School of Nursing, Taipei Medical University, Taipei, Taiwan.
Emergency Department, Keelung Hospital, Ministry of Health and Welfare, Keelung, Taiwan.
PLoS One. 2019 Feb 1;14(2):e0210946. doi: 10.1371/journal.pone.0210946. eCollection 2019.
Nurses serve as gatekeepers of the health of long-term care facility (LTCF) residents and are key members deciding whether residents should visit an emergency department (ED). Inappropriate decisions as to ED visits may result in ED overcrowding, excessive medical expenses, and nosocomial infections. Currently, there is a lack of effective tools for assessing the barriers and level of difficulty experienced by LTCF nurses. The purposes of this study were to develop a Patient Transfer Decision Difficulty Scale (PTDDS) and test its effectiveness.
This study randomly sampled LTCFs in Taiwan and surveyed two or three nurses in every institution selected. Registered return envelopes were provided for participants to return self-completed questionnaires. Three steps were used to develop the scale and items: in step I, the instrument was developed; in step II, psychometric testing was conducted, which entailed performing an exploratory factor analysis (EFA) to verify the construct validity and reliability of the developed items; and in step III, a confirmation study was conducted using a confirmatory factor analysis (CFA) and structural equation modeling to cross-validate the factors and items.
The cumulative sum of variance explained by the measurement models of the three factors in the PTDDS was 63.54%.When deciding whether to transfer LTCF residents to EDs, the most pronounced barrier experienced by nurses were for judging the severity of "clinical episodes", which had an explanatory power of 37.49%. The second and third pronounced barriers and decision difficulty experienced by nurses were "communication and information" and "timing of the residents' emergency visits," which explained 16.81% and 9.24% of the variance, respectively.
The cross-validation results obtained using the EFA and CFA showed favorable reliability and validity of the PTDDS. For future studies, this study recommends performing large-scale investigations of the level of decision difficulty and related factors experienced by nurses in LTCFs of varying levels and types.
护士是长期护理机构（LTCF）居民健康的把关者，也是决定居民是否应前往急诊部（ED）的关键成员。对 ED 就诊的不当决策可能导致 ED 过度拥挤、医疗费用过高和医院感染。目前，缺乏评估 LTCF 护士面临的障碍和难度水平的有效工具。本研究旨在开发患者转介决策困难量表（PTDDS）并检验其有效性。
本研究在台湾随机抽取了 LTCF，并对每个选定机构的两到三名护士进行了调查。为参与者提供了注册的回邮信封，以便他们填写完问卷后自行寄回。量表的开发分为三个步骤：步骤 I，开发量表；步骤 II，进行心理测量测试，包括进行探索性因素分析（EFA），以验证开发项目的结构有效性和可靠性；步骤 III，使用验证性因素分析（CFA）和结构方程模型进行确认性研究，以交叉验证因素和项目。
PTDDS 三个因素的测量模型的方差累积解释率为 63.54%。在决定是否将 LTCF 居民转介到 ED 时，护士遇到的最明显障碍是判断“临床发作”的严重程度，其解释力为 37.49%。其次和第三明显的障碍和护士的决策难度是“沟通和信息”和“居民急诊时间”，分别解释了 16.81%和 9.24%的方差。
EFA 和 CFA 的交叉验证结果表明 PTDDS 具有良好的信度和效度。未来的研究建议对不同级别和类型的 LTCF 护士的决策难度水平和相关因素进行大规模调查。
