ethical considerations
All procedures were approved by the Ethics Committee of Baqiyatallah University of Medical Sciences (code (IR.BMSU.REC.1402.021) and were performed in accordance with the ethical standards of the 1964 Declaration of Helsinki and subsequent amendments or comparable standards [58] Oral and written Informed consent was obtained from all subjects involved in the study. The questionnaire used in this study was referenced from a publication by the original author. Following an email request to the research team, permission was obtained from the corresponding author to initiate the translation and psychometric assessment [36].
Results
Socio-demographic information
In this study, 495 nurses initially participated. However, 30 nurses did not return the questionnaires, and 25 nurses left more than 20% of the questionnaire items unanswered. As a result, a total of 440 nurses were ultimately included in the study (response rate 88.89%). 285 people (64.8%) were women, and 155 people (35.2%) were men. Nearly half of the nurses aged between 22–30 years and most of them (41.7%) had 1–5 years work experience between. In this study, most participants had a bachelor's degree in nursing (86.8%) and most were married (66.1%). Also, 49.1% were officially employed, and more than half (54.8%) earned enough for their living expenses. Most of them (90.2%) had a history of participating in PC workshops. More than half of the participating nurses (51.4%) sometimes considered themselves religious. 60.2% of them had a history of caring for a dying patient in the family, while 80.9% of them had a history of caring for a dying patient in the hospital. Other demographic characteristics of the people participating in the study by participating in EFA and CFA phases are shown in Table 1.
Table 1
Original version of the nurses' willingness to engage in palliative care scale
Questions
Unimportant
Not Particularly Important
Moderately Important
Relatively Important
Very Important
Intention
I am prepared for what palliative care requires
I would like to promote palliative care
I would like to explain palliative care to dying patients and their families
I am willing to learn and improve my knowledge of palliative care and apply it to palliative care units
I would like to work with palliative staff to improve the existing system
I would like to work on the problems of terminal patients and their families
I would like to work in a palliative care unit
I like to participate in palliative training sessions every time they are held
Attitude toward the behavior
Helping terminal patients and their families embodies my professional values
I think multidisciplinary collaborations can facilitate palliative care delivery
Palliative care provides comfort and care for dying patients and their families
I think that constructing palliative care units is very important
I think that nursing has an important role in palliative care
I pay close attention to the physical, psychological, spiritual, and social status of terminally ill patients and their families
Perceived behavioral control
Working in palliative care units enhances my sense of self-worth and professional achievement and gives me a clear career development plan
Working in palliative care units has helped me to fully understand the meaning of death
I am well-qualified to work in palliative care units
Subjective norms
My family had a major influence on my attitude toward working in palliative care units
The construction of a palliative care ward in our hospital will heighten my interest in palliative care
The palliative care policies of the state have facilitated my palliative care work
Face validity
15 nurses participated in the face validity of the scale. The nurses stated that all the items are simple, clear, and related to the subject of the study. Furthermore, the impact score for all items was above 1.5 and none of the items changed.
Content validity
In the qualitative content validity, 15 expert nurses suggested that two items (9 and 18) be rewritten in Persian for clarity and better understanding of the meaning and concept. After rewriting, these two items were re-examined and confirmed by experts. CVI of each item was also calculated and varied between 0.8 and 1. Finally, SCVI/Average scale equal to 0.9 was obtained.
The ceiling and floor effects
The lowest score was 58 and the highest score was 95, and both ceiling and floor effects were 0.4% and 6.7%, respectively, which indicates a good ceiling and floor effect of the scale.
Exploratory Factor Analysis
The KMO of the scale was 0.89 and Bartlett's sphericity test was significant, which showed the adequacy of the sample for analysis (χ2 = 2246.289; df = 190, P < 0.001). The factor loading of all items except one item (number 11) was greater than 0.42, so this item was removed. The results of the EFA showed that four factors explained 59.52% of the total variance. Based on the scree plot, the scale included (Fig. 1). Four factors named behavioral intention, attitude toward the behavior, perceived behavioral control, and subjective norms. Also, the findings showed that the factor loadings of the items varied from 0.43 to 0.89 (Table 2).
Table 2
Frequency distribution of demographic characteristics (n=440)
Variable
EFA
(n=240)
CFA
(n=200)
N
%
N
%
Age
30-22
114
47.5
95
47.5
40-31
97
40.4
73
36.5
52-41
29
12.1
32
16
Work Experience
5-1
100
41.7
91
45.5
10-6
75
31.3
36
18
15-11
30
12.5
35
17.5
20-16
24
10
26
13
>20
11
4.6
12
6
Gender
Male
83
36.4
72
36
Female
157
65.4
128
64
Marital status
Unmarried
89
37.1
60
30
Married
151
62.9
140
70
Education level
Bachelor's degree in nursing
211
87.9
171
85.5
Master degree and Ph.D. degree in Nursing
29
12.1
29
14.5
Employment status
Official
106
44.2
110
55
a plan
32
13.3
38
19
Contractual
37
15.4
13
6.5
a treaty
65
27.1
39
19.5
Ward
Emergency
56
23.3
42
21
Critical
92
38.3
81
40.5
General
77
32.1
54
27
others
15
6.3
23
11.5
Income satisfaction
Yes
105
43.8
94
47
No
135
56.2
106
53
religiosity
Often
112
46.7
102
51
Sometime
128
53.3
98
49
Participation in PC workshops
Yes
33
13.8
10
5
No
207
86.2
190
95
History of caring for a dying person in the family
Yes
82
34.2
93
46.5
No
158
65.8
107
53.5
History of caring for the dying patient in the hospital
Yes
187
77.9
169
84.5
No
53
22.1
31
15.5
Confirmatory Factor Analysis
CFA showed a good fitness of the model and was confirmed with four factors including behavioral intention (4 items), attitude toward the behavior (6 items), perceived behavioral control (5 items), and subjective norms (4 items). In addition, the chi square of 256.59 (df = 146, p < 0.001) showed a good fit of the model. The goodness of fit index (GFI) was 0.88. Other indicators measured in this model were as follows: RMSEA = 0.062, CFI = 0.97, NFI = 0.93, IFI = 0.97, and GFI = 0.88; all tested indicators confirmed the fit of the extracted model (Fig. 3).
Fig. 3
Confirmatory factor analysis for Persian version of nurses’ willingness to engage in palliative care scale (n = 200)
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Reliability
The internal consistency of the dimensions of the scale was obtained as α = 0.75–0.85, and for the whole scale was α = 0.9, which indicates a satisfactory internal consistency of the instrument (Table 3). Also, the stability of the dimensions of the scale using the ICC was 0.5–0.85 and the whole scale was 0.79, which indicates the appropriate stability (Table 4).
Table 3
Promax factor loadings of the items of the instrument (n = 240)
Factor
Item
Factor loading (%)
Variance (%)
Behavioral intention
Q1
0.43
39.53
Q2
0.80
Q3
0.86
Q4
0.58
Attitude toward the behavior
Q5
0.53
9.05
Q6
0.67
Q7
0.55
Q8
0.82
Q9
0.68
Q10
0.59
Perceived behavioral control
Q12
0.54
5.74
Q17
0.45
Q18
0.61
Q19
0.89
Q20
0.79
5.2
Subjective norms
Q13
0.67
Q14
0.69
Q15
0.82
Q16
0.48
Cumulative %
59.52
Table 4
Cronbach’s alpha of subscales and the entire Persian version of nurses' willingness to engage in palliative care scale
The present study was conducted with the aim of translating and psychometric assessing of the nurses' willingness to engage in palliative care scale into Farsi and evaluating its validity and reliability among clinical nurses in Iran. The results showed that the Persian version of this scale, like the original version, has satisfactory factor construction, validity, and reliability. Until now, various tools have been designed to assess attitudes, self-reported practices, and knowledge of nurses involvement in PC. But none of them has investigated nurses' willingness as a behavior that is affected by attitude, perceived behavior control, and subjective norms [29, 59, 60].
The Content Validity Index (CVI) was calculated 0.8 and 1 for each item, and the scale-level content validity index (S-CVI) was 0.9, which is satisfactory [61]. Zhu et al. also reported a CVI value of 0.85 and 1 and with an S-CVI of 0.97 [36]. Inferences from assessment instruments with satisfactory content validity would be questionable, even when other validity indicators are satisfactory [62].
In the present study, the validity of EFA of nurses' willingness to engage in palliative care scale was assessed, and results showed that four factors explain 59.52% of the variance. After EFA, one item out of 20 items was removed, and 19 items remained. The first to fourth factors explain 39.53 (4 items), 9.05 (6 items), 5.74 (5 items), and 5.2 (4 items) percentage of the total variance, respectively. The factor loading of the items is between 0.43 and 0.89, which is satisfactory. Similarly, in a study by Zhu et al., results of EFA showed that the four subscales of the Korean version of the nurses' willingness to engage in PC scale explained 68.93% of the variance, and the factor loadings of the items ranged from 0.7 to 0.86. [36].
The items of this questionnaire were classified into different dimensions, which were based on the hypothesis of the theory, and as a result, it had good construct validity like Jung's study. However, previous studies represented that culture may have a significant influence in end-of-life care [63]. For example, a systematic review study that was conducted based on the perspective of patients and families evidenced that conservation of the cultural identity of origin, the value given to the family over the individual, the limited experience of immigrants in accessing the health system of the host country, and the language differences are known as barriers among the Chinese immigrant population to receive end-of-life care in high-income countries [64]. Meanwhile, Wicher and Meeker conducted a study to compare end-of-life preferences between African Americans and non-Hispanic whites. They found that African Americans used more aggressive life support therapies and fewer advance care planning (ACP) documents or hospice services [65]. Choudry et al. (2018) believed that religious beliefs can influence visions and perspectives of end-of-life care. So in the study they conducted among five religious traditions in the United Kingdom, they observed different concepts of life, life after death, and different rituals involved [66]. These findings support the validity of nurses' willingness to engage in palliative care scale measuring the willingness of clinical nurses to provide PC in Iran.
The first factor that was identified in the Persian version of nurses' willingness to engage in the PC scale was "behavioral intention", which consisted of four items. These items mainly focused on providing conditions and explaining PC to patients. According to TPB, all the factors that may influence behavior are indirectly related to "behavioral intention". Therefore, nurses' willingness to engage in PC can be assessed by understanding the factors affecting behavioral intention, which thus can improve the performance of PC teams and the quality of their care. Zhu et al., in the initial psychometric analysis of the Korean version of the nurses' willingness to engage in PC scale, also identified behavioral intention as one of the four main factors, which is equivalent to the factor present in the Persian version [36]. Considering that hypothesizes that the most proximal and direct predictor of human behavior is the individual's intention to engage in the behavior, it can be concluded that other factors such as additional contextual factors can influence the decisions of nurses [67].
"Attitude toward the behavior" appeared as the second factor in the Persian version, which included 6 items. This factor initially focuses on engagement of nurses in providing PC services and cooperation with other nurses and families of patients. This factor, like the Korean version of the tool, is one of the factors that exists in both Persian and Korean versions [36]. In this regard, it should be noted that attitude toward a behavior can influence the practice and intention of people in performing a behavior. As Similarly, Eskandari et al. showed a significant relationship between knowledge, attitude, intention, and performance of nurses regarding the use of physical restraints for patients [68]. Also, Chang-Chiao Hung et al. emphasized the effect of the attitudes of nurses on their willingness to report drug dispensing errors [69]. Similarly, according to Green's theory, nurses' behavior in palliative care is affected by their knowledge and attitude [70]. Previous studies reported that nurses lack knowledge about PC and have a negative attitude toward this care method [71, 72]. Knowledge, attitudes, beliefs, and actions are interconnected and interact with each other. Changes in one component can affect other components and lead to changes in behavior.
"Perceived behavioral control" is the third factor identified in the Persian version and consists of 5 items. This subscale mainly focuses on the importance of PC and the essential role of the nurse in this regard. The Korean version also considered this factor as one of the factors extracted from the questionnaire [36]. Payongayong et al. also emphasized that perceived behavioral control of nurses is significantly related to their communication behavior of end-of-life patients [73]. Hence, considering the effect of perceived behavioral control on the intention of nurses, this factor can be considered as an effective factor in willingness of nurses to engage in PC services.
The last identified factor is "subjective norms", which consists of four items and mainly focuses on individual qualifications for engagement in PC and the impact of family and support policies on engagement in PC. Zhu et al. have also referred to subjective norms as a vital element in the Korean version, like the Persian version of the questionnaire [36]. Chang et al.'s results also showed that nurses' attitude, mental norms, and their perceived behavioral control have a positive relationship with behavioral intention to participate in the nursing program [74]. This finding shows the important role of subjective norms on willingness of nurses to engage in PC.
The original version of the nurses' willingness to engage in palliative care scale, designed and psychoanalyzed by Zhu, had 20 items over four dimensions [36]. As stated, one of the items was removed from the scale, and 19 items were obtained in four subscales after EFA that were confirmed after CFA in the present study.
In this process, there was a change in the number of items related to each of the subscales compared to the original questionnaire. Regarding the objective of translation and validation of measurement tools, the aim of this research is to ensure the cross-cultural comparability of that tool in a specific population. Therefore, according to the cultural background of Iranian nurses, a four-factor structure was extracted for this tool in this research. Therefore, in some cases, the items were assigned to different factors compared to the original version of the questionnaire. This difference may be attributed to cultural or linguistic changes. Therefore, after a detailed examination by the research colleagues, the correctness of the assignment was evaluated, and these changes were confirmed.
After CFA, the average values of extracted variance were between 0.43 and 0.71, and the model fit indices were all within an acceptable range. Zhu did not performed CFA, which is one of the strengths of the present study [36]. The analysis of the results showed that the Persian version of nurses' willingness to engage in palliative care scale has an acceptable degree of reliability. In other words, Cronbach's alpha coefficients of the four subscales of the above tool ranged from 0.75 to 0.85 and 0.9 for the whole scale. Also, the ICC of the whole scale was estimated at 0.79, which is acceptable [75]. Similarly, Zhu et al. showed that the Korean version of nurses' willingness to engage in palliative care scale is reliable enough so that Cronbach's alpha coefficient of the whole tool was 0.89 [36]. In the original study, ICC was not calculated for this tool, which is one of the strengths of this study.
Strengths
In the present study, a large number of nurses engage and the willingness of nurses to engage in PC was comprehensively evaluated. Also, CFA and ICC of this scale were not conducted in the original version of the study conducted by Zhu et al., while it was done in the present study. By conducting confirmatory factor analysis, the proposed model identified in the exploratory factor analysis phase was confirmed. This model includes latent variables that measure nurses' willingness to engage in palliative care. Conducting ICC showed that this scale has sufficient stability, and measuring nurses' willingness at different times provides similar results.
Limitations
The target population of the present study consists exclusively of nurses, and no nursing students were investigated in this study. It is suggested that opinions of nursing students as future nurses be also investigated in future researches. Also, considering cultural differences and the impact of culture on care decisions in end-of-life patients, it is suggested that nurses' willingness to engage in PC scale be translated in other countries and its validity and reliability evaluated. Since this scale was first developed in South Korea and has only been psychometrically analyzed in that country, in the present study, the researchers could only compare their findings with the study by Zhu et al., which is one of the limitations of this study.
Conclusion
The Persian version of the Nurses' Willingness to engage in PC Scale has demonstrated sufficient validity and reliability, making it a valuable tool for assessing nurses' willingness in PC settings, including hospitals, hospices, and home care. Also, managers and supervisors can use this scale to assess nurses' willingness to continue or stop working in PC settings. By using this scale, nursing managers can better help align institutional strategies with nurses' needs and motivations, ultimately improving PC standards and outcomes. In fact, institutions can use it to provide an environment that has higher standards in PC. So, it is recommended that this scale be used in ongoing training and development programs to regularly assess and enhance nurses' readiness and willingness for providing PC. This in turn improves both patient outcomes and the overall satisfaction of health care providers in health care. Future research should focus on further using this tool in diverse healthcare settings to ensure its applicability across the nursing community. Additionally, studies could explore the impact of targeted interventions, informed by the results of this scale, on increasing nurses' willingness to engage in PC.
Acknowledgements
The authors would like to appreciate Baqiyatallah University of Medical Sciences & Clinical Research Development Unit of Baqiyatallah hospital.
Declarations
Ethics approval and consent to participate
The research related to human use has complied with all the relevant national regulations, institutional policies, and in accordance with tenets of the Helsinki declaration, and has been approved by the Research Ethics Committee of Baqiyatallah University of Medical Sciences. (IR.BMSU.REC.1402.021). Also, the necessary permits and coordination with the hospital's president and manager were done. Informed consent was obtained from the participants after clarifying the research objectives and introducing the researchers.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
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