Nurses’ Work Methods Assessment Scale: A Construct Validation

Background . A nursing work method is the base for the organization and implementation of nursing care to patients based on nurses’ skills. Nurses’ work methods are consensually organized into two groups: task-oriented work methods (functional method) and client-centered work methods (teamwork method, individual work method, and work method per reference nurse). As for the impact of the work method on clients, we highlight the interference in the quality of care provided and, regarding nurses, the impact on workload and job satisfaction. Terefore, the existence of tools that allow identifying the organizational methodologies of nursing care is relevant. Aim . Te aim of the study is to test the validity and reliability of the nurses work methods assessment scale (NWMAS). Methods . Te methodological study followed the recommendations of the EQUATOR network. Te NWMAS was previously developed as a self-completion questionnaire. To determine construct validity, exploratory and confrmatory factor analyses were performed. Results . 325 participants were enrolled in this study. In exploratory factor analysis, the 25 items comprising NWMAS were distributed in fve dimensions, contemplating the work methods. Cronbach’s alpha of the total scale was 0.846. Te confrmatory factor analysis revealed a good ft. Conclusion . Te NWMAS is a valid and reliable tool. Implications for Nursing Practice . Te NWMAS identifes the work methods adopted by nurses in hospital settings, is a valuable tool for nursing management, and contributes to the defnition of strategies that promote the quality of nursing care and the safety of patients.


Introduction
Quality in health is a complex and comprehensive concept involving multiple factors and the collaboration of various professionals.Improving the quality of care provided in health organizations is focused on the continuous search for service excellence and patient satisfaction, and the need to implement quality improvement systems is strongly encouraged by international and national entities [1,2].
Health professionals play a crucial role in implementing activities aimed at the quality of each specifc care domain, which is the organization's most important component.In Portugal, the regulatory body of professional practice guides nursing practice based on descriptive statements of the quality standards for nursing care, a document that structures the expected performance of nurses in the design and implementation of nursing care [2].
Inherent to their professional activity and role in health institutions, nurses must contribute judiciously, rigorously, and actively to the quality of care and patient safety [3,4].As a complex and demanding profession, nursing is always present in health institutions as the largest workforce.However, there are still diferences in nurse stafng levels worldwide [5,6].Terefore, the constant search for quality improvement in nursing care should be closely associated with the satisfaction of patients' needs across clinical practice settings.It is worth noting that, in addition to meeting patients' needs, nurses' actions should focus on the search for care safety, particularly the way they organize and distribute work, aspects that may infuence the efciency, and quality of the nursing care provided [7].
A work method corresponds to the infrastructures that facilitate the organization and provision of care to patients based on a set of skills acquired by nurses and on the expected outcomes of care [8].It also defnes the division of labor and facilitates sustained decision-making through interaction between the nursing team and other health professionals [9,10].How nurses organize nursing care by adopting qualitypromoting methodologies may infuence an integrated response to patients' health problems and needs.
Despite being a fundamental aspect in the design, organization, and implementation of nursing care, as well as nurse's visibility in society, the evidence is scarce in this domain and the one that exists focusses on the characterization of the traditional working methods.
Traditionally, the most referenced nursing work methods are essentially grouped into two distinct areas: taskcentered and client-centered work methods [5,9].Concerning the functional method, task-centered and infuenced by Taylorism, it is a work distribution based on the execution of tasks and procedures, where the target of the action is not the patient but the task, emphasizing task maximization in a routine and mechanistic logic [7]."Fragmented" interventions in task-oriented care delivery are seen, in which nurses are only specialized in the execution of a specifc activity, without coordination between the parts [5,11].
As for the client-centered work methods, in the individual method, there is a concern with the concept of integral care and allocating a nurse to one or more clients.A single nurse assumes total responsibility for providing care, during a work shift, to a group of patients.Te organization of nursing care refects the needs and centrality of the client as the focus of care [7,11].In the teamwork method, nurses are divided into groups coordinated by a team leader who enhances the group's capabilities and nurses' competencies, ensuring that the skills and qualifcations of each nursing professional are maximized.Tis method is based on two fundamental pillars: leadership in planning and evaluating the care provided to clients and efective communication, aiming for the continuity of care [12,13].In the nurse reference method, nurses are responsible for planning, implementing, and assessing nursing care needs and supervising care from clients' admission to discharge [5,14].
According to the nursing social mandate, designing and implementing nursing care supported by the best scientifc evidence is nurses' duty and responsibility [15], adopting a work method promoting quality care and client safety.In addition to adopting a work method, it is imperative to identify how nurses plan, organize, and implement nursing care for clients aimed at the quality and safety of nursing care.
No tools characterizing and assessing nurses' work methods were found.Terefore, developing the nurses' work method assessment scale (NWMAS) [16] was considered relevant to assess hospital nurses' work methods as a tool to support decision-making in nursing management.Using the NWMAS makes it possible to standardize the measure and carefully identify the work methods adopted by nurses in the hospital context.Te Nursing Care Quality Standards of the Portuguese Association of Nursing Professionals [2] and Imogene King's Teory of Goal Attainment [17] were used as a guiding theoretical framework for developing the NWMAS.Te fnal version of the NWMAS consisted of 28 items.
In this context, the objective of the present study focuses on to test the validity and reliability of the nurses' work methods assessment scale.

Materials and Methods
2.1.Design, Samples, and Settings.A methodological study was developed, using a nonprobability convenience sample, guided by Streiner and Norman's recommendations [18].Te taxonomy, terminology, and defnition of health measures of the International Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) were used as framework [19].Inclusion criteria were defned as being a nurse or specialist nurse, working in a hospital in Northern Portugal, with at least six months of professional practice in this hospital, in departments of medicine, surgery, and intensive care medicine.All nurses not providing care (due to absence or other noncare functions) were excluded.Te sample size calculation was based on a population of 604 nurses.For a confdence interval of 95% and a margin of error of 5%, a minimum of 236 participants would be necessary.Te results of the content validation of this instrument have already been published [16].

Nurses' Work Method Assessment Scale (NWMAS).
Te deductive method was used for item generation through scoping review by mapping existing evidence on nurses work methods in hospital settings [9].A refective approach to measurement was used to develop the scales' items (form and wording).Te relationship between items and the construct (nurses' work methods) is based on the fact that the items are an efect of the construct [19].Tis work resulted in a 40 items instrument, organized in four dimensions with a set of ten items characterizing each work method (functional work method, individual work method, teamwork method, and reference nurse work method).Tis frst version of the NWMAS was then assessed by an expert 2 Nursing Forum panel of 23 nurses (managers, specialist nurses, and faculty members) on the suitability of each item to adequately refect the construct of a given dimension [16].Te judgment on the relevance and comprehensiveness of each item provided the validity of the content [19].Results from the experts' panel [16] provided a 28-item scale distributed in four dimensions with a set of seven items.Each dimension corresponds to traditional nursing work methods.Items are scored with a Likert-type scale with fve options, where one corresponds to "never," two "rarely," three "sometimes," four "often," and fve "always."Nurses' prevalent working method is defned by the highest mean achieved in a given dimension, e.g., a highest mean in the dimension "reference nurse work method" points this method as the mostly used by the participants.Tis version progressed to the validation of the construct, which is reported in this paper.
Te sociodemographic and professional characteristics (gender, age, academic degree, professional status, area of specialization, work context, and length of professional experience) were collected when the NWMAS was applied.

Data Collection and Application
Procedure.Data collection occurred from November 1 to December 31, 2022, after prior scheduling and availability of the professionals.Te researchers went to the diferent care contexts, and in conjunction with the nurse managers, they gave each participant an informed consent form and the data collection instrument.Two unmarked envelopes were given to the participants to place separately the informed consent and the questionnaire after completion.Participants, after being informed about the objectives and procedures of the investigation, signed the informed consent, stating their agreement to participate in the study.Confdentiality and anonymity were guaranteed in the use and dissemination of the collected information.

Statistical Analysis.
For data analysis and treatment, the statistical package for the social sciences (SPSS), version 29.0 and IBM SPSS Amos-v.29 (for confrmatory analysis), were used, in which descriptive and metric analyses were performed.To evaluate the adequacy of the data, we used the item-total correlation, the interitem correlation, Guttman's two halves coefcient, and Spearman-Brown's coefcient [20,21].Exploratory factor analysis was used to validate the NWMAS construct based on the test of sphericity (5% signifcance level) and the Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy for each activity.It should be noted that KMO values should vary between 0.5 and 1 [20].
For exploratory factor analysis, the principal components method was used to extract the factors that presented factor loadings lower than 0.3.
To evaluate the reliability of the factor model of each dimension, we used composite reliability and Cronbach's alpha coefcient.For composite reliability, it was taken as a rule that a value of 0.7 or higher indicates appropriate construct reliability, although lower values may still be acceptable [21].Regarding Cronbach's alpha, a value higher than 0.8 means good internal consistency [20].
Regarding the confrmatory factor analysis, to assess the quality of adjustment of the proposed model, the following indexes were used: comparative ft index (CFI), assuming acceptance values greater than or equal to 0.9; goodness of ft index (GFI), for acceptance values equal to or greater than 0.85; adjusted goodness of ft index (AGFI), starting from an acceptance value equal to or greater than 0.80; root mean square residual (RMR), for acceptance values less than or equal to 0.1; root mean square error of approximation (RMSEA), with an acceptance value less than 0.1; and the modifed expected cross-validation index (MECVI) [20][21][22].
Te assessment of factor validity consisted of calculating the standardized regression weights of each identifed factor and the square of these weights, referred to as individual reliability.It is assumed appropriate for a value equal to or greater than 0.25.Concerning the convergent validity of each factor, the mean extracted variance (MEV) was used and values equal to or greater than 0.5 were considered appropriate [21].Te data obtained in data collection were used both for exploratory and confrmatory analysis.

Ethical Considerations. Te Ethics Committee for
Health approved the study, whose opinion number was 421-21.Afterward, it had the approval of the Board of Directors of the hospital where data were collected.Te nurses who agreed to participate signed the informed consent form, and confdentiality and anonymity were guaranteed.Te completed instrument was placed and sealed in unmarked envelopes by the participants and collected by the researcher.

Results
Te 325 nurses who participated in the study (Table 1) were predominantly female (80.9%), married, or cohabiting (60.9%).Te mean age was 38.4 ± 8.1 years, ranging from 25 to 62 years.Regarding academic degrees, most of them had college degrees (87.7%).Regarding their professional status, 70.8% were nurses and 29.2% were specialist nurses, with a predominance of nurses specialized in rehabilitation nursing (56.8%).
Te most representative clinical settings were wards from the Department of Medicine (42.1%).As for the time of professional practice, nurses had a mean time of 14.7 ± 8.1 years and specialist nurses had a mean of 16.8 ± 8.1 years.Regarding the time of professional practice in the current service, nurses had a mean of 10.2 ± 8.8 years and specialist nurses had a mean of 8.5 ± 6.4 years.Only a minority (19.7%) had training in nursing care organization methodologies.
From the 325 questionnaires obtained during data collection, no data were missing.All data were included in statistical analysis.NWMAS, initially comprising 28 items, presented three items with a loading factor lower than 0.3 and therefore were removed.Subsequently, the instrument was submitted to validation and internal consistency analysis, with factor loadings ranging from 0.444 to 0.842.Te corrected item-total correlations were mostly moderate, with an average of 0.384 (Table 2); the average interitem Nursing Forum correlation was 0.173; the Guttman two-half coefcient was 0.676; and the Spearman-Brown coefcient was 0.716.
Based on the KMO measure of sampling adequacy, it was found that the overall value and the value for each item are mainly high or very high, with the sole exception of item 2, whose coefcient is very close to 0.5.
To this end, we performed a factor analysis to extract factors using the principal components method that resulted in a solution with fve factors, explaining 55.3% of the total variance.Table 3 shows the results of the forced 5-factor analysis followed by varimax rotation and Kaiser normalization.
Within the scope of the confrmatory factor analysis, using the same sample of the exploratory factor analysis, regarding the quality of the model adjustment, there are only 108 nonredundant residuals (36%) with an absolute value higher than 0.05, which indicates a good quality adjustment.
As for the coefcients of adjustment quality, the CFI was 0.880; the GFI and the AGFI were, respectively, 0.875 and 0.841; the incremental ft index (IFI) was 0.882; the Tacker-Lewis index (TLI) was 0.859; the RMR was 0.077; the RMSEA was 0.065, and fnally the MECVI value was 2.335.
In order to evaluate the reliability, Cronbach's alpha value of 0.846 was obtained for the global scale, a high value showing good internal consistency.Te composite reliability of the frst two factors/dimensions is very high (respectively, 0.897 and 0.830), that of the third factor/ dimension is high (0.745), and that of the last two is somewhat low (0.562 and 0.448).Te consistency of the factors is good, except for the third factor, whose consistency is acceptable.Test-retest, inter-, and intrarater reliability were not assessed.
As for factor validity, assuming that individual reliability is appropriate for a value greater than or equal to 0.25, it is good or even high in most items, thus confrming factor validity.Te convergent validity of each dimension was measured through the mean extracted variance (MEV), being considered adequate when the MEV is greater than or equal to 0.5.Tus, it was verifed that the frst and second have a VEM greater than 0.5, while the remaining have a VEM less than 0.5.

Nursing Forum
Based on the factor model presented, the NWMAS was composed of fve dimensions: seven items in the dimension "team work method," fve items in the dimension "reference nurse work method," six items in the dimension "individual work method," fve items in the dimension "functional work method," and two items in the dimension "good practices in work organization." Figure 1 presents the path diagram that summarizes the confrmatory analysis of the NWMAS.

Discussion
Te participation of 325 nurses in this study allowed for testing the validity and reliability of the NWMAS.Considering the theoretical constructs, it was possible to support the implementation of this instrument.Te scale was composed of fve dimensions, with a high Cronbach's Alpha, translating into a robust internal consistency.
In quantitative and qualitative terms, the participants' profles, who were directly involved in care provision, contributed to validating the NWMAS.However, the lack of training in nursing care organization methodology reinforces the importance of strategies that allow monitoring of the work methods adopted by professionals.
We found that the factorability of the correlation matrix is good, and factor analysis by the principal components method and by Kaiser's rule indicated a 5-factor solution, justifying 55.3% of the total variance.Te emerging factorial structure corroborates the theoretical component [5,7,9,[11][12][13].Te factors were aggregated into the following dimensions: "team work method," "reference  Nursing Forum nurse work method," "individual work method," "functional work method," and "good practices in work organization."Regarding the dimension "teamwork method," the factorial structure that emerged is in line with the theoretical component [7,9,23].Te items highlight that this working method of nurses is based on the existence of a team leader, who designs, supervises the care provided, and promotes refection on the nursing care provided to clients [3].On the other hand, the assignment of patients privileges the individual skills and qualifcations of the nurses on the team, making the best use of the resources available and promoting maximization and professional satisfaction [7,24].
Te emerging factorial structure in the dimension "work method by reference nurse" corroborates the literature [14,25].Te items emphasize the responsibility of the same nurse, the reference nurse, to plan, execute, and assess nursing care to the patient, from admission to discharge, to meet the patient's actual needs.On the other hand, each nurse works in partnership with other nurses, delegating interventions and ensuring continuity of care without the reference nurse [25].It is essential to highlight that the reference nurse coordinates and supervises nursing care during hospitalization [9,26].
Te factorial structure emerging in the "individual work method|" dimension is consistent with the theoretical component.Te items emphasize that, within the scope of work organization, a single nurse is responsible for caring for a group of patients during a work shift, directing the design and implementation of care to meet all their needs [12].It is noteworthy that this method is benefcial for its individualized and personalized approach, having as its most signifcant infuence the nurse's ability to establish a relationship of trust and empathy with his or her clients, allowing sustained, client-centered decision-making [27], in addition to sound technical and scientifc knowledge, which ensure safe nursing care.
Concerning the "Functional Work Method" dimension, the factorial structure that emerged corroborates the literature, in which the items show that the division of work is performed in specifc tasks, often according to each professional's skills, within the nursing team, and when the target of action is not the client, but the task [7].
According to the factor loading, the dimension "good practices in work organization" only included two statements agreeing with a scientifc methodology nurses use in nursing care, namely, the nursing process.Tis methodology allows each nurse, throughout a work shift, to assess the care needs of the patients assigned to him/her, allowing for the defnition of problems and the implementation of interventions to solve them, as well as the assessment of nursing activities [7,28].
Terefore, the confrmatory factor analysis corroborated the number of factors and the relationships between items and factors.Cronbach's alpha was high (α � 0.846) for the overall scale and good for all subscales except the third one, whose consistency is acceptable.
Te individual item reliability, given by the squares of the standardized regression weights, allowed us to identify that all factors exhibit factor validity.Tese results confrm the association of the items with their respective factors [20].
Despite being possible to improve the adjustment in each dimension by excluding items and simplifying the structure of the overall scale, this was not carried out considering the authors' purpose to develop an instrument to assess the work methods in hospital settings, to promote the quality of nursing care and patient and nursing care safety.Te work methods adopted should be clear to patients and converge with their specifc care needs.Te defnition of the working method adopted is infuenced by the nursing leadership, which in turn should promote strategies that enhance the job satisfaction of the team, reducing nurse turnover and increasing work-related well-being [29].
Although the development of the NWMAS was initiated through fndings related to previous research, this study has limitations, namely, the fact that this phase of construct validation occurred only in a single hospital center.Given the scarcity of evidence in this domain, future research is suggested, in various hospital institutions, which may contribute to improving the metric properties and the assessment of convergent and divergent validity.
Given the comprehensiveness of the NWMAS, we consider that this scale represents an added value in identifying the nurses' work organization in hospital settings, with a signifcant impact on the quality of nursing care and patient safety.

Conclusion
Te NWMAS presents good metric properties to assess the work methods nurses adopt in hospital settings as promoters of quality and safety of care.Te scale presents an internal consistency equal to 0.846.Terefore, the application of this instrument presents itself as reliable and valid.

Figure 1 :
Figure 1: Path diagram of the confrmatory factor analysis.

Table 1 :
Participants' sociodemographic and professional descriptive measures.

Table 3 :
Factorial structure and quality of adjustment.Te values in the table indicate the factorial weights of the items in each factor, with the highest weight of each item being in bold.