Good nurse characteristics tool: development and psychometric testing

Providing high qualitative and appropriate care is the basic goal of healthcare service providers.¹ Improving the quality of healthcare services is an international priority in the healthcare system, and regarding this fact, compliance with the code of ethics principles in the provision of healthcare, which are considered as moral virtues, is of great importance.² Moral virtues focus on the wellness of society. Having good personality traits help people to perform their duties in the best way. Doctors and nurses with better characteristics reach better job positions.³

One of the most important healthcare professions that are in constant contact with society is nurses. Regarding this fact, society’s opinion toward nurses and the nursing system and the sensitivity of public opinion toward them are of great importance.⁴ Facing this challenging question of the “characteristics of a good nurse,” it must be accepted that the word “good” could have different definitions and interpretations.⁵ In the Oxford Dictionary, the word “good” is defined as favorable, sensible, pleasant, high quality, acceptable, and suitable.⁶

When reviewing the existing literature, the quality of healthcare has been defined and evaluated from a professional perspective, but the dimensions and definitions that patients describe as high-quality care are often controversial from the perspective of care providers.¹ From the doctor’s and nurse’s point of view, being good equals professional competence, while most patients defined it as being communicative and having good personality traits.^7,8 Some of the parameters that nurses have expressed as criteria for being good are not the same as what patients have expected from nurses.⁹ Various studies have investigated the word “good” and its definitions from the opinion of nurses and patients.^2,10 Von Essen and Sjodén,¹¹ in a study, stated that the most important characteristics of a good nurse from the patients’ point of view are clinical competence, honesty, and being up-to-date and knowledgeable, while the nurses considered listening, touching, and empathy with the patients as more important. Receiving care from a nurse about whom the patient has a positive view results in a sense of trust and security, and alleviates their pain; furthermore, their cooperation with the nurses also increases.^2,12 Therefore, it is important to survey the experience of the recipients of nursing services and their views on a good nurse definition. In a qualitative study, the characteristics of the good nurse from the point of view of service recipients were reported as affable, responsive, patient, and skillful.¹³

The reason for measuring and evaluating the service recipients’ views about the good nurse was to collect related data about the experiences and the principal ethics of the patients, for identifying potential points for improvement, and trying to improve the quality of healthcare over time.⁹ Patients normally consider a good nurse as having qualities such as being compassionate, respectful, honest, responsible, and clinically competent.^12,14 Nurses are one of the main and important groups who provide health services in the hospital context; therefore by identifying the characteristics of a good nurse and strengthening these features, we could provide better care and increase the satisfaction level of patients and nurses.¹⁵

The results of various studies showed the characteristics of a good nurse,^8,16 but in the related literature, there is no accurate and single tool that has been developed to measure the characteristics of a good nurse from the perspective of service recipients. However, when in a study, researchers examine a complex variable, they need testified, approved, and reliable tools.¹⁷ Since there is no precise and comprehensible definition of the concept of nursing, and different cultures and countries have different perspectives on the concept of the good nurse, therefore, it is necessary to examine the views of service recipients and their role in improving the quality of care.¹⁸ One of the ways to investigate the service recipients’ point of view is to develop a valid and reliable tool to measure the characteristics of a good nurse. The validity of a measurement tool is defined as the scores obtained in the application of a specific test, which is the degree to which the tool measures what it claims to measure.¹⁹

Due to the personality trait differences among nurses over time and in different places, the different views of people based on their cultures,¹⁶ and the inability to find a tool in this field, it is of great importance to develop and psychometrically test an authentic instrument for characterizing the good nurse definition and provide reasonable data on the psychometric process. Therefore, this study was conducted for the development and psychometric testing of a good nursing characteristics tool from the perspective of service recipients.

This present study aimed at the development and psychometric testing of a good nursing characteristics tool.

This was a sequential exploratory mixed-methods design study that was conducted in 2 phases. The first stage focused on identifying the characteristics of the good nurse through face-to-face interviews with a qualitative content analysis approach and a review of previous literature. In this stage of the research, 71 phrases were extracted, then reviewed, and consequently, 80 items were designed. The meetings with the research team, re-examining and removing the overlapping phrases of 74 items in the 6 primary categories of attentive and communicative, patron and companionable, complete caregiver, safer and skillful, advocate, confidant were categorized and documented. In 3 meetings that were held by the research team, the questionnaire items were evaluated and then checked by 10 professors and 20 service recipients in terms of their clarity of comprehension, and then the required corrections were made. In the next phase, the content validity of the research tool CVI was analyzed by 10 experts in the field of research instrumentation and nursing. Expressions with CVI <0.79 were eliminated, and finally 40 items remained. Then the questionnaires were answered by 200 people who had received nursing services in the past 6 months.

Exploratory factor analysis was performed on 40 statements, by which the KMO value of 0.92 was calculated. Also, BT was significant with 7.499 at the 0.0001 level, which justified implementation of the factor analysis based on the correlation matrix obtained in the study sample.

The range of factor changes by using exploratory factor analysis was between 0.325 and 0.791. The scree plot and eigenvalues >1 were used to determine the number of tool factors (Figure 1). Exploratory factor analysis demonstrated that 6 factors had >1 eigenvalue, the sum of which covered 63.99% of the information or variations (Table 1). The internal consistency of the items was investigated according to the 6 significant factors and through Varimax-rotated factor loadings (Table 2). The first factor was attentive and communicative, the second factor was patron and companionable, the third factor was complete caregiver, the fourth factor was safer and skillful, the fifth factor was advocate, and the sixth factor was called confidant.

Figure 1.

Scree plot.

Finally, to estimate the reliability of the questionnaire, it was completed by 100 service recipients and then the Cronbach’s alpha coefficient was calculated for the questionnaire. Cronbach’s alpha coefficient for 40 statements was calculated at 0.90.

This study was conducted in Iran with the aim of psychometric tool testing of the good nurse characteristics from the perspective of service recipients, on people who had received nursing services in the past 6 months. Results of the studies show that nurses and patients believed that the most important factor in the formation of the public image toward the profession of nursing is the opinion of the patient’s companion at the time of hospitalization, his/her direct contact with the nurses and their behaviors and relationships, and even their clothing style could play an important role in the formation of the public image toward nursing.²⁵ According to the results of this study, a good nurse could be defined as a nurse who fulfills his/her role well based on the 6 virtues of attentive and communicative, patron and companionable, complete caregiver, safer and skillful, advocate, and confidant. Questionnaire items were extracted based on a review of the related literature and a qualitative study. In the present study, face and content validity (qualitative and quantitative), construct validity (factor analysis), internal consistency (Cronbach’s alpha coefficient), and reliability (test–retest) were all done and calculated.

The first dimension of the tool was attentive and communicative domain, which has been referred to in various studies as one of the characteristics of a good nurse.^8,26 Communicative skills are defined as an important trait a nurse should have.²⁷ Collaboration and proper communication are moral responsibilities that every nurse should be competent in because high-quality and safer care is a crucial prerequisite in complex care that creates a link between healthcare teams and patients. Effective communication and proper dealing with nurses might be challenging issues for patients, therefore the modern nursing code of ethics emphasizes the cooperation of nurses with other healthcare professionals and patients.^28,29 Nurses communicate patient information to other members of the healthcare team. Therefore, today the virtue of communication has become even more vital than before and this skill should be strengthened in nurses.

The second dimension of the tool was patron and companionable. A review article had identified 6 virtues of a good nurse, with the most important highlighted virtue being patron and companionable.³⁰ Regarding the fact that the concepts of nursing and being a good nurse have undergone changes, surprisingly being patron and companionable is still one of the distinctive characteristics of good nurses.³¹ Today, medical treatment requires new technologies to maximize efficiency and accuracy, but patients more welcome kind behaviors from the nursing team. In other studies, patron and companionability have been mentioned as one of the basic characteristics for being a good nurse.^4,32 In general, the nurse should be as friendly as possible with the patients and treat them with kindness.

The third dimension of the instrument was the “complete caregiver” which was reported by nurses^8,33 as well as patients^12,14 in most studies. Being a knowledgeable person when faced with patients’ problems, being modern and innovative in providing nursing services, and having stylish and neat manner nurses are considered as attractive and prestigious factors from the point of view of patients.³⁴ Undoubtedly, a good nurse should provide his/her patients with up-to-date knowledge, skills, and positive attitudes in a comprehensive and complete manner. It can be concluded from these results that the more the severity of the disease increases the more the accurate implementation of the doctor’s prescriptions and the appropriate management of physical care become important. A nurse who does not have enough knowledge and skills cannot provide comprehensive care for his/her patients.

The safer and skillful is the fourth dimension of the designed tool. Nurses must continuously improve their knowledge and skills as healthcare professionals to adopt new treatments and applicate the latest healthcare technologies for the benefit of their patients. At the same time, a good nurse should be able to provide these measures for the safety of his/her patients. Patient safety is an international issue and healthcare professionals are ethically responsible for ensuring this safety. Patient safety is an issue that stresses safety in the healthcare system through the prevention, reduction, reporting, and analysis of errors and other types of unnecessary harm that often lead to adverse patient events.³⁵ Therefore, the good nurse must be able to provide patient-centered care, work in interdisciplinary teams, use evidence-based practices, improve the safety and quality of healthcare, and meet the needs of patients.³⁶ Nurses should be instructed with professional skills during their educational courses or career. A good nurse trusts in his/her abilities and satisfied with his/her performance. This is a common feature in all professions.³⁷ Nursing care is a professional reaction to a wide variety of severe patient conditions, which are reacted with differently depending on the skills of the nurses.³⁸ Generally, all patients need accurate, on time, and proper nursing care. As a result, a good nurse should be able to perform professional care in the best way and show a high level of proficiency and ability.

The advocate and confidant dimensions to a large extent define the concept of the good nurse. Nurses should not judge patients’ personal lives and respect their privacy, as well as preserve their personalities. Currently, from a holistic approach, a nurse is defined as a person who provides suitable and personal care to patients.³⁹ Therefore, nurses must constantly consider the needs of patients and feel responsible in their profession. Maybe it is necessary that the lecturers and nursing experts, in addition to emphasizing theoretical and clinical training, stress the importance of these issues to their students. Although nurses provide services in stressful contexts, they must be able to control their anxieties and act empathetic toward patients and their families when dealing with them and advocate for them in all these critical situations. Most of the patient’s needs may not be within the scope of the nurse’s duties, therefore in facing these cases, clear explanations should be given to the clients,¹³ and if necessary, ask for help from the other members of the healthcare team to keep the patients’ secrets.

Being a good nurse is a process that requires training, frequent and constant practice, and familiarization with the procedures. To train competent nurses, these virtues should be taught through educational contexts, the introduction of role models and mentorship, and extracurricular activities, especially in clinical experiments. Also, the virtues of a good nurse could be used to assess nurses and their performance in nursing contexts. The domains of the questionnaire may be used by nurses as a good role model for clinical practice as well as to guide in-service nursing education. The designed tool can be used to comprehensively evaluate nurses and their performance and to guide them in order to improve their strengths and overcome their weaknesses in terms of their goodness and better performance.

This tool has 40 questions on a 5-point Likert scale (completely disagree to completely agree), which could evaluate the views of service recipients about the good nurse. For example, a low score for each statement shows that the ability and skill of the nurse are low and there is a need for more training and development to provide better nursing care.

This questionnaire has 40 items in 6 dimensions of attentive and communicative, patron and companionable, complete caregiver, safer and skillful, advocate, and confidant, which were used to evaluate the characteristics of the good nurse from the perspective of service recipients. The features of this tool and its use have verified reliability and validity. Although the current questionnaire is a new tool and needs convergence validation, it seems to be a suitable tool for evaluating the characteristics of a good nurse from the perspective of service recipients. However, regarding the fact that the concept of nursing is changing over time along with the changes in the duties of nurses, continuous study of this concept is necessary.

The first limitation of this study is related to the research context. This research was conducted in the city of Sanandaj in the west of Iran, and cultural issues could affect the perspective of service recipients about the characteristics of the good nurse. It is suggested that in future studies, the tool should be used with diverse samples and in different countries so that possible causes that affect the data collection can be modified and validated. Regarding the dispersion of the items, it is suggested that the tool be completely applicated and further studies investigated its usefulness. In addition to the above-mentioned points, it is suggested to conduct studies on the characteristics of the good nurse from the nurses’ point of view.