Journal of Perinatology (2015) 35, 284–289 © 2015 Nature America, Inc. All rights reserved 0743-8346/15 www.nature.com/jp

ORIGINAL ARTICLE

Measurement of family-centered care in the neonatal intensive care unit and professional background N Himuro1, S Miyagishima2,3, N Kozuka4, H Tsutsumi5 and M Mori1 OBJECTIVE: The aims of this study were to examine the validity and reliability of the Measure of Processes of Care for Service Providers (MPOC-SP) for multidisciplinary teams in neonatal intensive care units (NICUs) and to examine differences among professions. STUDY DESIGN: A Japanese language version of the MPOC-SP questionnaire was distributed among the professionals employed at three perinatal medical centers. RESULT: A total of 83 multidisciplinary team members completed the questionnaire. The construct validity was examined by a confirmative analysis of each scale structure. The MPOC-SP showed adequate internal consistency. The test–retest analysis showed that the MPOC-SP, except the ‘providing general information’ scale, is a reliable tool. The results suggest that professional background affects the attitude and behavior of professionals involved in family-centered care. CONCLUSION: The MPOC-SP has good psychometric properties and can be used to identify areas for improvement in the familycentered care provided by multidisciplinary teams in the NICUs. Journal of Perinatology (2015) 35, 284–289; doi:10.1038/jp.2014.204; published online 27 November 2014

INTRODUCTION Family-centered care has become the gold standard in healthcare,1 with family-centered care now considered a fundamental principle in the provision of neonatal care.2,3 Collaboration between neonatal intensive care unit (NICU) staff and parents allows families to become more involved in decision making and empowers them to influence their infant’s recovery process. The incorporation of family-centered care principles into NICU practice can, therefore, positively influence the family’s well-being.4 According to Rosenbaum et al.,5 the guiding principles of family-centered care include the following: (1) parents should have the ultimate responsibility for the care of their children, (2) the involvement of family members should be encouraged, (3) each family should have the opportunity to decide their level of involvement in decision making for their child, (4) each family member should be treated with respect as an individual and (5) the needs of all family members should be considered. The provision of family-centered care, in line with these principles, is associated with higher levels of parental satisfaction in terms of services and better parental and child psychosocial well-being.6 The Measure of Processes of Care (MPOC) is the most widely used tool for the assessment of self-reported experiences of parents in relation to the family-centered behavior of rehabilitation services providers.7 The MPOC is a 56-item questionnaire designed to identify how the parents of children with disabilities feel about the services they and their children receive. The MPOC was developed in collaboration with ~ 2000 parents across Canada. Several studies were subsequently conducted to assess the psychometric properties of the MPOC.7–9 These studies demonstrated good internal consistency and test–retest reliability, as well as provided good evidence of construct validity. Validity

has also been shown through the correlation between MPOC scale scores and satisfaction and stress variables. A shorter and more user-friendly version, the MPOC-20, was later developed to improve the utility of the measure and increase its ability to discriminate between programs.10 The MPOC-20 is based on the original 56-item questionnaire and consists of 20 items taken from that version. The psychometric properties of the MPOC-20 are similar to those of the original 56-item MPOC in terms of internal consistency, test–retest reliability and construct validity.10 The MPOC-56 and MPOC-20 have been translated into Japanese and a study conducted to assess the psychometric properties when used with the families of children with disabilities.11 This study demonstrated good internal consistency and test–retest reliability as well as good evidence of construct and concurrent validity. As family-centered care is a model for collaborative relationships between families and service providers, an additional version, the MPOC-SP, was developed for service providers.12,13 The MPOC-SP has also shown very good internal consistency, test–retest reliability and validity, including cross-disciplinary scale score comparisons.12 The incorporation of family-centered care principles into NICU practice is mainly undertaken in collaboration with the multidisciplinary teams. A mutual understanding of the different professions involved is important for collaboration within the multidisciplinary teams. Multidisciplinary teams usually consist of experts with different professional backgrounds, and it is hypothesized that team members from the different professions might evaluate their family-centered behavior differently. To evaluate the family-centeredness of NICU care, a psychometrically sound measure is needed. The MPOC-SP has not yet been used to measure family-centered care for multidisciplinary teams

1 Department of Public Health, School of Medicine, Sapporo Medical University, Sapporo, Japan; 2Department of Pediatrics, Graduate School, Sapporo Medical University, Sapporo, Japan; 3Division of Rehabilitation Medicine, Sapporo Medical University Hospital, Sapporo, Japan; 4Department of First Division of Physical Therapy, School of Health Sciences, Sapporo Medical University, Sapporo, Japan and 5Department of Pediatrics, Sapporo Medical University, Sapporo, Japan. Correspondence: Dr N Himuro, Department of Public Health, School of Medicine, Sapporo Medical University, South 1 West 17, Chuo-ku, Sapporo 060-8556, Japan. E-mail: [email protected] Received 3 April 2014; revised 6 October 2014; accepted 9 October 2014; published online 27 November 2014

Measurement of family-centered care in the NICU N Himuro et al

285 in NICUs, and there is a possibility that neonates and their families have different needs and require different services than do children with disabilities. The aims of this study were, therefore: (1) to examine the reliability and validity of the MPOC-SP in an NICU setting and (2) to compare attitudes and behaviors in relation to family-centered care among professions. METHODS Japanese version of the MPOC-SP The Japanese translation was made with the permission of the CanChild Centre for Childhood Disability Research (CanChild Group) at McMaster University. The translation was executed according to the International Standard for Translation of Self-report Measures.14 The original Canadian MPOC-SP was translated into Japanese separately by two individuals. The consensus version was then translated back into English by a professional translator. After some minor adjustments, the CanChild Group approved our Japanese version of the MPOC-SP, and authorized its usage in Japan. The content validity of the Japanese version to Japanese values was examined by a multidisciplinary group of experts. They read the Japanese version of the MPOC-SP carefully, and provided feedback on the content (particularly its utility in Japan), wording and readability of the items. Their feedback led to some changes, although it should be noted that the construct validity did not change. Furthermore, the questionnaire was pretested by a multidisciplinary group of professionals not belonging to the target group. The items included in the Japanese version of the MPOC-SP are classified into one of the four scales. Ten items are included under ‘showing interpersonal sensitivity,’ which describes care that actively involves parents in their child’s care; five items are included under ‘providing general information,’ which describes care that meets the general information needs of parents; three items are included under ‘communicating specific information,’ which reflects behaviors through which parents obtain information about their own child; and nine items are included under ‘treating people respectfully,’ which reflects the proper provision of care by which all family members are treated with respect. All questions refer to behaviors occurring during the past year. Response options range from one (Not at all) to seven (To a very great extent). A ‘not applicable’ category was also included. The professionals answered questions such as: ‘In the past year, to what extent did you …?’ An MPOC-SP scale score is calculated as the mean of the ratings for the items in each scale. As items are not weighted, a scale score can range from 1.00 to 7.00. The authors of the tool recommend that items for which 33% or more of the respondents scored a behavior occurring between 1 and 4 (‘not at all’ to ‘to a moderate extent’) on the seven-point scale be regarded as the areas requiring improvement.15

Participants Participants included the entire NICU staff at three perinatal medical centers of different sizes and located in different parts of Hokkaido, in northern Japan. The medical centers covered both rural and urban areas. The number of beds in these NICUs was six, six and nine, respectively. The number of health professionals working in these NICUs was 31, 44 and 41, respectively. Survey packets were sent to the nurse manager of each NICU and the MPOC-SP questionnaires, together with a letter containing information about the study, were distributed by the nurse manager to all staff members by hand. The questionnaires were returned anonymously to a collection box in each respective NICU. The study protocol was approved by the Ethics Committee of Sapporo Medical University, and informed consent was obtained from all participants.

Statistics Cronbach’s α was calculated as a measure of internal consistency for each of the four scales in the MPOC. The construct validity of the MPOC-SP was examined by confirmative analysis of the scale structure. For this analysis, we first assessed the structure using the correlations between each item and its own scale. Second, the correlations between the scales were analyzed. To assess the test–retest reliability of the MPOC-SP, the questionnaire was completed on two occasions by 23 randomly chosen professionals. To evaluate the test–retest reliability for the four scale scores, the intraclass correlation coefficient (ICC2.1—two-way random effect model, absolute agreement) was calculated. Measurement error was © 2015 Nature America, Inc.

assessed by estimating the s.e. of measurement, minimal detectable change (MDC) and limits of agreement (LoA). The MDC was calculated on the basis of the LoA, which is based on the s.e. of measurement as follows: 1.96 × √2 × s.e.m.16 Changes larger than the MDC were considered to be real changes, that is, changes beyond the measurement error indicate a 95% confidence interval for real change between the two assessment scores.17 The s.e.m. was calculated by SDd/√2, where SDd is the s.d. of the differences between the test and the retest. The LoA was calculated according to the Bland–Altman method, and a Bland–Altman plot for visual judgment of the relationship between the individual mean MPOC-SP scale scores for the test and retest, and the differences in the four scale scores between the test and retest were obtained.18 The differences between the four scales were analyzed by the Kruskal–Wallis test. For a post hoc test, the Mann–Whitney U-test with the Bonferroni correction was used. All statistical analyses were performed using PASW Statistics 18 (SPSS, Tokyo, Japan).

RESULTS Of the 116 NICU staff, 86 returned the questionnaires (74.1%) of which 83 were usable. The demographic characteristics of the respondents in this study are outlined in Table 1. All respondents were from one of the three professions; neonatologists (n = 13, 15.7%), nurses (n = 61, 73.5%) or physical therapists (n = 9, 10.8%), and all were Japanese and spoke Japanese as their first language. The reliability and validity of the MPOC-SP in an NICU setting Descriptive statistics and internal consistency. The descriptive statistics as well as internal consistency, measured with Cronbach’s α for each of the four scales in the MPOC-SP, are outlined in

Table 1.

Distribution of multidisciplinary team members Neonatologists

Gender (n, %) Female Male Mean age ± s.d. (years)

8 (61.5) 5 (38.5) 34.8 ± 6.8

Years of clinical experience (n, %) 0–5 4 (30.8) 6–10 6 (46.2) 11–15 0 (0) 16–20 2 (15.4) 420 1 (7.7)

Nurses

Physical therapists

Total

61 (100) 3 (33.3) 72 (86.7) 0 (0) 6 (66.7) 11 (13.3) 33.8 ± 8.8 31.8 ± 9.1 33.4 ± 8.5

22 (36.1) 12 (19.7) 9 (14.8) 8 (13.1) 10 (16.4)

3 (33.3) 4 (44.4) 0 (0) 1 (11.1) 1 (11.1)

29 (34.9) 22 (26.5) 9 (10.8) 11 (13.3) 12 (14.5)

Years of neonatal care experience (n, %) 0–5 7 (53.8) 39 (63.9) 6–10 4 (30.8) 8 (13.1) 11–15 1 (7.7) 8 (13.1) 16–20 0 (0) 4 (6.6) 420 1 (7.7) 2 (3.3)

6 (66.7) 3 (33.3) 0 (0) 0 (0) 0 (0)

16 (19.3) 15 (18.1) 9 (10.8) 4 (4.8) 3 (3.6)

39 (63.9) 4 (6.6) 14 (23.0) NA

1 (11.1) 0 (0) 5 (55.6) NA

40 4 19 12

4 (6.6)

2 (22.2)

6 (7.2)

0 (0)

1 (11.1)

2 (2.4)

Educational background (n, %) Vocational school NA Junior college NA University NA University of 12 (92.3) Medicine Graduate school NA (master course) Graduate school 1 (7.7) (doctor course)

(48.2) (4.8) (22.9) (14.5)

Abbreviation: NA, not applicable.

Journal of Perinatology (2015), 284 – 289

Measurement of family-centered care in the NICU N Himuro et al

286 Table 2.

The descriptive statistics and internal consistency measured with Cronbach’s α for MPOC-SP

Scale

NI

M

Median

s.d.

Range

α-Value

Showing interpersonal sensitivity Providing general information Communicating specific information Treating people respectfully

10 5 3 9

4.47 3.62 3.69 4.74

4.40 3.60 3.67 4.67

0.95 1.38 1.39 0.92

1.80–6.80 0.60–7.00 0.00–6.67 2.89–6.67

0.89 0.85 0.70 0.97

Abbreviations: M, mean scale scores; MPOC-SP, Measure of Processes of Care for Service Providers; NI, number of items; α-value, Cronbach’s α.

Table 3.

Spearman’s rank correlation coefficients among MPOC-SP scales

Scale

Providing general information

Communicating specific information

Treating people respectfully

0.59a — —

0.63a 0.51a —

0.80a 0.62a 0.55a

Showing interpersonal sensitivity Providing general information Communicating specific information

Abbreviation: MPOC-SP, Measure of Processes of Care for Service Providers. aCorrelations with P o0.01.

Table 4.

Results from the test–retest analysis of MPOC-SP (n = 23)

Scale Showing interpersonal sensitivity Providing general information Communicating specific information Treating people respectfully

Test, mean (s.d.) 4.40 3.56 3.65 4.76

(0.81) (0.80) (1.24) (0.81)

Retest, mean (s.d.) 4.43 3.53 3.75 4.76

(0.73) (0.84) (1.16) (0.73)

d, mean (95% CI) − 0.026 0.026 −0.10 0.00

(−0.37, (−0.64, (−0.50, (−0.39,

0.31) 0.69) 0.29) 0.39)

ICC2,1 (95% CI) 0.91 0.68 0.95 0.88

(0.79, (0.39, (0.88, (0.74,

0.96) 0.85) 0.98) 0.95)

s.e.m.

MDC

0.24 0.47 0.28 0.27

0.67 1.30 0.77 0.76

Abbreviations: d, difference between test and retest; ICC2,1, intraclass correlation coefficient, two-way random effects analysis of variance; MDC, minimal detectable change; MPOC-SP, Measure of Processes of Care for Service Providers; s.e.m., s.e. of measurement; 95% CI, 95% confidence intervals.

Table 2. Cronbach’s α for each scale of the MPOC-SP was between 0.70 and 0.89. Construct validity. The scales were assessed using Spearman’s rank correlation coefficients between each item and its own scale. The 27 items of the MPOC-SP were correlated with their own scale scores after exclusion of the item under study. Correlation coefficients ranged from 0.43 (item 14 ‘tell parents about the results from tests and/or assessments’ in the scale ‘communicating specific information’) to 0.76 (item 25 ‘provide advice on how to get information or to contact other parents; for example, through a community’s resource library, support groups or the Internet’ in the scale ‘providing general information’). The correlations between the four scales are shown in Table 3. All scales were correlated significantly with all of the other scales. Test–retest reliability. To assess the test–retest reliability of the Japanese version, the MPOC-SP was completed on two occasions by 23 randomly chosen professionals. Two weeks after the first assessment, participants received a second questionnaire. The questionnaires were returned anonymously to a collection box in each NICU. The ICC2,1 ranged from 0.68 to 0.95, the s.e.m. ranged from 0.24 to 0.47 and the MDC ranged from 0.67 to 1.30 (Table 4). The Bland–Altman plot for the four MPOC-SP scale scores is shown in Figure 1. No systematic differences were observed between the first and second assessments. Differences in MPOC-SP results according to professional background Although the results, when compared according to the professional background of the members of the multidisciplinary teams, did not show any statistically significant differences among the Journal of Perinatology (2015), 284 – 289

four scales, there was a tendency for the results to reflect differences among the professionals (Figure 2). The neonatologists gave high scores for items in the scale ‘communicating specific information,’ whereas the nurses gave a wide range of scores for items in the scales ‘providing general information’ and ‘communicating specific information.’ The physical therapists, on the other hand, gave higher scores for items in the scale ‘treating people respectfully.’ We observed a number of items for which at least 33% of the respondents gave a score of 1 to 4, indicating an area of service in need of improvement. All the items belonging to the scales ‘providing general information’ and ‘communicating specific information’ were scored 1 to 4 by at least 33% of all the respondents. On the other hand, there were also items for which o33% of members of each profession rated 1 to 4. In the case of the neonatologists, o33% gave a score of 1 to 4 for the item ‘tell parents about the results from tests and/or assessment.’ In the case of the nurses, the relevant items were ‘offer parents and children positive feedback or encouragement (for example, in carrying out a home program)?’ and ‘answer parents’ questions completely.’ In the case of the physical therapists, the relevant items were ‘offer parents and children positive feedback or encouragement (for example, in carrying out a home program)?,’ ‘take the time to establish rapport with parents and children,’ ‘accept parents and their family in a nonjudgmental way,’ ‘trust parents as the ‘experts’ on their child’ and ‘treat each parent as an individual rather than as a ‘typical’ parent of a child with a ‘problem’.’ DISCUSSION The results from this study confirm the reliability and validity of the MPOC-SP when used with multidisciplinary teams in an NICU © 2015 Nature America, Inc.

Measurement of family-centered care in the NICU N Himuro et al

287 Providing General Information (PGI) Difference PGI score between test and retest

Difference SIS score between test and retest

Showing Interpersonal Sensitivity (SIS) 1

0.5

0

-0.5

-1 0

1

2

3

4

5

6

7

2.5 2 1.5 1 0.5 0 - 0.5 -1 - 1.5 -2 0

1

Mean SIS score, test and retest

Difference TPR score between test and retest

Difference CSI score between test and retest

0.5

0

-0.5

-1

-1.5 1

2

3

4

5

3

4

5

6

7

Treating People Respectfully (TPR)

Communicating Specific Information (CSI) 1

0

2

Mean PGI score, test and retest

6

7

Mean CSI score, test and retest

1.5

1

0.5

0

-0.5

-1 0

1

2

3

4

5

6

7

Mean TPR score, test and retest

Figure 1. Bland–Altman plot for the four scale scores of the MPOC-SP. Intra-individual differences (n = 23) plotted against the difference between test and retest scores for the four scale scores. The central horizontal line represents the mean difference, whereas the flanking lines represent the 95% limits of agreement. The dotted line indicates there was no difference between test and retest.

setting. In addition, the MPOC-SP can clarify differences between professions in terms of their family-centered behavior. The MPOCSP can also be used to evaluate the level of family-centered care provided in an NICU. Descriptive statistics for the MPOC-SP gave high scores for the ‘treating people respectfully’ scale, whereas they gave low scores for ‘providing general information’. The four scale scores were all lower than the respective scale scores obtained in Canadian studies undertaken in a rehabilitation setting.12 This result may reflect the unique characteristics of NICU practice. NICU care is provided for short periods of time. In the present study, the maximum period of hospitalization for neonates in the perinatal medical centers was 6 months. Rehabilitation services for children with disabilities, on the other hand, are provided for longer periods of time in many cases. The period of care is an important factor in family-centeredness. These differences in time frame may have contributed to the lower-scale scores seen in the present study in comparison with those observed in a rehabilitation setting. The results appear to indicate a high level of similarity among the items within a scale as a Cronbach’s α value between 0.70 and 0.90 is generally considered good, indicating that items in a scale measure the same aspect.19 Thus, the results indicated that the items within each scale were grouped together in a clinically meaningful way and within the same construct. The construct validity was found to be acceptable for the four MPOC-SP scales. The correlation coefficients for each individual scale, as well as those between the four scales, were all found to © 2015 Nature America, Inc.

be high. These findings, therefore, show that the items are closely related to their own scales and that the four scales are related to each other. When retesting was performed after 2 weeks, all scales, except ‘providing general information,’ showed high ICC2,1 values. These ICC2,1 values are similar to those previously described in a rehabilitation setting for the Dutch version of the MPOC-SP.20 These results indicated that the MPOC-SP scale scores, except that for the ‘providing general information’ scale, are consistent over time,19 and thus have good test–retest reliability. The responses to the items in the ‘providing general information’ scale may be influenced by recent events. Providing general information seems to be a significant problem when providing care in a NICU.21 It may also be that there is no clear agreement on to whom, where, when and how the general information should be given. The MDCs for the MPOC-SP scale scores were 0.67 to 1.30, indicating that the MDC is able to reveal the smallest within-person changes in score that can be interpreted as real change, that is, they exceed the measurement error. The MDC of the ‘providing general information’ scale was 1.30, which appears to be large when the fact that the MPOC-SP scale score can range from 1.00 to 7.00 is taken into consideration. We considered the reliability of the ‘providing general information’ scale to be moderate, owing to the ICC2,1 value and large MDC, and its efficacy as a follow-up instrument to assess the effectiveness of a program of intervention is limited. Although none of the differences observed in this study were significant, the differences observed between the professional Journal of Perinatology (2015), 284 – 289

Measurement of family-centered care in the NICU N Himuro et al

288 Providing General Information 7

6

6

5

5

scale score

scale score

Showing Interpersonal Sensitivity 7

4 3

4 3

2

2

1

1

0

0 Neonatologist

Nurse

Physical therapist

Neonatologist

7

6

6

5

5

4 3

Physical therapist

Treating People Respectfully

7

scale score

scale score

Communicating Specific Information

Nurse

4 3

2

2

1

1 0

0 Neonatologist

Nurse

Physical therapist

Neonatologist

Nurse

Physical therapist

Figure 2. The medians, 25th–75th percentiles and range for the multidisciplinary team member’s rating for the four scale scores of the MPOC-SP.

groups tend to reflect differences in their professional roles and were consistent with those reported by Woodside et al.12 In multidisciplinary teams, the neonatologists gave high scores in the ‘communicating specific information’ scale, particularly for the item ‘tell parents about the results from tests and/or assessment,’ which reflects their important role in the care process. The nurses gave widely varying scores for the ‘providing general information’ and ‘communicating specific information’ scales, reflecting differences in work role between the various nurses. There may also be some areas requiring improvement in terms of providing information. On the other hand, the nurses gave high scores for ‘answer parents’ questions completely.’ These results may reflect that the fact that nurses are required to provide care in consideration of how parents are feeling. The physical therapists gave high scores for the ‘Treating People Respectfully’ scale. The item that physical therapists scored highly was ‘take the time to establish rapport with parents and children.’ This appears to reflect the fact that the primary role of physical therapists is in developmental assessment and care rather than in the provision of medical care. These cross-discipline comparisons provide evidence that the differences in professional roles are reflected in the MPOC-SP score patterns. Ultimately, these findings contribute to the validity of the MPOC-SP as a measure for differentiating professional care-giving behaviors. Family-centered care is becoming the standard of care in NICUs, and is regarded as beneficial to the families, patients and staff. However, the ability to provide family-centered care may be challenging for NICU staff. To embrace family-centered care, educational and supportive strategies for staff are important. It is Journal of Perinatology (2015), 284 – 289

also important to foster interdisciplinary relationships between the staff from each profession and the family. We expect that the evaluation of care using the MPOC-SP will improve interdisciplinary care in NICUs. STUDY LIMITATIONS This study has several limitations. Criterion validity was not examined because the MPOC-SP does not have measures of the same construct or of very similar underlying constructs that should theoretically be related. For test–retest reliability, the test conditions should be similar for both measurements, but we are not sure if the test conditions were similar. There were also differences among the sample sizes for each profession, which may have reduced the statistical power. Further, we could not address the possible cultural differences in the MPOC-SP. The final limitation is that the clinical sample was from Hokkaido alone. This problem may reduce our ability to generalize the findings to include other parts of Japan. CONCLUSIONS This study shows that the MPOC-SP demonstrates good reliability and validity when used by the various professions involved in NICU care, although the ability of the scale ‘providing general information’ to assess the effectiveness of a program of intervention is limited. Moreover, this questionnaire can be used to identify areas for improvement in the family-centered care provided by multidisciplinary teams in NICUs. © 2015 Nature America, Inc.

Measurement of family-centered care in the NICU N Himuro et al

CONFLICT OF INTEREST The authors declare no conflict of interest.

ACKNOWLEDGEMENTS We are very grateful to colleagues of the CanChild Center for Childhood Disability Research for sharing their knowledge and support. We thank therapists Kaori Kamatsuka, Marie Kawabata, Saki Nakata, Hidetsugu Sengoku, Yoko Higuchi and Mr. Garry Heterick for their support.

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Measurement of family-centered care in the neonatal intensive care unit and professional background.

The aims of this study were to examine the validity and reliability of the Measure of Processes of Care for Service Providers (MPOC-SP) for multidisci...
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