Nursing Inquiry 2015; 22(2): 106–120

Review

A systematic review of instruments

measuring patients0 perceptions of
patient-centred nursing care
Stefan K€ oberich and Erik Farin
Medical Center - University of Freiburg, Freiburg, Germany

Accepted for publication 14 July 2014

DOI: 10.1111/nin.12078

€
KOBERICH S and FARIN E. Nursing Inquiry 2015; 22: 106–120
A systematic review of instruments measuring patients0 perceptions of patient-centred nursing care
This systematic review identified and evaluated instruments measuring patients’ perceptions of patient-centred nursing care. Of
2629 studies reviewed, 12 were eligible for inclusion. Four instruments were reported: The Individualized Care Scale, the Client-
Centred Care Questionnaire, the Oncology Patients’ Perceptions of the Quality of Nursing Care Scale and the Smoliner scale.
These instruments cover themes addressing patient participation and the clinician–patient relationship. Instruments were
shown to have satisfactory psychometric properties, although not all were adequately assessed. More research is needed regard-
ing test–retest reliability, convergent and discriminant validity, validity with known groups and structural validity using confirma-
tory factor analysis.

Key words: assessment instrument, patient participation, patient-centred nursing care, patient-nurse relationship, systematic lit-
erature review.

Dating back to the late 1960’s, patient-centred care has a
long tradition, with some suggesting its origins are in the
work of Florence Nightingale (Lauver et al. 2002). There
was an increasing popularity of patient-centred care in the
1970’s (Balint 1969; Robinson et al. 2008), but the concept
has attracted the greatest attention in the last two decades.
Patient-centred care emphasizes the need to perceive the
patient less as the medium of a disease (Mead and Bower
2000), and more as the person in the very centre of the care
process whose needs, values and individuality are respected
and acknowledged. This effectively means that health-care is
no longer standardized or just disease-oriented; rather it is
holistic, individualized, tailored, respectful and empowering
(Lauver et al. 2002; Morgan and Yoder 2012). Patient-cen-
tred care entails a broad perspective on illness reflecting
social and psychological factors, with an additional focus on
health promotion (Mead and Bower 2000). Some authors
Correspondence: Stefan K€oberich, Institute for Quality Management & Social
Medicine, Medical Center – University of Freiburg, Engelbergerstr. 21, 79106 Frei-
burg, Germany. E-mail: <stefan.koeberich@uniklinik-freiburg.de>
suggest that patient-centred nursing and medical care
improves patient outcomes (Robinson et al. 2008; Hobbs
2009).
To evaluate the effects of patient-centred care, valid and
reliable instruments of patient centred care are needed. This
systematic review aimed to identify instruments measuring
patient-centredness within the nursing setting, evaluate their
psychometric properties and to identify the elements of
patient-centred care.
Based on an analysis of relevant literature for this review,
we define patient-centred nursing care (PCNC) as the
degree to which the patient’s wishes, needs and preferences
are taken into account by nurses when the patient requires
professional nursing care. We consider PCNC as a process
influencing nursing-sensitive patient outcomes and that is
affected by several nurse- and context-related factors (such
as nurses’ attitudes towards patient-centredness and the
organization of nursing care).
Empirical data support the hypothesis that patient-centred
care improves patient outcomes. For example, Poochikian-
Sarkissian et al. (2010) found that the implementation of

© 2014 John Wiley & Sons Ltd


PCNC moderately improved patient’s self-care abilities and
their satisfaction with care. In their descriptive study, PCNC
was operationalized as the extent of patients’ participation in
care and the individualization of care, that is, nurses’ consid-
eration of patients’ needs and preferences. Functional status,
self-care and satisfaction with care were measured within
48 hours of the patient’s admission (T1) and two weeks after
discharge (T2). In addition, perceived patient-centredness
was measured at T2. The correlation between patient out-
comes and the dimension of PCNC assessed at T2 was statisti-
cally significant.
In cross-sectional studies with nearly 2000 inpatients
from five countries, it was found that PCNC, operationalized
as individualized care, was associated with improved patient
satisfaction, patient autonomy and quality of life (Suhonen
et al. 2007b; Suhonen et al. 2012a). However, no investiga-
tor has used an experimental design to test the influence of
fostering PCNC on patient outcomes. Thus, there is a need
for more evidence to confirm positive correlations between
PCNC and improved patient outcomes.
One problem associated with demonstrating a specific
link between patient-centred care in general and patient out-
comes is the lack of instruments based on a generally
accepted definition of patient-centred care. Although the
medical and nursing professions share most of the concep-
tual elements of patient-centredness, there are differences in
how these groups conceptualize patient-centred care. In a
narrative literature review and synthesis, Kitson et al. (2013)
reported that health policy stakeholders and nurses perceive
patient-centred care more broadly than do medical profes-
sionals. Medical professionals tend to focus on the relation-
ship with the patient and the nature of the decision-making
process. In contrast, the nursing literature tends to empha-
size the acceptance of patients’ beliefs and values and
addresses how patient-centred care is promoted (Kitson
et al. 2013).
Therefore, an instrument measuring patient-centred
care in general is at risk of not detecting profession-specific
patient-centredness. For example, items measuring a
patient’s perception of patient-centred care regarding per-
sonal hygiene (a specific nursing task) will probably be lack-
ing in a generic instrument. It would thus seem reasonable
to provide instruments specific to different professions avail-
able for measuring the degree of patient-centred care reali-
zation.
There are literature reviews providing an overview of
tools measuring patients’ perception of patient-centred care
in medicine (Mead and Bower 2000; Hudon et al. 2011);
however, to the best of our knowledge, there is no review of
instruments measuring patient-centred care in nursing.
© 2014 John Wiley & Sons Ltd
Patient-centred nursing care
Therefore, the aim of this systematic literature review is to
provide an overview of instruments measuring patients’ per-
ception of PCNC. Our research questions were:
 What instruments are available to measure perceived
PCNC from the patient’s perspective?
 Which elements of patient-centredness does each
instrument measure?
 What are the psychometric properties of each instru-
ment?
METHODS
We conducted a systematic review based on the methods
described by the Centre for Reviews and Dissemination
(Centre for Reviews Dissemination 2009). The CRD0 s guid-
ance for undertaking reviews in health-care describes in
detail the following elements to ensure high quality reviews:
(1) content of a review protocol, (2) literature search sources,
(3) selecting appropriate studies, (4) data extraction, (5)
quality assessment and (6) data synthesis and guidelines on
writing, archiving and disseminating the findings of a review.
Literature Review
DATABASES AND SEARCH TERMS
PubMed and the Cumulative Index to Nursing and Allied
Health Literature (CINAHL) were searched with similar
strategies using the following terms: patient-centred care,
patient-focused care, person-centred care, person-focused care, client-
centred care, client-focused care, resident-centred care, resident-
focused care, personalized care, personalized nursing, individualized
care, individualized nursing, tailored care, tailored nursing (as well
as the British spellings of centred, personalised, individua-
lised) in combination with questionnaire*, assessment instru-
ment*, scale* and measuring instrument using Boolean
operators AND/OR. The search was conducted in October–
November 2012 and limited to articles published in the Eng-
lish or German between 1997 and 2012 that were indexed
with an abstract. The decision to start the literature search in
1997 was based upon expert opinions that the most relevant
work in the field of patient-centredness has been published
since 1997. References were screened for eligible papers,
and experts in the field of patient-centred care were con-
tacted by mail and asked about instruments not identified by
the database search. We also included reviews about instru-
ments measuring patient-centred care and extracted relevant
references.
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After identifying relevant instruments, we conducted a
second search using the instruments’ names and acronyms
as key words (i.e. Individualized Care Scale – ICS, Oncology
Patients’ Perceptions of the Quality of Nursing Care Scale –
OPPQNCS, Client-Centred Care Questionnaire – CCCQ) to
find additional studies using the identified instruments and
reporting on their psychometric properties.
INCLUSION AND EXCLUSION CRITERIA
Articles were included in this review if they reported on
the development and/or any kind of psychometric testing
of an instrument measuring patients’ perceptions of
PCNC. As there is currently no consensus on how PCNC is
defined, we used three core themes with eight subthemes
and 23 categories derived from a review of the health pol-
icy, medicine and nursing literature conducted by Kitson
et al. (2013) to guide our decisions during the inclusion
process (table 1). The three core themes are ‘participation
and involvement’, ‘relationship between the patient and
the health professional’ and ‘the context where care is
delivered.’ ‘Participation and involvement’ describes the
attitudes of health professionals towards the patient and
the patient’s involvement in decisions about his/her care.
‘Relationship between the patient and the health profes-
sional’ comprises attributes about the relationship between
the health professional and patient, intraprofessional com-
munication and communication between health profes-
sionals and patients, as well as competencies and skills of
health professionals. ‘The context where care is delivered’
describes system barriers (e.g. lack or shortage of staff),
requirements to implement patient-centred care, themes
of patient-centred care definitions and the translation of
patient-centred care into practice.
Articles were included if the instrument measures at
least two of the core themes and patients0 perceptions of
nursing care. Articles were excluded if the reported instru-
ment measures the person-centredness of care provided by
physicians, occupational therapists, multidisciplinary teams
(e.g. physicians and nurses, independently from an exist-
ing nurse-specific subscale) or other allied healthcare pro-
viders. Articles were also excluded in cases where the
instrument is to be filled out by a child, adolescent or per-
sons other than the patient, or if the instrument measures
patient-centredness from the perspective of healthcare pro-
viders. We based these decisions on the assumption that
perceived patient-centredness is an individual perception
that cannot be judged by anyone other than the patient
him- or herself.
In addition, we excluded articles on the development
and psychometric testing of patient satisfaction measures.
108
This decision was based on a concept analysis of patient
satisfaction (Mahon 1996) and Cox’s Interaction Model of
Client Health Behavior (Cox 2003), both of which regard
patient satisfaction as an outcome of client-professional
interaction.
SEARCH OUTCOME
A total of 3003 references were imported to EndNote X2,
a software tool for managing bibliographies, citations and
references. Duplicates were removed either automatically
or by hand (n = 374). The titles and (if they were not
meaningful enough) the abstracts of 2629 articles were
then screened by the first author (SK) and potentially rel-
evant articles were identified (n = 75). Next, we (SK and
EF) independently screened the titles and abstracts of the
75 articles; any disagreement about inclusion or exclusion
of an article was resolved by discussion. This left 46 arti-
cles for full-text screening. We then analysed the entire
texts in the remaining articles and included 13 of the 46
in this review. In addition, references of included articles
were checked for eligible articles not identified in the lit-
erature search (n = 31), and six experts in the develop-
ment of patient-centred care instruments were asked
about other instruments not detected in the literature
search (n = 2). However, none of the articles or scales
identified by reference checks or expert survey fulfilled
our inclusion criteria. After conducting the second litera-
ture search, one article of 11 was included additionally.
After that, instruments reported within the reviews were
checked but none of the reported instruments fulfilled
our inclusion criteria or they had already been included
in our search of original articles; thus 12 articles were
analysed (fig. 1).
DATA ABSTRACTION
Data from the identified instruments were extracted by the
first author (SK) using a predefined checklist developed by
the authors. Entries were classified as follows: (a) name,
abbreviations and version of the instrument; (b) reference
(s); (c) theoretical background; (d) structure (number of
items, scales, subscales); (e) setting where the instrument
was tested; (f) information on the translation process, if
applicable; (g) information about validity and reliability
based on the taxonomy and measurement property defini-
tions provided by Mokkink et al. (2010); and (h) additional
information. The questionnaire items were also indepen-
dently cross-checked with the matrix provided by Kitson
et al. (2013). Results of the categorization were discussed
among the authors and any disagreement resolved through
further discussion.
© 2014 John Wiley & Sons Ltd

Table 1 Core themes, subthemes and categories of patient-centred care definitions
Core theme Subthemes
Participation and Patient participation as a respected
involvement and autonomous individual
Care plan based on patient’s
individual needs
Addressing a patient’s physical and
emotional needs
Relationship between Genuine clinician–patient relationship
the patient and the
health professional Open communication of knowledge, personal
expertise and clinical expertise
between the patient and the professional
Health professionals have appropriate
skills and knowledge
A cohesive and co-operative team
of professionals
The context where System issues
care is delivered
Matrix adapted from Kitson et al. (2013).
RESULTS
Twelve articles describe the process of developing and psycho-
metrically testing an instrument measuring PCNC. Of these
12 articles, seven describe the Individualized Care Scale (ICS) in
its original version, its modification or translations (Suhonen,
V€alim€aki and Katajisto 2000a,b; Suhonen, Leino-Kilpi and
V€alim€aki 2005; Acaroglu et al. 2011; Petroz et al. 2011; Suho-
nen et al. 2010, 2012b). One article describes the develop-
ment of the Oncology Patients’ Perceptions of the Quality of Nursing
Care Scale (OPPQNCS) (Radwin, Alster and Rubin 2003),
another the translation into Finnish and its testing of internal
consistency and construct validity (Suhonen, Schmidt and Ra-
dwin 2007a), and yet another the translation of its short form
into Turkish and testing of internal consistency (Can et al.
2008). One article presents the development and testing of
the Client-Centred Care Questionnaire (CCCQ) (de Witte, Schoot
and Proot 2006). A further report addresses an instrument
© 2014 John Wiley & Sons Ltd
Patient-centred nursing care
Categories
Respect for patient’s values, preferences
and expressed needs
Patient as a source of control
Patient actively involved and participating
Autonomy
Care customized according to patient’s needs
and values
Transition and continuity
Physical comfort, physical care
Emotional support
Alleviation of anxiety
Care based on a continuous healing relationship
Clinician–patient relationship
Knowledge shared and information flows freely
Information, communication and education
Feedback mechanisms to measure patient experience
Skill and competency
Attributes of the patient-centred professional
Cooperation among clinicians a priority
Differences in perception of role between
doctors, nurses and patients
Policy practice continuum/language used
Access
Barriers to patient-centered care
Supportive organizational system
Therapeutic environment
with no specific name (Smoliner et al. 2009), in the following
referred to as the Smoliner scale.
In the next four sections, theoretical background, devel-
opment process and information on validity and reliability of
every scale are described in detail and table 2 summarizes
the findings about the scales0 psychometric properties.
Individualized Care Scale
THEORETICAL BACKGROUND
The ICS is the most frequently tested instrument we identi-
fied. It was originally developed in 2000 by Suhonen and col-
leagues in a Finnish healthcare setting (Suhonen et al.
2000a,b). The aim of the ICS is to measure adult patients’
perceptions of individualized care at the time of hospital dis-
charge. Two elements of individualized care served as opera-
tional definitions: (1) the patient’s individuality with its
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Search in PubMed Nursing Inquiry

Search in CINAHL
DEVELOPMENT PROCESS
n = 1965 n = 1038
The first draft of the ICS contained 115 items that were
reviewed by a panel of nursing experts and a nurse-
PubMed + CINAHL
n = 3003
researcher. Consecutive reductions led to a total of 93 items.
Remove duplicates
n = 374 The relevance and clarity of these items were judged by 15
Title, abstract screened different nursing experts; this led to the deletion of 50 items.
(1.reviewer)
n = 2629 The revised 43-item instrument was then pilot-tested in a
Not selected
n = 2554 cohort of 30 patients. Subsequently, data obtained from 203
Title, abstract screened patients were used to refine the scale which led to another
(1. and 2. reviewer)
n = 75
six items being deleted. Exploratory factor analysis (EFA)
Not selected n = 29
• No information on instrument revealed a three-factor solution concordant with the theoreti-
development/testing (n = 9)
•
•
Not measuring patient-centredness (n = 10)
Measuring patient centredness of physician
cal framework (Scale 1 ‘Patient0 s individuality – PI’ with its
•
or nurse/physician (n = 9)
Not filled out by patient (n = 1) subscales ‘Patient0 s situation during hospitalization – PIa’
Full-text screened
and ‘Patient0 s personal life situation – PIb’ and scale 2 ‘Facili-
tating participation in decision making – FPD’).
(1. reviewer)
n = 46

•
Not selected n = 33
Not filled out by patient (n = 8)
In 2005, the theoretical framework was refined and the
• Studies with a known instrument (n = 6)
• Measuring patient centredness of scale revised. Now the ICS consisted of two parts. Part 1,
physician or nurse/physician (n = 10)
• Not measuring (process of) patient- labelled ‘Individualized Care Scale, Part A (ICS-A)’, con-
centredness (n = 7)
• Others (n = 2)
sisted of items reflecting patients’ views on how individuality
n = 13 is supported through nursing interventions. Part 2, labelled
Added through
reference–check of reviews ‘Individualized Care Scale, Part B (ICS-B)’, reflected
(n = 31)
patients’ perceptions of how the individual their own care is.
n = 44
Each of these two parts included three subscales: the clinical
Not selected n = 31 situation, personal life situation and decisional control over
• Not filled out by patient (n = 5)
• Not measuring (process of) patient-
centredness (n = 17)
care. The scale comprises 38 items in all (19 items in Part A
• Measuring patient centredness of
physician or nurse/physician (n = 5) and 19 items in Part B).
• Others (n = 4)
In 2010, the ICS was translated into several different lan-
n = 13 guages and tested in different countries (Greece, Sweden,
Added following personal communication with USA, UK). The translation process led to further scale revi-
experts (n = 2)
sion with the number of items reduced from 38 to 34. The
n = 15
complex process of translation and cross-cultural adaptation
Not selected n = 2
• Not filled out by patient (n = 1) of the ICS took place in several steps, namely forward and
• Not measuring (process of) patient-
centredness (n = 1) backward translations by different translators, a reconcilia-
n = 13
tion process, international focus group discussions and pilot
tests using convenience samples in five countries. The num-
Added through 2nd search (n = 11)
ber of items in the fourth version of the ICS was reduced
n = 24
from 19 to 17 for both parts A (ICS-A) and B (ICS-B) (Suho-
Not selected n = 12
nen et al. 2010). Items have to be rated using a five-point
• Not filled out by patient (n = 5)
• Not reporting psychometric testing (n = 4) Likert scale with the extreme answer categories ‘strongly dis-
• Instruments reported in Reviews did not
fulfill inclusion criteria or were already agree’ (=1) and ‘strongly agree’ (=5). The fourth version was
included (n = 2)
• Report of internal consistency only (n = 1)
also tested in a Canadian (Petroz et al. 2011) and a Turkish
n = 12
patient sample (Acaroglu et al. 2011).
Figure 1 Flowchart of literature search.
VALIDITY AND RELIABILITY
elements (1a) patient’s situation (e.g. physical and psycho- Psychometric properties of the fourth version of the ICS
logical needs) and (1b) the patient’s personal life situation were assessed in five samples from different countries. Cron-
(e.g. life-situation in general) and (2) participation in deci- bach’s alpha values ranged from 0.92 to 0.97 (ICS-A) and
sion-making. Individualized care was defined as nurses’ 0.90 to 0.97 (ICS-B). As expected, EFA revealed a three-fac-
actions taking into account the patient’s individuality and tor solution for the ICS-A and ICS-B. The three factors
facilitating patient participation in decision-making. accounted for 61.9–79.7% (ICS-A) and 58.2–79.7% (ICS-B)

110 © 2014 John Wiley & Sons Ltd


Table 2 Psychometric properties of identified scales
Scale name and version
Individualized Care Scale – Nurses; Patients Construct Validity
4th version) – Finnish, only for Swedish Structural validity
Greek, Swedish and version
English version
(Suhonen et al. 2010)
Individualized Care
Scale – 4th version –
English version
(Canada)
(Petroz et al. 2011)
© 2014 John Wiley & Sons Ltd
Patient-centred nursing care
Validity
Content validity
assessed by Construct and criterion validity Internal consistency
Finnish version:
ICS-A: 0.92; ClinA: 0.87;
EFA: PersA: 0.82; DecA: 0.85
ICS-B: 0.90; ClinB: 0.88;
 Three factor for ICS-A and ICS-B PersB: 0.78; DecB: 0.77
 Factors accountable for n% of the
Greek version:
variance
ICS-A: 0.97; ClinA: 0.96;
1 Finnish version: ICS-A: 61.9%;
ICS-B: 58.2% PersA: 0.90; DecA: 0.92
2 Greek version: ICS-A: 73.9%; ICS-B: 0.97; ClinB: 0.96;
ICS-B: 68.8% PersB: 0.87; DecB: 0.89
3 Swedish version: ICS-A:
Swedish version:
65.6%; ICS-B: 62.1%
4 UK version: ICS-A: ICS-A: 0.93; ClinA: 0.88;
79.7%; ICS-B: 79.7% PersA: 0.84; DecA: 0.89
Cross-cultural validity ICS-B: 0.92; ClinB: 0.88;
Rasch-Analysis:
PersB: 0.80; DecB: 0.84
 Measurement of invariance
between the ICS versions of UK version:
four countries: general ICS-A: 0.97; ClinA: 0.93;
congruence in item PersA: 0.86; DecA: 0.94
calibration ICS-B: 0.95; ClinB: 0.94;
patterns, but slight
differences in PersB: 0.80; DecB: 0.85
the rank order USA version:
ICS-A: 0.94; ClinA: 0.86;
PersA: 0.88; DecA: 0.88
ICS-B: 0.93; ClinB: 0.90;
PersB: 0.78; DecB: 0.78
No information Construct Validity ICS-A: 0.94; ClinA: n/a;
available Structural validity PersA: n/a: DecA: n/a
EFA: ICS-B: 0.94; ClinB: n/a;
 Three factor for ICS-A and two PersB: n/a; DecB: n/a
factors for ICS-B
 Factors accountable for 69.2%
of the variance in ICS-A and 63.6%
of the variance in ICS-B
Hypothesis-testing
Convergent validity:
 Schmidt Perception of
Nursing Care Survey
(SPNCS) was used (measuring
patient satisfaction)
 Spearman’s Rho: SPNCS vs. ICS-A:
0.76 (95% CI: 0.72, 0.80); SPNCS vs.
ICS-B: 0.80 (95% CI: 0.77, 0.83)
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Table 2 Continued

Validity

Content validity
Scale name and version assessed by Construct and criterion validity Internal consistency
Individualized Nurses Construct Validity ICS-A: 0.92; ClinA: 0.86;
Care Scale – Structural validity PersA: 0.72; DecA: 0.83
4th version – EFA: ICS-B: 0.93; ClinB: 0.89;
Turkish version  Three factor for ICS-A and ICS-B PersB: 0.80; DecB: 0.84
 Factors accountable for 65% of the
(Acaroglu
variance in ICS-A and 62% of the
et al. 2011) variance in ICS-B

Oncology Patients’ Nurses, Construct Validity Total scale: 0.99

Perceptions of the patients Structural validity (Short form: 0.97)
Quality of Nursing EFA: Responsiveness: 0.99
Care Scale  Four factors: (1) Responsiveness, (Short form: 0.95)
(OPPQNCS) (2) Individualization, (3) Individualization: 0.97
Coordination, (4) Proficiency
(Radwin et al. 2003)  Four factors explain 80.5% of (Short form: 0.93)
the variance Coordination: 0.87
(Short form: 0.87)
Proficiency: 0.95
(Short form: 0.95)
Oncology Patients0 No information Construct Validity Total scale: 0.94
Perception of the available Hypothesis-testing Responsiveness: 0.91
Quality of Nursing Individualization: 0.87
Care Scale Convergent validity (Pearson0 s r): Coordination: 0.85
(OPPQNCS) –  Correlation of OPPQNCS subscales Proficiency: 0.90
Finnish version assessing individualized care with
ICS subscales assessing individualized
(Suhonen care: r = 0.64/0.66
et al. 2007a,b)  Correlation of OPPQNCS subscales
assessing individualized care with
Schmidtdt Perception of Nursing
Care Survey subscales assessing
individualized care: r = 0.67

Divergent validity (Pearson0 s r):

 Correlation of OPPQNCS subscales
not assessing individualized care with
ICS subscales assessing individualized
care: r = 0.51–0.60
 Correlation of
OPPQNCS subscales
not assessing individualized
care with Schmidtdt
Perception of Nursing
Care Survey subscales
assessing individualized
care: r = 0.53–0.62

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 Patient-centred nursing care

Table 2 Continued

Validity

Content validity
Scale name and version assessed by Construct and criterion validity Internal consistency
Oncology Patients’ Patients Not assessed Total scale: 0.91
Perceptions of the Responsiveness: 0.74
Quality of Nursing Individualization: 0.79
Care Scale (OPPQNCS) – Coordination: 0.66
Short form – Turkish Proficiency: 0.87
version (Can et al. 2008)
Client-Centred Care Nurses, clients Construct Validity Total scale: 0.94
Questionnaire Structural validity
(CCCQ) (de EFA:
Witte et al. 2006)  One factor
 Factor explains 58% of the variance

Hypothesis-testing
Validity with known groups:
 Differences between clients of three
organizations (P = 0.08)
 Differences between clients of two
organizations (P = 0.049)

Convergent validity:
 Correlation ‘client-centredness’ –
‘overall satisfaction’: r = 0.81

Smoliner Scale Nurses Construct Validity Total scale: n/a

(Smoliner Hypothesis-testing Preferences: 0.84
et al. 2009) Validity with known-groups: Experiences: 0.86
 Group 1: experience with decision-
making = preference of decision-making;
Group 2: experience with decision-
making ¼ 6 preference of decision-making
 Groups differ in overall satisfaction
with decision-making (P < 0.001)

Convergent validity:
 Correlation ‘experiences’ – ‘patient
satisfaction with information process’: r = 0.673
 Correlation ‘preferences’ – ‘patient satisfaction
with information process’: r = 0.358

Internal consistency is displayed as Cronbach’s alpha values; test–retest-reliability was assessed only for the 1st version of the ICS.
EFA: Exploratory Factor Analysis; ICS: Individualized Care Scale; ICS-A: Individualized Care Scale – Part A; ICS-B: Individualized
Care Scale – Part B; ClinA/ClinB: Subscale of ICS-A/B (‘Clinical situation’); PersA/PersB: Subscale of ICS-A/B (‘Personal life
situation’); DecA/DecB: Subscale of ICS-A/B (‘Decisional control over care’).

of the measured variance (Suhonen et al. 2010; Acaroglu sonal life situation’ subscale not loading on a separate factor.
et al. 2011; Petroz et al. 2011). Using data from a Canadian Researchers presumed that this difference in factorial struc-
patient population, EFA revealed only a two-factor solution ture of the ICS-B was based on the different patient popula-
for the ICS-B with items belonging theoretically to the ‘per- tion used in the Canadian study compared with the original

© 2014 John Wiley & Sons Ltd 113

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study0 s population (other medical setting, older patients)
and the different cultures in which the studies were con-
ducted. Convergent validity was also assessed in a Canadian
population using the Schmidt Perception of Nursing Care
Survey (SPNCS). The Spearman’s Rho correlation coeffi-
cient between SPNCS and ICS-A was 0.76; between SPNCS
and ICS-B it was 0.80 (Petroz et al. 2011). A cross-cultural
validity study using a Rasch model analysis revealed general
correspondence in the item calibration patterns across the
different versions, but led to the recommendation to
rephrase and retarget some of the items (Suhonen et al.
2012b).
Test–retest reliability was assessed only for the first ver-
sion of the ICS (Suhonen et al. 2000a), with a retest interval
of two weeks. Data from 22 patients were used. The ICS was
administered in the hospital and after patient0 s discharge at
home. Reliability coefficients (Pearson’s r) of the two scales
(PI and FPD) were 0.81 and 0.82, and for the subscales (PIa
and PIb) 0.65 and 0.79. Suhonen and colleagues considered
this as preliminary evidence of the ICS scores0 stability over
time.
Oncology Patients’ Perceptions of the Quality of
Nursing Care Scale
THEORETICAL BACKGROUND
The OPPQNCS measures the quality of cancer nursing
care from the patient’s perspective; it is based on the mid-
dle-range theory of high-quality cancer nursing care devel-
oped by its author (Radwin and Alster 1999; Radwin
2000). The theory comprises two multidimensional con-
cepts: (1) attributes of high-quality cancer nursing care
with the dimensions (1a) professional knowledge, (1b)
continuity, (1c) attentiveness, (1d) coordination, (1e) part-
nership, (1f) individualization, (1g) rapport and (1h) car-
ing; and (2) the concept of outcomes. However, in
developing the OPPQNCS, only the first concept was oper-
ationalized.
DEVELOPMENT PROCESS
In the first step, 112 items were created, then evaluated for
clarity and relevance and matched with qualitative data
which left 85 items. These items were assessed for content
validity by an expert panel consisting of five patients, two
nurses with doctoral degrees, one executive director of a
patient-advocacy group and a survey scientist. Each expert
received the definition of the concept being measured and a
list of the concept’s eight dimensions. Raters were told to
indicate which item belonged to which dimension. Raters
114
also were asked to evaluate the congruence of each item with
the conceptual definition that was provided using a four-
point Likert scale. Based on the experts0 rating on the four-
point Likert scale, a content validity index was calculated.
This process left 59 items to be rated on a six-point Likert
scale (1 = never to 5 = always) reflecting the nursing activi-
ties0 frequency. Content validity index measures were not
provided within the publication.
VALIDITY AND RELIABILITY
Psychometric testing was conducted using data from 552
hospitalized patients. The first analysis led to a deletion of 14
items, leaving 45 items for further evaluation of construct
validity and internal consistency.
Exploratory factor analysis revealed a four-factor struc-
ture with 41 items. One item was deleted due to low factor
loading. The remaining 40 items belonged to the factors
responsiveness (22 items), individualization (10 items),
coordination (3 items) and proficiency (5 items). Cron-
bach’s alpha for the total scale and the subscales were 0.99
and 0.87–0.99 respectively. A short form also was devel-
oped containing 18 items with Cronbach0 s alpha of 0.97
for the total scale and an alpha of 0.87–0.95 for the sub-
scales.
There is also a Turkish version of the short form of
the OPPQNCS (Can et al. 2008). Forward and backward
translation of the OPPQNCS into the Turkish language
was conducted by independent translators. The transla-
tors0 professions were not reported. Back-translated ver-
sions were compared with the original, and revisions and
modifications made by bilingual experts in nursing
research and clinical nursing. Total scale0 s Cronbach0 s
alpha of the Turkish version was 0.91. and 0.66–0.87 for
the subscales.
A Finnish version was tested in 2007 (Suhonen et al.
2007a,b). The original version was translated into Finnish by
a nursing scientist and a professional translator. The two ver-
sions were compared and a conjoint version was back-trans-
lated into English by another professional translator.
Cronbach0 s alpha was assessed using data of 861 patients.
Alpha value of the total scale was 0.94 and 0.85–0.91 for the
subscales. Convergent validity was assessed by correlating
subscale of the OPPQNCS, ICS and SPNCS all assessing
aspects of individualization in nursing care. Pearson0 s r was
0.64–0.66 (OPPQNCS-ICS) and 0.67 (OPPQNCS-SPNCS).
In addition, divergent validity was assessed by correlating OP-
PQNCS subscale not assessing individualized care with ICS
and SPNCS subscales assessing individualization. Pearson r
was 0.51–0.60 (OPPQNCS-ICS) and 0.53–0.62 (OPPQNCS-
SPNCS).
© 2014 John Wiley & Sons Ltd

Client-centred care questionnaire
THEORETICAL BACKGROUND
De Witte, Schoot and Proot developed the CCCQ based on
their work on how clients experience care as client-centred
(Schoot et al. 2005a,b). According to the illustrated frame-
work, clients experience their care ‘as client-centred when they
feel recognized and respected by the nurse and when they
experience autonomy with respect to the way in which care is
delivered’ (de Witte et al. 2006, 63). These expectations com-
prise five central values: (a) autonomy, (b) continuity of life, (c)
uniqueness, (d) comprehensiveness and (e) fairness. Regard-
ing the care relationship, three underlying values were identi-
fied: (a) equality, (b) partnership and (c) interdependence.
DEVELOPMENT PROCESS
Fifteen scale items were formulated, each of which refers to
several of the values and expectations mentioned above.
Content validity of the 15 items was assessed through discus-
sion by a group of experienced nurses and experienced cli-
ents. Afterwards, the instrument was tested in six clients of
different ages, gender and educational levels. Items have to
be rated using a five-point Likert scale. Likert scale ranged
from 1 (totally disagree) to 5 (totally agree).
VALIDITY AND RELIABILITY
Using data from 107 subjects, construct validity was evaluated
via EFA revealing a one-factor solution that explained 58%
of the measured variance. Internal consistency using Cron-
bach’s alpha was 0.94. Validity with known groups was calcu-
lated comparing clients’ scores in three different home-care
organizations. Only the difference in two of the three
organizations was statistically significant (P = 0.049). The
hypothesis behind assessing validity with known groups was
not stated. However, the authors claimed that differences
had been anticipated based on their previous research.1 The
correlation between perceived client-centredness and overall
satisfaction with care was used to assess convergent validity.
These constructs were highly correlated (r = 0.81).
Smoliner Scale
THEORETICAL BACKGROUND
The Smoliner scale aims to measure the favoured and per-
ceived process of shared decision-making in the nursing set-
ting. It is based on the model of treatment decision-making
1 L. de Witte, personal communication, May 10, 2014.
© 2014 John Wiley & Sons Ltd
Patient-centred nursing care
described by Charles, Gafni and Whelan (1999) who discrim-
inate three stages of treatment decision-making: (1) informa-
tion exchange, (2) deliberation and (3) deciding on
treatment to implement. The model was applied to nursing
setting and the stages operationalized.
DEVELOPMENT PROCESS
Twenty-nine items were formulated and attributed to one of
the three stages by a panel of nursing scientists. Items were
discussed, and consecutively reduced to nine items. Three
clinical nurse specialists and two nursing scientists evaluated
content validity. Six patients evaluated the items’ compre-
hensibility and usability. A tripartite questionnaire was then
devised that was pretested by six patients. Parts 1 and 2 were
handled as subscales. Part 1 comprises questions about
patient preferences regarding information exchange, delib-
eration and decision-making. Part 2 evaluates the patient’s
perception of the three stages, and Part 3 collects sociode-
mographic data. Items in part 1 and 2 could be rated using a
six-point Likert scale with different poles depending on the
item0 s content.
VALIDITY AND RELIABILITY
The first two parts of the questionnaire were psychometri-
cally tested using data from 967 hospitalized patients. Cron-
bach’s alpha revealed internal consistency values of 0.84 and
0.86 for the subscales. Convergent validity was evaluated by
correlating a question on overall satisfaction with scores for
Part 2 of the questionnaire (r = 0.67). As expected, the cor-
relation between satisfaction and the first part of the ques-
tionnaire was low (r = 0.36).
Construct validity (known groups) was tested assessing
the relationship between overall satisfaction with decision-
making of patients (1) whose experience with decision-mak-
ing correspond to their preferences about decision-making
and (2) patients whose expectations were not met. Patients
whose expectations regarding decision-making were met
scored significantly higher in overall satisfaction with
decision-making than those with unmet expectations
(P < 0.001). Patients whose expectations regarding decision-
making were met scored significantly higher in overall
satisfaction with decision-making than those with unmet
expectations (P < 0.001).
Theoretical background and dimensions of
person-centred care instruments
Two of the instruments’ developers derived the instru-
ments’ theoretical background from earlier studies they
had conducted. Not surprisingly, there was not one single
115
S K€
o berich and E Farin
concept on which the instruments were based; however, we
identified commonalities among all four instruments
(table 3).
Using the patient-centred care matrix provided by Kitson
et al. (2013), all instruments contained items that can be
allocated to the core themes ‘patient participation and
involvement’ and ‘relationship between the patient and
health professional.’ Only one instrument (OPPQNCS)
incorporated items addressing the core theme ‘context
where the care is delivered’ (e.g. ‘the nurse arranged the
same nurses to care for me regularly’).
All instruments comprised items that can be allocated to
the subthemes ‘patient’s participation (in their care) as a
respected and autonomous individual’, followed by ‘open
communication of knowledge, personal expertise and clini-
cal expertise between the patient and the professional’,
shared by three of the instruments. Only the OPPQNCS
incorporated items related to the subthemes ‘a cohesive co-
operative team of professionals’ and ‘system issues.’
DISCUSSION
To the best of our knowledge, this is the first systematic
review of instruments measuring patient’s perception of
PCNC. Having reviewed an initial sample of more than 2600
articles, we identified four instruments measuring different
aspects of patient-centredness in nursing care. We have dem-
onstrated that only one instrument (the OPPQNCS) takes a
broad perspective of the patient-centred care concept in
terms of measuring all three dimensions of patient-centred
care according to the matrix of Kitson et al. (2013). What
patient-centred care precisely is and what it comprises is
actively discussed in all healthcare fields. Several concepts of
patient-centred care have been developed so far, but each
was primarily developed from the perspective of a single
health profession, leading to different conceptualizations of
patient-centred care. Patients themselves, however, do not
distinguish between different professions when discussing
patient-centredness. They tend to view patient-centredness
in terms of the staff and the system in which care is taking
place (Marshall, Kitson and Zeitz 2012). Instruments devel-
oped to measure PCNC should therefore incorporate ques-
tions about specific nursing tasks and take patients0 views on
patient-centred care into account; thus instruments need to
incorporate questions regarding both staff and the system of
care.
The various theoretical backgrounds of the four instru-
ments we identified reflect this discussion. The back-
grounds of the CCCQ and the OPPQNCS focus on
patients’ views of patient-centredness derived from
116
interviews with them. The ICS’s concept is based on an
extensive literature review that led to a rather broad
patient-centred care concept, and the Smoliner scale is
based on a medical treatment decision-making model. The
OPPQNCS is the only instrument that partially covers con-
textual issues of patient-centred care and thus seems to
lean towards patients’ views thereof to a greater extent
than the other instruments. When choosing one of these
instruments, one should also keep in mind that the CCCQ
and OPPQNCS were developed in specific settings and for
particular patient populations that can have different
wishes, needs and preferences in terms of the individuali-
zation of nursing care. Further research on the differences
in perceived patient-centredness in various patient popula-
tions is therefore needed.
Despite the limitations of some psychometric evaluations
of the PCNC instruments, preliminary evidence supports the
use of the instruments in research and practice. Internal
consistency exceeded the generally-accepted threshold of
Cronbach’s alpha of ≥0.7 (except the subscale ‘Coordina-
tion’ of the Turkish version of the OPPQNCS short form).
Structural validity was tested for three of four instruments
using EFA. Variance, as explained by extracted factors,
exceeded the acceptable minimum of 50% in all cases. How-
ever, EFA is only partially useful when evaluating whether
extracted factors are consistent with the underlying theoreti-
cal concept. Confirmatory factor analysis for establishing
strong evidence of the extent to which an instrument0 s struc-
ture corresponds to the underlying theory was not applied,
but it should be in future studies to establish structural
validity.
However, evidence is lacking for the stability of all instru-
ments. Only the first version of the ICS was evaluated for
test–retest reliability, with satisfactory correlation between
first and second administration; however, this was tested in a
small cohort. Overall, test–retest reliability is a neglected
domain of measurement properties in these instruments
that requires further investigation.
In addition, all instruments lack evidence of adequate
validity. Assessing concurrent validity as an element of crite-
rion validity is difficult because there is no generally
accepted definition of PCNC, leading to the absence of a
gold standard to measure PCNC. Hypothesis testing as one
measure of assessing the validity of an instrument was most
commonly used in the instruments0 developmental process.
Two instruments were assessed for validity with known
groups (CCCQ, Smoliner scale) and three instruments (in
their original version) for convergent validity (ICS, CCCQ,
Smoliner scale). The Finnish version of the OPPQNCS was
tested for convergent validity as well. Evaluation of
© 2014 John Wiley & Sons Ltd
 Patient-centred nursing care

Table 3 Instruments’ dimensions of person-centred care

Dimensions of patient-centredness Instruments

Core theme
Participation and
involvement
Relationship between
the patient and the
health professional
The context where
care is delivered
ICS
Subthemes (4th version) OPPQNCS CCCQ Smoliner Scale
Patient participation + + + +
Care plan based on +  + 
individual needs
Care addresses needs + +  
Genuine clinician-patient  + + 
relationship
Open communication + +  +
between the patient
and the professional
Appropriate skills and  + + 
knowledge of health
professions
A cohesive and  +  
co-operative team
of professionals
System issues  +  

Dimensions according to the matrix of Kitson et al. (2013) – see table 1. ICS: Individualized Care Scale; CCCQ: Client-Centred
Care Questionnaire; OPPQNCS: Oncology Patients’ Perceptions of the Quality of Nursing Care Scale.

instruments0 convergent validity usually lacks a clear descrip-
tion of the underlying hypothesis and theory. To correlate
the scores of instruments measuring patients0 satisfaction
with those of instruments evaluating patient-centredness
might make sense initially; however, not all the reports pro-
vide a clear explanation of how these constructs correlate in
theory. Nevertheless, this might foster the understanding of
the constructs0 correlation and contribute to strengthening
the validity instrument being developed. None of the instru-
ments were assessed for discriminant validity. To establish
any instrument0 s validity, it should be mandatory to assess
convergent and discriminant validity and validity with known
groups. For example, assessing the correlations between
patients0 satisfaction with nursing care and PCNC or the cor-
relation between the nursing systems (process oriented vs.
patient oriented, such as primary nursing) with PCNC in
terms of assessing validity with known groups might be help-
ful. Furthermore, assessing the correlation between PCNC
and patient-oriented communication as an element of PCNC
might help to establish validity of PCNC instruments. How-
ever, one must consider that these approaches to assess con-
vergent validity as well as discriminant validity bear the risk
of interpreting high correlations between the constructs as
evidence of validity. Porter (2011) critically pointed out that
three points should be considered regarding associations
between related constructs. First, simple correlations calcu-
lating should be replaced by more sophisticated approaches
(e.g. multiple regression). Second, related constructs0 corre-
lations might be high even though measures of the related
construct are systematically biased, which he calls the ‘corre-
lation fallacy in validity research’ (Porter 2011, 50). And
third, there are often no clear criteria for declaring correla-
tions to be substantively significant or not.
The reported process of evaluating content validity was
hampered by a lack of important information in some arti-
cles. It is often unclear when and how patients were
involved. Because PCNC instruments are designed to reflect
patients’ views on patient-centred care, patient feedback on
understanding the items and their perception of whether
or not they reflect the concept intended to be measured is
crucial (U. S. Food and Drug Administration 2009). Only
the items in the Swedish version of the ICS, the OPPQNCS
and CCCQ were evaluated by patients/clients regarding
content validity. The reports by Suhonen et al. (2000a,b),
Smoliner et al. (2009) and Petroz et al. (2011) lack detailed
descriptions of whether – and, if so, how – patients were

© 2014 John Wiley & Sons Ltd 117

S K€
o berich and E Farin
involved. For further refinement of these scales or when
developing new ones, we recommend that patients be
incorporated in all phases of the developing process, espe-
cially when evaluating content validity or the items0 compre-
hensibility and relevance (U. S. Food and Drug
Administration 2009). In addition, it is important to involve
patients to determine the consequences of using such
instruments as another aspect of validity (Hubley and Zu-
mbo 1996).
The translation process of some of the instruments
reported is generally well described. Translations were often
done by professional translators. Whether these translators
had a professional healthcare background or knowledge
about the contents being measured was not reported. How-
ever, not having knowledge about the profession-related
meanings of items could lead to misinterpretation and mis-
translation of the instruments0 items. Patients were not
involved in translation process. This might also limit content
validity, because patients from different cultures may per-
ceive patient-centredness differently. In summary, although
aspects of validity and reliability have been tested in all the
instruments described, further assessment of these criteria is
needed.
Our systematic review highlights the need for validity
assessment involving patient and clients. Evidence is also
lacking of the instruments’ convergent and discriminant
validity, validity with known groups, structural validity in
terms of using confirmatory factor analysis, test–retest reli-
ability and cross-cultural validity. Only the ICS was suffi-
ciently tested for its administration in different cultures. The
lack of assessing important aspects of validity and test–retest
reliability is a major weakness of all the current instruments
measuring PCNC.
The following conclusion can be drawn regarding instru-
ments reviewed. The ICS is the most commonly used and
best-tested instrument measuring PCNC. However, patients
were not involved in its development. The ICS reveals good
internal consistency; test–retest reliability was only assessed
for the first version of the instrument, providing preliminary
evidence of stability. Structural validity was assessed using
EFA with different results (two factors vs. three factors),
meaning that the ICS0 s structure has not so far been con-
firmed. The ICS is related to patient satisfaction and displays
cross-cultural validity. In further studies using the fourth ver-
sion of the ICS, test–retest reliability, convergent and discri-
minant validity as well as validity with known groups should
be investigated. Structural validity should be reassessed using
confirmatory factor analysis.
The OPPQNCS was developed for oncology patients.
Content validity was assesses by nurses and patients. Due to
118
the high internal consistency of alpha = 0.99, a short form
was developed to reduce redundancy of items. Test–retest
reliability was not assessed. Only EFA was used to assess struc-
tural validity. Construct validity in terms of hypothesis testing
was not assessed. Data on cross-cultural validity are missing
from the Turkish and Finnish versions of the instrument.
The OPPQNCS requires further testing to ensure its validity
and reliability.
De Witte and colleagues’ CCCQ was designed for use in
home-care settings. Content validity was assessed by nurses
and clients. Internal consistency is good (Cronbach0 s
alpha = 0.94). Its authors did not assess test–retest reliability.
Construct validity in terms of structural validity was only
assessed using EFA. Hypothesis-testing (validity with known
groups, convergent validity) were well assessed. Data on dis-
criminant validity are missing.
The Smoliner Scale was developed for use in patients in
hospitals and based on a model of treatment decision-mak-
ing. Patients did not review content validity; internal consis-
tency was calculated with alpha of 0.84 and 0.86, respectively.
Structural validity was not assessed; convergent validity and
validity with known groups were assessed. As with the other
instruments, the authors did not assess test–retest reliability.
Structural, discriminant and test–retest validity should be
evaluated in future studies.
LIMITATIONS
Our review contains some limitations. First, the search strat-
egy may not have captured all relevant instruments measur-
ing patients’ perceptions of PCNC. We conducted the
literature research in the most extensively used databases,
PubMed and CINAHL, but decided not to conduct a search
for the grey literature due to difficulties in tracing articles sys-
tematically and thoroughly. Furthermore, our exclusion cri-
teria ruled out instruments measuring patient satisfaction,
which may have caused us to miss some instruments measur-
ing the target trait of patient-centredness. We are aware that
patient satisfaction is sometimes referred to interchangeably
with patient-centredness and that patient-centredness is
sometimes regarded as a component of patient satisfaction.
However, we considered patient satisfaction as an outcome
rather than a process in nursing-care. As we aimed to provide
an overview of instruments measuring the PCNC process,
addressing patient satisfaction was not within the scope of
this review.
Moreover, we did not include instruments measuring
only one of the three themes of patient-centredness as cited
in the work of Kitson et al. (2013). There are instruments
that only measure one of the themes – for example, the
© 2014 John Wiley & Sons Ltd

context in which patient-centred care is being delivered (Ed-
vardsson, Fetherstonhaugh and Nay 2011). Again, including
these instruments was not within the aim of this study.
In addition, we analysed aspects of validity and reliability
according to the proposed classification by Mokkink et al.
(2010). Their classification was developed using a Delphi-
Study with international experts from the field of epidemiol-
ogy, statistics, psychology and clinical medicine. However, we
are aware that this classification might be viewed as a some-
what classical approach of reporting validity. There is an alter-
native validity concept developed in 1970s which emphasizes
that validation is an ongoing process and ‘is about the infer-
ence, interpretation, actions or decisions that are based on a
test score and not the test itself’ (Hubley and Zumbo 1996,
220). The authors stated that validity is not a static entity but
rather it depends on the sample from which or the context in
which the information was obtained. Validity is not consid-
ered as possessing specific types as we have reported in this
article. These types of validity are regarded as part of the con-
struct validation process. Therefore, the results we present
are not static. Instead, we hope they will be perceived as a step
within the ongoing validation process of all instruments.
CONCLUSION
This systematic review highlights the need for further
research on validity and reliability of existing instruments
measuring patients’ perceptions of patient-centred nursing
care, including convergent and discriminant validity, validity
with known groups and test–retest reliability. Furthermore,
there is a need to assess structural validity using confirmatory
factor analysis.
As caring for a patient is a communicative process in
which the patient0 s perspective plays an important role,
the consideration of individuals0 perspectives contributes to
improving patient outcomes. For example, to evaluate the
effectiveness of measures to prevent pressure ulcers in bed-
ridden hospitalized patients, it is important to include all
structural process indicators (e.g. whether nurses are aware
of all aspects of pressure ulcer prevention), technical mea-
sures (e.g. time interval for body re-positioning) as well as
the appropriate outcome. However, the outcome can be
seen from two perspectives: first, from the nursing perspec-
tive, which focuses on preventing pressure ulcers, and sec-
ond from the patient0 s perspective. In general, patients
certainly do not want to develop a pressure ulcer, but
there could be situations when this aim conflicts with
patient0 s wish to feel comfortable without being reposi-
tioned every two hours. Taking the patient0 s perspective,
wishes and preferences into account might change the
© 2014 John Wiley & Sons Ltd
Patient-centred nursing care
appropriate outcome to assess. A shift from nursing-
defined outcomes to patient-defined outcomes or a mix of
both seems reasonable when talking about patient-centred-
ness. Therefore, evaluating the contribution of patient-
centredness in preventing pressure ulcer could potentially
add another perspective to evidence-based nursing care
and might prove to be an important but still neglected
influencing factor in evaluating patient outcomes. This
overview of PCNC instruments enables us to select an
appropriate instrument when measuring nursing outcomes
or when planning to develop a new instrument tailored to
a specific patient population and care setting.
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