nurses' patient education questionnaire - development and validation process

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published online 21 May 2014Journal of Research in NursingAnne-Louise Bergh, Inger Johansson, Eva Persson, Jan Karlsson and Febe Friberg

development and validation process−Nurses' Patient Education Questionnaire

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Nurses’ Patient EducationQuestionnaire – developmentand validation process

Anne-Louise BerghDoctoral Student, School of Health Sciences, University of Boras, Sweden

Inger JohanssonProfessor, Department of Nursing, University College Gjøvik, Norway; Associate Professor,

Department of Nursing, University of Karlstad, Sweden

Eva PerssonAssociate Professor, Faculty of Medicine, Department of Health Sciences, Lund University, Sweden;

School of Health Sciences, University of Boras, Sweden

Jan KarlssonAssociate Professor, Institute of Health and Care Sciences, The Sahlgrenska Academy, University of

Gothenburg, Sweden; Centre for Health Care Sciences, Orebro University Hospital, Sweden

Febe FribergProfessor, Department of Health Studies, Faculty of Social Sciences, University of Stavanger, Norway;

Associate Professor, Institute of Health Care Sciences, The Sahlgrenska Academy, University of

Gothenburg, Sweden

Abstract

Conditions for nurses’ daily patient education work are unclear and require clarification. The aim

was to develop and validate the Nurses’ Patient Education Questionnaire, a questionnaire that

assesses nurses’ perceptions of appropriate conditions for patient education work: what nurses

say they actually do and what they think about what they do. The questionnaire was developed

from a literature review, resulting in the development of five domains. This was followed by

‘cognitive interviewing’ with 14 nurses and dialogue with 5 pedagogical experts. The five

domains were identified as significant for assessing nurses’ beliefs and knowledge; education

environment; health care organisation; interdisciplinary cooperation and collegial teamwork;

and patient education activities. A content validity index was used for agreement of relevance

and consensus of items by nurses (n¼ 10). The total number of items in the final questionnaire is

60, consisting of demographic items, what nurses report they do and perceptions about patient

Corresponding author:

Anne-Louise Bergh, School of Health Sciences, University of Boras, S-501 90 Boras, Sweden.

Email: [email protected]

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education in daily work. The questionnaire can be used by managers and nurses to identify

possibilities and barriers to patient education in different care contexts.

Keywords

‘cognitive interviewing’, content validity, information, nurse, patient education, questionnaire/

instrument, teaching

Introduction

Why develop a Patient Education Questionnaire?Patient education (PE) is an important multidisciplinary health care strategy that includes

any set of planned educational activities designed to improve the health behaviour and statusof patients (Albada et al., 2007; Hubley, 2006). The demands on health professionals’ teachingskills increases all the time because of changes within health care practice towards more healthpromotion and prevention (Kelley and Abraham, 2007; Whitehead, 2008; Whitehead et al.,2008), the increasing incidence of chronic lifestyle diseases (National Board of Health andWelfare, 2005) and the new disease panorama (World Health Report, 2008). Together withother health professionals, nurses play a significant role in health education (Koutsopoulouet al., 2010; NBHW, 2005). In nursing practice, there is a need for educating nurses in patientteaching to facilitate further development in clinical situations (Benner et al., 2010).

Although PE is a daily task for nurses, numerous hindering factors are identified, such ascasually and inconsistently performed teaching (Balcou-Debussche and Debussche, 2008;Devine, 2003; Fitzpatrick and Hyde, 2006; Osterlund-Efraimsson et al., 2009), lack oforganisational support (Lewis, 2005; Marcum et al., 2002), disturbing environments(Lewis, 2005; Lipponen et al., 2006), lack of teaching materials (Casey, 2007; Lewis,2005), unclear interdisciplinary cooperation (Casey, 2007; Gregor, 2001) and lack ofpedagogical competence (Balcou-Debussche and Debussche, 2008; Macdonald et al.,2008). Furthermore, although nurses consider that documentation of patient knowledgeneeds and educational activities is an important daily activity, this is not always reflectedby proper documentation in patient records (Avsar and Kasikci, 2011; Bergh et al., 2007). Inaddition, shifts from a disease-oriented to a health-promotive perspective (Caraher, 1998;Glanville, 2000; Whitehead, 2008) and from a moralistic to a more democratic paradigm(Glanville, 2000) impact on nurses’ PE, with recognition of the importance of respect forpatients’ autonomy (Friberg et al., 2007) and self-management skills (Redman, 2008).

In recent decades, the increasingly complex demands on nurses’ PE work and theshortcomings therein evident at different workplaces (Lipponen et al., 2006; Macdonaldet al., 2008; Whitehead, 2008) indicate that further research is needed on conditions ofnurses’ PE work. More knowledge about influencing factors to critically inform safe andevidence-based PE is needed. An instrument to study conditional factors based on nurses’perceptions of what is important in their PE work will contribute to a more comprehensiveview of PE work and will contribute to comparisons of nurses’ skills in different health caresettings, nationally and internationally.

Aim

The aim was to develop and validate the Nurses’ Patient Education Questionnaire (NPEQ), aquestionnaire that measures nurses’ perceptions of prerequisite conditions for PE work (what

2 Journal of Research in Nursing 0(0)




nurses actually do) and attitudes (what they think about what they do). The validationprocess is carried through by means of content validity, specifically if the itemsrepresent the intended concepts, and if the item content and response options areappropriate, comprehensive and understandable to the target population (Patrick et al.,2011: 982). The questionnaire has a general focus to be used across different health carecontexts (primary, municipal and hospital care) and the outline of the overall process issummarised in Figure 1.

The study is part of a project on nurses’ PE work, where a distinction is made betweenpatient teaching and information, both concepts being included in PE. Patient teaching isdefined as a two-way communication process (a dialogue), while patient information meansthat the nurse simply transfers information. The expression ‘pedagogic’ refers to knowledgeof teaching, learning and the accomplishment/achievement of teaching. Primary care refersto care centred on patients’ visits to out-patient clinics, where nurses often have aspecialisation in primary health care and access to their own offices, whereas municipalcare refers to patient contact taking place in nursing homes or in the patients’ own homes.

Initial literature review – formulation of a conceptual framework for the questionnaire

A literature review of conditional domains for nurses’ PE work (Friberg et al., 2012) formsthe conceptual basis for construction of the NPEQ. The databases CINAHL, MEDLINEand ERIC were used and search terms in different combinations were: patient education,patient teaching, patient information, nurses attitudes or role or skill and professionalcompetence. Thirty-two articles were analysed using an integrative review method(Whittemore and Knafl, 2005). The review reveals five domains: nurses’ beliefs andknowledge, education environment, health care organisation, interdisciplinary cooperationand collegial teamwork, and patient education activities (Table 1). Nurses’ beliefs andknowledge involve aspects related to attitudes to the education role (Nolan et al., 2001),responsibility to practice educational skills developed through personal experience oracademic training (Jones, 2010), and interprofessional sharing of skills or issues related toteaching patients (Balcou-Debussche and Debussche, 2008). This domain also involvesperceptions of personal competence/teaching skills. Education environment concernsallocation of place for education (Virtanen et al., 2007) and sufficient time for patienteducation (Eriksson and Nilsson, 2008; Thoma, 1999). Health care organisation involveslevel of support from managers (Lee and Chien, 2002) as part of the work culture (Casey,2007), while organisational aspects include work load (Lewis, 2005), occurrence of guidelinesand work descriptions for PE work (Zakrisson and Hagglund, 2010) and occurrence ofteaching materials such as tools and written materials (Cashin et al., 2009).Interdisciplinary cooperation and collegial teamwork concerns aspects such as nurses’ andphysicians’ different roles in PE (Moret et al., 2008) and the legitimacy of occupying the roleas patient teacher (Park, 2005). Co-ordination of PE work (Jones, 2010) and perceptions ofcooperation among nurses in out-patient and in-patient units (Kaariainen and Kyngas,2010) are other aspects of significance. Patient education activities involve perceptions ofthe accomplishment of PE, while occurrence of planned or spontaneous PE (Avsar andKasikci, 2011) involves characteristics of the activities, such as one-way or two-waycommunication (Friberg et al., 2007), routines for documentation (Marcum et al., 2002),and teaching content (Barber-Parker, 2002). The conceptual framework is informed byepistemological assumptions about nurses’ PE as situated, interactively shaped and

Bergh et al. 3




Figure 1. Outline of the overall process.





Table 1. Five domains and their specific items numbera and total number of items in the final questionnaire

(NPEQ).

Domains, description of content Specific items no.a

Total

no.of

items

Nurses’ beliefs and knowledge:

– nurses’ maintenance of a professional level

for patient education

– priority given to this

24,25,29,30,35,39,40,41,44,45,46 11

Education environment:

– time spent on patient education

– existence of disturbing factors

– place where patient education takes place

1,2,3,4,5,6,47 7

Health care organisation: 7,8,9,10,16,17,18,31,32,33,34 11

– management support

– existence and content of policy documents/

guidelines for patient education

– possibilities for education in patient education

– if there is a special nurse following

pedagogical matters in scientific and/or

professional literature

– teaching materials and its usage

Interdisciplinary cooperation and collegial teamwork:

– interaction with other caregivers concerning

patient education

– uncertainty about how to inform and teach

the patient - the patient’s understanding of

teaching and/or information given by

physicians

– cooperation with other caregivers

– responsibility for co-organisation of patient

education among caregivers

19,20,21,22,23,27,28,42,43 9

Patient education activities:

– nurses’ documentation of different aspects

(patient’s need of knowledge/need of learning,

objectives for teaching/information,

intervention and evaluation) related to patient

education

11,12,13,14,15,26,36,37,38 9

Demographic itemsb 13

Total items, the NPEQ 60

NPEQ: Nurses’ Patient Education Questionnaire.aThe final version, see the items in Table 4.bSee Table 3.

Bergh et al. 5




socially and culturally dependent. The conditional domains identified in the review regardedas either enabling or hindering for the PE work form five conceptual domains as a basis forthe item construction and content validation procedures.

Establish nature – extent of other questionnaires

A search for existing questionnaires focusing on nurses’ PE work was conducted in thedatabases CINAHL, ERIC and PubMed and in dissertations using Dissertations &Theses (North America), Index to Theses (Great Britain, Ireland), Diva (Scandinavia) andLibris (Sweden). The purpose was to compare existing questionnaires with the aboveconceptual framework in order to assess the optimum conditions for nurses to engage inPE activities in daily work (Figure 1).

Search terms were: questionnaire/instrument, nurse, patient education, teaching,information, competence and documentation in different combinations. Only self-assessment questionnaires were included. We found a limited number of articles anddissertations that described questionnaires in sufficient detail that could inform itemcontent development (n¼ 9 and n¼ 5), as most surveys were poorly described and somewere unpublished. The questionnaire used by Honan et al. (1988) was based on a conceptualmodel of factors influencing patient teaching programmes. The factors were: responsibility,priority, knowledge, materials, environment, time/staff and documentation. Thisquestionnaire has been modified and used by others (Marcum et al., 2002; Thoma, 1999).Although these questionnaires contain items that match our conceptual framework, there isno clear separation between the concepts of teaching and information, and no item could beused directly. Other studies used instruments containing some items that were in accordancewith our factors (Barrett et al., 1990; Lewis, 2005; Ohman, 2003), while in yet other studies,part of the instrument contained pedagogical items focusing on nurses’ competence inpedagogical activities (Meretoja et al., 2004; Schwirian, 1978). These questionnairesinspired the creation of items but no item could be used directly.

Most of the existing questionnaires were constructed for use in hospital care. In Ohman’sstudy (2003), concepts of teaching and information were separated into different items, butthe questionnaire was designed for geriatric care. Another study (Martin, 1988) had the samecontexts as our study, but the items were not applicable for use in a generic questionnaire.We did not find any questionnaire that only addressed the documentation of nurses’pedagogical activities in patients’ records.

The review of existing questionnaires showed that their content did not correspondsufficiently with our five domains, and groups of items or single items could not be useddirectly to represent our areas (Friberg et al., 2012). In addition, previous questionnaireswere designed for special groups of nurses, patients or specific contexts, and consequentlycould not be used to construct a generic questionnaire. Another problem was that mostquestionnaires made no clear distinction between the concepts of patient teaching andpatient information, which was considered an important issue (Friberg et al., 2012).Furthermore, the identified questionnaires had methodological weaknesses in accordancewith the literature review of questionnaires for evaluating practising nurses’ competence(Meretoja and Leino-Kilpi, 2001). A critical issue is that descriptions of methodologicalprocedures are often sparse in articles using newly constructed questionnaires (Honanet al., 1988; Lewis, 2005; Lipponen et al., 2006; Park, 2005; Selby-Harrington et al., 1994).There was no Swedish questionnaire that matched our five domains and items addressing the





content in nurses’ educational activities and beliefs. As our questionnaire is in Swedish, atranslation procedure from English was required for the few items that could be used.

Methodology

Questionnaire development

The following section presents the participants, methods and process of assessing the contentvalidity under the questionnaire development: October 2005 to January 2007. Participantswere engaged in a number of sequential panels as shown in Figure 1.

Participants

Fourteen nurses independently assessed the content validity of the questionnaire at twodifferent times (‘first nurses’ panel’ and ‘second nurses’ panel’). The ‘first nurses’ panel’comprised four nurses working at university or county hospitals. The ‘second nurses’panel’ comprised ten nurses: three in primary care, three in municipal/community careand four in medical/surgical wards at hospitals. Before the ‘second nurses’ panel’, a‘pedagogical expert panel’, including five experts (PhD in the area of patient education)reviewed the content and design of the NPEQ. In this step, two authors had a telephonicconference with each expert individually. Informed consent was obtained and confidentialitywas assured (World Medical Association, 2005). A research group (about 10–12) at theuniversity, consisting of professors, senior lecturers and PhD students also reviewed thecontent of the questionnaire to give feedback on its face validity. Finally, a statisticianwas consulted for evaluation of the design and layout of the questionnaire.

The methods used for questionnaire development

The questionnaire was developed using influential sources: an initial literature reviewyielding the conceptual framework (Friberg et al., 2012), a second review to show thatthere were no questionnaires that sufficiently covered nurses’ perceptions of conditions forPE work, and a search for guidelines for constructing questionnaires; a checklist, TheQuestion Appraisal System (QAS), for questionnaire development (Willis, 2005: 25–26;Willis and Lessler, 1999) and a check for technical accuracy (Dillman, 2000; Dillman andRedline, 2004). ‘Cognitive interviewing’ (CI) as recommended by Willis (2005) was also used.

The search aimed at finding guidelines for constructing questionnaires was conducted inthe databases CINAHL, ERIC and PubMed. Search terms were: questionnaire/instrument,pretesting and survey methodology. This highlighted the significance of combining surveymethodology and cognitive theory (Drennan, 2003; Willis, 2005).

The QAS (Willis, 2005; Willis and Lessler, 1999) was used to consider potential sources oferrors in the questionnaire development, for example, clarity and redundancy of items andidentification of problems related to respondents communicating the meaning/content ofitems. Dillman’s (2000) and Dillman and Redline’s (2004) recommendations for checkingitems for technical accuracy and construction layout were also useful, for example, skippinginstructions of items when items are not relevant for the respondent, and use of arrows. Inthis process, Dillman and Redline (2004) have highlighted the importance of CI for testingthe use of nonverbal language (arrows, symbols, numbers and graphics) since suchproblems/uncertainty with the layout can reduce response rates.

Bergh et al. 7




CI is an accepted and successful method of eliciting problems in the construct process(Drennan, 2003; Willis, 2005). It is used to gain insight into the respondent’s thoughts andreasoning when completing the questionnaire, such as cognitive understanding of the itemsand relevance of item-content (Patrick et al., 2011: 979). CI can be performed in a number ofways, and Willis’s (2005) recommendations were the inspirational source as he highlights thedifference in how to grasp the respondent’s understanding e.g. if the respondents areteenagers or a homogeneous group, such as nurses with a narrow topic (PE). Further, an‘intellectual experiment’ was used to direct nurses’ attention towards what it means to reasonout loud. The nurses were asked to say what they thought about while they were countingwindows in their homes as a concrete example of what it means to reflect and verbalise(Willis, 2005: 44). CI allows integration of cognitive theory with survey methodology, as itgrasps and elicits the respondent’s understanding of the items. Tourangeau (Tourangeau,1984; Willis, 2005) has described the interaction between the respondent and thequestionnaire as consisting of four main cognitive steps: comprehension, retrieval,judgement and communication. ‘Comprehension’ indicates that the respondent interpretsand understands the meaning of the question. ‘Retrieval’ refers to the process of recallingrelevant information from memory. ‘Judgement’ indicates that the respondent has to assessthe relevance of the retrieved information relative to the meaning of the question. This stepalso includes motivation and willingness to answer the question. ‘Communication’ indicatesthat the respondent generates an answer by selecting the most appropriate response categoryor communicates the content in an open-ended item. The first author conducted all CI,which were tape-recorded.

The selected item response choices were of four different designs: scales where each itemresponse has a verbal rank order definition running in one direction (rated 1–5),dichotomous response options (yes or no), open-ended answers and rank-order items. Themost common response categories in the questionnaire were: almost never/never (1), seldom(2), occasionally (3), often (4) and almost always/always (5). We also used: strongly disagree(1), somewhat disagree (2), neither agree nor disagree (3), agree (4) and strongly agree (5).All items were analysed as single-items.

Process of assessing the content validity of the questionnaire from the perspective ofnurses and experts

During CI, both concurrent and retrospective interviews were used (Drennan, 2003; Willis,2005). In a concurrent interview, the interviewer asks the nurses to think out loud whengoing through the questionnaire. To further gauge the nurses’ thoughts, the interviewerasked probing questions to avoid potential pitfalls (Hak, 2004; Willis, 2005). Probingquestions can be written before or thought of during the interview (Conrad et al., 2000;Willis, 2005; Willis and Lessler, 1999). The interviewer also observed the nurse’s behaviourto capture hesitations, reactions, etc. that were not pronounced in words (Willis, 2005). In aretrospective interview, responses are recalled after the nurse has answered thequestionnaire.

First nurses’ panel. The nurses were asked to complete the questionnaire and identify itemsthat they found unclear or ambiguous. The nurses were asked to read all items and responsecategories aloud and think aloud as they answered each item. Nurses wrote comments aboutthe items as they were reasoning out loud. The interviewer asked probing questions, e.g.





‘What does the term ‘‘mandate’’ mean to you?’ The nurses’ behaviours were observed andnotes were made both during and after the CI. The probing questions were both pre-scriptedand unscripted. After completion of the questionnaire, the nurses were asked for more itemsadequately surveying the breadth of conditions of nurses’ PE work in relation to the fivedomains formulated in the literature review (Friberg et al., 2012) (Figure 1).

After the CI, nurses were instructed to review each item again and rate its relevance/validity using a rating scale from 0 to 2 (Grant et al., 1999), where 0 indicates that the itemdid not target the issue and should be deleted, 1 indicates that the item is relevant, and 2indicates that the item is very relevant and important to retain. This test was also used toassess the relevance of item response categories. Finally, the nurses were again asked to makecomments on content, construction, layout, wording of items, and to indicate any missingissues in the condition of nurses’ PE work.

Two authors independently listened to all recorded CI and the nurses’ reasoning on eachitem was summarised and written down, often verbatim. Three authors compared, discussedand rated the results until a consensus was reached. Both clear expressions and those thatrequired interpretation were identified. Ambiguities were identified after each CI and relatedto the next CI (a constant comparative way of working).

Pedagogical expert panel. Five experts were asked to examine the content validity/face validity,compare (Grant and Davis, 1997) and evaluate the representativeness of the individual item,and judge the total questionnaire for comprehensiveness of the domains in relation to thedefinitions of patient teaching and information. The clarity of the item construction andwording was evaluated, and missing items and domains were asked for.

Second nurses’ panel. To test if the questionnaire was useful in different workplaces, thesecond panel included nurses from primary (n¼ 3), municipal (n¼ 3) and hospital (n¼ 4)care. The authors decided not to group the items in domains. The aim was to test the clarityand validity of each separate item and, if the items were well written, distinct and had anappropriate reading level, there was no need for the domains.

The CI procedure was similar to that used in the first panel, except that the interviewerconducted more retrospective probing questions on reconstructing thoughts. Anotherdifference was the addition of an extra relevance rating level to the rating for each item, arating scale from 1 to 4 (Davis, 1992; Polit et al., 2007), where 1 indicates that the item is notrelevant, 2 means somewhat relevant (major revision is needed), 3 indicates quite relevant(minor revision) and 4 denotes highly relevant (the item is relevant). This scale does notinclude the ambivalent middle rating (Dillman, 2000). Furthermore, the items were moredistinct and easier for the nurses to understand, meaning the rating could be prioritisedmore. Accordingly, the nurses reviewed each item and its response category again.Procedures for quantifying content validity index (CVI) were used in the second panelbased on nurses’ ratings (from 1 to 4) of the relevance, and focus on agreement ofrelevance (consensus) for each item among the 10 nurses (Polit et al., 2007). Judgmentand agreement of each item are referred to as I-CVI (proportion of nurses who judgedthe item as relevant). The result for the overall questionnaire is referred to as S-CVI/average (the average I-CVI across all items). A content valid questionnaire should havean I-CVI value of 0.78 or higher (Polit et al., 2007) and an S-CVI/average value of 0.90or higher (Waltz et al., 2005; Polit et al., 2007). Ratings were also used for assessing therelevance of item response categories. Testing of response categories was considered as

Bergh et al. 9




equally relevant, although this procedure was not suggested in the literature (Grant et al.,1999; Polit et al., 2007; Waltz et al., 2005). CVI was not calculated in the ‘first nurses’ panel’because the questionnaire was too immature during this early part of the developmentprocess and after just four CIs.

Results

The different steps in the questionnaire development, item construction and item status, areshown in Figure 1.

Item construction

Initial item development. The items were based in the five domains (literaturereview) and first version of the NPEQ comprised 78 PE-related and 9 demographic items(Figure 1).

Additional co-worker. A researcher with experience of quantitative research was then asked tocooperate in the authors’ group. In this group, several items were deleted because of itemoverlap. Demographic items were created, e.g. ‘How extensive was the pedagogical course?’The second version of the NPEQ comprised a total of 63 items (Figure 1).

Ongoing revision and development based on the revision of the panel feedback

The content validity of the questionnaire was assessed in two rounds of CI (first and secondnurses’ panel) and between the two CI panels a ‘pedagogical expert panel’ (Figure 1).

First nurses’ panel. While item content did not change during revision after this panel, therewere changes related to improvements in comprehension of the items and to achieving adeeper understanding of separate items. For example, if an item was: ‘I have support frommy work manager in my patient teaching’ and the nurse answered that she hadsupport (choose ‘Yes’ from the Yes/No response categories), we decided to have aconsequence open-ended item: ‘If you have support, please describe your support’. Twoextra demographic items were added regarding formal pedagogical competence. Anotherissue raised by the nurses was the importance of referring back to the definitions of patientteaching and information on the introduction page. After this revision, the NPEQ comprised67 items.

Pedagogical expert panel. After the dialogue conference with the experts, 26 PE-related itemswere retained without revision, 23 items were slightly modified and readability wasimproved. Three items were deleted (one item about the occurrence of a special nurseresponsible for nurses’ documentation in patient records and two items about formulatingobjectives for PE), and two new items were added (one item regarding nurses’ teamwork andanother about the co-organisation of nurses’ responsibility for PE in relation to other healthcare professionals). The number of demographic items did not change but the items aboutformal pedagogic competence were reworded. The response categories for the item aboutnurses’ perception of managers’ support in their PE were changed from dichotomous to 1–5categories.





Second nurses’ panel. One question (prescript/prepared before the interview) put to the panelwas how often to reference the definitions on the front page. The nurses recommendedreferring to these definitions as often as possible, which resulted in references for 31 of 47PE-related items. The nurses in primary care asked for items about patient teaching bytelephone, as this is a common task in primary care. The authors decided to exclude itemsabout telephone contacts as they were judged to be specific to primary care. Nurses inmunicipal care asked for items concerning dementia and patient teaching. However, theauthors chose not to incorporate items about dementia as they are too specific forinclusion in a generic instrument.

The I-CVI for demographic items and its response alternatives was 1.00, except for theitems about formal pedagogic competence. Six out of ten nurses wanted these items or theirresponse alternatives to be reworded. The nurses thought the content of the items was veryimportant to be retained. All 10 nurses in the ‘second nurses’ panel’ were asked at the end ofthe CI how these items could be improved (a pre-scripted probe). Their suggestion was to askabout formal pedagogical education without prefixed response categories i.e. they wantedopen-ended questions. This recommendation was followed. The number of demographicitems was reduced to 13.

Final version: evaluation among authors. CVI scores based on the nurses’ ratings werecalculated. The lowest I-CVI value for PE-related items was 0.80 (for 3 items) and the S-CVI/average was 0.97 (Table 2). Thus, after literature review, CI with nurses, dialogues withexperts in PE and a continuous assessment/evaluation of this version of the NPEQ could beregarded as content valid. However, after discussions and evaluations among the authors,some alterations were made. Two items (19 and 20) were removed because of minor contentoverlap with other items (Table 2). Two further items were deleted because of minor

Table 2. Ratings on a 51-item, patient education related item scale by the ‘second nurses’ panel’ (n¼ 10).

Items rated as relevant (3 or 4) on a 4-point relevance scale.

Items

No. of

items

Nurses in

agreement Item CVIaItems

deletedb

1–6, 10–17, 19–22, 25–27–29, 31–32, 34,

36, 38–44, 46–48, 50

38 10 1.00 19c, 20d

7–9, 18, 23–24, 30, 33, 45, 49 10 9 0.90

35, 37, 51 3 8 0.80 35e, 37f

Scale CVI/Average 0.97g

aI-CVI¼ item-level content validity index (proportion of nurses who judged the item as relevant, 3 or 4 on relevance

scale).bItems deleted at the last revision.cI have support from my colleagues, if I need it, in the activity patient teaching/information.dIf you have support from your colleagues, please describe your support.eTo meet patient information needs, it is important that I am knowledgeable in the following subjects: medical science,

nursing/caring science, educational science and psychological science. After ranking the subjects important for your

information work, describe the motivation behind your ranking.fTo meet patient teaching needs, it is important that I am knowledgeable in the following subjects: medical science, nursing/

caring science, educational science and psychological science. After ranking the subjects of important for your teaching

work, describe the motivation behind your ranking.gS-CVI/Average¼ the average I-CVI across all items.

Bergh et al. 11




difficulties using open-ended questions. For these items (35 and 37), the nurses were asked towrite down motivations for rank-ordering subjects in relation to the importance of PE work(Table 2). The S-CVI/average for PE-related item response categories was 0.98 and 1.00 afterthe rank-ordered items 35 and 37 were removed. These changes had only a minor impact onCVI scores but the resulting questionnaire was shorter (by a sheet).

The overall process of the NPEQ development can be seen in Figure 1. In Table 1, itemsin relation to the five domains (conceptual framework) are presented. The total number ofitems in the questionnaire is 60, including 13 demographic items (Table 3), 47 items on actualexperience and beliefs about PE in daily work (Table 4). Each item has a possible commentand at the end of the questionnaire we ask: ‘If you have an opinion on the design and contentof the questions on the form, write here or on a separate sheet’. The front page has conceptdefinitions.

The NPEQ has been tested on 701 nurses (response rate 83%) working in primary,municipal and hospital care: a stratified random sample. Results relating to items aboutthe environment, organisation, interdisciplinary cooperation and collegial teamwork havebeen published (Bergh et al., 2012). Due to a high level of participation, this paper indicatesthat nurses considered the NPEQ to be important, relevant and easy to understand. Theresults also indicate that there are barriers in nurses’ PE. Interviews with managers have beenconducted that focused on their conceptions of nurses’ conditions for PE and a manuscriptconsidering this is under preparation.

Discussion

Reflection on the process of questionnaire development

Various methodological steps were taken to ensure the content validity of the NPEQ. CI wasused at two different levels to assure nurses’ cognitive understanding of the items andrelevance of item-content (Patrick et al., 2011). To our knowledge, CI has not been used

Table 3. Demographic items.

1. In which year were you born?a

2. Are you a man or a woman?b

3. In which year did you become a registered nurse?a

4. How many years of working experience have you had without postgraduate nursing specialisation?a

5. Do you have a postgraduate nursing specialisation?c

6. In which year did you become a postgraduate specialist nurse?a

7. How many years have you worked actively with a postgraduate specialisation?a

8. Which postgraduate specialisation/s do you have?a

9. Where do you work: primary care, municipal/community care, hospital care or other?b

10. When do you typically work: day, day/evening, night, and day/evening/night?b

11. Do you have any pedagogical education: diploma in nursing education or education, at university level

(credits)?b

12. If you have pedagogical education at university level, please describe its content.a

13. If you have pedagogical education, such as staff training in pedagogical issues in the workplace (not at

university level), please describe its content.a

aOpen-ended answer.bFixed options.cFixed options, yes/no.





Table 4. Nurses’ Patient Education Questionnaire, focusing on both patient teaching and information

activities.

1. I have time for patient information in my daily work.Aa

2. I have time for patient teaching in my daily work.Aa

3. I can inform the patient undisturbed, e.g. I am not disturbed by colleagues, other patients or by phone

calls.Aa

4. I can teach the patient undisturbed, e.g. I am1 not disturbed by colleagues, other patients or by phone

calls.Aa

5. Where do you inform the patient: in the patient’s room in the presence of other patients, corridor,

private room/at the patient’s home, patients’ dining room at the ward, nursing office, medical office or

other places.B

6.Where do you teach the patient: in the patient’s room in the presence of other patients, corridor, private

room/at patient’s home, patients’ dining room at the ward, nursing office, medical office or other places.B

7.There are written policies/formal guidelines for achievement of (activity/area) patient information at my

workplace.C

8.What is the content of these policies/formal guidelines?D

9.There are written policies/formal guidelines for achievement of (activity/area) patient teaching at my

workplace.C

10. What is the content of these policies/formal guidelines?D

11. I document the patients’ need of knowledge of their health situation in the record.Aa

12. I document nursing activities of patient information in the record.Aa

13. I document nursing activities of patient teaching in the record.Aa

14. I document nursing evaluation of patient information in the record.Aa

15. I document nursing evaluation of patient teaching in the record.Aa

16. I have support from my manager in my patient teaching/information, i.e. the activity patient teaching.Aa

17. If you have support, please describe your support.D

18. There is a nurse at my work place who is responsible for developing the activity/ area of patient

education.C

19. I am uncertain of what patient information the physician should provide as opposed to myself as a nurse

and what the content should be.Aa

20. I am uncertain of what patient teaching the physician should provide as opposed to myself as a nurse and

what the content should be.Aa

21. At my workplace, I discuss with colleagues how to help the patients acquire knowledge.Aa

22. At my workplace, we discuss nurses’ patient information, e.g. activity/area information.Aa

23. At my workplace, we discuss nurses’ patient teaching, e.g. activity/area teaching.Aa

24. I make sure I know about the patients’ need of knowledge in terms of what the patients want to know

and understand about their health situation (directly from the patient).Aa

25. How do you ensure you understand the patients’ need of knowledge and understanding?D

26. I document learning objectives for patient teaching in the record.Aa

27. After the patient has had a conversation with the physician, I check how the patient has understood the

physician’s patient education.Aa

28. How do you do this?D

29. I follow the development of patient education knowledge in scientific literature, e.g. articles in journals.Aa

30. I follow the development of patient education knowledge in professional literature, e.g. books and

professional journals.Aa

31. My manager offers professional development in the activity/area of patient education.Aa

32. I have access to teaching/information materials at my workplace.C

33. Describe the type of teaching/information materials.D

34. I use the teaching/information materials.C

(continued)

Bergh et al. 13




previously in the construction of a PE questionnaire. The nurses’ responses to itemsinfluenced the decision to retain or exclude items, rewording and the layout. Theparticipating nurses worked in primary, municipal and hospital care and thus hadexperience of different aspects of PE work. This was important in our aim of creating ageneral questionnaire. In our study, a set of single items was regarded adequate for the aimof measuring conditions for nurses’ PE in complex work situations. No summary scores arecalculated and responses to each item in the questionnaire are analysed separately. Single-item measures require less time and less space to complete than multi-item measures, whichcan be important for response rate. Multi-item scales have psychometric advantages, forinstance, internal consistency reliability (Cronbach’s alpha) can be estimated. Also, itis difficult to evaluate the construct validity of single-item measures. Customarypsychometric methods used for testing multi-item constructs are not applicable since eachitem is used as a separate measurement unit. However, the correlations between global singleitems (as in NPEQ) and multi-item scale scores are often acceptable, implying that a single-item approach may be adequate for measurement purposes (Nagy, 2002; Sloan et al., 2002;Youngblut and Casper, 1993). In cases where the measured dimension is unambiguous andstraightforward, global single-item measures are especially suitable. This is true for the largerpart of the survey, which consists of straightforward questions about factual experience ofpatient education.

A potential limitation could be that we did not incorporate a specific search for PEquestionnaires in the initial literature review, which might have shaped that review. As aconsequence, an additional search for existing questionnaires was conducted to ensure thatno available questionnaires were missed.Willis (2005) points out that the value of CI can belimited if the interviewer is unfamiliar with the research field, or if there is more than oneinterviewer in the same project. In our study, one person with 25 years of professional

Table 4. Continued.

35. I know what my mandate is in patient teaching and information.Ab

36. I know how to document the patient’s need for knowledge about the health situation in the record.Ab

37. I know how to document patient information in the record.Ab

38. I know how to document patient teaching in the record.Ab

39. I am qualified/competent in patient information work.Ab

40. I am qualified/competent in patient teaching work.Ab

41. Patient teaching has high priority in my daily work.Ab

42. Co-operating with other professionals in patient education is important.Ab

43. It is important that the nurse is responsible for co-organising patient education between different

professional groups in regard to the patients the nurse is caring for/nursing.Ab

44. I think patient teaching is an important nursing responsibility.Ab

45. To meet patient information needs, it is important that I am knowledgeable in the following subjects:

medical science, nursing/caring science, educational science and psychological science.Ab

46. To meet patient teaching needs, it is important that I am knowledgeable in the following subjects: medical

science, nursing/caring science, educational science and psychological science.Ab

47. During a normal work day, I devote around. . .. . . percent of the shift to patient teaching.D

ALikert scale, 1 to 5. a(1¼ almost never/never to 5¼ almost always/always); b(1¼ strongly disagree to 5¼ strongly agree).BRank-order the places, from 1 to 7. 1¼ the most common, 2¼ the second most common and so on, 7¼other place,

where?. . .. . .CDichotomous, yes/no.DOpen-ended answer.





nursing experience conducted all the CI. Another validity aspect was that two authorsindependently analysed all the interviews and then compared the results.

There are recommended methods to systematically elicit expert judgements on contentusing a standardised content review questionnaire in the interview process (Davis, 1992;Grant and Davis, 1997; Lynn, 1986). We did not use such standardised methods for the‘pedagogical expert panel’ as the CI procedure was standardised. Instead, the interviewsopened up discussions on issues raised by these experts. Another aspect of significance forcontent validity was nurses’ ratings both before and after the interviews with the pedagogicalexperts. Nurses’ involvement at both stages is important because the questionnaire is to beused by nurses, and this procedure of continuous correction ought to ensure a validquestionnaire (Lasch et al., 2010).

Polit et al. (2007) recommend using CVI when the focus is on agreement of relevance andconsensus of items and scales. We measured the CVI, for example, when changing thedemographic items about pedagogical competence, and in the final questionnaire theseitems had been changed from fixed to only open ended. Here, CI was again valuable as itresulted in better readability and less text. These time-reducing changes are important tofacilitate participation and response rate, although there was more work in data processing.CI also contributed to the deletion of two rank-ordered items that the nurses considered tobe a little problematic. Our questionnaire has many items and it has been reported that thetime-consuming procedure of item ranking is less acceptable when there are a large numberof items. Item reduction could also reduce the number of internal drop outs when answeringthe questionnaire (Dillman, 2000).

The value of the questionnaire

It is important to address nurses’ shortcomings in PE work and the NPEQ was created toenhance understanding in this area. This questionnaire assesses nurses’ perceptions ofconditions for daily PE work in different health settings and no such questionnaire hasbeen found. Having both closed- (all with possibility for comments) and open-ended itemsabout how nurses currently work and their current perceptions, a better understanding ofnurses PE can be obtained (Polit and Beck, 2008). The content validity was assured by CIwith nurses both before and after the dialogues with experts in PE. During the iterativeprocess of development, focus was on language and content, which is important for highparticipation rate and low internal missing data.

In patient education literature, a variety of terms are used forPE (Rankin et al., 2005). In thisstudy, wemade a distinction between the concepts of patient teaching and patient information.It is important to differentiate between the two because they require different strategies(compare Ohman, 2003) to encourage nurses to reflect on these different aspects of PE.

Finally, in the development, construction and validation of the NPEQ (a questionnairethat assesses nurses’ perceptions of conditions for PE work: what nurses actually do andwhat they think about what they do in primary, municipal and hospital care) the domainsidentified in the literature review were used for item construction. The concepts ‘patientteaching’ and ‘information’ have been separated in different questions. We have describedthe development of the NPEQ in detail, thus allowing further evaluation and improvementsto be made to our version.

We anticipate that the NPEQ will reveal appropriate conditions for this work andconsequently be a help for promoting PE. Content validity was assured by CI and

Bergh et al. 15




accepted CVI among nurses and dialogues with experts. Earlier questionnaires focusedmainly on hospital settings, while this questionnaire allows us to investigate pedagogicalissues regardless of workplace.

This questionnaire will allow managers and nurses to identify nurses’ perceptions ofconditions, possibilities and barriers, and the resulting knowledge can be used to ascertainwhat sort of support is needed for the development of PE in different health settings.Comparative studies at a national and international level are required to create a morecomprehensive overview of conditions for PE work. We have begun to further developthe NPEQ including insights from the two published articles using this questionnaire.

Key points for policy, practice and/or research

. Scant evidence regarding conditions for nurses’ patient education prompted thedevelopment of a Nurses’ Patient Education Questionnaire.

. Content validity was assured by ‘cognitive interviewing’ with nurses and dialogueswith experts in patient education regarding language and content.

. CVI scores based on nurses’ ratings were found to be acceptable.

Contributions

Study Design: ALB, IJ, FF; Data Collection and Analysis: ALB, IJ, FF and Manuscript Preparation:

ALB, IJ, EP, JK, and FF

Acknowledgements

The authors thank Professor Kathleen Galvin for reading and commenting on earlier versions of this

paper. They are also grateful to the participating nurses, pedagogical experts and research group, and

to Professor Lena Nordholm for advice and support.

Declaration of conflicting interest

None declared.

Disclosure statement

We confirm all personal identifiers have been removed or disguised so the persons described are not

identifiable and cannot be identified through the details of the study.

Funding

This research received no specific grant from any funding agency in the public, commercial or not-for-

profit sectors.

References

Albada A, Elbers E and Visser A (2007) Patient education inWestern European hospitals: A comparison of the

Netherlands, Flanders and England. Patient Education andCounseling 66: 4–10.





Avsar G and Kasikci M (2011) Evaluation of patient educationprovided by clinical nurses in Turkey. International Journalof Nursing Practice 17: 67–71.

Balcou-Debussche M and Debussche X (2008) Type 2 diabetespatient education in Reunion Island: Perceptions andneeds of professionals in advance of the initiation of aprimary care management network. Diabetes andMetabolism 34: 375–381.

Barber-Parker ED (2002) Integrating patient teaching intobedside patient care: A participant-observation study ofhospital nurses. Patient Education and Counseling 48:107–113.

Barrett C, Doyle M, Driscoll S, et al. (1990) Nurses’perceptions of their health educator role. Journal of NursingStaff Development 6: 283–286.

Benner P, Supthen M, Leonards V, et al. (2010) EducatingNurses - A Call for Radical Transformation. San Francisco,CA: Jossey-Bass, A Wiley Imprint.

Bergh A-L, Bergh C-H and Friberg F (2007) How do nursesrecord pedagogical activities? Nurses’ documentation inpatient records in a cardiac rehabilitation unit for patientswho have undergone coronary artery bypass surgery. Journalof Clinical Nursing 16: 1898–1907.

Bergh A-L, Karlsson J, Persson E, et al. (2012) Registerednurses’ perceptions of conditions for patient education -focusing on organizational, environmental and professionalcooperation aspects. Journal of Nursing Management 20:758–770.

Caraher M (1998) Patient education and health promotion:Clinical health promotion – the conceptual link. PatientEducation and Counseling 33: 49–58.

Casey D (2007) Findings from non-participant observationaldata concerning health promoting nursing practice in theacute hospital setting focusing on generalist nurses. Journalof Clinical Nursing 16: 580–592.

Cashin A, Buckley T, Newman C, et al. (2009)Nurses practitioner provision of patient educationrelated to medicine. Australian Journal of Advanced Nursing27: 12–18.

Conrad F, Blair J and Tracy E (2000) Verbal report are data! Atheoretical approach to cognitive interviews. In: Office ofmanagement and budget: Proceedings of the 1999 federalcommittee on statistical methodology research conference,Research Conference, Arlington, VA. pp. 317–326.

Davis LL (1992) Instrument review: Getting the mostfrom a panel of experts. Applied Nursing Research 5:194–197.

Devine EC (2003) Meta-analysis of the effect ofpsychoeducational interventions on pain in adults withcancer. Oncology Nursing Forum 30: 75–89.

Dillman D (2000)Mail and Internet surveys: The tailored designmethod. New York, NY: Wiley.

Dillman D and Redline C (2004) Testing paper self-administered questionnaires: Cognitive interview and fieldtest comparisons. In: Presser S, Rothgeb J, Couper M, et al.(eds) Methods for Testing and Evaluating SurveyQuestionnaires. Hoboken, NJ: John Wiley & Sons, Inc.

Drennan J (2003) Cognitive interviewing: Verbal data in thedesign and pretesting of questionnaires. Journal of AdvancedNursing 42: 57–63.

Eriksson I and Nilsson K (2008) Preconditions needed forestablishing a trusting relationship during healthcounselling - an interview study. Journal of Clinical Nursing17: 2352–2359.

Fitzpatrick E and Hyde A (2006) Nurse-related factors in thedelivery of preoperative patient education. Journal of ClinicalNursing 15: 671–677.

Friberg F, Granum V and Bergh A-L (2012) Nurses’ patient-education work: Conditional factors - an integrative review.Journal of Nursing Management 20: 170–186.

Friberg F, Pilhammar Andersson E and Bengtsson J (2007)Pedagogical encounters between nurses and patients in amedical ward - a field study. International Journal of NursingStudies 44: 534–544.

Glanville IK (2000) Moving towards health orientedpatient education (HOPE). Holistic Nursing Practice 14:57–66.

Grant EN, Turner-Roan K, Daugherty SR, et al. (1999)Development of a survey of asthma knowledge, attitudes,and perceptions - The Chicago Community Asthma Survey.Chest 116: 178S–183S.

Grant JS and Davis LL (1997) Focus on quantitativemethods. Selection and use of content experts forinstrument development. Research in Nursing & Health 20:269–274.

Gregor FM (2001) Nurses’ informal teaching practices: Theirnature and impact on the production of patient care.International Journal of Nursing Studies 38: 461–470.

Hak T, van der Veer K and Jansen H (2004) The three steptest-interview (TSTI). An observational instrument forpretesting self-completion questionnaires (ERIM ReportERS-2004-029-ORG). Erasmus Research Institute ofManagement. Rotterdam. Available at: hdl.handle.net/1765/1265 (accessed 21 May 2004).

Honan S, Krsnak G, Petersen D, et al. (1988) The nurse aspatient educator: Perceived responsibilities and factorsenhancing role development. Journal of Continuing Educationin Nursing 19: 33–37.

Hubley J (2006) Patient education in the developing world–adiscipline comes of age. Patient Education and Counseling 61:161–164.

Jones RA (2010) Patient education in rural communityhospitals: Registered nurses’ attitudes and degrees ofcomfort. The Journal of Continuing Education in Nursing 41:41–48.

Kelley K and Abraham C (2007) Health promotion forpeople aged over 65 years in hospitals: Nurses’perceptions about their role. Journal of Clinical Nursing 16:569–579.

Koutsopoulou S, Papathanassoglou ED, Katapodi MC, et al.(2010) A critical review of the evidence for nurses asinformation providers to cancer patients. Journal of ClinicalNursing 19: 749–765.

Kaariainen M and Kyngas H (2010) The quality of patienteducation evaluated by the health personnel. ScandinavianJournal of Caring Sciences 24: 548–556.

Lasch K, Marquis P, Vigneux M, et al. (2010) PROdevelopment: Rigorous qualitative research asthe crucial foundation. Quality of Life Research 19:1087–1096.

Lee D and Chien W (2002) Pre-operative patient teaching in anacute care ward in Hong Kong: A case study. ContemporaryNurse 13: 271–280.

Lewis TT (2005) Teaching effectiveness: Are RNs prepared andsupported for their teaching role? PhD Thesis: The Universityof Southern Mississippi, USA.

Lipponen K, Kyngas H and Kaariainen M (2006) Surgicalnurses readiness for patient counselling. Journal ofOrthopaedic Nursing 10: 221–227.

Bergh et al. 17




Lynn MR (1986) Determination and quantification of contentvalidity. Nursing Research 35: 382–385.

Macdonald W, Rogers A, Blakeman T, et al. (2008) Practicenurses and the facilitation of self-management in primarycare. Journal of Advanced Nursing 62: 191–199.

Marcum J, Ridenour M, Shaff G, et al. (2002) A study ofprofessional nurses’ perceptions of patient education. Journalof Continuing Education in Nursing 33: 112–118.

Martin F (1988) Hospital nurses and non-hospital nurses aspatient teachers: Factors affecting nurse assumption of theteaching role. PhD Thesis: The Florida State University,USA.

Meretoja R, Isoaho H and Leino-Kilpi H (2004) Nursecompetence scale: Development and psychometric testing.Journal of Advanced Nursing 47: 124–133.

Meretoja R and Leino-Kilpi H (2001) Instruments forevaluating nurse competence. Journal of NursingAdministration 31: 346–352.

Moret L, Rochedreux A, Chevalier S, et al. (2008) Medicalinformation delivered to patients: Discrepancies concerningroles as perceived by physicians and nurses set againstpatient satisfaction. Patient Education and Counseling 70:94–101.

Nagy MS (2002) Using a single-item approach to measure facetjob satisfaction. Journal of Occupational & OrganizationalPsychology 75: 77–86.

National Board of Health and Welfare (2005) Folkhalsorapport2005. Stockholm, Sweden: Socialstyrelsen.

NBHW (2005) National Board of Health and Welfare.Standards of qualifications for registered nurses. Availableat: http://www.socialstyrelsen.se/publikationer2005/2005-105-1 (accessed 25 February 2012).

Nolan J, Nolan M and Booth A (2001) Developing the nurse’srole in patient education: Rehabilitation as a case example.International Journal of Nursing Studies 38: 163–173.

Ohman B (2003) The nurse’s patient education in geriatric careand rehabilitation. PhD Thesis, HSL Forlag Stockholm:Sweden.

Osterlund-Efraimsson E, Klang B, Larsson K, et al. (2009)Communication and self-management education at nurse-ledCOPD clinics in primary health care. Patient Education andCounseling 77: 209–217.

Park MY (2005) Nurses’ perception of performance andresponsibility of patient education. Journal of KoreanAcademy of Nursing (Taehan Kanho Hakhoe Chi) 35:1514–1521.

Patrick DL, Burke LB, Gwaltney CJ, et al. (2011) Contentvalidity—establishing and reporting the evidence in newlydeveloped patient-reported outcomes (PRO) instruments formedical product evaluation: ISPOR PRO good researchpractices task force report: Part 2—assessing respondentunderstanding. Value in Health 14: 978–988.

Polit D, Beck C and Owen S (2007) Is the CVI an acceptableindicator of content validity? Appraisal andrecommendations. Research in Nursing & Health 30:459–467.

Polit DF and Beck CT (2008) Nursing research: Generating andassessing evidence for nursing practice. Philadelphia, PA:Wolters Kluwer Health/Lippincott Williams and Wilkins.

Rankin SH, Stallings KD and London F (2005) Patienteducation in health and illness. Philadelphia, PA: LippincottWilliams & Wilkins.

Redman BK (2008) When is patient education unethical?Nursing Ethics 15: 813–820.

Schwirian PM (1978) Evaluation the performance of nurses: Amultidimensional Approach. Nursing Research 27: 347–351.

Selby-Harrington ML, Mehta SM, Jutsum V, et al. (1994)Reporting of instrument validity and reliability in selectedclinical nursing journals, 1989. Journal of ProfessionalNursing 10: 47–56.

Sloan JA, Aaronson N, Cappelleri JC, et al. (2002) Assessingthe clinical significance of single items relative to summatedscores. Mayo Clinic Proceedings 77: 479–487.

Thoma GB (1999) A comparison of the role of patient educatorto other nursing roles: Identifying influences affecting theattainment of the patient educator role among staff nurses.PhD Thesis: The University of Memphis, USA.

Tourangeau R (1984) Cognitive science and survey methods: Acognitive perspective. In: Jabin T, Straf M, Tanur J, et al.(eds) Cognitive aspects of survey design: Building a bridgebetween disciplenes. Washington, DC: National AcademyPress, pp. 73–100.

Waltz CF, Strickland O and Lenz ER (2005)Measurement in nursing and health research. New York, NY:Springer.

Whitehead D (2008) An international Delphi study examininghealth promotion and health education in nursing practice,education and policy. Journal of Clinical Nursing 17:891–900.

Whitehead D, Wang Y, Wang J, et al. (2008) Healthpromotion and health education practice: Nurses’perceptions. Journal of Advanced Nursing 61: 181–187.

Whittemore R and Knafl K (2005) The integrative review:Updated methodology. Journal of Advanced Nursing 52(5):546–553.

Willis GB (2005) Cognitive interviewing: A tool for improvingquestionnaire design. Thousand Oaks, CA: SagePublications.

Willis GB and Lessler J (1999) The BRFSS-QAS: A guide forsystematically evaluation question wording. Rockville, MD:Research Triangle Institute.

Virtanen H, Leino-Kilpi H and Salantera S (2007)Empowering discourse in patient education. PatientEducation and Counseling 66: 140–146.

World Health Report (2008) The primary health care - nowmore than ever. Available at: http://www.who.int/whr/2008/en/index.html (accessed 15 December 2011).

World Medical Association (2005) World Medical AssociationDeclaration of Helsinki. Available at: http://www.wma.net/en/20activities/10ethics/10helsinki/draft_historical_contemporary_perspectives.pdf (accessed 22 September2011).

Youngblut JM and Casper GR (1993) Focus on psychometricssingle-item indicators in nursing research. Research inNursing & Health 16: 459–465.

Zakrisson A and Hagglund D (2010) The asthma/COPD nurses’ experience of educating patientswith chronic obstructive pulmonary disease inprinmary health. Scandinavian Journal of Caring Sciences 24:147–155.

Anne-Louise Bergh, (MSc, RN) is a registered nurse with specialty in intensive care. She is alecturer (has a teacher’s education) and a doctoral student at the Department of Nursing at





the University of Boras and at Institute of Health Care Sciences at the University ofGothenburg. Her master’s degree thesis was published: ‘‘Bergh A-L, Persson LO andAttvall S (2000) Psychometric properties of the Swedish version of the Well-BeingQuestionnaire in a sample of patients with diabetes type 1. Scandinavian Journal of PublicHealth 28: 137–145.’’ In her earlier daily work, both at different wards and intensive careunits, she focused on patients’ well-being. Her first research was about patients’ well-beingand then patients’ need of qualified patient education became apparent. Since the 1990s, herresearch has focused on nurses’ daily patient education. She has also published articles aboutnurses’ documentation of patient education.

Inger Johansson, (RN) is a senior lecturer, associate professor at the department of nursingKarlstad University and professor in nursing at the Faculty of Health, Care and NursingGjovik University College, Gjovik Norway. Her research focuses mainly on elderly patientsin acute care and community care, with particular focus on health, quality of life andpatients with hip fracture regarding assessment of acute confusion. Other research areasinclude instrument validation, development of nurse competence, assessing nursing staff’swork satisfaction related to changes of nursing organisation, family caregivers’ daily life andpressure ulcers in the trajectory of care. In her thesis ‘Quality of care and assessment of healthamong elderly in acute care’ she has also studied about psychometric testing of an instrumentassessing acute confusion and the predictive power of a sense of coherence scale regardingfuture needs of care.

Eva Persson, (RN) is an associate professor and a senior lecturer in nursing at LundUniversity, with specialty in surgery. Her research focuses mainly on patients withcolorectal diseases and patients with a stoma and their partners. The thesis ‘A new lifewith a stoma and quality of care among patients and their partners’ is about patients’ andtheir partners’ perception after a stoma operation and about quality of care. There are alsostudies about quality of life in these patients and about stoma-related complications. Otherresearch areas are about change from hospitalisation in multi-bed rooms to single-bedrooms, collaboration between academia and the medical staff and the application ofnursing research. The research also includes studies about nurses’ opportunities forpatient education.

Jan Karlsson, (M Psy) is an associate professor and has over 20 years’ experience in medicalscience. He is the author of more than 50 peer-reviewed articles and several book chapters.Dr Karlsson has a Master’s Degree in Psychology and received his PhD in Medical Sciencefrom the University of Gothenburg, Sweden, in 2003. His main research interests are health-related quality of life, obesity, eating behavior, and psychometric methods for developingand validating self-report instruments. Dr Karlsson is currently working as a scientificsupervisor at the Centre for Health Care Sciences, Orebro University Hospital and as aresearch psychologist at the Department of Medicine, Orebro University Hospital, Orebro,Sweden.

Febe Friberg, (RN) is a professor at the Faculty of Social Sciences, the University ofStavanger, Norway and an associate professor at the Sahlgrenska Academy, University ofGothenburg, Sweden. Main research areas are patient education, patient learning andcommunication. In the doctoral thesis ‘Pedagogical encounters between patients and nurses

Bergh et al. 19




at a medicial ward. Towards a didactics on a life world basis’ nurses’ patient educationfunction was studied by means of field work. The constituents of a theoretical model forpatient education were formulated. Other studies focus on documentation of nurses’ patienteducation work in hospital contexts. In addition, several articles are published about patientlearning in palliative cancer care. Communication as part of patient education is studied inthe contexts of oncology outpatient unit, surgical care, diabetes care and maternity care.Friberg is initiator and leader of the ‘Nordic network for patient education and learning –practice and research’.




nurses' patient education questionnaire - development and validation process

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