Introduction
Today, terminal illness or death not only overshadows adults or the elderly but can also happen to children (Adistie et al. Reference Adistie, Lumbantobing and Maryam2019). The Lancet Commission emphasizes that 2.5 million children die every year in the world due to serious health problems, and the majority of deaths occur in low- and middle-income countries (Knaul et al. Reference Knaul, Farmer and Krakauer2018). According to these estimates, every year 21 million children under 19 years, including newborns and infants, require end-of-life care due to cancer, cardiovascular diseases, liver cirrhosis, congenital anomalies, neurological disorders, and neonatal conditions (Adistie et al. Reference Adistie, Lumbantobing and Maryam2019; Connor et al. Reference Connor, Downing and Marston2017). A child’s end-of-life circumstances and care are extremely important, and health professionals have a responsibility to provide high-quality care, including dignity, respect, and symptom control, during this time (Mayland et al. Reference Mayland, Sunderland and Fraser2022).
A specific part of palliative care, end-of-life care, is a special type of care that recognizes death as the last stage of life, designed to focus on quality of life rather than length (Ranallo Reference Ranallo2017). End-of-life care includes the management of physical symptoms, the provision of psychological, social, and spiritual support, and the fulfilment of wishes of the patient and their families (Alshammari et al. Reference Alshammari, Sim and Lapkin2022). End-of-life care, which focuses on the last days and last hours of life, is for people who are about to die; needs, when to die, what to expect, preference for control and desires, being informed, quality of life, physical, emotional and cognitive symptoms, pre-planning of care, functional status, spirituality, grief, quality and satisfaction of care (Chan et al. Reference Chan, Lam and Siu2016). If the end-of-life care needs of patients are not met, poor quality of life, including traumatic death, decreased sense of spiritual well-being, and increased risk of depression, may result (Muscat et al. Reference Muscat, Shepherd and Morony2016; O’Brien et al. Reference O’Brien, Kinloch and Groves2019).
End-of-life care with pediatric patients is considered to be particularly difficult because typically the death of children is considered “against the natural order.” Therefore, providing end-of-life care for pediatric patients has significant emotional effects on health professionals and brings with it a number of challenges (Muscat et al. Reference Muscat, Shepherd and Morony2016). End-of-life care is provided by a professional team of doctors, nurses, social workers, and other specialists, who play an important role and spend more time than other healthcare professionals (Fernando and Hughes Reference Fernando and Hughes2019; Geum et al. Reference Geum, Ahn and Kim2019; Tamaki et al. Reference Tamaki, Inumaru and Yokoi2019). Caring for a dying child is often described as a painful and stressful experience for a pediatric nurse (Chew et al. Reference Chew, Ang and Shorey2021). Nurses experience personal grief when a child dies, and the experience of grief can be long-lasting, painful, and stressful. Stress may intensify if the nurse’s roles and responsibilities are not clear or there is a feeling that optimal end-of-life care is not provided (Bloomer et al. Reference Bloomer, O’Connor and Copnell2015). Also, in some cases, the death of a patient results in inadequate nursing actions and therapeutic efforts to save the patient’s life, leading to feelings of professional failure and impotence. It is a fact that nurses are affected by the intense emotional state they experience and the anxiety, stress, and workload created by the environment they work in because they witness the death of the individuals they care for (Jang et al. Reference Jang, Park and Kim2019; Nia et al. Reference Nia, Lehto and Ebadi2016). For this reason, it is important to investigate the thoughts and fears of end-of-life care nurses about death and to determine their stress and anxiety levels (Nia et al. Reference Nia, Lehto and Ebadi2016) because this situation may affect the empathic concerns of nurses, the quality of care they provide, and the way they cope with work-related stressors (Peters et al. Reference Peters, Cant and Payne2013). In addition, caring for dying patients leads to grief and perceptions of failure, which may raise increased anxiety about managing the death process in the work environment (Peterson et al. Reference Peterson, Johnson and Halvorsen2010).
End-of-life care is given with a multidisciplinary team approach such as doctors, nurses, physiotherapists, and play therapists who are experts in their fields, centered on the individual and the family, and the nurse is the team member who is in constant communication and meets the care needs the most. In order for the nurse to provide adequate, effective, and holistic care, it is necessary to acquire sufficient knowledge and technical skills before graduation (Ferrell et al. Reference Ferrell, Virani and Paice2010; Kudubeş et al. Reference Kudubeş, Özkan and Semerci2022). Studies for the inclusion of “end-of-life care, good death concepts” in the nursing curriculum in Turkey started in 1990, and they started to enter undergraduate programs in the last 10 years, and the deficiencies are tried to be eliminated with the training and certificate programs provided by the Ministry of Health (Aksakal Reference Aksakal, Aksakal, Kahveci and Koç2018). In a systematic review, it was found that the “quality and reflection of practice” of the training that newly graduated nurses received before graduation on palliative care or end-of-life care was insufficient and that nurses were nervous, helpless, powerless, stressed, uncertain about palliative care or care for individuals in the end-of-life period. It was found that they gave different emotional reactions such as anger (Zheng et al. Reference Zheng, Lee and Bloomer2016). Therefore, this situation shows that there is a need for objective, valid, and reliable standardized measurement tools in order to carry out qualified studies on the subject with pediatric nurses. It is known that there are a limited number of studies and valid and reliable data collection tools in the foreign literature (Park Reference Park2018; Park and Ju Reference Park and Ju2020; Sansó et al. Reference Sansó, Vidal-Blanco and Galiana2021), while there is no measurement tool in Turkey as far as we know. Therefore, this study was conducted to evaluate the Turkish psychometric properties of the “Stress in Korean Nurses Performing End-of-Life Care for Children Scale.”
Methods
Design and participants
A methodological design was used in the study. The data for this study were collected between May 2021 and January 2022 in the form of an online survey as a result of the COVID-19 pandemic. The application of the survey was made available to the pediatric nurses with the link created via Google Form.
Among the suggested methods for sample calculation in scale development studies, the rules of 5s, 10s, and 100s were applied (Şencan Reference Şencan2005). A researcher should recruit at least 5 persons per item to perform factor analysis. If there is no problem in reaching the number of sample, the number of people per item should be 10 (Brown Reference Brown2015; Finch Reference Finch2019). The Stress Scale for Nurses Performing End-of-Life Care to children includes 22 items, and the number of nurses per item was calculated as 10, and the study was planned to include 220 nurses.
Pediatric nurses who work in the pediatric ward or intensive care unit of university or state hospitals in 4 big cities in the east and west of Turkey and who have experience in caring for children with terminal illnesses were invited to participate in the study. Information about the purpose and scope of the study was given through WhatsApp and Facebook groups where pediatric nurses are subscribed, and the nurses were invited to the study. “Nurse information form” and “Stress in Korean Nurses Performing End-of-Life Care for Children” scale were sent online and filled by 222 pediatric nurses who volunteered to participate in the study. The time to answer the survey was approximately 10–12 minutes for each participant.
Data collection tools
Study data were collected using the Information Form for Nurses and the Stress in Korean Nurses Performing End-of-Life Care for Children Scale.
Nurse information form
The information form prepared by the researchers in line with the literature consisted of questions such as the nurse’s age, gender, education, working time, the unit he/she worked in, and receiving training on pediatric terminal care.
Stress in Korean Nurses Performing End-of-Life Care for Children
It is a scale developed by Park and Ju (Reference Park and Ju2020), which measures the stress level of nurses who care for children with terminal disease. The scale consists of a total of 22 items and 5 subdimensions: “Psychological Difficulties,” “Conflict with Parents,” “Communication Difficulties,” “Lack of Information on End-of-Life Care,” and “Restricted Working Environment.” The tool, which includes 5-point Likert-type response options, is rated on a 5-point scale ranging from strongly disagree (1 point), disagree (2 points), not sure (3 points), agree (4 points), and strongly agree (5 points). A high score from the scale indicates a high level of stress. The Cronbach’s alpha reliability coefficient of the scale was determined as 0.90 (Park and Ju Reference Park and Ju2020).
Steps of research
Language validity stage
The English text created by the author of the scale was used in the language validity study of the “Stress in Nurses Performing End-of-Life Care for Children” scale. The language validity process includes the translation stages of the scale first from English to Turkish and then from Turkish to English. In the first stage, 3 different linguists, who knew both English and Turkish languages professionally, independently translated the scale into Turkish. After the scale was translated into Turkish, it was corrected by the researchers’ group work. The Turkish language of the scale was approved by a Turkish language expert. The Turkish scale was translated back to English by a linguist who speaks both languages at a native level and whose mother tongue is English. The Turkish and English scales were compared by the other linguist; no change in meaning was observed in the scale items, and the language validity of the scale was completed.
Content validity stage
After the language adaptation of the scale, the content validity was then conducted with the expert opinion method to evaluate its validity. Content validity index (CVI) is the most widely used index in quantitative evaluation. Content validity consists of obtaining expert opinions in order to determine whether the items in the measurement tool are suitable for the purpose of the measurement and whether or not they represent the field to be measured (Erci and Aslan Reference Erci and Aslan2022; Şencan Reference Şencan2005). For this purpose, 11 specialists (a palliative care specialist, a pediatric hematology–oncology specialist, 2 pediatric oncology nurses, 2 pediatric intensive care nurses, a neonatal nurse, and 4 pediatric nursing lecturers working in this field) were consulted to evaluate the scope validity of the scale, which was translated into Turkish. It is recommended to obtain at least 3 expert opinions to evaluate the content validity of the scales (Morgado et al. Reference Morgado, Meireles and Neves2017). The scale was sent to them via e-mail. They were informed about the measurements and concepts involved. Content validity was calculated using the Davis technique (Davis Reference Davis1992). The experts were asked to evaluate whether or not each scale item measured the “Stress in Nurses Performing End-of-Life Care for Children” scale and the understandability of the scale items on a scale rated between 1 and 4. On this scale, as “appropriate” is 4 point, “the item should be slightly revised” is 3 point, “the item should be seriously reviewed” is 2 point, and “the item not appropriate” is 1 points. The number of experts who chose options (3) and (4) was divided by the total number of experts to obtain the “content validity ratio” of the item (Almanasreh et al. Reference Almanasreh, Moles and Chen2019).
Pretrial stage
It is recommended to apply the scale to a group of approximately 20–30 people after specialists’ opinions are taken (Şencan Reference Şencan2005). The scale was applied to 20 nurses who perform end-of-life care to children with similar characteristics to the sample and agreed to participate in the study, but these nurses were not included in the sample (Şencan Reference Şencan2005). Nurses did not give negative feedback regarding intelligibility, readability, and response process. The intelligibility of the scale was found to be sufficient in the pilot application, and then it was applied to the full sample.
Data collection process
Due to the COVID-19 pandemic, study data were collected online. Data were obtained by sharing the online link of the survey, which was created using Google Forms, via social media (Facebook, etc.) and WhatsApp groups of the nurses.
Data analysis
Data were analyzed using SPSS Statistics (v.25.0; SPSS, Chicago, IL) and AMOS 21 software packages. Descriptive statistics on sociodemographic information collected from nurses were presented as frequency, percentage, and mean values.
In this study, content validity and construct validity were used to ensure the validity of the Turkish form of the scale. The CVI was used to assess agreement among specialists (Polit et al. Reference Polit, Beck and Owen2007). Construct validity, item analysis, Kaiser–Meyer–Olkin–Bartlett tests, confirmatory factor analyses, Cronbach’s alpha reliability coefficient, split-half analysis (Spearman–Brown and Guttman), and split-half values were calculated.
Ethical considerations
In order to conduct the study, permission was obtained from the scale owner (Park and Ju Reference Park and Ju2020) via e-mail. Also, approval was obtained from the scale owner to remove the word “Korean” in the original scale title. Ethics committee approval was obtained from the human research ethics committee of a university (Date: 30/04/2021 Protocol No: 05/37), and necessary permissions were obtained from the Ministry of Health. The consent form, which included informing regarding the purpose of the study, was sent to the nurses online, and their consent was obtained and recorded.
Results
Demographic characteristics of participants
A total of 222 pediatric nurses participated in the study. 86.0% of the nurses were female, 57.7% single, 33.8% had children, 63.5% were university graduates, and the mean age was 28.7 (±5.77) years (Table 1). In the study, 53.1% of the nurses had clinical experience for 1 to 5 years, 37.4% were working in the Pediatric Intensive Care Unit, and 89.2% were service nurses. The average number of pediatric patient deaths faced by the participants was 6.3 (±8.19) per year, and 20.3% of the participants stated that they received training on end-of-life care. Stress Scale for Nurses Providing End-of-Life Care for Children mean scores were compared according to the descriptive characteristics of the nurses participating in the study. It was found that the mean score of the scale was significantly higher for women than for men. According to the results of the analysis, it was determined that there was a statistically significant difference between the mean scores of the Stress Scale for Nurses Providing End-of-Life Care for Children according to the education level of the nurses (p < 0.05). Tamhane’s test was applied from post hoc pairwise comparisons to find the group that made a difference. According to the test results, it was found that the mean score from the scale was lower for those with a Medical Vocational High School education than those with a bachelor’s degree and those with a graduate education at Medical Vocational High School (Table 1).
Descriptive characteristics of nurses (n = 222)
a Those whose education level is a health vocational high school.
b Those with a bachelor’s degree in education.
c Educational graduate students.
Validity
Content validity
The translated scale, consisting of 22 items, was judged by the expert panel for relevance and phrasing of the items. The experts mostly evaluated the items as quite relevant. The content validity ratios of the items ranged from 0.80 to 1.
Item-total score correlations
As a result of the analysis made with 22 items in the scale, it was determined that the item-total score correlation coefficients ranged between r = 0.594 and 0.885.
Construct validity
The construct validity of the scale was evaluated with confirmatory factor analysis (CFA). Before these analyses, Kaiser–Meyer–Olkin (KMO) value and Bartlett test results were examined. In this scale, the KMO test value was 0.95 and Bartlett’s test value was 4360.06 (p < 0.001). When the correlations between the variables are examined, it is seen that the factor loads of the items are above 0.40 and all correlation relationships are significant.
Goodness-of-fit statistics of the conceptual model of the scale were tested with CFA. According to the CFA, the structural equation modeling results of the scale were found to be significant at the p = 0.000 level, and it was found to be related to the 22 items that make up the scale and the scale structure with 5 factors (Figure 1). The model had been improved. While making the improvement, the variables that reduced the fit were determined, and a new covariance was created for those with high covariance among the residual values. Afterwards, it was shown that the accepted values for the goodness-of-fit index (GFI), comparative fit index (CFI), normed fit index (NFI), and standardized root mean square residual (SRMR) fit indices were provided in the renewed fit index calculations. When the goodness-of-fit indices of the Stress in Nurses Performing End-of-Life Care for Children are examined, it can be said that the GFI 0.813, CFI 0.921, and χ 2/df 3.3013 (p = 0.000) values are at an acceptable level (Table 2).
Confirmatory factor analysis of the Stress Scale for Nurses Performing End-of-Life Care for Children.
Stress scale first level multi-factor model confirmatory factor analysis fit indices for nurses providing end-of-life care for children
Reference: Bayram Reference Bayram2011; Browne and Cudeck Reference Browne, Cudeck, Bollen and Long1993; Meydan and Şenen Reference Meydan and Şenen2011; Şimşek Reference Şimşek2007. CMIN/DF, Chi-square/df; GFI, goodness-of-fit index; CFI, comparative fit index; IFI, incremental fit index; TLI, Tucker–Lewis Index; RFI, relative fit index; NFI, normed fit index; SRMR, standardized root mean square residual.
Reliability
The reliability of the measurement model was tested by looking at the average variance explained (AVE) and composite reliability (CR) values for each factor separately. The CR value of the latent variables in the measurement model should be higher than 0.70 and the AVE value should be higher than 0.50 (Hair et al. Reference Hair, Black and Babin2010, 124). The CR value of the latent variables in the measurement model should be higher than 0.70 and the AVE value should be higher than 0.50 (Hair et al. Reference Hair, Black and Babin2010, 124). As a result, it was determined that the scale had discriminant validity (Table 3).
Results regarding the measurement model of the scale
KMO, Kaiser–Meyer–Olkin coefficient; AVE, average variance extracted; and CR, critical ratio.
The Cronbach’s alpha coefficient of the Turkish version of the scale is 0.97. It was determined that Factor 1 (Psychological difficulties) α value was 0.95, Factor 2 (Conflict with parents) α value was 0.90, Factor 3 (Difficulties in communication) α value was 0.92, Factor 4 (Lack of terminal care knowledge) α value was 0.83, and Factor 5 (Restricted working environment) α value was 0.91 (Table 3).
The results of the split half analysis of the scale are shown in Table 4. First, the test questions were randomly divided into 2 parts, then both parts were sent simultaneously to a group of participants. Each half of the test was scored for each participant. According to the split half analysis, the Cronbach’s alpha coefficients of the first and second half were found to be 0.93 and 0.96, the Spearmen–Brown coefficient was 0.93, the Guttman 2-half coefficient was 0.93, and the correlation coefficient between the halves was 0.87 (Table 4).
Half-half reliability of the scale
Discussion
In the study, it was found that nurses’ gender and educational status variables were effective variables on the Stress Scale for Nurses Providing End-of-Life Care for Children score averages. Nurses who provide end-of-life care to pediatric patients face intense stress (Pearson Reference Pearson2013). Factors such as caring for a dying child, lack of knowledge, communication problems with parents, and working environment are common characteristics that cause stress in nurses (Jang Reference Jang2013). It is emphasized that there is a need for valid and sensitive measurement tools that measure the stress and difficulties experienced by nurses while giving end-of-life care to pediatric patients (Park and Ju Reference Park and Ju2020). Akay and Aytekin Özdemir (Reference Akay and Aytekin Özdemir2021), in their study with newborn nurses in Turkey, tested the validity and reliability of the Neonatal Palliative Care Attitude Scale. Although it is important to determine the level of stress experienced by nurses caring for dying children, there is no valid and reliable tool to determine and evaluate the extent of this stress in pediatric nurses in Turkey. Therefore, testing the end-of-life care stress assessment tool in terms of validity and reliability is necessary to evaluate the stress dimension of pediatric nurses in Turkey.
The results of this study showed that the psychometric properties of the Turkish version of the “Stress Scale for Korean Nurses Providing End-of-Life Care for Children” were promising. According to expert opinions, it is seen that the scale is suitable for the purpose of measurement and represents the area to be measured. The CVI of the scale items was between 0.81 and 1.0. In this study, the CVI values above 0.80 indicate (Şencan Reference Şencan2005) that the scale adequately measures the agreement among experts and its subjects. As a result of expert opinions, content validity criteria were met.
Pediatric nurses participating in this study experienced moderate to high levels of end-of-life care stress. In other studies using the same measurement tool as the current study, the levels of end-of-life stress of pediatric nurses working in the hospital were similar (Park and Jeong Reference Park and Jeong2021; Park and Ju Reference Park and Ju2020). In addition, similar results were reported in a study using an end-of-life care stress tool developed by Jang (Reference Jang2013) for neonatal intensive care unit nurses in a tertiary hospital.
Item analysis was performed to test the relationship between scale items and total, and the lower limit for item-total score correlation values was accepted as 0.30 (Büyüköztürk Reference Büyüköztürk2002). In this study, item-total score correlation analyses were performed to evaluate the fit of the items with each other and with the scale. Item correlation values between 0.594 and 0.885 revealed that each item of the scale was related to other items and the scale. The scale is sufficient to measure the stress level of pediatric nurses performing end-of-life care to children.
Bartlett Sphericity test and KMO analysis are important tests that evaluate the suitability and adequacy of data for factor analysis. The Bartlett Sphericity test result should be statistically significant and the KMO value should be 0.60 and above for factor analysis (Boateng et al. Reference Boateng, Neilands and Frongillo2018). The KMO value of the scale was found to be above 0.90 and Bartlett’s test was found to be significant (χ 2 = 4360.063, p = 0.000) (Aroian and Norris Reference Aroian and Norris2007). Park and Ju (Reference Park and Ju2020) determined in their study that the sampling adequacy measure of KMO was strong at 0.90 and Bartlett’s test of sphericity was significant (p < 0.001).
The rate of variance explained is an important indicator of construct validity. As the variance ratio increases, the factor structure of the scale gets stronger (Boateng et al. Reference Boateng, Neilands and Frongillo2018; Finch Reference Finch2019). The fact that the variance explained in multidimensional scales is 50% at minimum is considered sufficient (Tabachnick and Fidell Reference Tabachnick and Fidell2007). The fact that the variance explained in this study is over 50% indicates a strong construct validity. In the study of Park and Ju (Reference Park and Ju2020), 5 factors were accepted, representing 61.13% of the variance. The results of the research were found to be compatible with each other.
In this study, item factor loads of the scale were found to range between 0.67 and 0.94. The factor structure of the data is determined with the help of factor loads. It is recommended that the minimum factor load be 0.30 and above (Finch Reference Finch2019; Polit and Hungler Reference Polit and Hungler1999). In this study, no item was removed from the scale because the factor load of each item was over 0.30. In the original study of the scale, the factor loads of the items in the 5 subdimensions were ≥0.40 (Park and Ju Reference Park and Ju2020). The results of this study were similar to the factor loadings in the original scale and revealed a strong factor structure.
The factor structure of the scale was tested with CFA (Brown Reference Brown2015; Xia and Yang Reference Xia and Yang2019). In this study, 5 subdimensions were created similar to the original scale. The chi-square value (χ 2/df) divided by the degrees of independence was 3.013. Some of the commonly used indices are GFI, CFI, NFI, and GFI. SRMR < 0.10, NNFI and CFI ≥ 0.90, and GFI ≥ 0.80 indicate a good fit (Harrington Reference Harrington2009). CFA showed that CFI, NFI, SRMR, and GFI values were sufficient. Model fit indices greater than 0.80 are accepted as an indicator of acceptable fit in the current literature. It is also emphasized that the χ 2/df value should be less than 5 (Brown Reference Brown2015; Marsh et al. Reference Marsh, Guo and Dicke2020). The results of the CFA in this study were found to be compatible with the criteria specified in the literature for the fit indices. The results of CFA in the study in which the original scale was developed are similar to the results in this study, showing the scale’s compatibility with the model. The fit indices confirm the 5-factor scale structure and the items adequately describe the factors. CFA analysis results support the scale structure and show that the scale is a valid tool that can be used for Turkish society.
In this study, the Cronbach’s α coefficient of the scale was 0.97, and the Cronbach’s α values of the 5 factors were found to vary between 0.83 and 0.95. Park and Ju (Reference Park and Ju2020) found the Cronbach’s α coefficient of the scale to be 0.90. Cronbach’s α from 5 factors was found to vary between 0.77 and 0.90 (Park and Ju Reference Park and Ju2020). It is seen that the results of the study are similar. The reliability coefficient (α) of a measurement tool is expected to be close to 1. The reliability coefficient (α) reveals whether the items measure the same feature and whether they are related to the subject. It is recommended that this value be between 0.60 and 1.00 (Nunnally and Bernstein Reference Nunnally and Bernstein2010). In this study, the Cronbach’s α value of the scale was 0.97, indicating that the items were consistent with each other and the internal consistency of the scale was high. The items adequately measured the stress of nurses providing end-of-life care to children and had high reliability. Park and Jeong (Reference Park and Jeong2021) found the Cronbach’s α of the “End-of-Life Care Stress” scale to be 0.88. In the study of Kim and Kim (Reference Kim and Kim2020), the Cronbach’s α of the “Palliative Cancer Care Stress” scale was found to be 0.94. As a result, item reliability analysis of the scale was found at an acceptable level.
In the split-half analysis, one of the analyses showing reliability is expected to have coefficients greater than 0.70 at the level of the scale (Chakrabartty and Nath Chakrabartty Reference Chakrabartty and Nath Chakrabartty2013; Nunnally and Bernstein Reference Nunnally and Bernstein2010). The coefficients in this study were above 0.70, indicating a strong and significant relationship between the 2 halves. Results of 2 studies could not be given, since split-half analysis results were not presented in the original study (Park and Ju Reference Park and Ju2020).
This study provided evidence for the reliability and validity of the assessment tool to measure the end-of-life care stress of pediatric nurses in Turkey. This tool may contribute to future research to identify the stress that pediatric end-of-life care causes in nurses.
Limitations
Although this study has strengths, it has some limitations. The sample of the study consisted of pediatric nurses working in university and state hospitals in the east and west regions of Turkey. This may increase the risk of selection bias, reduce representativeness, and therefore the study results may not be generalizable. Intercultural comparisons could not be made since there was no validity and reliability study of the scale in different languages.
In this study, 18 of the participants did not answer all the questions in the survey, and the surveys of these participants (considering incomplete, inaccurate, and low-confidence data) were excluded from the evaluation.
Also in the study, direct CFA was performed without exploratory factor analysis. Factor analysis has 2 main purposes; the first is to reduce the number of variables (reducing size) and the second is to classify the variables. However, there is a suggestion that direct CFA can be done instead of exploratory factor analysis in the process of adapting the measurement tool (Seçer Reference Seçer2020). Therefore, in this study, only CFA was performed to test the reliability of the scale. There is no other previously validated scale used to assess the end-of-life care or palliative care stress of pediatric nurses in Turkey. Therefore, concurrent validity could not be tested. Since the data of this study were collected online, the split-half method was preferred instead of the test–retest, considering that it would be difficult to reach and apply the same participants under similar conditions.
Conclusion
As a result of this study, it was found that the scale is a valid, reliable, and objective measurement tool in evaluating the stress levels of pediatric nurses performing end-of-life care to children in Turkey.
The use of the scale in clinical practice
Clinicians, psychologists, and all health professionals can use this scale, which aims to evaluate the stress of pediatric nurses who care for children and their families in their working environments. Thus, it can contribute to the planning of intervention attempts to alleviate the stress levels of pediatric nurses and to provide better nursing care services.
Also, it is considered that bringing this scale to the literature will enable the examination of the stress levels and affecting factors of pediatric nurses performing end-of-life care to children in different cultures and contribute to the field by providing an intercultural comparison. It is also recommended to be used on different regions and sample groups.
Funding
No competing financial interests exist.
Conflict of interest
The authors declare that there are no conflict of interests.
