Validation of the index for the core competence of nurses leading discharge planning for older patients in China^†

The World Health Organization (WHO) estimated that, in 2018, there were 125 million people aged ≥80 years worldwide. By 2050, it is estimated that approximately many people aged ≥80 years (120 million) will be living in China alone and that there will be 434 million people in this age group worldwide.¹ The growth of the aging population not only increases the burden of the country’s pension system but also increases the need for medical resources, and these consequences are becoming more severe in China. The China Multi-Center Report on Geriatric Diseases showed that the number of older hospitalized patients in China has increased rapidly in the past decade. It has been reported that there were 4.68 diseases, especially chronic diseases and comorbidities, per capita in older people and that the proportion of comorbidities exceeds 90%.² Due to the physiological, psychological, and cognitive changes caused by diseases, older patients in China still require long-term care after discharge.

Driven by the reform of China’s medical and health system and the grading diagnosis and treatment system, the treatment model that 2-way referral, rapid division and treatment, and the up-and-down linkage diagnosis makes shortening average hospitalization days become the main measures to improve medical efficiency and make effective use of medical resources in most tertiary hospitals. This led to older patients facing discharge only after passing through the acute stage of the disease. They were transferred from the hospital with professional care to the hospital without professional and standardized care.³ In the process of adapting to the life outside the hospital, they were prone to aggravate their illness and even re-hospitalize. At the same time, it also grew the burden of medical expenses for older patients.^4,5

In response to the aging of China’s population and provide integrated health care services for the elderly, the Health Planning Commission stated in the National Care Development Plan (2016–2020) that medical institutions should provide various forms of continuing care for older patients after discharge, extending care to communities and families.⁶ Discharge planning is an important model of continuous care, and it has received increasing attention from nursing researchers and clinical practitioners in China. It has been promoted as a basic medical service in the United States, UK, and Japan and has been commonly used in older patients with a high demand for continued care.^7–10

Discharge planning has been defined as the process of developing a series of events that occur shortly after a person is admitted to a healthcare setting to facilitate continuity of care, reduce the length of hospital stay, reduce the risk of unplanned readmission to a hospital, ensure the optimal use of hospital beds, and improve the coordination of services following hospital discharge.^10,11 Several studies have shown that discharge planning can reduce the number of patients needing to be readmitted, reduce medical costs, and improve clinical outcomes.^5,12 The results of a meta-analysis showed that the implementation of a discharge planning model could reduce the risk of readmission by 28% and shorten the length of hospitalization by an average of 2 d.⁵

The core competence of a nurse comprises the professional knowledge, skills, judgment, and personal qualities required to provide safe and competent nursing services.¹³ Nurses play a leading role in discharge planning.^14,15 According to Naylor et al.,¹² the nurses who implement discharge planning directly affect the quality of discharge planning. In the United States, advanced practice nurses with extensive expertise and professional skills implement discharge planning. They often have graduate degrees and have a wealth of theoretical knowledge, proficiency, and clinical experience.¹⁶ In addition, a study showed that advanced practice nurse (APNs) with master’s degrees have more professional knowledge and skills than registered nurses and can better complete discharge planning.¹⁷ To evaluate and improve the core competence of nurses leading discharge planning, Japanese scholars developed an evaluation index and a self-rating scale that measure nurses’ abilities to implement discharge planning.^18,19

In 2015, according to Doris et al.,²⁰ the nurse-led discharge planning model that was introduced into the Chinese culture and the medical environment in Hong Kong was beneficial. Some domestic researchers have suggested that specialist nurses or senior nurses with a rich working experience should implement discharge planning.²¹ However, there is no relevant evaluation tool available in China for evaluating the core abilities of nurses leading discharge planning for older patients. The aim of this study was to provide an operable evaluation tool for evaluating the core competence of nurses in implementing discharge planning for older patients in China.

In the early stage, our research group interpreted China’s pension policy, considered the physiological, psychological, and social characteristics of older patients and used the 4 stages of discharge planning as a theoretical framework to establish an index for the core competence of nurses leading discharge planning for older patients (ICCNLDPOP). A literature review, existing scale analysis, group review, and Delphi method were used in the construction stage. The ICCNLDPOP consists of 4 first-level indicators, 13 second-level capacity characteristic indicators, and 57 third-level behavior indicators. The purpose of this study was to conduct an item analysis and validate the reliability and validity of the ICCNLDPOP that was developed earlier.

In the past decade, the number of elderly inpatients in China has increased rapidly, and the chronic and comorbidity problems of elderly patients are prominent, which makes the elderly patients face the problem of long-term care during the transition from discharge to family. In response to China’s aging population, the Chinese government has successively promulgated a number of policies that point out that medical institutions should provide various forms of continuous care for elderly patients after discharge. As an important mode of continuous care, discharge planning is widely used in the elderly patients who have high demand for continuous care. Nurses are the leaders of discharge planning, and their core competence directly affects the quality of discharge planning. In order to objectively measure the ability of nurses to implement discharge planning for elderly patients, the research team used the Delphi method to construct ICCNLDPOP. In order to comprehensively cover the core competence of nurses, ICCNLDPOP took the 4 stages of discharge planning as the theoretical framework and developed secondary and tertiary indicators on the basis of the 4 stages. In order to ensure the specialization and representativeness of the ICCNLDPOP, the ICCNLDPOP referred to the relevant research on Chinese elderly patients and relevant domestic pension policies to improve and refine the specific content of the three-level indicators. Therefore, the ICCNLDPOP has a reasonable theoretical framework and has good representativeness and comprehensiveness. The purpose of this study was to carry out project analysis and reliability and validity tests on the index that were developed earlier and to provide a reliable assessment tool for the core competence of nurses leading discharge planning for older patients.

The decision value of the 57 three-level indicators of ICCNLDPOP ranged from 14.89 to 27.01, and all values in this range are >3.00 (P < 0.01). The results show that the 57 three-level indicators have good homogeneity and discriminatory abilities and can be used to effectively identify the differences in the abilities of different subjects. Therefore, all 57 three-level indicators were retained.

The 4 common factors were extracted after EFA, which explained 72.79% of the total variance, and the factor load of each 3-level index on the corresponding common factor was >0.40.^31,32 The 4 common factors were mostly consistent with the 4 first-level indicators of the index system, namely, “assessment of discharge planning,” “formulation of discharge planning,” “implementation of discharge planning,” and “follow-up and effectiveness evaluation.” According to the results of the EFA, the 5 three-level indicators, “3.3.1 Collaborates with community health service centers and other medical institutions to ensure the smooth referral of older patients,” “3.3.2 Coordinates the implementation of discharge planning between community health service centers and other medical institutions,” “3.3.3 Coordinates nursing clinics to provide follow-up services and nursing specialist guidance for older patients,” “3.3.4 Coordinates beds and other resources for older patients when referring to lower medical institutions,” and “3.3.5 Provides technical guidance and training for lower medical service centers” were adjusted from “implementation of discharge planning” to “follow-up and effectiveness evaluation.” The reasons for the adjustment were as follows: (1) The three-level indicators 3.3.1–3.3.5 are all about helping patients coordinate revisit services and providing referrals to community health service centers or other medical institutions. In foreign countries, these measures should be implemented as early as possible when patients are in the hospital. In China, these measures are implemented simultaneously after a patient leaves a hospital.³³ Thus, it seemed more consistent with China’s national conditions to include it in the first-level index “follow-up and effectiveness evaluation.” (2) The loads of the three-level indicators 3.3.1–3.3.5 on the first-level indicators “follow-up and effectiveness evaluation” were all >0.60, and the loads on the original first-level indicators “implementation of discharge planning” were <0.27. To ensure the structural stability of the index system, adjustments were made.

Psychometric analyses show that the Cronbach’s α coefficients of the evaluation tools are >0.80 and preferably >0.85, which indicates good reliability of the evaluation tools. The total Cronbach’s α coefficient of the index system developed in this study was 0.98, the Cronbach’s α coefficient of the first index was 0.96–0.97, and the Cronbach’s α coefficient of the second index was 0.84–0.96; all of these coefficients met the requirements of psychometrics and showed good internal consistency and reliability.³⁴ The total retest reliability of the index system was 0.86, the retest reliability of the 4 first-level indicators was 0.81–0.85, and the retest reliability of the 13 second-level indicators was 0.72–0.83. Generally, the retest reliability should be >0.70 so that good consistency of the index system across time is ensured.^34,35 The index system used in this study met all the standards.

Validity refers to the degree of validity of the measurement results. It refers to the degree to which the measurement tools or methods can accurately measure the variables of interest or the degree to which the measured results coincide.³⁶

To ensure the structural stability of the ICCNLDPOP, EFA and CFA cross-validation were used to verify the ICCNLDPOP structure in this study. The CFA results showed that the root mean square residual (RMR), root mean square error of approximation (RMSEA), adjusted goodness-of-fit index (AGFI) values for the absolute fitness index were 0.047, 0.07, and 0.671, respectively, indicating that the fitness of the index system architecture was acceptable.³⁷ The non-normed fit index (NNFI) value, normed fit index (NFI) value, and comparative fit index (CFI) value for the value-added fitness index were 0.879, 0.846, and 0.885, respectively, which were close to 1, indicating that the index structure model was well adapted. The χ²/df value for the contracted fitness index was 3.481, indicating that the model structure was acceptable. The parsimony-adjusted fit index (PNFI) value was 0.806, and the parsimony goodness-of-fit index (PGFI) value was 0.642, which were both >0.500, indicating that the model had good adaptability and that the second-order CFA model of the index system developed in this study had a fair degree of fitness and stability. Thus, the ICCNDPOP index had good structural validity.³¹

The CIRN was used to assess the validity of the index. Previous research has shown that the correlation between the total scores of the 2 scales is between 0.40 and 0.80, while the 2 scales are considered to have an ideal degree of correlation. The results of this study showed that the total score of the ICCNLDPOP is positively related to the CIRN, as the correlation coefficient was 0.73 (P < 0.01), which met the psychometric requirements.^38,39 Therefore, the ICCNLDPOP has good validity.

The number of older patients has increased dramatically in the past 10 years in China. At present, the State encourages medical institutions to carry out discharge planning. Nurses lead discharge planning; so, they play a key role, and their core competence largely affects the quality of discharge planning. The ICCNLDPOP has good reliability and validity, and it can consistently measure the core competence levels of nurses leading discharge planning for older patients. In summary, the index can serve as a comprehensive, reliable, and operable evaluation tool for evaluating and training nurses leading discharge planning for older patients to improve their core competence level and promote discharge planning in clinical practice.

The ICCNLDPOP is a simple self-evaluation tool that is developed for nurses. This study shows that the ICCNLDPOP has enough psychometric characteristics to effectively evaluate the core competence of nurses who implement the discharge planning for older patients. Therefore, the ICCNLDPOP can be used as an effective tool to evaluate the core competence of nurses in China. In addition, the theoretical framework of the ICCNLDPOP is based on the whole process of discharge planning, which can provide reference for other countries in developing assessment tools suitable for their national conditions.