Introduction
Heidelise Als created the developmental care programme in the 1980s, based on the uniqueness of the newborn. Reference Als1 Developmental supportive care interventions reduce stress in high-risk neonates. Reference Pineda, Tjoeng, Vavasseur, Kidokoro, Neil and Inder2 Developmental care interventions have been shown to improve neurological outcomes and infant growth and development. Reference Altimier and Phillips3,Reference Spilker, Hill and Rosenblum4 The frequency of developmental and neurological problems in infants is an important finding in assessing the effectiveness of nursing care in the neonatal ICU. Reference Altimier and Phillips3,Reference Kahraman, Gümüş, Akar, Sipahi, Bal Yılmaz and Başbakkal5 Some infants monitored in the neonatal ICU have congenital heart disease (CHD), and it has been reported that approximately half of the newborns with CHD have neurodevelopmental delays. Reference Arter, Miller, Bakas and Cooper6–Reference Miller, Lisanti and Witte8 In this situation, newborns with CHD require neuroprotective support, quality, and adequate developmental care approaches. Reference Byers7 Most studies that examined developmental care in newborn ICUs excluded infants born with complex CHD. Reference Lisanti, Uzark and Harrison9 Developmental care for newborns with CHD improves cardiac and respiratory patterns. Reference Peterson10,Reference Peterson and Evangelista11 According to the American Heart Association, developmental care in newborns with CHD is an important practice for improving neurodevelopmental outcomes, and there is a need for research evaluating developmental care interventions. Reference Lisanti, Uzark and Harrison9
One of the most important roles and responsibilities of neonatal intensive care nurses in the nursing process is to evaluate the developmental care needs of newborns with CHD in the neonatal ICU and to provide quality developmental care. Reference Kahraman, Gümüş, Akar, Sipahi, Bal Yılmaz and Başbakkal5,Reference Arter, Miller, Bakas and Cooper6,Reference Coughlin12 According to reports, nurses prioritise basic life functions in the care of newborns with CHD, and more effort is required to systematically apply developmental care to these vulnerable newborns. Reference Arter, Miller, Bakas and Cooper6 The Developmental Care Scale for Neonates with Congenital Heart Disease was created to assess the quality of developmental care provided to newborns with CHD by neonatal ICU. Reference Arter, Miller, Bakas and Cooper6 This could not be assessed because there is no scale in Turkey that can assess the status and quality of developmental care provided by neonatal intensive care nurses to newborns with CHD. This has been a deficiency in practice and literature. This study examined the validity and reliability of the Turkish version of the Developmental Care Scale for Neonates with Congenital Heart Disease.
Methods
Setting and sample
Between April and June 2021, data were collected from eight hospitals in two cities in Western Turkey. Sample selection method was not used in the study because it is recommended to take samples with a size of at least five and maximum 10 times the number of scale items in scale validity and reliability studies. Reference Bektas and Kudubes13,Reference Kahraman and Ceylan14 The study’s inclusion criteria were working as a nurse in the NICU for at least 6 months, caring for newborns with CHD, and volunteering to participate in the study. One hundred sixty-nine nurses from a tertiary-level neonatal ICU participated.
Ethics statement
Ethical approval was obtained for the study from the Medical Research Ethics Committee of the Faculty of Medicine (decision number: 21-3.1/21, approval date: 18 March 2021). Before the study, nurses were informed, and their written consent was obtained. All procedures performed in studies involving human participants were by the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.
Data collection forms
Demographical Information Form: This form included questions about the nurses’ sociodemographic characteristics.
The Developmental Care Scale for Neonates with Congenital Heart Disease: Arter et al. (2019) created the scale. It is a 5-point Likert-type scale with 31 items and four subscales that can be scored between 1 and 5 (1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, and 5 = strongly agree). The lowest possible score on this scale is 31, and the highest score is 155. There were no cut-off points on the scale. Higher scores indicated improved developmental care performance and quality of care. The subscales were as follows: creating an external environment (1–11 items), assessing family well-being (12–17 items), caregiver activities towards the neonate (18–26 items), and basic needs (27–31 items). Cronbach’s α coefficient for the scale was 0.89, and that of the subscales ranged between 0.74 and 0.87. Reference Arter, Miller, Bakas and Cooper6
Translation and adaptation of the scale
The authors of the original scale granted permission to adapt the scale to Turkish via email, which was then adapted to the Turkish society. Three expert translators translated the scale from English into Turkish. An expert translator performed the back translation. The researchers developed the scale items after back translation. Eight experts were presented with Turkish and the original forms to determine language and content validity. The experts had a Ph.D. in paediatric nursing. For expert opinion, it is necessary to get the opinion of at least six experts. Reference Yusoff15 The Davis method and content validity index were used to assess expert opinions. Reference Zamanzadeh, Rassouli, Abbaszadeh, Alavi-Majd, Nikanfar and Ghahramanian16 Following expert consultation, pilot implementation was conducted with 10 nurses who met the inclusion criteria. No modifications were made because each item was found understandable in the pilot study.
Data collection
Data were collected online because of limited access to neonatal ICUs owing to the COVID-19 pandemic. The questionnaires were created using Google Docs and administered using the web-based software, LimeSurvey. The link to the online questionnaire was distributed to nurses of eight hospitals via WhatsApp groups. Nurses who clicked on the link to the online survey were first informed about the study, and their permission was obtained. Permission was obtained for the care and delivery of newborns with CHD. Nurses who completed the consent form were able to answer the survey questions. During the nurse work shift, data collection forms were filled out through self-reporting. This process required approximately 5–10 min.
Data analysis
IBM SPSS 23 and LİSREL v. 8.72 statistical packages were used for the analysis. Descriptive characteristics were evaluated using numbers, percentages, means, and standard deviations. The validity of the scale was judged on the basis of its content and structure. Content validity index was calculated (using the Davis method) for content validity. Confirmatory factor analysis (e.g., Kaiser–Meyer–Olkin) and explanatory factor analysis were used to assess the scale’s structural validity. Cronbach’s α and item–total score correlations were used to determine internal consistency.
Results
The average age of the nurses who took part was 34.05 ± 6.14, and 97.0% were female. Fifty-five percent of the participants worked in the neonatal ICU between the ages of 6 months and 5 years. Seventy-one percent of the nurses had a bachelor’s degree, and 82.2% had developmental care training. Of the nurses, 98.2% provided developmental care to newborns, and 97.0% provided developmental care to newborns with CHD.
The content validity index values of the scale items calculated for content validity ranged from 0.90 to 1.00. The Kaiser–Meyer–Olkin score for explanatory factor analysis was 0.906, and Bartlett’s test was significant. Figure 1 depicts the model’s factor loadings. The values on the left in the figure represent error variance, whereas those in the middle represent factor loadings. These items account for 65% of the total variance. The factor loadings for the items were 0.44 and 0.82.
Confirmatory factor analysis path diagram of the scale.
Based on the confirmatory factor analysis results, the suggested modifications were carried out because the root-mean-square error of approximation value was 0.12. The final data analysis revealed that the chi-square value was 914.36, the degrees of freedom were 409, and the p value was 0.000. The chi-square to degrees of freedom ratio was calculated to be 2.25. The root-mean-square error of approximation was 0.086 after modification. The goodness of fit index was 0.74, adjusted goodness of fit index was 0.68, comparative fit index was 0.96, normed fit index was 0.94, and non-normed fit index was 0.96 (Table 1).
Confirmatory factor fit index results of the developmental support competency scale
a RMSEA = root-mean-square error of approximation;
b GFI = goodness of fit index;
c AGFI = adjusted goodness of fit index;
d CFI = comparative fit index;
e NFI = normed fit index;
f NNFI = non-normed fit index.
Cronbach’s α was 0.95 for the entire instrument, 0.91 for developing the external environment subscale, 0.94 for assessing family well-being, 0.86 for the caregiver activities towards the neonate, and 0.82 for the basic need subscale (Table 2). Table 2 displays the item–total score correlations of the scale. The item–subscale total score correlations varied from 0.34 to 0.75.
Factor analysis, Cronbach’s α coefficient, and corrected item–total correlation of the Turkish version of the Developmental Care Scale for Neonates with Congenital Heart Disease
Discussion
First, language and content validity studies were conducted to adapt the Turkish version of the scale. It was determined that there was an agreement between the experts. Reference Bektas and Kudubes13,Reference Jonhson and Christensen17
The fit of the sample included in the factor analysis was evaluated using the Kaiser–Meyer–Olkin and Bartlett X 2 tests, and the Kaiser–Meyer–Olkin value was greater than 0.60, indicating that the data were appropriate for factor analysis and that the sample size was adequate. Reference Boateng, Neilands, Frongillo, Melgar-Quiñonez and Young18 According to theexplanatory factor analysis, the scale’s four-factor structure explained 65% (64.707%) of the overall variance. Factor loads ranged from 0.44 to 0.82. The factor loads in the original scale were in the range of 0.418–0.823, with a variance of 52%. Reference Arter, Miller, Bakas and Cooper6 Previous research suggests that the factor load of each item should be≥0.30. Reference Jonhson and Christensen17,Reference Ceylan, Keskin and Yavaş19,Reference Turan, Erdoğan and Serap Ceylan20 These values indicate that the factor loadings were satisfactory.
According to cultural adaptation studies, confirmatory factor analysis should be conducted after explanatory factor analysis. Confirmatory factor analysis was used to assess the suitability of the scale’s factor structure. The fit indices are extremely diverse. 21 The chi-squared–to–degrees of freedom ratio was calculated to be 2.25. This value was less than five, indicating that the fit was satisfactory. Reference Kahraman and Ceylan14,Reference Marsh, Guo, Dicke, Parker and Craven22
This scale has not yet been adapted to other languages. Therefore, the results of the confirmatory factor analysis are discussed along with the general literature. A value of <0.08 indicates a good fit for root-mean-square error of approximation. Reference Marsh, Guo, Dicke, Parker and Craven22 A value of >0.95 indicates a perfect fit, and a value of >0.90 indicates an acceptable fit for other fit indices. 21 The root-mean-square error of approximation value was close to the acceptable value. The goodness of fit index and adjusted goodness of fit index values were below the threshold. The sample size influenced the values of the root-mean-square error of approximation, goodness of fit index, and goodness of fit index. Reference Ainur, Sayang, Jannoo and Yap23,Reference Shi, Maydeu-Olivares and Rosseel24 Because the sample size was less than 200 people, it may be more appropriate to evaluate the comparative fit index, normed fit index, and non-normed fit index, which are unaffected by the sample size. Values greater than 0.90 for these indices indicate that the model is acceptable. 21
Item–total correlation is a method for determining a scale’s reliability. Jonhson and Christensen (2014) recommended that the item–total correlation coefficient be higher than 0.20. Reference Jonhson and Christensen17 The item–subscale correlations in the original scale ranged from 0.31 to 0.77. Reference Arter, Miller, Bakas and Cooper6 The scale’s item–total score correlations were acceptable, and no items were removed because their correlations were not less than 0.20.
Cronbach’s α reliability coefficient is another value commonly used to determine scale reliability. Cronbach’s α coefficients between 0.00 and 0.40 indicate unreliability, 0.40–0.60 indicate low reliability, 0.60–0.80 indicate moderate reliability, and 0.80–1.00 indicate high reliability. Reference Jonhson and Christensen17 Cronbach’s α was 0.89, and the reliability of the subscales ranged between 0.74 and 0.87 in the original scale. Reference Arter, Miller, Bakas and Cooper6 In this study, Cronbach’s α coefficient of the scale was extremely reliable.
Study limitations
During the COVID-19 pandemic, data were collected online. Test–retest analysis could not be performed because the same person could not reach the second time after a 15-day interval. The small sample size of this study is one of its limitations. Due to the pandemic, it was difficult to find nurses who voluntarily participated in this study. Therefore, these findings cannot be generalised. Further research with a larger sample size is warranted.
Conclusion
A reliable and valid measure is required to adequately intervene and improve the quality of developmental care. As a result of the study, the Turkish form of the scale was found to be valid and reliable. In Turkey, a scale to assess the quality of developmental care for newborns with CHD is now available. The scale can be used to identify developmental care methods in which nurses are ineffective so that necessary interventions can be planned. The use of this scale could improve the performance of neonatal intensive care nurses in providing developmental care to newborns with CHD as well as the quality of care. Neonatal intensive care nurses should be aware that quality developmental care can improve the neurodevelopmental outcomes of newborns with heart disease.
Acknowledgements
We would like to thank the nursing staff for their collaboration. We would like to thank the Ege University Department of Biostatistics for statistical analysis. We are grateful to the Ege University Planning and Monitoring Coordination of Organizational Development and Directorate of Library and Documentation for their support in editing and proofreading this study.
Financial support
This research did not receive any specific grants from funding agencies in the public, commercial, or not-for-profit sectors.
Competing interests
The authors declare no potential conflicts of interest with respect to the research, authorship, or publication of this article.
Ethical standard
The study was approved by the Ege University Medical Research Ethics Committee of the Faculty of Medicine (decision number: 21-3.1/21, approval date: 18 March 2021). The nurses were informed about the study and provided written informed consent. All procedures performed in studies involving human participants were by the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.
