1. Background

To ensure the quality of life for elderly people living in long-term care facilities, there is a growing perception that the long-term care facilities need to provide ‘person-centered care’ rather than ‘provider-centered care’ in many countries such as Europe, the United States, the United Kingdom and Australia [1]. Person-centered care is similar to client/resident-centered care, but it is a more comprehensive term. Person-centered care represents a philosophy of care that aims to improve the quality of services of long-term care facilities and the residents' quality of life [2]. Specifically, person-centered care is holistic care that considers the physical, social, emotional, and spiritual aspects of residents [3]. Also, person-centered care presents individualized care upon individual needs, empowers residents' decision-making on their care, and instills autonomy and confidence in them [3]. In addition, person-centered care is a continuous process of determining the direction of care together in consideration of individual residents' preference, values, and lifestyle, which should be based on sincere communication between the residents and staff, instead of not simply giving residents whatever they want, nor about merely providing information [4].

Several studies have shown that the person-centered care in long-term care facilities had positive effects on the residents and staff. As for the resident outcomes, studies showed a decrease in boredom, helplessness, and depression by improving residents' social relationships, growing plants or animals, or involving the residents in care decision-making [5]. The small-scale nursing homes (NHs) have also improved residents' quality of life by allowing residents to have more comfortable and individualized care [6]. Regarding the staff outcomes, the improvement of communication with residents decreased the staff's burnout and emotional exhaustion from work, increased their job satisfaction [7], and enhanced their confidence and ability by providing individualized care to residents based on the philosophical change of person-centeredness [8].

According to the conceptual framework of McCormack and McCane [9], person-centered care is largely composed of four concepts. 1) The first concept is the attributes of caregivers, which is whether caregivers have professional capacity for care and whether they know the values or preferences of clients based on effective communication skills. 2) The environment encompasses not only the physical environment but also the organizational aspects (eg, staffing level, organizational culture, leadership, etc.) within the organization. The level of person-centeredness of the physical and organizational environments of an facility is known to play a very important role in implementing person-centered care. 3) The person-centered care process is a process in which individual care activities are planned based on the preferences and values of residents and their active participation are encouraged throughout the care processes. 4) The fourth concept is the outcomes that can be expected from the three components described above. Positive outcomes can be expected through person-centered care activities, and they can be assessed at the resident level (eg. satisfaction and well-being) and at the organizational level (eg. quality of care).

Among the four components above, the environment is a fundamental element in transforming long-term care facilities into person-centered environments, as it is an important factor in promoting or restricting the person-centered care process in practice. The supportive physical environment that ensures privacy and facilitates activities is expected to reduce the anxiety and behavioral symptoms of residents with dementia and to decrease dependence in social relationships and daily life [10]. In addition, the person-centered organizational environment can be defined as a sharing of power, appropriate skill-mix, shared decision-making, collaborative staff relationships, supportive organizational system, and the potential for innovation and risk-taking [9]. This person-centered organizational environment allows the staff to have autonomy and responsibility on their work, which can allow residents to experience higher life satisfaction [11] and to develop social relations with others [12].

To date, a variety of measurement tools have been developed and used to assess diverse aspects of such person-centered care in long-term care facilities internationally. However, only the ‘Person-Directed Care Measure’[13] and the ‘Person-Centered Care Assessment Tool’[14] are currently available to use in Korea. Moreover, these both tools assess the degree of person-centered care processes in long-term care facilities; thus, there is no measurement tool available to assess the extent of person-centeredness of the overall climate or environment of the long-term care facilities in Korea.

The purpose of this study was to test the validity and reliability of the Korean version of ‘Person-centred Climate Questionnaire-Staff (PCQ-S)’ tool translated from the English version developed by Edvardsson et al [15]. The PCQ-S was originally developed in Swedish and it is a self-reporting tool for staff working in the hospitals to assess the degree of person-centeredness of the environments in which they work [16]. The PCQ-S has been translated and adapted in English (2010)[15], Norwegian (2012)[17] and Slovenian (2017)[18] to date. In particular, the validity and reliability of PCQ-S have been tested in all areas of general and surgical wards in hospitals [15, 18] and long-term care facilities [17]. In other words, The PCQ-S can be used to measure the person-centered environment in various medical environments as well as long-term care facilities with a focus on evaluating the environmental person-centeredness perceived by the staff upon the physical and psychological aspects [15]. The PCQ has three versions depending on the subjects; for the staff [16], for patients/residents [19], and for families [20]. As all three versions have similar items, the PCQ has the advantage that it can be used to evaluate the degree of person-centeredness of the physical and organizational environments of an facility in multiple perspectives.

Currently, Korea is in the early stage of research on person-centered care. Despite the need to disseminate the person-centered care in Korean long-term care facilities, there is a lack of proven tools for assessing the person-centered aspects. The types of long-term care facilities in Korea include NHs and long-term care hospitals (LTCHs). Although the roles and functions of the two types of facilities are different from each other in legal terms, both facilities offer long-term care services to older adults, and there is no clear distinction in terms of the health status and medical needs of residents [21]. Therefore, the present study was designed to develop the PCQ-S in Korean by examining its cultural adaptation and applicability in NHs and LTCHs in Korea.

2. Objectives

The purpose of this study is to examine the reliability and validity of the Korean version of the PCQ-S (KPCQ-S) among staff in long-term care facilities including NHs and LTCHs. The specific aims are to develop the KPCQ-S and to test the reliability and validity of the KPCQ-S.

1. Study Design

This study is a methodological study to test the reliability and validity of the KPCQ-S translated from the English version of PCQ-S [15].

2. Data Collection and Participants

The data were collected in 9 NHs and 4 LTCHs located in Seoul, Kyeonggi-do, Gwangju, and Busan by convenience sampling from November 2016 to February 2017. After describing the purpose and procedure of the study to the manager of each institution, the participants were recruited specifically, registered nurses (RNs), nurse aids (NAs), personal care workers (PCWs), social workers, and physical therapists. Inclusion criteria were those who had the work experience of one month or more, and understood the purpose of the study and voluntarily agreed to participate. A total of 297 persons (163 in NHs and 134 in LTCHs) were included in data analysis. This sample size meets the criterion of 10 times of the number of items of the instrument (14 items) for obtaining a stable factor structure. In addition, the sample size of more than 200 participants has been presented as sufficient for factor analysis in recent years [22], so the number of participants in this study is thought to be sufficient. The organizational characteristics of the long-term care facilities were collected from the manager of the facilities.

3. Measures

4. Procedures

After obtaining approval from the original author for the use of the tool on developing the KPCQ-S, the English version of KPCQ-S was translated and adapted in accordance with the guidelines on the process of translation and adaptation of instruments proposed by the World Health Organization [25]. The original tool was developed in Swedish, but due to the difficulty of translation, the English version translated from the original tool [15] was used for translation into Korean under the permission of the original author. First, a graduate student in nursing who lived in the United States for secondary and college education for more than 10 years translated the English version into Korean. Second, three researchers (a professor, a doctoral student, and a master's student in nursing) who were fluent in English and had sufficient experiences in personcentered care reviewed and revised the Korean version of the questionnaire in terms of correctness and cultural and institutional suitability several times. In the process, one item (3. A place where I feel I can be myself.) was considered somewhat vague, so the research team checked the exact meaning of the item with the original author by e-mail, and we translated it into a more specific question after obtaining the author's consent. Third, a graduate student in nursing who is bilingual in both English and Korean and has completed her bachelor's degree in nursing in the United States translated it back into English to verify the revised Korean version of the questionnaire. Then, three researchers compared the original English version and the English version of back translated from the Korean version, confirming that there were not any significant differences in the meaning of each item and the choice of words. Finally, after cognitive interviews and pilot surveys of five staff members (one RNs, two NAs, and two social workers) working in long-term care facilities using the final KPCQ-S, it was found that there is no difficulty in understanding and responding to the questions. The final KPCQ-S was used to collect data from the staff working in the long-term care facilities, and then tested the reliability and validity of the tool.

5. Ethical Considerations

This study was approved by the Institutional Review Board of the Seoul National University (IRB No. 1609/001-003). The participants of the study were those who agreed to participate in the study and signed the informed consent form after they were provided with the explanation of the study. The participants were informed that the responses would not be used for any purpose other than research and they could discontinue or reject anytime during the survey without any disadvantages. They were also provided with the name and contact information of the principal investigator so that they could contact us when they had questions about their rights or the content of the survey.

6. Data Analysis

First, general characteristics of the participants and long-term care facilities were analyzed using descriptive statistics including mean, standard deviation, frequency and percentage. The t-test and the χ² test were used to compare the characteristics of NHs and LTCHs.

Second, for the item analysis, item-to-total correlation and Cronbach's α if item deleted were calculated, and Cronbach's α was calculated for all items and sub-factors to examine internal consistency, a measure of reliability.

Third, exploratory factor analysis (EFA) was conducted to examine the construct validity. Considering that the structures of sub-factors differed slightly in different facilities in various countries, EFA was performed to determine how the factor structure of PCQ-S in Korean long-term care facilities. The maximum likelihood method was used as the factor extraction method and the geomin method among oblique rotation methods was used for factor rotation. In addition, we separately conducted EFA by facility type to investigate whether there are any differences in the factor structure between NHs and LTCHs.

Fourth, we used correlation analysis to test convergent validity with job satisfaction.

The descriptive statistics were conducted using IBM SPSS 24.0 and the EFA was performed using Mplus 7.0.

1. General Characteristics of Participants and Long-term Care Facilities

Table 1 shows the characteristics of the participants of each type of facility. The average operating period was 12.22 years for NHs and 7.75 years for LTCHs. The average number of beds per facility was 73 in NHs and 200 in LTCHs. The number of patients per PCW was 22.08 persons for NHs and 6.99 persons for LTCHs. The number of patients per RN was 19.84 persons in LTCHs and 46.45 persons in NHs. The staffing levels between NHs and LTCHs were not directly compared because each facility type has a different staffing standard on workforce regulation.

Table 1 General Characteristics of Long-term Care Facilities Click for larger image

Table 2 shows the general characteristics of the participants. Most of the staff in long-term care facilities were women, with an average age of about 50 years. Regarding staffing levels, the proportion of PCW was the highest at 58.3%, followed by that of social workers at 12.9% in NHs, while the proportion of PCW was 34.3% and that of RNs was 29.9% in LTCHs.

Table 2 General Characteristics of Study Participants Click for larger image

The number of education about person-centered care refers to the number of education perceived by the staff and it is measured by the question ‘Have you had training/education in person-centered care (internal or external training/education)?’. The frequency of person-centered training/education was higher in the staff of NHs than that of LTCHs, especially in the external training/education (t=4.49, p<.05).

2. Item Analysis and Reliability Analysis

Table 3 shows the results of item analysis of KPCQ-S. The mean score of KPCQ-S was 4.71 out of 6. The item with the highest score (5.07) was ‘13. A place where it is easy for the patients to talk to the staff,’ and the item with the lowest score (4.31) was ‘3. A place where I feel I can be myself.’ The correlation coefficients of the 14 items ranged from .52 to .72, which means no redundancy or duplication of items. The Cronbach's α value was .91 which satisfied the internal consistency of the scale.

Table 3 Item Performance, Reliability and Result of Factor Analysis Click for larger image

3. Validity Analysis