Confirmatory factor analysis of the pain care quality surveys (PainCQ

Measuring and improving the quality of health care has become imperative for health care services. Performance measurement, in which health care processes, outcomes, and patient perceptions are quantified, has achieved new significance with national financial repercussions such as pay for reporting and performance. Valid and reliable performance tools are critical in establishing baseline measures and informing subsequent quality improvement efforts (Naylor 2007). Within this context, health services researchers must intensify efforts to develop and rigorously test performance measures that can be applied both locally and nationally for quality improvement and ultimately public reporting. The Robert Wood Johnson Foundation recognized this need and prioritized performance measure development as part of the Interdisciplinary Nursing Quality Research Initiative (INQRI 2011). The intent of this report is to summarize progress on an INQRI-funded project to develop a patient-centered quality measure focused on pain management. Specifically, we will report findings from a confirmatory factor analysis of the Pain Care Quality (PainCQ©) Surveys. A major goal of the analysis was to reduce the battery of items to produce more parsimonious and valid measures of patients' experiences of the management of their pain. Standards for widespread adoption of quality measures are very rigorous. In addition to standard evaluation criteria such as reliability and validity, evidence that the measure can discriminate across clinical settings and populations is necessary. The National Quality Forum (NQF) includes four criteria to assess a quality measure: importance, scientific acceptability, usability and relevance, and feasibility of data collection (NQF 2010). This manuscript adds to the evidence to support the scientific acceptability of the PainCQ© Surveys, their validity, reliability, and feasibility as quality measures in clinical oncology units. This work is preliminary to assessing the measures' ability to discriminate across diverse settings. To date, assessment of patient-centered care has been primarily global (e.g., overall satisfaction with care or pain management), not specific to particular providers (e.g., nurses, physicians, or other care providers), and temporally framed within the entire hospital stay. For example, one question from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) national survey asks patients whether hospital staff did everything they could to help with pain (CMS 2009). Such questions lack specific details that could be used to strategically improve pain care quality within the organization. Development of the Pain Care Quality Surveys (PainCQ ©) The PainCQ© Surveys were designed to target specific aspects of the patient experience with pain care quality in the context of a specific provider during a specific encounter or shift of care (Beck et al. 2010a). Expert and patient feedback in the formative stages of instrument development suggested that it was also important to consider the care provided by the patient's team during his/her hospital experience. Thus, the PainCQ© Surveys are two companion tools that measure the quality of nursing and interdisciplinary care related to pain management as perceived by individuals hospitalized with varying types of pain. The reports of testing to date have focused on hospitalized medical and surgical patients in the oncology setting. The PainCQ© Surveys were developed using a mixed methods approach by combining qualitative and quantitative methods that have been reported in detail (Beck et al. 2010a). Items were generated from qualitative data and systematically evaluated. Cognitive interviews with 39 patients revealed that some items were relevant to nursing care during a specific time frame, whereas others were more relevant to care provided by a patient's interdisciplinary team during the hospital stay. Thus, the referent (nurse vs. team) and the timeframe (last shift vs hospital stay) for each survey differ. These findings supported an approach that included two tools: an Interdisciplinary Care Survey (PainCQ-I) and a Nursing Care Survey (PainCQ-N). This model was further supported in a series of exploratory factor analyses (EFA)—one with each survey—using principal axis factoring with an oblimin rotation. Data were obtained from 109 hospitalized patients from three oncology settings (Beck et al. 2010c). PainCQ-I The initial 11-item PainCQ-I generated from the EFA resulted in two subscales, Partnership with the Health Care Team and Comprehensive Interdisciplinary Pain Care; each exceeded the internal consistency reliability estimates (Cronbach's alpha = .70) recommended for new tools (.85 and .76, respectively) (Nunnally and Bernstein 1994; Beck et al. 2010c). The first subscale, Partnership with the Health Care Team (PainCQ-I Partnership), contained six items that relate to collaboration among health care team members and with the patient. Partnership occurs when health care team members believe the patient and involve that person in pain management (Beck et al. 2010b). The second subscale, Comprehensive Interdisciplinary Pain Care (PainCQ-I Comprehensive), was composed of five items that reflected care focusing on the whole person and how pain influences patients' relationship and activities. The items reflect pain management that is more comprehensive in scope such as nonpharmacological approaches, impact on family and friends, and fear of addiction (Beck et al. 2010c). PainCQ-N The 22-item PainCQ-N contained three subscales; the coefficient alphas ranged from .77 (Comprehensive Nursing Pain Care) to .95 (Being Treated Right), again indicating sufficient internal consistency for all three subscales (Beck et al. 2010c). The Being Treated Right (PainCQ-N Being Treated Right) subscale represents care provided by concerned nurses who are listening, anticipating problems, responding promptly, and believing the individual's reports of pain. The patient feels that there is a plan and medications available. Comprehensive Nursing Pain Care (PainCQ-N Comprehensive) reflects pain management provided by nurses that includes patient education about side effect management and the use of approaches such as positioning, distraction, relaxation and breathing, and/or massage. Efficacy of Pain Management (PainCQ-N Efficacy of Pain Management) indicates that patient comfort results from medications that work effectively and quickly (Beck et al. 2010c). Need for a Confirmatory Factor Analysis of the PainCQ© Surveys In scale development, it cannot be assumed that all of the items that define a given construct have been delineated with a single evaluation of the psychometric properties of a generated scale. Additional confirmatory analytic studies are needed to assess the extent to which the scale structure holds up in additional populations. Although the exploratory factor analyses of the PainCQ© Surveys yielded five promising subscales for evaluating effective interdisciplinary and nursing care management of patient pain, we were concerned about the large number of items (k = 15) and the very high coefficient alpha (.95) in the PainCQ-N Being Treated Right and the total number of items in the two surveys. This evidence suggested that some redundant items could be removed without affecting scale reliability. Such a reduction would increase the feasibility of its use. The primary purpose of this current research, therefore, was to undertake a confirmatory factor analysis (CFA) using Structural Equation Modeling (SEM) to determine the stability of the structure and reliability of the PainCQ© Surveys in a second larger national sample of an additional 337 hospitalized patients. Two additional goals of this study were to further reduce the number of redundant items in the PainCQ-I and PainCQ-N subscales and to examine the relationships between the PainCQ© subscales and pain reports.