{"paper_id":"2bc3bc14-861e-42df-ae14-614af8197084","body_text":"Validation and psychometric evaluation of the Dutch Person-centred care of Older People with cognitive impairment in Acute Care (POPAC) | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research article Validation and psychometric evaluation of the Dutch Person-centred care of Older People with cognitive impairment in Acute Care (POPAC) Annette Keuning-Plantinga, Evelyn J Finnema, Wim Krijnen, David Edvardsson, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.2.22472/v3 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 13 Jan, 2021 Read the published version in BMC Health Services Research → Version 3 posted 2 You are reading this latest preprint version Show more versions Abstract Background: Person-centred care is the preferred model for caring for people with dementia. Knowledge of the level of person-centred care is essential for improving the quality of care for patients with dementia. The person-centred care of older people with cognitive impairment in acute care (POPAC) scale is a tool to determine the level of person-centred care. This study aimed to translate and validate the Dutch POPAC scale and evaluate its psychometric properties to enable international comparison of data and outcomes. Methods: After double-blinded forward and backward translations, a total of 159 nurses recruited from six hospitals (n=114) and via social media (n=45) completed the POPAC scale. By performing confirmatory factor analysis, construct validity was tested. Cronbach’s alpha scale was utilized to establish internal consistency. Results: The confirmatory factor analysis showed that the comparative fit index (0.89) was slightly lower than 0.9. The root mean square error of approximation (0.075, p=0.012, CI 0.057-0.092) and the standardized root mean square residual (0.063) were acceptable, with values less than 0.08. The findings revealed a three-dimensional structure. The factor loadings (0.69-0.77) indicated that the items to be strongly associated with their respective factors. The results also indicated that deleting Item 5 improved the Cronbach’s alpha of the instrument as well as of the subscale ‘using cognitive assessments and care interventions’. Instead of deleting this item, we suggest rephrasing it into a positively worded item. Conclusions: Our findings suggest that the Dutch POPAC scale is sufficiently valid and reliable and can be utilized for assessing person-centred care in acute care hospitals. The study enables nurses to interpret and compare person-centred care levels in wards and hospital levels nationally and internationally. The results form an important basis for improving the quality of care and nurse-sensitive outcomes, such as preventing complications and hospital stay length. Health Economics & Outcomes Research Acute care Dementia Nurses Person-centered care Psychometrics Quality of care Figures Figure 1 Background Worldwide, approximately 50 million people are living with dementia. Due to the ageing population, this number will increase (1). People with dementia are regularly hospitalized due to comorbidities; they occupy approximately 25% of the hospital beds (2,3). This population is at risk for falls during a hospital stay, inadequate hydration and nutrition, delirium, infection, and functional decline (4–6). These factors impact the duration of stay, the person’s functioning, and the care required following discharge (7). Nursing care for people with dementia should be based on evidence, best-practice care, and processes combined with person-centred care to prevent complications (6,8–11). It is known that person-centred care can improve their quality of life. In spite of that, specific knowledge about person-centred care, also referred to as patient-centred or client-centred care, is limited in hospitals (11). However, worldwide, it is the paragon in the care of people with dementia (10,12). The basis of person-centred care in caring for people with dementia is laid by Tom Kitwood (13,14). In a broader context, the framework of McCormack ad McCance is often used (15–17). In the care for people with dementia, Brooker's definition and framework are often used (3,18). To improve the quality of care for people with dementia in an acute care setting, knowledge of the level of person-centredness of the care is important. The literature reports a limited number of instruments that measure person-centred care for dementia patients in an acute hospital setting (8,19). Available instruments are aimed at long-term care (20) or more generically on person-centred care in the acute hospital setting and lack a specific focus on the quality of care for people with dementia (21–24). The person-centred care of older people with cognitive impairment in acute care (POPAC) scale (19) was developed for the acute hospital setting and measures the person-centredness of care for older people with dementia. The scale consists of three subscales, which can be connected to the elements of person-centred care of the definition used. The subscale ‘using cognitive assessments and care interventions’ is suitable for valuing people; ‘using evidence and cognitive expertise’ is suitable for understanding situations from the perspective of the person with dementia; and ‘individualizing care’ is related to individualizing approaches and the social environment. In addition to measuring and improving the quality of care, translating tools into different language versions enables international comparisons of data and comparative analysis of levels, correlations, and person-centred care outcomes. In addition, there are no Dutch-language instruments available that measure person-centred care in the hospital setting. The POPAC scale was designed in 2013 by Edvardsson in Australia to establish quantitative measurements to assess experienced levels of person-centred care for people with dementia in acute hospital settings (19,25). Based on the literature, eight dimensions of best practice were used to construct the instrument. Further development with a panel of international experts led to an instrument that consisted of statements on recognizing cognitive impairment, consulting specialist expertise, using evidence-based care protocols or guidelines, making environmental adjustments, providing social enrichments, prioritizing staff continuity and close interactions, avoiding restraints, and individualizing care (19). The degree to which participants agree with item statements is expressed on a 6-point Likert scale with the categories ' never ’ (1), ‘ very rarely’ (2), ‘ rarely ’ (3), ‘ frequently ’ (4), ‘ very frequently’ (5), and ‘ always ’ (6) (10,19,25). A significant Bartlett's spherical test and a Kaiser-Meyer-Olkin (SME) sample adequacy measurement of >0.7 were used to assess the construct validity. Construct validity was then assessed using principal component analysis with oblimin rotation due to the factors' expected correlation (19). The original instrument was pilot tested with a sample of 212 nurses from different types of wards, such as neurology, orthopaedics, and cardiology, in an acute care hospital in Melbourne, Australia. After the preliminary test, six items were removed because they did not meet the cutoff for acceptable homogeneity (>0.3). A retest was conducted with 25 nurses from an orthopaedic ward, and the outcomes indicated satisfactory temporal stability (19). The assumption that all items reliably measure a single underlying construct was supported by the item-total correlations ranging from 0.40 to 0.67, where values 0.4 and above indicate very good discrimination (26). The subscales can be combined into a total score, where higher scores indicate higher person-centredness levels to evaluate the overall level of person-centred care. An interpretation of the score is not yet available. The totals of the items per subscale suggest possible areas for improvement of care. The instrument allows the comparison of person-centred care at both national and international levels (19). Nilsson psychometrically evaluated the instrument in Sweden (2013), and Grealish (2017) evaluated the scale in Australia (10,25). Both Nilsson and Grealish used Cronbach’s alpha and corrected total correlation for internal consistency and CFA for construct validity. In addition, in Nilsson's study, temporal stability was measured through the correlation between test and retest scores (10). Both studies reported that the POPAC scale is valid and reliable and can be used to provide insight into nursing care's person-centredness in a hospital setting. However, the high correlations between the subscales and the authors' conclusion that the instrument’s dimensionality requires further research are important tenets for this study (10,25). For using the POPAC scale in the Netherlands to study person-centred care in a hospital setting, the instrument needed to be translated into Dutch. Measuring psychometric properties is important for assessing validity and reliability (27). Nurses and nursing managers can use the outcomes of the POPAC scale to improve the quality of care in their ward, and outcomes and data can be used for national and international comparison. Therefore, this study aimed to conduct a cross-national validation and psychometric evaluation of the Dutch version of the POPAC scale. Methods This study aimed to translate and validate the POPAC scale into Dutch and test the Dutch version of the questionnaires for psychometric properties among Dutch nurses working in acute hospital settings (28). Data were collected with the online questionnaire program Qualtrics XM (version 2018, Provo, UT USA). The instrument The POPAC scale consists of 15 items, as shown in Table 1. The items describe care procedures and processes in patients with dementia in hospitals (19). With the self-report of nurses in hospitals, the POPAC scale measures the extent to which nursing interventions are based on best practices in association with person-centred care. The items are divided into three subscales: cognitive assessments and care interventions (items 1–5), evidence and cognitive expertise (items 6–8), and individualizing care (items 9–15) (19). The scores can be evaluated per subscale, or the score of the total scale can be used. The subscale or total scale scores can be calculated by dividing the sum of the scores by the number of items, whereby higher scores imply higher levels of person-centredness (10,19,25). Translation of the person-centred care of older people with cognitive impairment on the acute care scale The instrument's principal author was involved in the translation, validation, and writing of the evaluation. Therefore, the instrument was translated according to the guidelines described by Sousa (29). Two independent translators from a certified translation agency translated the questionnaire into Dutch. Two researchers (AK and EF) independently assessed these two translations to determine the optimal translation of the question formulations and the answer options. During the translation process, there was some discussion about using the term ‘cognitive functioning’ or ‘cognitive status’, whereby all translators agreed upon the choice for ‘cognitive functioning’ because this term is commonly used in nursing care in the Netherlands. There were no disagreements on a lingual or cultural basis. There was unanimous consensus for the final selection of all items. This Dutch version was also translated back into English by two other independent translators from the same certified translation agency. These translations were again independently assessed by the same researchers to decide on the best translation. This time, there was consensus on all of the items. The author reviewed this final English version, and the conclusion was that the outcomes closely resembled the original version. There were no specific reasons to expect systematic errors during the translation due to linguistic or cultural differences (30). The final version is attached as Additional file 1. Sample size According to the scientific literature, the sample size depends on the number of factors and the factor load, where a minimum sample size of 100 is recommended, and a sample size of 150 is suggested for three-phase models (30, 31). The COSMIN (Consensus-based Standards for the selection of health status measurement instruments) checklist advocates seven times the number of items (33). Based on this knowledge, the optimal sample size was at least 150 (34, 35). It may be noted that in the post hoc analysis, the sample size was sufficient for almost all estimated parameters to be (highly) significant. Setting, recruitment, and participants Six hospitals in the northern part of the Netherlands participated in this study and were supplemented by Dutch nurses who were recruited via LinkedIn and Facebook. The data were collected in one university hospital, two non-university teaching hospitals, and three rural hospitals. The capacity of the hospitals varied from 241 to 1300 beds, with additional outpatients. Nurses with at least three months of experience in the clinical setting, working in the direct care of people with dementia, and willing to participate were included in the study. All hospital departments were included, except for paediatrics and obstetrics. The data collection took place from July 2018 to March 2019. The recruitment of participants in the hospitals was performed by contact persons working in the hospital based on a convenience sample (27). The authors also used LinkedIn and Facebook to recruit hospital nurses. A general request was made for nurses to participate via LinkedIn, in which nursing managers are active and then the call was repeated once. For Facebook, which is often used by Dutch nurses, a different approach was used for which the authors requested two groups on Facebook. One was in a private group for questionnaires of a professional nursing magazine, and the other was in an open group for nurses in general. On Facebook, a daily update of the response was provided. This Facebook group has many members; however, it is not known how many members are active. Data analysis For the data analysis, we used IBM SPSS statistics (for Macintosh, version 25, Armonk, NY: IBM Corp.). Only complete scales were used in the data analysis. To perform confirmatory factor analysis (CFA), JASP (Version 0.11.1) with Lavaan was used (34). Before starting the analysis, Item 5 was reverse coded due to the negative wording of this item. The decision to use only completed scales was made based on the response rate of 159 complete cases instead of 164 with the inclusion of incomplete scales. Because the sample was sufficiently large and the differences in outcomes were minimal, it was decided that only completed questionnaires would be included. This makes the data as accurate as possible. The Shapiro-Wilk test was used to assess the normality of the distribution. Descriptive analyses were used to describe the sample. Item performance was assessed by calculating item means and standard deviations, the inter-item correlation matrix, and the corrected item-total correlation. The CFA was performed by robust maximum likelihood estimation, after which four types of fit indices were used to evaluate the fit of the model to the data: the chi-square model fit, the comparative fit index (CFI), the root mean square error of approximation (RMSEA), and the standardized root mean-square residual (SRMR). The Hoelter index was utilized to check the smallest sample size at which the chi-square interpretation would not be significant. As a criterion for significance, a p-value <0.05 was used. The model fit was considered acceptable if the following criteria were met: p-value for the χ2 model fit compared to the baseline model smaller than 0.05, CFI and GFI values between 0.90 and 0.95 or above RMSEA and RMR values of 0.08 or below (35). Cronbach's alpha on the total scale and its subscales were assessed to determine the internal consistency. Ethics approval and consent to participate The study was performed following the Helsinki declaration, and all of the participants provided written informed consent before filling out the questionnaire. Nurses had an option to choose whether the results would also be available for further research. The Medical Ethical Committee of the University Medical Center Groningen considered approval unnecessary (decision M17.221048) because the questionnaire was intended for staff. The questionnaire was completely anonymous; no one could be identified based on the results. The managers received an email with a general explanation and a link to the questionnaire to forward it to the nurses of their team. Managers were not informed about the number of participating nurses from their ward or about their responses. Based on the contact persons' information and the response per ward, there was no reason to believe that nurses felt obliged to participate in this survey. The voluntary nature of participation was emphasized in the explanations. Results Characteristics of the sample In total, 159 hospital nurses completed the POPAC scale; 114 nurses were recruited directly from hospitals, and 45 nurses were recruited through social media. The hospitals' general response rate was 33%, based on the managers of the participating wards’ information. More specifically, responses came from nurses working in medical (21.4%), surgical (20.1%), and geriatric (13.2%) wards as well as in wards with different combinations of specialized care (45.3%), as shown in Table 2. The education of the nurses varied from a care assistant level to a master level. The nurses had an average experience of 18 years of working with the elderly population, ranging from a few weeks to 45 years (SD 12.6). A total of 43.3% of the nurses had participated in a course in the past year about care for people with dementia. They graded their skills on caring for people with dementia with an average of 7.3 on a scale from 1 to 10 with a range from 4 to 9 (SD 0.095). Item performance The mean score per item varied between 3.59 and 5.28, as shown in Table 3. The total score was 66.88 (SD (10.04), with a mean of 4.46 (SD 0.53). The Shapiro-Wilk test indicated that the data were skewed. The skewness per item varied between -0.04 and -1.83. Internal consistency was based on a cutoff point of Cronbach’s alpha 0.7, an item-total correlation of 0.3, and inter-item correlations between 0.2-0.4 (26). The correlation between the different items revealed some negative correlations with Item 5. It shows a corrected item-total correlation of 0.11. The other values varied from 0.34 (Item 14) to 0.63 (Items 8 and 9). The Cronbach’s alpha increased by 0.1 when Item 5 was deleted. The visual expectation of the data gave indications for a three-block structure. Construct validity Construct validity was evaluated with the CFA loadings for the items and the interfactor correlations based on ML estimation. Lavaan’s iterative maximum likelihood estimation converged after 22 iterations. An overview of the different fit indices is shown in Table 4 and indicates an acceptable model fit. The Hoelter's critical N was 106.8, which means that the sample size was adequate. A chi-square test was performed to check the model fit. This test showed that the factor model differed significantly from the baseline model, χ2 (87, N=159) =164,84, p<.001. The obtained CFI of 0.89 was slightly smaller than the cutoff value of 0.9. Both the RMSEA (0.075, p=0.012, CI 0.057-0.092) and the SRMR of 0.063 were acceptable, with values less than 0.08. The CFA showed that all loadings were fairly large, positive, and significantly different from zero, as presented in Table 5 with Item 5 as the only exception. The factor correlations were between 0.69 and 0.77, indicating that the factors were strongly associated. Figure 1 provides the final model with significant correlations between the subscales, residual variances, and factor covariances. Internal consistency For measuring internal consistency, Item 5 was reversed. The total instrument’s internal consistency measured by Cronbach’s alpha was 0.85 (CI 0.82-0.88). The internal consistency of using cognitive assessments and care interventions was 0.60 (CI 0.45-0.66) with item five and 0.72 (CI 0.63-0.78) without it; using evidence and cognitive expertise had an internal consistency of 0.78 (CI 0.70-0.83) and individualizing care 0.8 (CI 0.74-0.84). Discussion This study aimed to translate and validate the Dutch version of the POPAC scale and evaluate the psychometric properties to make international comparisons possible. The outcomes confirm that this Dutch version of the POPAC scale is a valid and reliable instrument for measuring person-centred care and the quality of care of people with dementia in acute care (10,19,25). The results obtained from the factor analysis with three factors were comparable with those from earlier research (10,19,25). All of the earlier studies derived a three-factor solution whereby Nilsson found that Cronbach’s alpha values of Subscales 2 (using evidence and cognitive expertise) and 3 (using evidence and cognitive expertise) did not reach the necessary cutoff point of 0.7 (10). Grealish used an exploratory factor analysis because the items did not meet the predetermined cutoff points for using confirmatory factor analysis (25). They created a revised version of the instrument in which Item 5, concerning leaving people with cognitive impairments alone in the ward, was deleted, and several items were grouped into another subscale. The model fit confirmed the three-factor solution. That is, the Chi-square rejected the model. However, this test has been found to be unreliable for small sample sizes (36). The CFI indicated a nearly acceptable model fit, as with Nilsson and Grealish, who reported CFIs of 0.88 and 0.90, respectively (10,25). The RMSEA and the SRMR suggested an acceptable model fit (36). However, the findings confirmed the three-dimensional structure suggested by previous research. The loadings of the items indicate that these are strong associations with each of the factors. In addition, the factor correlations also indicated that there were strong associations, which indicated that the factors were strongly associated with one general factor of the POPAC scale. Future research is necessary to elucidate the scientific benefits of distinguishing three factors in explaining person-centred care over that of a single generic POPAC factor. The Dutch version of the POPAC scale has similar results as the Edvardsson and Nilsson study (10,19). Grealish assigned three variables to other subscales 925). In the current study, evidence was found that the POPAC has psychometric properties very similar to those previously reported in the literature. For this reason, the POPAC can be applied in the Netherlands as three separate subscales as well as a total scale measuring the level of person-centred care. Furthermore, Cronbach’s alpha of 0.86 corresponds with earlier research in which the internal consistency varies from 0.83 to 0.87. (10,19,25). Additionally, this research confirms that, statistically, Item 5 (about leaving patients with cognitive impairments alone), which is on the ‘Using cognitive assessments and care interventions’ subscale, could be deleted to improve the instrument’s internal consistency. This is because this subscale has an internal consistency of 0.6, which is lower than the cutoff of 0.7 (26,27). Instead of deleting this item, the authors suggest rephrasing it into a positively worded item. It is the only negatively formulated item, which may influence the outcomes. The background of the instrument's construction can provide direction in changing the focus of this question. Nurses are always present in the hospital ward, so they do not experience leaving patients by themselves. However, this does not mean that people with dementia are always visible to nurses and monitored when needed, which might influence care. Our suggestion is to reformulate this question from: “ We leave older people with cognitive impairments alone in the ward.” to: “We make sure older people with cognitive impairments are not left alone in the ward .\" The mean scores in our study were higher than the scores in earlier studies. A higher score reflects a higher level of the construct of person-centred care (19). This score can partly be explained by the obtained high score found for Item 1 regarding assessing cognitive status. In the Netherlands, assessing cognition is a criterion on which hospital care quality is judged, which might have influenced this positive outcome. Scores on the POPAC scale among a sample of nurses can be utilized to measure the level of person-centred care for people with dementia in hospitals. Nursing professionals and nursing managers can use the outcomes as indicators to determine which areas of care can be improved in their ward (37). Additionally, the POPAC scale can be used in the education of nurses and nursing students to create awareness of person-centred care. The POPAC scale is applicable in research on person-centred care, for example, to investigate if a relationship exists between the outcomes of the POPAC scale and complications such as falls, poor hydration and nutrition, delirium, infection, and functional decline. It can also be used to determine whether there is a relation between the level of person-centredness of the care and the length of the hospital stay. In brief, the POPAC scale can be applied to investigate various important research questions regarding interventions for people with cognitive impairment in acute wards. The authors will use this instrument to determine nurses' perceptions of person-centred care for people with dementia. Limitations The POPAC scale is a relatively novel instrument, and its validity and reliability need to be further developed. There is no gold standard available to compare the results with. This study aimed to measure the validity by using factor analysis, as in previous studies. This was done using one group. To improve construct validity, the authors suggest using other methods to strengthen the theoretical basis, such as item response theory, the use of multiple groups, and a test-retest construction. Our study had a lower response rate (33%) in the hospital setting than those of previous studies, e.g., 59% (19), 51% (10), and 54.3% (25), possibly due to the different methods of recruiting responders. There were two primary aspects. On the one hand, nursing managers did not always want to cooperate because there were only a small number of people with dementia in their ward, or they perceived no added value in the study. This could result in a nonresponse bias and affect the external validity of the study. The nonresponse may have caused some bias in the direction of the null. However, since our results were mainly in line with those previously found in the literature, we consider this bias to be relatively weak. By using a convenience sample, participating nurses with a high affinity for the topic may be overrepresented. This leads to a limitation of the external validity and, consequently, the generalization. Since the recruitment was rather general, yielding a rather broad sample of participants, we expect the results to be generalizable for the setting of general hospitals. In future research, it may be useful to validate actual care provision and behaviour in practical working situations. However, the combination of nurses from hospitals and via social media provided a significant scope of the Netherlands. The questionnaire was conducted in combination with another lengthy questionnaire. The numerous questions negatively influenced the motivations to complete the questionnaire, which could have caused missing information. This may affect internal validity negatively. We used different orders of the questionnaire to prevent this bias. Conclusions The findings of this study confirm the validity and reliability of the Dutch version of the POPAC scale. However, the results provide grounds for further research on the instrument's dimensionality with a rephrased Item 5. The results can help nursing managers improve person-centred care in hospitals for people with dementia. The authors advise using total sum scores for interpretation of the scale for national and international comparison. Further research can provide insight into the relationship of person-centred care with the quality of care and nurse-sensitive outcomes, such as preventing complications hospital stay length. Implications for nursing practice The results are of significance for nurses in facilitating the improvement of care for people with dementia. The instrument can be used to hold reflective discussions in clinical settings about the extent to which nurses can perform person-centred care and how they can improve this care. This study's findings also enable the broader use of the POPAC scale: a total sum score can be calculated and consequently used to determine and interpret the level of person-centred care. Person-centred care and evidence-based nursing are important ingredients for high-quality nursing care for people with cognitive impairments. Therefore, the instrument is easy for nurses to use as an instrument for practice improvement. Furthermore, nurses can employ the results of the POPAC scale for benchmarking the level of person-centred care at a hospital as well as on a national or international level. Declarations Ethics approval and consent to participate The study was performed following the Helsinki declaration, and all of the participants provided written informed consent before filling out the questionnaire. Nurses had an option to choose whether the results would also be available for further research. The Medical Ethical Committee of the University Medical Centre Groningen considered approval unnecessary (decision M17.221048) because the questionnaire was intended for staff. The questionnaire was completely anonymous; no one could be identified based on the results. Consent for publication Not applicable. Availability of data and materials The datasets generated and analysed during the current study are not publicly available, as more papers will be written based on this dataset. The corresponding author can provide data upon reasonable request. Competing interests The authors declare that they have no competing interests. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Authors’ contribution AKP, EJF, and PFR were responsible for the study design. AKP and EJP were responsible for the translation process. AKP performed the data collection. AKP and WK contributed to the data analysis and interpretation of the data. AKP, EJP. WK, DE and PFR were involved in drafting and revising the manuscript critically for important intellectual content and gave final approval of the version to be published. Acknowledgements The authors would like to thank all participating nurses for completing the questionnaires and all contact persons in the hospitals for their help with distributing the questionnaires. Authors’ information AKP: RN, MSc, Ph.D.-candidate EJF: Ph.D. Professor WK: Ph.D. Professor ED: RN, Ph.D. Professor PFR: Ph.D. Professor Abbreviations CFA: Confirmatory Factor Analysis; CFI: Comparative Fit Index; CI: Confidence interval; COSMIN: Consensus-based Standards for the selection of health status Measurement Instruments; POPAC: Person-centred care of Older People with cognitive impairment in Acute Care; RMSEA: Root Mean Square Error of Approximation; SD: Standard deviation; SRMR: Standardized Root Mean-square Residual References World Health Organization. Key Facts [Internet]. World Health Organization. 2017. p. 5. Available from: http://www.who.int/news-room/fact-sheets/detail/dementia Nederlandse vereniging voor klinische geriatrie. 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Available from: http://dx.doi.org/10.1016/j.ijnurstu.2015.05.002 Edvardsson D, Nilsson A, Fetherstonhaugh D, Nay R, Crowe S. The person-centred care of older people with cognitive impairment in acute care scale (POPAC). JNursManag. 2013 Jan;21(0966-0429 (Linking)):79–86. Edvardsson D, Fetherstonhaugh D, Nay R, Gibson S. Development and initial testing of the Person-centered Care Assessment Tool (P-CAT). Int Psychogeriatrics [Internet]. 2010 Feb;22(1):101–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19631005 Suhonen R, Gustafsson ML, Katajisto J, Välimäki M, Leino-Kilpi H. Individualized care scale - Nurse version: A Finnish validation study. J Eval Clin Pract [Internet]. 2010 [cited 2019 Nov 1];16(1):145–54. Available from: https://onlinelibrary-wiley-com.proxy-ub.rug.nl/doi/pdfdirect/10.1111/j.1365-2753.2009.01168.x Edvardsson D, Sandman PO, Rasmussen B. Construction and psychometric evaluation of the Swedish language Person-centred Climate Questionnaire - Staff version. J Nurs Manag. 2009;17(7):790–5. Wolverton CL, Lasiter S, Duffy JR, Weaver MT, McDaniel AM. Psychometric testing of the caring assessment tool: Administration (CAT-Adm © ) . SAGE Open Med. 2018;6:205031211876073. Slater P, Mccance T, Mccormack B. The development and testing of the Person-centred Practice Inventory - Staff (PCPI-S). Int J Qual Heal Care. 2017;29(4):541–7. Grealish L, Chaboyer W, Harbeck E, Edvardsson D. The person-centred care of older people with cognitive impairment in acute care (POPAC) scale - psychometric evaluation. JNursManag. 2017 Mar;25(0966-0429 (Linking)):139–47. Field A. Discovering Statistics Using IBM SPSS [Internet]. 4TH ed. Michal Carmichael, editor. Discovering Statistics Using SPSS. Los Angeles/London/ New Delhi: Sage Publications, Ltd; 2013 [cited 2018 Oct 10]. 1–916 p. Available from: http://www.fb4all.com/download/ebooks/statistics/%23Discovering Statistics Using SPSS 2013.pdf Polit DF, Beck CT. 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Available from: https://link-springer-com.proxy-ub.rug.nl/content/pdf/10.1007%2FBF02294248.pdf Wolf EJ, Harrington KM, Clark SL, Miller MW. Sample Size Requirements for Structural Equation Models: An Evaluation of Power, Bias, and Solution Propriety. Educ Psychol Meas [Internet]. 2013 [cited 2019 Nov 18];73(6):913–34. Available from: https://journals.sagepub.com/doi/pdf/10.1177/0013164413495237 Mokkink LB, Terwee CB, Patrick DL, Alonso J, Stratford PW, Knol DL, et al. The COSMIN checklist for assessing the methodological quality of studies on measurement properties of health status measurement instruments: an international Delphi study. Qual Life Res [Internet]. 2010 May [cited 2019 Jun 13];19(4):539–49. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20169472 Rosseel Y. Lavaan: An R package for structural equation modeling. J Stat Softw. 2012;48(2). Schreiber JB. Modeling and Confirmatory Factor Analysis Results : A Review. Th J Educ Res [Internet]. 2006 [cited 2019 Nov 22];99(09):323–37. Available from: https://steinhardtapps.es.its.nyu.edu/create/courses/3311/reading/7-Reporting_SEM_and_CFA__Schreiber__Stage__King__Nora__Barlow_.pdf Harrington D. Confirmatory Factor Analysis [Internet]. Confirmatory Factor Analysis. 2009 [cited 2019 Nov 25]. 1–128 p. Available from: www.oxfordscholarship.com Kodama Y, Fukahori H. Nurse managers’ attributes to promote change in their wards: a qualitative study. Nurs Open. 2017;4(4):209–17. Tables Table 1 Original items POPAC (Edvarsson, 2013) Item 1 We assess the cognitive status of our older patients on admission 2 We make environmental adjustments to avoid over-stimulation in older people with cognitive impairment (e.g. single rooms, noise reductions etc.) 3 We diagnose symptoms of cognitive impairment (e.g. dementias, delirium etc.) 4 We spend more time with older patients with cognitive impairments as compared to cognitively intact patients 5 We leave older people with cognitive impairments alone in the ward 6 We use evidence-based tools to assess cognitive status of older patients (e.g. the MMSE, SPMSQ, CAM) 7 We consult specialist expertise (e.g. psychologist, gerontologist) if we find that a patient has cognitive impairment 8 We use evidence-based care guidelines in the care of older cognitively impaired patients 9 We use biographical information about older patients (e.g. habits, interests and wishes etc.) to plan their care 10 We involve family members in the care of older patients with cognitive impairment 11 We provide staff continuity for older patients with cognitive impairments (e.g. the same nurses providing care to these patients as often as possible) 12 We systematically evaluate whether or not older patients with cognitive impairment receive care that meets their needs 13 We involve older patients with cognitive impairment in decisions about their care (e.g. examinations, treatments etc.) 14 We ensure that older patients with cognitive impairment have tests/examinations/consultations in the unit rather than having to go to another department 15 We discuss ways to meet the complex care needs of people with cognitive impairment Table 2 Characteristics of nurses (n=159) Directly from hospital Via Social Media Total Frequency Percent Frequency Percent Frequency Percent Level of nurses Student level 0 0 1 2.2 1 0.6 Care assistant 1 0.9 1 2.2 2 1.3 Secondary vocational level 60 53.5 24 53.3 64 52.8 Bachelor level 52 46.6 8 17.8 60 37.7 Master level 1 0.9 11 24.4 12 7.6 Ward type Medical 17 14.9 17 37.8 34 21.4 Surgical 23 20.2 9 20 32 20.1 Geriatric 17 14.9 4 8.9 21 13.2 Other 57 50 15 33.3 72 45.3 Mean SD Mean SD Mean SD Years’ experience in working with elderly 19.7 12,7 13,7 11.15 18 12.6 Grade skills 7.1 1,5 7.2 1.1 7.2 1.8 Followed a course on dementia last year Yes 50 43.8 19 42.2 69 43.4 No 64 56.1 26 57.8 90 56.6 Table 3 Mean, Standard Deviation, Item-rest correlation, Item-total correlation, Cronbach’s alpha if item deleted, Cronbach’s alpha overall, and Cronbach’s alpha per subscale (n=159) Mean Standard deviation Item-rest correlation Item-total correlation Cronbach’s alpha if item deleted Cronbach’s alpha overall Cronbach’s alpha per subscale Item1 5.28 1.06 0.48 0.54 0.84 0.85 1. Using cognitive assessments and care interventions with item 5: 0.60 without item 5: 0.72 Item2 4.75 1.05 0.56 0.67 0.84 Item3 4.90 1.06 0.46 0.49 0.84 Item4 3.87 1.20 0.43 0.48 0.84 Item5 4.64 1.31 0.11 -0.32 0.86 Item6 5.09 1.32 0.55 0.59 0.84 2. Using evidence and cognitive expertise 0.78 Item7 5.06 1.05 0.48 0.51 0.84 Item8 4.45 1.13 0.63 0.67 0.83 Item9 4.27 1.07 0.63 0.64 0.83 3. Individualizing care 0.80 Item10 4.77 0.88 0.48 0.51 0.84 Item11 3.62 1.29 0.52 0.51 0.84 Item12 3.59 1.37 0.59 0.58 0.83 Item13 4.16 1.12 0.34 0.34 0.85 Item14 4.26 1.46 0.35 0.37 0.85 Item15 4.15 1.18 0.73 0.73 0.83 Table 4 Fit indices Metric Value Comparative Fit Index (CFI) 0.89 Root mean square error of approximation (RMSEA) 0.08 RMSEA 90% CI lower bound 0.06 RMSEA 90% CI upper bound 0.09 RMSEA p-value 0.01 Standardized root mean square residual (SRMR) 0.06 Hoelter's critical N (α = .05) 106.88 Goodness of fit index (GFI) 0.99 Expected cross validation index (ECVI) 1.64 Table 5 Factor loadings Factor loadings 95% Confidence Interval Factor Indicator Symbol Estimate Std. Error z-value p Lower Upper Factor 1 Item1 λ11 0.675 0.117 5.754 < .001 0.445 0.905 Item2 λ12 0.711 0.095 7.465 < .001 0.524 0.898 Item3 λ13 0.649 0.094 6.944 < .001 0.466 0.833 Item4 λ14 0.641 0.106 6.058 < .001 0.434 0.849 Item5 λ15 0.057 0.106 0.538 0.590 -0.150 0.264 Factor 2 Item6 λ21 1.000 0.127 7.878 < .001 0.751 1.249 Item7 λ22 0.671 0.098 6.814 < .001 0.478 0.864 Item8 λ23 0.899 0.098 9.176 < .001 0.707 1.091 Factor 3 Item9 λ31 0.756 0.078 9.706 < .001 0.603 0.909 Item10 λ32 0.496 0.069 7.171 < .001 0.360 0.631 Item11 λ33 0.753 0.099 7.589 < .001 0.559 0.948 Item12 λ34 0.930 0.092 10.120 < .001 0.750 1.110 Item13 λ35 0.501 0.085 5.891 < .001 0.334 0.668 Item14 λ36 0.606 0.127 4.790 < .001 0.358 0.854 Item15 λ37 0.948 0.078 12.198 < .001 0.796 1.100 Supplementary Files Additionalfile1.DutchversionofthePOPAC.docx Additional File 1 Dutch version of the POPAC Cite Share Download PDF Status: Published Journal Publication published 13 Jan, 2021 Read the published version in BMC Health Services Research → Version 3 posted Submission checks completed at journal 24 Dec, 2020 Editorial decision: Accept 23 Dec, 2020 You are reading this latest preprint version Show more versions Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-13047\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":false,\"archivedVersions\":[],\"articleType\":\"Research article\",\"associatedPublications\":[],\"authors\":[{\"id\":7079262,\"identity\":\"fd3dc7c6-c73c-487c-b6ff-c65df22af146\",\"order_by\":0,\"name\":\"Annette Keuning-Plantinga\",\"email\":\"data:image/png;base64,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\",\"orcid\":\"https://orcid.org/0000-0002-4361-3910\",\"institution\":\"NHL University of Applied Sciences\",\"correspondingAuthor\":true,\"submittingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Annette\",\"middleName\":\"\",\"lastName\":\"Keuning-Plantinga\",\"suffix\":\"\"},{\"id\":7079263,\"identity\":\"585b2dc3-0e2b-4e18-b231-6803447a0d85\",\"order_by\":1,\"name\":\"Evelyn J Finnema\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Rijksuniversiteit Groningen\",\"correspondingAuthor\":false,\"submittingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Evelyn\",\"middleName\":\"J\",\"lastName\":\"Finnema\",\"suffix\":\"\"},{\"id\":7079264,\"identity\":\"d9e51b90-5687-483e-9c66-03de11637975\",\"order_by\":2,\"name\":\"Wim Krijnen\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Hanzehogeschool Groningen\",\"correspondingAuthor\":false,\"submittingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Wim\",\"middleName\":\"\",\"lastName\":\"Krijnen\",\"suffix\":\"\"},{\"id\":7079265,\"identity\":\"51d63fab-c72f-4b83-a947-94ae756e8434\",\"order_by\":3,\"name\":\"David Edvardsson\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"La Trobe University School of Nursing and 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12:38:37\",\"currentVersionCode\":3,\"declarations\":\"\",\"doi\":\"10.21203/rs.2.22472/v3\",\"doiUrl\":\"https://doi.org/10.21203/rs.2.22472/v3\",\"draftVersion\":[],\"editorialEvents\":[{\"content\":\"https://doi.org/10.1186/s12913-020-06048-x\",\"type\":\"published\",\"date\":\"2021-01-13T15:01:46+00:00\"}],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":4783061,\"identity\":\"d071c5c8-9fdb-4306-8e1c-1126c0a5c679\",\"added_by\":\"auto\",\"created_at\":\"2021-01-07 17:13:32\",\"extension\":\"png\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":67497,\"visible\":true,\"origin\":\"\",\"legend\":\"Model with factor loadings, residual variances, and factor covariances (n=159)\",\"description\":\"\",\"filename\":\"fig1.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-13047/v3/08c6fa4609e96c13aab614e4.png\"},{\"id\":13644378,\"identity\":\"46d4d1db-d5dc-4650-8b8b-82077b1c730e\",\"added_by\":\"auto\",\"created_at\":\"2021-09-17 09:15:58\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":853583,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-13047/v3/11d1e964-9367-4cf5-be75-e3852423e2f6.pdf\"},{\"id\":4782968,\"identity\":\"4b8cc9da-8b4d-40f1-bb49-0c95d7367fc5\",\"added_by\":\"auto\",\"created_at\":\"2021-01-07 17:10:32\",\"extension\":\"docx\",\"order_by\":1,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":14078,\"visible\":true,\"origin\":\"\",\"legend\":\"Additional File 1 Dutch version of the POPAC\",\"description\":\"\",\"filename\":\"Additionalfile1.DutchversionofthePOPAC.docx\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-13047/v3/cc10ae425f08b21cdb6588bb.docx\"}],\"financialInterests\":\"\",\"formattedTitle\":\"\\u003cp\\u003eValidation and psychometric evaluation of the Dutch Person-centred care of Older People with cognitive impairment in Acute Care (POPAC)\\u003c/p\\u003e\",\"fulltext\":[{\"header\":\"Background\",\"content\":\"\\u003cp\\u003eWorldwide, approximately 50 million people are living with dementia. Due to the ageing population, this number will increase (1). People with dementia are regularly hospitalized due to comorbidities; they occupy approximately 25% of the hospital beds (2,3). This population is at risk for falls during a hospital stay, inadequate hydration and nutrition, delirium, infection, and functional decline (4\\u0026ndash;6). These factors impact the duration of stay, the person\\u0026rsquo;s functioning, and the care required following discharge (7). Nursing care for people with dementia should be based on evidence, best-practice care, and processes combined with person-centred care to prevent complications (6,8\\u0026ndash;11). It is known that person-centred care can improve their quality of life. In spite of that, specific knowledge about person-centred care, also referred to as patient-centred or client-centred care, is limited in hospitals (11). However, worldwide, it is the paragon in the care of people with dementia (10,12). The basis of person-centred care in caring for people with dementia is laid by Tom Kitwood (13,14). In a broader context, the framework of McCormack ad McCance is often used (15\\u0026ndash;17). In the care for people with dementia, Brooker's definition and framework are often used (3,18). To improve the quality of care for people with dementia in an acute care setting, knowledge of the level of person-centredness of the care is important. The literature reports a limited number of instruments that measure person-centred care for dementia patients in an acute hospital setting (8,19). Available instruments are aimed at long-term care (20) or more generically on person-centred care in the acute hospital setting and lack a specific focus on the quality of care for people with dementia (21\\u0026ndash;24).\\u003c/p\\u003e\\n\\u003cp\\u003eThe person-centred care of older people with cognitive impairment in acute care (POPAC) scale (19) was developed for the acute hospital setting and measures the person-centredness of care for older people with dementia. The scale consists of three subscales, which can be connected to the elements of person-centred care of the definition used. The subscale \\u0026lsquo;using cognitive assessments and care interventions\\u0026rsquo; is suitable for valuing people; \\u0026lsquo;using evidence and cognitive expertise\\u0026rsquo; is suitable for understanding situations from the perspective of the person with dementia; and \\u0026lsquo;individualizing care\\u0026rsquo; is related to individualizing approaches and the social environment. In addition to measuring and improving the quality of care, translating tools into different language versions enables international comparisons of data and comparative analysis of levels, correlations, and person-centred care outcomes. In addition, there are no Dutch-language instruments available that measure person-centred care in the hospital setting.\\u003c/p\\u003e\\n\\u003cp\\u003eThe POPAC scale was designed in 2013 by Edvardsson in Australia to establish quantitative measurements to assess experienced levels of person-centred care for people with dementia in acute hospital settings (19,25). Based on the literature, eight dimensions of best practice were used to construct the instrument. Further development with a panel of international experts led to an instrument that consisted of statements on recognizing cognitive impairment, consulting specialist expertise, using evidence-based care protocols or guidelines, making environmental adjustments, providing social enrichments, prioritizing staff continuity and close interactions, avoiding restraints, and individualizing care (19). The degree to which participants agree with item statements is expressed on a 6-point Likert scale with the categories '\\u003cem\\u003enever\\u003c/em\\u003e\\u0026rsquo; (1), \\u0026lsquo;\\u003cem\\u003every rarely\\u0026rsquo;\\u003c/em\\u003e (2), \\u0026lsquo;\\u003cem\\u003erarely\\u003c/em\\u003e\\u0026rsquo; (3), \\u0026lsquo;\\u003cem\\u003efrequently\\u003c/em\\u003e\\u0026rsquo; (4), \\u0026lsquo;\\u003cem\\u003every frequently\\u0026rsquo;\\u003c/em\\u003e (5), and \\u0026lsquo;\\u003cem\\u003ealways\\u003c/em\\u003e\\u0026rsquo; (6) (10,19,25). A significant Bartlett's spherical test and a Kaiser-Meyer-Olkin (SME) sample adequacy measurement of \\u0026gt;0.7 were used to assess the construct validity. Construct validity was then assessed using principal component analysis with oblimin rotation due to the factors' expected correlation (19).\\u003c/p\\u003e\\n\\u003cp\\u003eThe original instrument was pilot tested with a sample of 212 nurses from different types of wards, such as neurology, orthopaedics, and cardiology, in an acute care hospital in Melbourne, Australia. After the preliminary test, six items were removed because they did not meet the cutoff for acceptable homogeneity (\\u0026gt;0.3). A retest was conducted with 25 nurses from an orthopaedic ward, and the outcomes indicated satisfactory temporal stability (19). The assumption that all items reliably measure a single underlying construct was supported by the item-total correlations ranging from 0.40 to 0.67, where values 0.4 and above indicate very good discrimination (26). The subscales can be combined into a total score, where higher scores indicate higher person-centredness levels to evaluate the overall level of person-centred care. An interpretation of the score is not yet available. The totals of the items per subscale suggest possible areas for improvement of care. The instrument allows the comparison of person-centred care at both national and international levels (19).\\u003c/p\\u003e\\n\\u003cp\\u003eNilsson psychometrically evaluated the instrument in Sweden (2013), and Grealish (2017) evaluated the scale in Australia (10,25). Both Nilsson and Grealish used Cronbach\\u0026rsquo;s alpha and corrected total correlation for internal consistency and CFA for construct validity. In addition, in Nilsson's study, temporal stability was measured through the correlation between test and retest scores (10). Both studies reported that the POPAC scale is valid and reliable and can be used to provide insight into nursing care's person-centredness in a hospital setting. However, the high correlations between the subscales and the authors' conclusion that the instrument\\u0026rsquo;s dimensionality requires further research are important tenets for this study (10,25). For using the POPAC scale in the Netherlands to study person-centred care in a hospital setting, the instrument needed to be translated into Dutch. Measuring psychometric properties is important for assessing validity and reliability (27). Nurses and nursing managers can use the outcomes of the POPAC scale to improve the quality of care in their ward, and outcomes and data can be used for national and international comparison. Therefore, this study aimed to conduct a cross-national validation and psychometric evaluation of the Dutch version of the POPAC scale.\\u003c/p\\u003e\"},{\"header\":\"Methods\",\"content\":\"\\u003cp\\u003eThis study aimed to translate and validate the POPAC scale into Dutch and test the Dutch version of the questionnaires for psychometric properties among Dutch nurses working in acute hospital settings (28). Data were collected with the online questionnaire program Qualtrics\\u003csup\\u003eXM\\u003c/sup\\u003e (version 2018, Provo, UT USA).\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eThe instrument\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe POPAC scale consists of 15 items, as shown in Table 1. The items describe care procedures and processes in patients with dementia in hospitals (19). With the self-report of nurses in hospitals, the POPAC scale measures the extent to which nursing interventions are based on best practices in association with person-centred care. The items are divided into three subscales: cognitive assessments and care interventions (items 1\\u0026ndash;5), evidence and cognitive expertise (items 6\\u0026ndash;8), and individualizing care (items 9\\u0026ndash;15) (19). The scores can be evaluated per subscale, or the score of the total scale can be used. The subscale or total scale scores can be calculated by dividing the sum of the scores by the number of items, whereby higher scores imply higher levels of person-centredness (10,19,25).\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eTranslation of the person-centred \\u003c/strong\\u003e\\u003cstrong\\u003ecare\\u003c/strong\\u003e\\u003cstrong\\u003e of older people with \\u003c/strong\\u003e\\u003cstrong\\u003ecognitive impairment on the\\u003c/strong\\u003e\\u003cstrong\\u003e acute care \\u003c/strong\\u003e\\u003cstrong\\u003escale\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe instrument's principal author was involved in the translation, validation, and writing of the evaluation. Therefore, the instrument was translated according to the guidelines described by Sousa (29). Two independent translators from a certified translation agency translated the questionnaire into Dutch. Two researchers (AK and EF) independently assessed these two translations to determine the optimal translation of the question formulations and the answer options.\\u003c/p\\u003e\\n\\u003cp\\u003eDuring the translation process, there was some discussion about using the term \\u0026lsquo;cognitive functioning\\u0026rsquo; or \\u0026lsquo;cognitive status\\u0026rsquo;, whereby all translators agreed upon the choice for \\u0026lsquo;cognitive functioning\\u0026rsquo; because this term is commonly used in nursing care in the Netherlands. There were no disagreements on a lingual or cultural basis. There was unanimous consensus for the final selection of all items.\\u003c/p\\u003e\\n\\u003cp\\u003eThis Dutch version was also translated back into English by two other independent translators from the same certified translation agency. These translations were again independently assessed by the same researchers to decide on the best translation. This time, there was consensus on all of the items. The author reviewed this final English version, and the conclusion was that the outcomes closely resembled the original version. There were no specific reasons to expect systematic errors during the translation due to linguistic or cultural differences (30). The final version is attached as Additional file 1.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eSample size\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eAccording to the scientific literature, the sample size depends on the number of factors and the factor load, where a minimum sample size of 100 is recommended, and a sample size of 150 is suggested for three-phase models (30, 31). The COSMIN (Consensus-based Standards for the selection of health status measurement instruments) checklist advocates seven times the number of items (33). Based on this knowledge, the optimal sample size was at least 150 (34, 35). It may be noted that in the post hoc analysis, the sample size was sufficient for almost all estimated parameters to be (highly) significant.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eSetting, recruitment, and participants\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eSix hospitals in the northern part of the Netherlands participated in this study and were supplemented by Dutch nurses who were recruited via LinkedIn and Facebook. The data were collected in one university hospital, two non-university teaching hospitals, and three rural hospitals. The capacity of the hospitals varied from 241 to 1300 beds, with additional outpatients.\\u003c/p\\u003e\\n\\u003cp\\u003eNurses with at least three months of experience in the clinical setting, working in the direct care of people with dementia, and willing to participate were included in the study. All hospital departments were included, except for paediatrics and obstetrics. The data collection took place from July 2018 to March 2019.\\u003c/p\\u003e\\n\\u003cp\\u003eThe recruitment of participants in the hospitals was performed by contact persons working in the hospital based on a convenience sample (27). The authors also used LinkedIn and Facebook to recruit hospital nurses. A general request was made for nurses to participate via LinkedIn, in which nursing managers are active and then the call was repeated once. For Facebook, which is often used by Dutch nurses, a different approach was used for which the authors requested two groups on Facebook. One was in a private group for questionnaires of a professional nursing magazine, and the other was in an open group for nurses in general. On Facebook, a daily update of the response was provided. This Facebook group has many members; however, it is not known how many members are active.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eData analysis\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eFor the data analysis, we used IBM SPSS statistics (for Macintosh, version 25, Armonk, NY: IBM Corp.). Only complete scales were used in the data analysis. To perform confirmatory factor analysis (CFA), JASP (Version 0.11.1) with Lavaan was used (34). Before starting the analysis, Item 5 was reverse coded due to the negative wording of this item. The decision to use only completed scales was made based on the response rate of 159 complete cases instead of 164 with the inclusion of incomplete scales. Because the sample was sufficiently large and the differences in outcomes were minimal, it was decided that only completed questionnaires would be included. This makes the data as accurate as possible.\\u003c/p\\u003e\\n\\u003cp\\u003eThe Shapiro-Wilk test was used to assess the normality of the distribution. Descriptive analyses were used to describe the sample. Item performance was assessed by calculating item means and standard deviations, the inter-item correlation matrix, and the corrected item-total correlation.\\u003c/p\\u003e\\n\\u003cp\\u003eThe CFA was performed by robust maximum likelihood estimation, after which four types of fit indices were used to evaluate the fit of the model to the data: the chi-square model fit, the comparative fit index (CFI), the root mean square error of approximation (RMSEA), and the standardized root mean-square residual (SRMR). The Hoelter index was utilized to check the smallest sample size at which the chi-square interpretation would not be significant. As a criterion for significance, a p-value \\u0026lt;0.05 was used. The model fit was considered acceptable if the following criteria were met: p-value for the \\u0026chi;2 model fit compared to the baseline model smaller than 0.05, CFI and GFI values between 0.90 and 0.95 or above RMSEA and RMR values of 0.08 or below (35).\\u003c/p\\u003e\\n\\u003cp\\u003eCronbach's alpha on the total scale and its subscales were assessed to determine the internal consistency.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eEthics approval and consent to participate\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe study was performed following the Helsinki declaration, and all of the participants provided written informed consent before filling out the questionnaire. Nurses had an option to choose whether the results would also be available for further research. The Medical Ethical Committee of the University Medical Center Groningen considered approval unnecessary (decision M17.221048) because the questionnaire was intended for staff. The questionnaire was completely anonymous; no one could be identified based on the results. The managers received an email with a general explanation and a link to the questionnaire to forward it to the nurses of their team. Managers were not informed about the number of participating nurses from their ward or about their responses. Based on the contact persons' information and the response per ward, there was no reason to believe that nurses felt obliged to participate in this survey. The voluntary nature of participation was emphasized in the explanations.\\u003c/p\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eCharacteristics of the sample\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eIn total, 159 hospital nurses completed the POPAC scale; 114 nurses were recruited directly from hospitals, and 45 nurses were recruited through social media. The hospitals' general response rate was 33%, based on the managers of the participating wards\\u0026rsquo; information. More specifically, responses came from nurses working in medical (21.4%), surgical (20.1%), and geriatric (13.2%) wards as well as in wards with different combinations of specialized care (45.3%), as shown in Table 2. The education of the nurses varied from a care assistant level to a master level. The nurses had an average experience of 18 years of working with the elderly population, ranging from a few weeks to 45 years (SD 12.6). A total of 43.3% of the nurses had participated in a course in the past year about care for people with dementia. They graded their skills on caring for people with dementia with an average of 7.3 on a scale from 1 to 10 with a range from 4 to 9 (SD 0.095).\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eItem performance\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe mean score per item varied between 3.59 and 5.28, as shown in Table 3. The total score was 66.88 (SD (10.04), with a mean of 4.46 (SD 0.53). The Shapiro-Wilk test indicated that the data were skewed. The skewness per item varied between -0.04 and -1.83. Internal consistency was based on a cutoff point of Cronbach\\u0026rsquo;s alpha 0.7, an item-total correlation of 0.3, and inter-item correlations between 0.2-0.4 (26). The correlation between the different items revealed some negative correlations with Item 5. It shows a corrected item-total correlation of 0.11. The other values varied from 0.34 (Item 14) to 0.63 (Items 8 and 9). The Cronbach\\u0026rsquo;s alpha increased by 0.1 when Item 5 was deleted. The visual expectation of the data gave indications for a three-block structure.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConstruct validity\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eConstruct validity was evaluated with the CFA loadings for the items and the interfactor correlations based on ML estimation. Lavaan\\u0026rsquo;s iterative maximum likelihood estimation converged after 22 iterations. An overview of the different fit indices is shown in Table 4 and indicates an acceptable model fit. The Hoelter's critical N was 106.8, which means that the sample size was adequate.\\u003c/p\\u003e\\n\\u003cp\\u003eA chi-square test was performed to check the model fit. This test showed that the factor model differed significantly from the baseline model, \\u0026chi;2 (87, N=159) =164,84, p\\u0026lt;.001. The obtained CFI of 0.89 was slightly smaller than the cutoff value of 0.9. Both the RMSEA (0.075, p=0.012, CI 0.057-0.092) and the SRMR of 0.063 were acceptable, with values less than 0.08.\\u003c/p\\u003e\\n\\u003cp\\u003eThe CFA showed that all loadings were fairly large, positive, and significantly different from zero, as presented in Table 5 with Item 5 as the only exception. The factor correlations were between 0.69 and 0.77, indicating that the factors were strongly associated.\\u003c/p\\u003e\\n\\u003cp\\u003eFigure 1 provides the final model with significant correlations between the subscales, residual variances, and factor covariances.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eInternal consistency\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eFor measuring internal consistency, Item 5 was reversed. The total instrument\\u0026rsquo;s internal consistency measured by Cronbach\\u0026rsquo;s alpha was 0.85 (CI 0.82-0.88). The internal consistency of using cognitive assessments and care interventions was 0.60 (CI 0.45-0.66) with item five and 0.72 (CI 0.63-0.78) without it; using evidence and cognitive expertise had an internal consistency of 0.78 (CI 0.70-0.83) and individualizing care 0.8 (CI 0.74-0.84).\\u003c/p\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eThis study aimed to translate and validate the Dutch version of the POPAC scale and evaluate the psychometric properties to make international comparisons possible. The outcomes confirm that this Dutch version of the POPAC scale is a valid and reliable instrument for measuring person-centred care and the quality of care of people with dementia in acute care (10,19,25).\\u003c/p\\u003e\\n\\u003cp\\u003eThe results obtained from the factor analysis with three factors were comparable with those from earlier research (10,19,25). All of the earlier studies derived a three-factor solution whereby Nilsson found that Cronbach\\u0026rsquo;s alpha values of Subscales 2 (using evidence and cognitive expertise) and 3 (using evidence and cognitive expertise) did not reach the necessary cutoff point of 0.7 (10). Grealish used an exploratory factor analysis because the items did not meet the predetermined cutoff points for using confirmatory factor analysis (25). They created a revised version of the instrument in which Item 5, concerning leaving people with cognitive impairments alone in the ward, was deleted, and several items were grouped into another subscale. The model fit confirmed the three-factor solution. That is, the Chi-square rejected the model. However, this test has been found to be unreliable for small sample sizes (36). The CFI indicated a nearly acceptable model fit, as with Nilsson and Grealish, who reported CFIs of 0.88 and 0.90, respectively (10,25). The RMSEA and the SRMR suggested an acceptable model fit (36). However, the findings confirmed the three-dimensional structure suggested by previous research. The loadings of the items indicate that these are strong associations with each of the factors. In addition, the factor correlations also indicated that there were strong associations, which indicated that the factors were strongly associated with one general factor of the POPAC scale. Future research is necessary to elucidate the scientific benefits of distinguishing three factors in explaining person-centred care over that of a single generic POPAC factor. The Dutch version of the POPAC scale has similar results as the Edvardsson and Nilsson study (10,19). Grealish assigned three variables to other subscales 925). In the current study, evidence was found that the POPAC has psychometric properties very similar to those previously reported in the literature. For this reason, the POPAC can be applied in the Netherlands as three separate subscales as well as a total scale measuring the level of person-centred care.\\u003c/p\\u003e\\n\\u003cp\\u003eFurthermore, Cronbach\\u0026rsquo;s alpha of 0.86 corresponds with earlier research in which the internal consistency varies from 0.83 to 0.87. (10,19,25). Additionally, this research confirms that, statistically, Item 5 (about leaving patients with cognitive impairments alone), which is on the \\u0026lsquo;Using cognitive assessments and care interventions\\u0026rsquo; subscale, could be deleted to improve the instrument\\u0026rsquo;s internal consistency. This is because this subscale has an internal consistency of 0.6, which is lower than the cutoff of 0.7 (26,27). Instead of deleting this item, the authors suggest rephrasing it into a positively worded item. It is the only negatively formulated item, which may influence the outcomes. The background of the instrument's construction can provide direction in changing the focus of this question. Nurses are always present in the hospital ward, so they do not experience leaving patients by themselves. However, this does not mean that people with dementia are always visible to nurses and monitored when needed, which might influence care. Our suggestion is to reformulate this question from:\\u003c/p\\u003e\\n\\u003cp\\u003e\\u0026ldquo;\\u003cem\\u003eWe leave older people with cognitive impairments alone in the ward.\\u0026rdquo;\\u003c/em\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eto:\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003e\\u0026ldquo;We make sure older people with cognitive impairments are not left alone in the ward\\u003c/em\\u003e.\\\"\\u003c/p\\u003e\\n\\u003cp\\u003eThe mean scores in our study were higher than the scores in earlier studies. A higher score reflects a higher level of the construct of person-centred care (19). This score can partly be explained by the obtained high score found for Item 1 regarding assessing cognitive status. In the Netherlands, assessing cognition is a criterion on which hospital care quality is judged, which might have influenced this positive outcome.\\u003c/p\\u003e\\n\\u003cp\\u003eScores on the POPAC scale among a sample of nurses can be utilized to measure the level of person-centred care for people with dementia in hospitals. Nursing professionals and nursing managers can use the outcomes as indicators to determine which areas of care can be improved in their ward (37). Additionally, the POPAC scale can be used in the education of nurses and nursing students to create awareness of person-centred care. The POPAC scale is applicable in research on person-centred care, for example, to investigate if a relationship exists between the outcomes of the POPAC scale and complications such as falls, poor hydration and nutrition, delirium, infection, and functional decline. It can also be used to determine whether there is a relation between the level of person-centredness of the care and the length of the hospital stay. In brief, the POPAC scale can be applied to investigate various important research questions regarding interventions for people with cognitive impairment in acute wards. The authors will use this instrument to determine nurses' perceptions of person-centred care for people with dementia.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eLimitations\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe POPAC scale is a relatively novel instrument, and its validity and reliability need to be further developed. There is no gold standard available to compare the results with. This study aimed to measure the validity by using factor analysis, as in previous studies. This was done using one group. To improve construct validity, the authors suggest using other methods to strengthen the theoretical basis, such as item response theory, the use of multiple groups, and a test-retest construction.\\u003c/p\\u003e\\n\\u003cp\\u003eOur study had a lower response rate (33%) in the hospital setting than those of previous studies, e.g., 59% (19), 51% (10), and 54.3% (25), possibly due to the different methods of recruiting responders. There were two primary aspects. On the one hand, nursing managers did not always want to cooperate because there were only a small number of people with dementia in their ward, or they perceived no added value in the study. This could result in a nonresponse bias and affect the external validity of the study. The nonresponse may have caused some bias in the direction of the null. However, since our results were mainly in line with those previously found in the literature, we consider this bias to be relatively weak.\\u003c/p\\u003e\\n\\u003cp\\u003eBy using a convenience sample, participating nurses with a high affinity for the topic may be overrepresented. This leads to a limitation of the external validity and, consequently, the generalization. Since the recruitment was rather general, yielding a rather broad sample of participants, we expect the results to be generalizable for the setting of general hospitals. In future research, it may be useful to validate actual care provision and behaviour in practical working situations. However, the combination of nurses from hospitals and via social media provided a significant scope of the Netherlands.\\u003c/p\\u003e\\n\\u003cp\\u003eThe questionnaire was conducted in combination with another lengthy questionnaire. The numerous questions negatively influenced the motivations to complete the questionnaire, which could have caused missing information. This may affect internal validity negatively. We used different orders of the questionnaire to prevent this bias.\\u003c/p\\u003e\"},{\"header\":\"Conclusions\",\"content\":\"\\u003cp\\u003eThe findings of this study confirm the validity and reliability of the Dutch version of the POPAC scale. However, the results provide grounds for further research on the instrument's dimensionality with a rephrased Item 5. The results can help nursing managers improve person-centred care in hospitals for people with dementia. The authors advise using total sum scores for interpretation of the scale for national and international comparison. Further research can provide insight into the relationship of person-centred care with the quality of care and nurse-sensitive outcomes, such as preventing complications hospital stay length.\\u003c/p\\u003e\\n\\u003ch3\\u003eImplications for nursing practice\\u003c/h3\\u003e\\n\\u003cp\\u003eThe results are of significance for nurses in facilitating the improvement\\u0026nbsp;of care for people with dementia.\\u0026nbsp;The instrument can be used to hold reflective discussions in clinical settings about the extent to which nurses can perform person-centred care and how they can improve this care.\\u0026nbsp;This study's findings also enable the broader use of the POPAC scale: a total sum score can be calculated and consequently used to determine and interpret the level of\\u0026nbsp;person-centred care. Person-centred care\\u0026nbsp;and evidence-based nursing are important ingredients for high-quality nursing care for people with cognitive impairments.\\u0026nbsp;Therefore, the instrument is easy for nurses to use as an instrument for practice improvement. Furthermore, nurses can employ the results of the POPAC scale for benchmarking the level of\\u0026nbsp;person-centred care\\u0026nbsp;at a hospital as well as on a national or international level.\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eEthics approval and consent to participate\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe study was performed following the Helsinki declaration, and all of the participants provided written informed consent before filling out the questionnaire. Nurses had an option to choose whether the results would also be available for further research. The Medical Ethical Committee of the University Medical Centre Groningen considered approval unnecessary (decision M17.221048) because the questionnaire was intended for staff. The questionnaire was completely anonymous; no one could be identified based on the results.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConsent for publication\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eNot applicable.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAvailability of data and materials\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe datasets generated and analysed during the current study are not publicly available, as more papers will be written based on this dataset. The corresponding author can provide data upon reasonable request.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eCompeting interests\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe authors declare that they have no competing interests.\\u003c/p\\u003e\\n\\u003ch1\\u003eFunding\\u003c/h1\\u003e\\n\\u003cp\\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAuthors\\u0026rsquo; contribution\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eAKP, EJF, and PFR were responsible for the study design. AKP and EJP were responsible for the translation process. AKP performed the data collection. AKP and WK contributed to the data analysis and interpretation of the data. AKP, EJP. WK, DE and PFR were involved in drafting and revising the manuscript critically for important intellectual content and gave final approval of the version to be published.\\u003c/p\\u003e\\n\\u003ch1\\u003eAcknowledgements\\u003c/h1\\u003e\\n\\u003cp\\u003eThe authors would like to thank all participating nurses for completing the questionnaires and all contact persons in the hospitals for their help with distributing the questionnaires.\\u003c/p\\u003e\\n\\u003ch1\\u003eAuthors\\u0026rsquo; information\\u003c/h1\\u003e\\n\\u003cp\\u003eAKP: RN, MSc, Ph.D.-candidate\\u003c/p\\u003e\\n\\u003cp\\u003eEJF: Ph.D. Professor\\u003c/p\\u003e\\n\\u003cp\\u003eWK: Ph.D. Professor\\u003c/p\\u003e\\n\\u003cp\\u003eED: RN, Ph.D. Professor\\u003c/p\\u003e\\n\\u003cp\\u003ePFR: Ph.D. Professor\\u003c/p\\u003e\"},{\"header\":\"Abbreviations\",\"content\":\"\\u003cp\\u003eCFA: Confirmatory Factor Analysis; CFI: Comparative Fit Index; CI: Confidence interval; COSMIN: Consensus-based Standards for the selection of health status Measurement Instruments; POPAC: Person-centred care of Older People with cognitive impairment in Acute Care; RMSEA: Root Mean Square Error of Approximation; SD: Standard deviation; SRMR: Standardized Root Mean-square Residual\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\n\\u003cli\\u003eWorld Health Organization. Key Facts [Internet]. World Health Organization. 2017. p. 5. Available from: http://www.who.int/news-room/fact-sheets/detail/dementia\\u003c/li\\u003e\\n\\u003cli\\u003eNederlandse vereniging voor klinische geriatrie. Addendum dementie comorbiditeit in het ziekenhuis 2016-08. Utrecht; 2015.\\u003c/li\\u003e\\n\\u003cli\\u003eBrooker D, Milosevic S, Evans S, Bruce M, Thompson R. RCN Development Programme: Transforming Dementia Care in Hospitals Evaluation Report [Internet]. Worcester; 2014. Available from: http://www.worcester.ac.uk/documents/FULL_RCN_report_Transforming_dementia_care_in_hospital.pdf\\u003c/li\\u003e\\n\\u003cli\\u003eWeitzel T, Robinson S, Barnes MR, Berry TA, Holmes JM, Mercer S, et al. The special needs of the hospitalized patient with dementia. Medsurg Nurs. 2011 Jan;20(1):13-18;\\u003c/li\\u003e\\n\\u003cli\\u003eGladman J, Porock D. Better Mental Health: Care for Older People with Cognitive Impairment in General Hospitals. Final report NIHR Service Delivery and Organisation programme [Internet]. 2012. Available from: http://www.netscc.ac.uk/netscc/hsdr/files/project/SDO_FR_08-1809-227_V01.pdf\\u003c/li\\u003e\\n\\u003cli\\u003eDewing J, Dijk S. What is the current state of care for older people with dementia in general hospitals? A literature review. Dement Int J Soc Res Pract [Internet]. 2016 Jan;15(1471-3012 (Linking)):106\\u0026ndash;24. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24459188\\u003c/li\\u003e\\n\\u003cli\\u003eHandley M, Bunn F, Goodman C. Dementia-friendly interventions to improve the care of people living with dementia admitted to hospitals: a realist review. BMJ Open [Internet]. 2017 Jul 16;7(2044-6055 (Linking)):e015257. Available from: http://bmjopen.bmj.com/lookup/doi/10.1136/bmjopen-2016-015257\\u003c/li\\u003e\\n\\u003cli\\u003eFogg C, Griffiths P, Meredith P, Bridges J. Hospital outcomes of older people with cognitive impairment: An integrative review. Int J Geriatr Psychiatry. 2018;33:1177\\u0026ndash;97.\\u003c/li\\u003e\\n\\u003cli\\u003eClissett P, Porock D, Harwood RH, Gladman JRF. The challenges of achieving person-centred care in acute hospitals: A qualitative study of people with dementia and their families. Int J Nurs Stud. 2013;50:1495\\u0026ndash;503.\\u003c/li\\u003e\\n\\u003cli\\u003eNilsson A, Lindkvist M, Rasmussen BH, Edvardsson D. Measuring levels of person-centeredness in acute care of older people with cognitive impairment: evaluation of the POPAC scale. BMCHealth ServRes [Internet]. 2013 Aug 19 [cited 2018 Mar 6];13(1472-6963 (Linking)):327. Available from: http://bmchealthservres.biomedcentral.com/articles/10.1186/1472-6963-13-327\\u003c/li\\u003e\\n\\u003cli\\u003eSurr CA, Smith SJ, Crossland J, Robins J. Impact of a person-centred dementia care training programme on hospital staff attitudes, role efficacy and perceptions of caring for people with dementia: A repeated measures study. Int J Nurs Stud. 2016 Jan;53(0020-7489 (Linking)):144\\u0026ndash;51.\\u003c/li\\u003e\\n\\u003cli\\u003eThe American Geriatrics Society Expert Panel on Person-Centered Care. Person-Centered Care: A Definition and Essential Elements. Am Geriatr Soc. 2016;JANUARY 20(1):15\\u0026ndash;8.\\u003c/li\\u003e\\n\\u003cli\\u003eKitwood T. Towards a Theory of Dementia Care: The Interpersonal Process. Ageing Soc [Internet]. 1993 [cited 2020 Jan 13];13(1):51\\u0026ndash;67. Available from: https://doi.org/10.1017/S0144686X00000647\\u003c/li\\u003e\\n\\u003cli\\u003eKitwood T. Dementia Reconsidered: The Person Comes First. Berkshire, UK: Open Univer- sity Press; 1997.\\u003c/li\\u003e\\n\\u003cli\\u003eMcCormack B, McCance T. Person-Centred Nursing: Theory and Practice. Person-Centred Nursing: Theory and Practice. 2010. 1\\u0026ndash;194 p.\\u003c/li\\u003e\\n\\u003cli\\u003eBorg M, Cardiff S, Dewing J, Jacobs G, Janes N, Karlsson B, et al. Person-centredness - the \\u0026ldquo;state\\u0026rdquo; of the art. Int Pract Dev J [Internet]. 2015;5:1\\u0026ndash;15. Available from: http://ro.uow.edu.au/smhpapers/3798\\u003c/li\\u003e\\n\\u003cli\\u003eMcCance T, Gribben B, McCormack B, Laird L. Promoting person-centred practice within acute care: the impact of culture and context on a facilitated practice development programme. Int Pract Dev J. 2013;3(1):1\\u0026ndash;17.\\u003c/li\\u003e\\n\\u003cli\\u003eLaird EA, McCance T, McCormack B, Gribben B. Patients\\u0026rsquo; experiences of in-hospital care when nursing staffwere engaged in a practice development programme to promote person-centredness: A narrative analysis study. Int J Nurs Stud [Internet]. 2014;52(9):1454\\u0026ndash;62. Available from: http://dx.doi.org/10.1016/j.ijnurstu.2015.05.002\\u003c/li\\u003e\\n\\u003cli\\u003eEdvardsson D, Nilsson A, Fetherstonhaugh D, Nay R, Crowe S. The person-centred care of older people with cognitive impairment in acute care scale (POPAC). JNursManag. 2013 Jan;21(0966-0429 (Linking)):79\\u0026ndash;86.\\u003c/li\\u003e\\n\\u003cli\\u003eEdvardsson D, Fetherstonhaugh D, Nay R, Gibson S. Development and initial testing of the Person-centered Care Assessment Tool (P-CAT). Int Psychogeriatrics [Internet]. 2010 Feb;22(1):101\\u0026ndash;8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19631005\\u003c/li\\u003e\\n\\u003cli\\u003eSuhonen R, Gustafsson ML, Katajisto J, V\\u0026auml;lim\\u0026auml;ki M, Leino-Kilpi H. Individualized care scale - Nurse version: A Finnish validation study. J Eval Clin Pract [Internet]. 2010 [cited 2019 Nov 1];16(1):145\\u0026ndash;54. Available from: https://onlinelibrary-wiley-com.proxy-ub.rug.nl/doi/pdfdirect/10.1111/j.1365-2753.2009.01168.x\\u003c/li\\u003e\\n\\u003cli\\u003eEdvardsson D, Sandman PO, Rasmussen B. Construction and psychometric evaluation of the Swedish language Person-centred Climate Questionnaire - Staff version. J Nurs Manag. 2009;17(7):790\\u0026ndash;5.\\u003c/li\\u003e\\n\\u003cli\\u003eWolverton CL, Lasiter S, Duffy JR, Weaver MT, McDaniel AM. Psychometric testing of the caring assessment tool: Administration (CAT-Adm \\u0026copy; ) . SAGE Open Med. 2018;6:205031211876073.\\u003c/li\\u003e\\n\\u003cli\\u003eSlater P, Mccance T, Mccormack B. The development and testing of the Person-centred Practice Inventory - Staff (PCPI-S). Int J Qual Heal Care. 2017;29(4):541\\u0026ndash;7.\\u003c/li\\u003e\\n\\u003cli\\u003eGrealish L, Chaboyer W, Harbeck E, Edvardsson D. The person-centred care of older people with cognitive impairment in acute care (POPAC) scale - psychometric evaluation. JNursManag. 2017 Mar;25(0966-0429 (Linking)):139\\u0026ndash;47.\\u003c/li\\u003e\\n\\u003cli\\u003eField A. Discovering Statistics Using IBM SPSS [Internet]. 4TH ed. Michal Carmichael, editor. Discovering Statistics Using SPSS. Los Angeles/London/ New Delhi: Sage Publications, Ltd; 2013 [cited 2018 Oct 10]. 1\\u0026ndash;916 p. Available from: http://www.fb4all.com/download/ebooks/statistics/%23Discovering Statistics Using SPSS 2013.pdf\\u003c/li\\u003e\\n\\u003cli\\u003ePolit DF, Beck CT. Nursing Research Generating and Assessing Evidence for Nursing Practice. 10th ed. Burns C, editor. Nurse Education in Practice. Philadelphia: Wolters Kluwer Health; 2017. 784 p.\\u003c/li\\u003e\\n\\u003cli\\u003eArafat SMY. Validation study can be a separate study design. Int J Med Sci Public Heal [Internet]. 2016;5(11):2421\\u0026ndash;2. Available from: http://www.scopemed.org/?mno=225923\\u003c/li\\u003e\\n\\u003cli\\u003eSousa VD, Rojjanasrirat W. Translation, adaptation and validation of instruments or scales for use in cross-cultural health care research: A clear and user-friendly guideline. J Eval Clin Pract. 2011;17(2):268\\u0026ndash;74.\\u003c/li\\u003e\\n\\u003cli\\u003eManeesriwongul W, Dixon JK. Instrument translation process: a methods review. J Adv Nurs [Internet]. 2004;48(2):175\\u0026ndash;86. Available from: http://gateway.library.qut.edu.au/login?url=http://search.ebscohost.com/login.aspx?direct=true\\u0026amp;db=c8h\\u0026amp;AN=2004209102\\u0026amp;site=ehost-live\\u0026amp;scope=site\\u003c/li\\u003e\\n\\u003cli\\u003eBoomsma A. Monte Carlo design. Psychometrika [Internet]. 1985 [cited 2019 Dec 13];50(2):229\\u0026ndash;42. Available from: https://link-springer-com.proxy-ub.rug.nl/content/pdf/10.1007%2FBF02294248.pdf\\u003c/li\\u003e\\n\\u003cli\\u003eWolf EJ, Harrington KM, Clark SL, Miller MW. Sample Size Requirements for Structural Equation Models: An Evaluation of Power, Bias, and Solution Propriety. Educ Psychol Meas [Internet]. 2013 [cited 2019 Nov 18];73(6):913\\u0026ndash;34. Available from: https://journals.sagepub.com/doi/pdf/10.1177/0013164413495237\\u003c/li\\u003e\\n\\u003cli\\u003eMokkink LB, Terwee CB, Patrick DL, Alonso J, Stratford PW, Knol DL, et al. The COSMIN checklist for assessing the methodological quality of studies on measurement properties of health status measurement instruments: an international Delphi study. Qual Life Res [Internet]. 2010 May [cited 2019 Jun 13];19(4):539\\u0026ndash;49. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20169472\\u003c/li\\u003e\\n\\u003cli\\u003eRosseel Y. Lavaan: An R package for structural equation modeling. J Stat Softw. 2012;48(2).\\u003c/li\\u003e\\n\\u003cli\\u003eSchreiber JB. Modeling and Confirmatory Factor Analysis Results : A Review. Th J Educ Res [Internet]. 2006 [cited 2019 Nov 22];99(09):323\\u0026ndash;37. Available from: https://steinhardtapps.es.its.nyu.edu/create/courses/3311/reading/7-Reporting_SEM_and_CFA__Schreiber__Stage__King__Nora__Barlow_.pdf\\u003c/li\\u003e\\n\\u003cli\\u003eHarrington D. Confirmatory Factor Analysis [Internet]. Confirmatory Factor Analysis. 2009 [cited 2019 Nov 25]. 1\\u0026ndash;128 p. Available from: www.oxfordscholarship.com\\u003c/li\\u003e\\n\\u003cli\\u003eKodama Y, Fukahori H. Nurse managers\\u0026rsquo; attributes to promote change in their wards: a\\u0026nbsp;qualitative study. Nurs Open. 2017;4(4):209\\u0026ndash;17.\\u003c/li\\u003e\\n\\u003c/ol\\u003e\"},{\"header\":\"Tables\",\"content\":\"\\u003cp style=\\\"margin: 0in;font-family: Calibri, sans-serif;\\\"\\u003e\\u003cstrong\\u003e\\u003cspan style=\\\"font-size: 11px; font-family: Verdana, Geneva, sans-serif; color: rgb(0, 0, 0);\\\"\\u003eTable 1\\u003c/span\\u003e\\u003c/strong\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u0026nbsp;Original items POPAC (Edvarsson, 2013)\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n\\u003ctable border=\\\"1\\\" cellpadding=\\\"0\\\" cellspacing=\\\"0\\\" style=\\\"border-collapse: collapse;border: none;\\\"\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd colspan=\\\"2\\\" style=\\\"width: 666.25pt;border-top-width: 1pt;border-style: solid none;border-top-color: black;border-bottom-width: 1pt;border-bottom-color: rgb(127, 127, 127);padding: 0in 5.4pt;vertical-align: top;\\\" valign=\\\"top\\\" width=\\\"100%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;line-height: 18.399999618530273px;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cstrong\\u003e\\u003cspan style=\\\"line-height: 16.100000381469727px;\\\"\\u003eItem\\u003c/span\\u003e\\u003c/strong\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 22.8pt;border: none;padding: 0in 5.4pt;vertical-align: top;\\\" valign=\\\"top\\\" width=\\\"3.3783783783783785%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;line-height: 18.399999618530273px;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cstrong\\u003e\\u003cspan style=\\\"line-height: 16.100000381469727px;\\\"\\u003e1\\u003c/span\\u003e\\u003c/strong\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 643.45pt;border: none;padding: 0in 5.4pt;vertical-align: top;\\\" valign=\\\"top\\\" width=\\\"96.62162162162163%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;line-height: 18.399999618530273px;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cspan style=\\\"line-height: 16.100000381469727px;\\\"\\u003eWe assess the cognitive status of our older patients on admission\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 22.8pt;border: none;padding: 0in 5.4pt;vertical-align: top;\\\" valign=\\\"top\\\" width=\\\"3.3783783783783785%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;line-height: 18.399999618530273px;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cstrong\\u003e\\u003cspan style=\\\"line-height: 16.100000381469727px;\\\"\\u003e2\\u003c/span\\u003e\\u003c/strong\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 643.45pt;border: none;padding: 0in 5.4pt;vertical-align: top;\\\" valign=\\\"top\\\" width=\\\"96.62162162162163%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;line-height: 18.399999618530273px;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cspan style=\\\"line-height: 16.100000381469727px;\\\"\\u003eWe make environmental adjustments to avoid over-stimulation in older people with cognitive impairment (e.g. single rooms, noise reductions etc.)\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 22.8pt;border: none;padding: 0in 5.4pt;vertical-align: top;\\\" valign=\\\"top\\\" width=\\\"3.3783783783783785%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;line-height: 18.399999618530273px;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cstrong\\u003e\\u003cspan style=\\\"line-height: 16.100000381469727px;\\\"\\u003e3\\u003c/span\\u003e\\u003c/strong\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 643.45pt;border: none;padding: 0in 5.4pt;vertical-align: top;\\\" valign=\\\"top\\\" width=\\\"96.62162162162163%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;line-height: 18.399999618530273px;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cspan style=\\\"line-height: 16.100000381469727px;\\\"\\u003eWe diagnose symptoms of cognitive impairment (e.g. dementias, delirium etc.)\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 22.8pt;border: none;padding: 0in 5.4pt;vertical-align: top;\\\" valign=\\\"top\\\" width=\\\"3.3783783783783785%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;line-height: 18.399999618530273px;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cstrong\\u003e\\u003cspan style=\\\"line-height: 16.100000381469727px;\\\"\\u003e4\\u003c/span\\u003e\\u003c/strong\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 643.45pt;border: none;padding: 0in 5.4pt;vertical-align: top;\\\" valign=\\\"top\\\" width=\\\"96.62162162162163%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;line-height: 18.399999618530273px;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cspan style=\\\"line-height: 16.100000381469727px;\\\"\\u003eWe spend more time with older patients with cognitive impairments as compared to cognitively intact patients\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 22.8pt;border: none;padding: 0in 5.4pt;vertical-align: top;\\\" valign=\\\"top\\\" width=\\\"3.3783783783783785%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;line-height: 18.399999618530273px;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cstrong\\u003e\\u003cspan style=\\\"line-height: 16.100000381469727px;\\\"\\u003e5\\u003c/span\\u003e\\u003c/strong\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 643.45pt;border: none;padding: 0in 5.4pt;vertical-align: top;\\\" valign=\\\"top\\\" width=\\\"96.62162162162163%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;line-height: 18.399999618530273px;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cspan style=\\\"line-height: 16.100000381469727px;\\\"\\u003eWe leave older people with cognitive impairments alone in the ward\\u0026nbsp;\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 22.8pt;border: none;padding: 0in 5.4pt;vertical-align: top;\\\" valign=\\\"top\\\" width=\\\"3.3783783783783785%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;line-height: 18.399999618530273px;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cstrong\\u003e\\u003cspan style=\\\"line-height: 16.100000381469727px;\\\"\\u003e6\\u003c/span\\u003e\\u003c/strong\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 643.45pt;border: none;padding: 0in 5.4pt;vertical-align: top;\\\" valign=\\\"top\\\" width=\\\"96.62162162162163%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;line-height: 18.399999618530273px;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cspan style=\\\"line-height: 16.100000381469727px;\\\"\\u003eWe use evidence-based tools to assess cognitive status of older patients (e.g. the MMSE, SPMSQ, CAM)\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 22.8pt;border: none;padding: 0in 5.4pt;vertical-align: top;\\\" valign=\\\"top\\\" width=\\\"3.3783783783783785%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;line-height: 18.399999618530273px;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cstrong\\u003e\\u003cspan style=\\\"line-height: 16.100000381469727px;\\\"\\u003e7\\u003c/span\\u003e\\u003c/strong\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 643.45pt;border: none;padding: 0in 5.4pt;vertical-align: top;\\\" valign=\\\"top\\\" width=\\\"96.62162162162163%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;line-height: 18.399999618530273px;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cspan style=\\\"line-height: 16.100000381469727px;\\\"\\u003eWe consult specialist expertise (e.g. psychologist, gerontologist) if we find that a patient has cognitive impairment\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 22.8pt;border: none;padding: 0in 5.4pt;vertical-align: top;\\\" valign=\\\"top\\\" width=\\\"3.3783783783783785%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;line-height: 18.399999618530273px;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cstrong\\u003e\\u003cspan style=\\\"line-height: 16.100000381469727px;\\\"\\u003e8\\u003c/span\\u003e\\u003c/strong\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 643.45pt;border: none;padding: 0in 5.4pt;vertical-align: top;\\\" valign=\\\"top\\\" width=\\\"96.62162162162163%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;line-height: 18.399999618530273px;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cspan style=\\\"line-height: 16.100000381469727px;\\\"\\u003eWe use evidence-based care guidelines in the care of older cognitively impaired patients\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 22.8pt;border: none;padding: 0in 5.4pt;vertical-align: top;\\\" valign=\\\"top\\\" width=\\\"3.3783783783783785%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;line-height: 18.399999618530273px;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cstrong\\u003e\\u003cspan style=\\\"line-height: 16.100000381469727px;\\\"\\u003e9\\u003c/span\\u003e\\u003c/strong\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 643.45pt;border: none;padding: 0in 5.4pt;vertical-align: top;\\\" valign=\\\"top\\\" width=\\\"96.62162162162163%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;line-height: 18.399999618530273px;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cspan style=\\\"line-height: 16.100000381469727px;\\\"\\u003eWe use biographical information about older patients (e.g. habits, interests and wishes etc.) to plan their care\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 22.8pt;border: none;padding: 0in 5.4pt;vertical-align: top;\\\" valign=\\\"top\\\" width=\\\"3.3783783783783785%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;line-height: 18.399999618530273px;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cstrong\\u003e\\u003cspan style=\\\"line-height: 16.100000381469727px;\\\"\\u003e10\\u003c/span\\u003e\\u003c/strong\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 643.45pt;border: none;padding: 0in 5.4pt;vertical-align: top;\\\" valign=\\\"top\\\" width=\\\"96.62162162162163%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;line-height: 18.399999618530273px;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cspan style=\\\"line-height: 16.100000381469727px;\\\"\\u003eWe involve family members in the care of older patients with cognitive impairment\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 22.8pt;border: none;padding: 0in 5.4pt;vertical-align: top;\\\" valign=\\\"top\\\" width=\\\"3.3783783783783785%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;line-height: 18.399999618530273px;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cstrong\\u003e\\u003cspan style=\\\"line-height: 16.100000381469727px;\\\"\\u003e11\\u003c/span\\u003e\\u003c/strong\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 643.45pt;border: none;padding: 0in 5.4pt;vertical-align: top;\\\" valign=\\\"top\\\" width=\\\"96.62162162162163%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;line-height: 18.399999618530273px;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cspan style=\\\"line-height: 16.100000381469727px;\\\"\\u003eWe provide staff continuity for older patients with cognitive impairments (e.g. the same nurses providing care to these patients as often as possible)\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 22.8pt;border: none;padding: 0in 5.4pt;vertical-align: top;\\\" valign=\\\"top\\\" width=\\\"3.3783783783783785%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;line-height: 18.399999618530273px;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cstrong\\u003e\\u003cspan style=\\\"line-height: 16.100000381469727px;\\\"\\u003e12\\u003c/span\\u003e\\u003c/strong\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 643.45pt;border: none;padding: 0in 5.4pt;vertical-align: top;\\\" valign=\\\"top\\\" width=\\\"96.62162162162163%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;line-height: 18.399999618530273px;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cspan style=\\\"line-height: 16.100000381469727px;\\\"\\u003eWe systematically evaluate whether or not older patients with cognitive impairment receive care that meets their needs\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 22.8pt;border: none;padding: 0in 5.4pt;vertical-align: top;\\\" valign=\\\"top\\\" width=\\\"3.3783783783783785%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;line-height: 18.399999618530273px;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cstrong\\u003e\\u003cspan style=\\\"line-height: 16.100000381469727px;\\\"\\u003e13\\u003c/span\\u003e\\u003c/strong\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 643.45pt;border: none;padding: 0in 5.4pt;vertical-align: top;\\\" valign=\\\"top\\\" width=\\\"96.62162162162163%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;line-height: 18.399999618530273px;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cspan style=\\\"line-height: 16.100000381469727px;\\\"\\u003eWe involve older patients with cognitive impairment in decisions about their care (e.g. examinations, treatments etc.)\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 22.8pt;border: none;padding: 0in 5.4pt;vertical-align: top;\\\" valign=\\\"top\\\" width=\\\"3.3783783783783785%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;line-height: 18.399999618530273px;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cstrong\\u003e\\u003cspan style=\\\"line-height: 16.100000381469727px;\\\"\\u003e14\\u003c/span\\u003e\\u003c/strong\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 643.45pt;border: none;padding: 0in 5.4pt;vertical-align: top;\\\" valign=\\\"top\\\" width=\\\"96.62162162162163%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;line-height: 18.399999618530273px;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cspan style=\\\"line-height: 16.100000381469727px;\\\"\\u003eWe ensure that older patients with cognitive impairment have tests/examinations/consultations in the unit rather than having to go to another department\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 22.8pt;border-style: none none solid;border-bottom-width: 1pt;border-bottom-color: rgb(127, 127, 127);padding: 0in 5.4pt;vertical-align: top;\\\" valign=\\\"top\\\" width=\\\"3.3783783783783785%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;line-height: 18.399999618530273px;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cstrong\\u003e\\u003cspan style=\\\"line-height: 16.100000381469727px;\\\"\\u003e15\\u003c/span\\u003e\\u003c/strong\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 643.45pt;border-style: none none solid;border-bottom-width: 1pt;border-bottom-color: rgb(127, 127, 127);padding: 0in 5.4pt;vertical-align: top;\\\" valign=\\\"top\\\" width=\\\"96.62162162162163%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;line-height: 18.399999618530273px;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cspan style=\\\"line-height: 16.100000381469727px;\\\"\\u003eWe discuss ways to meet the complex care needs of people with cognitive impairment\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cbr\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n\\u003cp style=\\\"margin: 0in;font-family: Calibri, sans-serif;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cstrong\\u003eTable 2\\u0026nbsp;\\u003c/strong\\u003eCharacteristics of nurses (n=159)\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n\\u003ctable border=\\\"1\\\" cellpadding=\\\"0\\\" cellspacing=\\\"0\\\" style=\\\"border-collapse: collapse;border: none;\\\"\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 59.35pt;border-top-width: 1pt;border-style: solid none;border-top-color: black;border-bottom-width: 1pt;border-bottom-color: black;padding: 0in 5.4pt;vertical-align: top;\\\" valign=\\\"top\\\" width=\\\"13.079470198675496%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u0026nbsp;\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 67.8pt;border-top-width: 1pt;border-style: solid none;border-top-color: black;border-bottom-width: 1pt;border-bottom-color: black;padding: 0in 5.4pt;vertical-align: top;\\\" valign=\\\"top\\\" width=\\\"14.900662251655628%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u0026nbsp;\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"2\\\" style=\\\"width: 109.2pt;border-top-width: 1pt;border-style: solid none;border-top-color: black;border-bottom-width: 1pt;border-bottom-color: black;padding: 0in 5.4pt;vertical-align: top;\\\" valign=\\\"top\\\" width=\\\"24.172185430463575%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cstrong\\u003eDirectly from hospital\\u003c/strong\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"2\\\" style=\\\"width: 108.65pt;border-top-width: 1pt;border-style: solid none;border-top-color: black;border-bottom-width: 1pt;border-bottom-color: black;padding: 0in 5.4pt;vertical-align: top;\\\" valign=\\\"top\\\" width=\\\"24.00662251655629%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cstrong\\u003eVia Social Media\\u003c/strong\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"2\\\" style=\\\"width: 107.8pt;border-top-width: 1pt;border-style: solid none;border-top-color: black;border-bottom-width: 1pt;border-bottom-color: black;padding: 0in 5.4pt;vertical-align: top;\\\" valign=\\\"top\\\" width=\\\"23.841059602649008%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cstrong\\u003eTotal\\u003c/strong\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 59.35pt;border: none;padding: 0in 5.4pt;vertical-align: top;\\\" valign=\\\"top\\\" width=\\\"13.122923588039868%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u0026nbsp;\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 67.8pt;border: none;padding: 0in 5.4pt;vertical-align: top;\\\" valign=\\\"top\\\" width=\\\"14.950166112956811%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cstrong\\u003e\\u0026nbsp;\\u003c/strong\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 60.95pt;border: none;padding: 0in 5.4pt;vertical-align: top;\\\" valign=\\\"top\\\" width=\\\"13.455149501661129%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cstrong\\u003eFrequency\\u003c/strong\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 48.25pt;border: none;padding: 0in 5.4pt;vertical-align: top;\\\" valign=\\\"top\\\" width=\\\"10.631229235880399%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 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11px;\\\"\\u003e\\u0026nbsp;\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 67.8pt;border: none;padding: 0in 5.4pt;vertical-align: top;\\\" valign=\\\"top\\\" width=\\\"14.950166112956811%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003eBachelor level\\u0026nbsp;\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 60.95pt;border: none;padding: 0in 5.4pt;vertical-align: top;\\\" valign=\\\"top\\\" width=\\\"13.455149501661129%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan 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style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e8\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 47.7pt;border: none;padding: 0in 5.4pt;vertical-align: top;\\\" valign=\\\"top\\\" width=\\\"10.631229235880399%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e17.8\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 60.95pt;border: none;padding: 0in 5.4pt;vertical-align: top;\\\" valign=\\\"top\\\" width=\\\"13.455149501661129%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: 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width=\\\"13.122923588039868%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u0026nbsp;\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 67.8pt;border: none;padding: 0in 5.4pt;vertical-align: top;\\\" valign=\\\"top\\\" width=\\\"14.950166112956811%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003eMaster level\\u0026nbsp;\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 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style=\\\"width: 46.85pt;border: none;padding: 0in 5.4pt;vertical-align: top;\\\" valign=\\\"top\\\" width=\\\"10.299003322259136%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e1.8\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd rowspan=\\\"2\\\" style=\\\"width: 59.35pt;border-style: none none solid;border-bottom-width: 1pt;border-bottom-color: black;padding: 0in 5.4pt;height: 0.45in;vertical-align: top;\\\" valign=\\\"top\\\" width=\\\"13.122923588039868%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, 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solid;border-bottom-width: 1pt;border-bottom-color: black;padding: 0in 5.4pt;vertical-align: top;\\\" valign=\\\"top\\\" width=\\\"15.48757170172084%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e26\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 47.7pt;border-style: none none solid;border-bottom-width: 1pt;border-bottom-color: black;padding: 0in 5.4pt;vertical-align: top;\\\" valign=\\\"top\\\" width=\\\"12.237093690248566%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e57.8\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 60.95pt;border-style: none none solid;border-bottom-width: 1pt;border-bottom-color: black;padding: 0in 5.4pt;vertical-align: top;\\\" valign=\\\"top\\\" width=\\\"15.48757170172084%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e90\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 46.85pt;border-style: none none solid;border-bottom-width: 1pt;border-bottom-color: black;padding: 0in 5.4pt;vertical-align: top;\\\" valign=\\\"top\\\" width=\\\"11.854684512428298%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e56.6\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cbr\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n\\u003cp style=\\\"margin: 0in;font-family: Calibri, sans-serif;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cstrong\\u003eTable 3\\u003c/strong\\u003e\\u0026nbsp;Mean, Standard Deviation, Item-rest correlation, Item-total correlation, Cronbach\\u0026rsquo;s alpha if item deleted, Cronbach\\u0026rsquo;s alpha overall, and Cronbach\\u0026rsquo;s alpha per subscale (n=159)\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n\\u003ctable border=\\\"1\\\" cellpadding=\\\"0\\\" cellspacing=\\\"0\\\" style=\\\"width: 595.35pt;border-collapse: collapse;border: none;\\\" width=\\\"794\\\"\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 49.15pt;border-top-width: 1pt;border-style: solid none;border-top-color: black;border-bottom-width: 1pt;border-bottom-color: black;padding: 0in 5.4pt;vertical-align: top;\\\" valign=\\\"top\\\" width=\\\"8.312342569269521%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cstrong\\u003e\\u0026nbsp;\\u0026nbsp;\\u003c/strong\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 37.7pt;border-top-width: 1pt;border-style: solid none;border-top-color: black;border-bottom-width: 1pt;border-bottom-color: black;padding: 0in 5.4pt;vertical-align: top;\\\" valign=\\\"top\\\" width=\\\"6.297229219143577%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cstrong\\u003eMean\\u0026nbsp;\\u003c/strong\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 54.85pt;border-top-width: 1pt;border-style: solid none;border-top-color: black;border-bottom-width: 1pt;border-bottom-color: black;padding: 0in 5.4pt;vertical-align: top;\\\" valign=\\\"top\\\" width=\\\"9.193954659949622%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cstrong\\u003eStandard deviation\\u0026nbsp;\\u003c/strong\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 63.35pt;border-top-width: 1pt;border-style: solid none;border-top-color: black;border-bottom-width: 1pt;border-bottom-color: black;padding: 0in 5.4pt;vertical-align: top;\\\" valign=\\\"top\\\" width=\\\"10.57934508816121%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cstrong\\u003eItem-rest correlation\\u0026nbsp;\\u003c/strong\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 62.75pt;border-top-width: 1pt;border-style: solid none;border-top-color: black;border-bottom-width: 1pt;border-bottom-color: black;padding: 0in 5.4pt;vertical-align: top;\\\" valign=\\\"top\\\" width=\\\"10.57934508816121%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cstrong\\u003eItem-total correlation\\u003c/strong\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 98.8pt;border-top-width: 1pt;border-style: solid none;border-top-color: black;border-bottom-width: 1pt;border-bottom-color: black;padding: 0in 5.4pt;vertical-align: top;\\\" valign=\\\"top\\\" width=\\\"16.624685138539043%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cstrong\\u003eCronbach\\u0026rsquo;s alpha if item deleted\\u003c/strong\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"2\\\" style=\\\"width: 74.4pt;border-top-width: 1pt;border-style: solid none;border-top-color: black;border-bottom-width: 1pt;border-bottom-color: black;padding: 0in 5.4pt;vertical-align: top;\\\" valign=\\\"top\\\" width=\\\"12.468513853904282%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cstrong\\u003eCronbach\\u0026rsquo;s alpha overall\\u003c/strong\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 154.35pt;border-top-width: 1pt;border-style: solid none;border-top-color: black;border-bottom-width: 1pt;border-bottom-color: black;padding: 0in 5.4pt;vertical-align: top;\\\" valign=\\\"top\\\" width=\\\"25.944584382871536%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cstrong\\u003eCronbach\\u0026rsquo;s alpha per subscale\\u003c/strong\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 49.15pt;border: none;padding: 0in 5.4pt;vertical-align: top;\\\" valign=\\\"top\\\" width=\\\"8.312342569269521%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cstrong\\u003eItem1\\u0026nbsp;\\u003c/strong\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 37.7pt;border: none;padding: 0in 5.4pt;vertical-align: top;\\\" valign=\\\"top\\\" width=\\\"6.297229219143577%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e5.28\\u0026nbsp;\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 54.85pt;border: none;padding: 0in 5.4pt;vertical-align: top;\\\" valign=\\\"top\\\" width=\\\"9.193954659949622%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e1.06\\u0026nbsp;\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 63.35pt;border: none;padding: 0in 5.4pt;vertical-align: top;\\\" valign=\\\"top\\\" width=\\\"10.57934508816121%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e0.48\\u0026nbsp;\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 62.75pt;border: none;padding: 0in 5.4pt;vertical-align: top;\\\" valign=\\\"top\\\" width=\\\"10.57934508816121%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e0.54\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"2\\\" style=\\\"width: 114.95pt;border: none;padding: 0in 5.4pt;vertical-align: top;\\\" valign=\\\"top\\\" width=\\\"19.269521410579344%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e0.84\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd rowspan=\\\"15\\\" style=\\\"width: 58.25pt;border-style: none none solid;border-bottom-width: 1pt;border-bottom-color: black;padding: 0in 5.4pt;vertical-align: top;\\\" valign=\\\"top\\\" width=\\\"9.82367758186398%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e0.85\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd rowspan=\\\"5\\\" style=\\\"width: 154.35pt;border: none;padding: 0in 5.4pt;vertical-align: top;\\\" valign=\\\"top\\\" width=\\\"25.944584382871536%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cstrong\\u003e1. Using cognitive assessments and care interventions\\u0026nbsp;\\u003c/strong\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003ewith item 5: 0.60\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003ewithout item 5: 0.72\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 49.15pt;border: none;padding: 0in 5.4pt;vertical-align: top;\\\" valign=\\\"top\\\" width=\\\"12.941176470588236%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cstrong\\u003eItem2\\u0026nbsp;\\u003c/strong\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 37.7pt;border: none;padding: 0in 5.4pt;vertical-align: top;\\\" valign=\\\"top\\\" width=\\\"9.803921568627452%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 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style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e0.84\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 49.15pt;border: none;padding: 0in 5.4pt;vertical-align: top;\\\" valign=\\\"top\\\" width=\\\"12.941176470588236%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cstrong\\u003eItem3\\u0026nbsp;\\u003c/strong\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 37.7pt;border: none;padding: 0in 5.4pt;vertical-align: top;\\\" valign=\\\"top\\\" 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\\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cbr\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n\\u003cp style=\\\"margin: 0in;font-family: Calibri, sans-serif;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cstrong\\u003eTable 4\\u0026nbsp;\\u003c/strong\\u003eFit indices\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n\\u003ctable border=\\\"0\\\" cellpadding=\\\"0\\\" cellspacing=\\\"0\\\" style=\\\"border-collapse: collapse;\\\"\\u003e\\n \\u003cthead\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd colspan=\\\"3\\\" style=\\\"border-style: none none solid;border-bottom-width: 1pt;border-bottom-color: black;padding: 0.75pt;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cbr\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd colspan=\\\"2\\\" style=\\\"border-style: none none solid;border-bottom-width: 1pt;border-bottom-color: black;padding: 0.75pt;\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;text-align: center;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cstrong\\u003eMetric\\u0026nbsp;\\u003c/strong\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"2\\\" style=\\\"border-style: none none solid;border-bottom-width: 1pt;border-bottom-color: black;padding: 0.75pt;\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;text-align: center;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cstrong\\u003eValue\\u0026nbsp;\\u003c/strong\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/thead\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"padding: 0.75pt;\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003eComparative Fit Index (CFI)\\u0026nbsp;\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"padding: 0.75pt;\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u0026nbsp;\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"padding: 0.75pt;\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;text-align: right;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e0.89\\u0026nbsp;\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"padding: 0.75pt;\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;text-align: right;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u0026nbsp;\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"padding: 0.75pt;\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003eRoot mean square error of approximation (RMSEA)\\u0026nbsp;\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"padding: 0.75pt;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cbr\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/td\\u003e\\n \\u003ctd style=\\\"padding: 0.75pt;\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;text-align: right;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e0.08\\u0026nbsp;\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"padding: 0.75pt;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cbr\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"padding: 0.75pt;\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003eRMSEA 90% CI lower bound\\u0026nbsp;\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"padding: 0.75pt;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cbr\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/td\\u003e\\n \\u003ctd style=\\\"padding: 0.75pt;\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;text-align: right;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e0.06\\u0026nbsp;\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"padding: 0.75pt;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cbr\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"padding: 0.75pt;\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003eRMSEA 90% CI upper bound\\u0026nbsp;\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"padding: 0.75pt;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cbr\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/td\\u003e\\n \\u003ctd style=\\\"padding: 0.75pt;\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;text-align: right;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e0.09\\u0026nbsp;\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"padding: 0.75pt;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cbr\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"padding: 0.75pt;\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003eRMSEA p-value\\u0026nbsp;\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"padding: 0.75pt;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cbr\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/td\\u003e\\n \\u003ctd style=\\\"padding: 0.75pt;\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;text-align: right;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e0.01\\u0026nbsp;\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"padding: 0.75pt;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cbr\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"padding: 0.75pt;\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003eStandardized root mean square residual (SRMR)\\u0026nbsp;\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"padding: 0.75pt;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cbr\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/td\\u003e\\n \\u003ctd style=\\\"padding: 0.75pt;\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;text-align: right;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e0.06\\u0026nbsp;\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"padding: 0.75pt;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cbr\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"padding: 0.75pt;\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003eHoelter\\u0026apos;s critical N (\\u0026alpha; = .05)\\u0026nbsp;\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"padding: 0.75pt;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cbr\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/td\\u003e\\n \\u003ctd style=\\\"padding: 0.75pt;\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;text-align: right;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e106.88\\u0026nbsp;\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"padding: 0.75pt;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cbr\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"padding: 0.75pt;\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003eGoodness of fit index (GFI)\\u0026nbsp;\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"padding: 0.75pt;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cbr\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/td\\u003e\\n \\u003ctd style=\\\"padding: 0.75pt;\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;text-align: right;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e0.99\\u0026nbsp;\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"padding: 0.75pt;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cbr\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"padding: 0.75pt;\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003eExpected cross validation index (ECVI)\\u0026nbsp;\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"padding: 0.75pt;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cbr\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/td\\u003e\\n \\u003ctd style=\\\"padding: 0.75pt;\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;text-align: right;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e1.64\\u0026nbsp;\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"padding: 0.75pt;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cbr\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cbr\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n\\u003cp style=\\\"margin: 0in;font-family: Calibri, sans-serif;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cstrong\\u003eTable 5\\u0026nbsp;\\u003c/strong\\u003eFactor loadings\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n\\u003ctable border=\\\"0\\\" cellpadding=\\\"0\\\" cellspacing=\\\"0\\\" style=\\\"border-collapse: collapse;\\\"\\u003e\\n \\u003cthead\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd colspan=\\\"18\\\" style=\\\"width: 439.65pt;border-style: none none solid;border-bottom-width: 1pt;border-bottom-color: black;padding: 0.75pt;\\\" width=\\\"100%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cstrong\\u003eFactor 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style=\\\"font-size: 11px;\\\"\\u003e\\u003cstrong\\u003e95% Confidence Interval\\u0026nbsp;\\u003c/strong\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd colspan=\\\"2\\\" style=\\\"width: 43.7pt;border-style: none none solid;border-bottom-width: 1pt;border-bottom-color: black;padding: 0.75pt;\\\" width=\\\"9.897610921501707%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;text-align: center;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cstrong\\u003eFactor\\u0026nbsp;\\u003c/strong\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"2\\\" style=\\\"width: 49.55pt;border-style: none none solid;border-bottom-width: 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style=\\\"font-size: 11px;\\\"\\u003e\\u003cstrong\\u003eSymbol\\u0026nbsp;\\u003c/strong\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"2\\\" style=\\\"width: 46.85pt;border-style: none none solid;border-bottom-width: 1pt;border-bottom-color: black;padding: 0.75pt;\\\" width=\\\"10.580204778156997%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;text-align: center;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cstrong\\u003eEstimate\\u0026nbsp;\\u003c/strong\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"2\\\" style=\\\"width: 54.85pt;border-style: none none solid;border-bottom-width: 1pt;border-bottom-color: black;padding: 0.75pt;\\\" width=\\\"12.457337883959044%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;text-align: center;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cstrong\\u003eStd. 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style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;text-align: center;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 11px;\\\"\\u003e\\u003cstrong\\u003ep\\u0026nbsp;\\u003c/strong\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"2\\\" style=\\\"width: 69.5pt;border-style: none none solid;border-bottom-width: 1pt;border-bottom-color: black;padding: 0.75pt;\\\" width=\\\"15.870307167235495%\\\"\\u003e\\n \\u003cp style=\\\"margin: 0in;font-size:16px;font-family: Calibri, sans-serif;text-align: center;\\\"\\u003e\\u003cspan style=\\\"color: rgb(0, 0, 0);\\\"\\u003e\\u003cspan style=\\\"font-family: Verdana, Geneva, sans-serif;\\\"\\u003e\\u003cspan style=\\\"font-size: 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style=\\\"font-size: 11px;\\\"\\u003e\\u003cbr\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd colspan=\\\"18\\\" style=\\\"width: 439.65pt;border-style: none none solid;border-bottom-width: 1.5pt;border-bottom-color: black;padding: 0.75pt;\\\" width=\\\"100%\\\"\\u003e\\u003cspan style=\\\"font-size: 11px; font-family: Verdana, Geneva, sans-serif; color: rgb(0, 0, 0);\\\"\\u003e\\u003cbr\\u003e\\u003c/span\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":true,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-health-services-research\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"bhsr\",\"sideBox\":\"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/BHSR/default.aspx\",\"title\":\"BMC Health Services Research\",\"twitterHandle\":\"BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true},\"keywords\":\"Acute care, Dementia, Nurses, Person-centered care, Psychometrics, Quality of care\",\"lastPublishedDoi\":\"10.21203/rs.2.22472/v3\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.2.22472/v3\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003e\\u003cstrong\\u003eBackground: \\u003c/strong\\u003ePerson-centred care is the preferred model for caring for people with dementia. Knowledge of the level of person-centred care is essential for improving the quality of care for patients with dementia. The person-centred care of older people with cognitive impairment in acute care (POPAC) scale is a tool to determine the level of person-centred care. This study aimed to translate and validate the Dutch POPAC scale and evaluate its psychometric properties to enable international comparison of data and outcomes.\\u003c/p\\u003e\\u003cp\\u003e\\u003cstrong\\u003eMethods: \\u003c/strong\\u003eAfter double-blinded forward and backward translations, a total of 159 nurses recruited from six hospitals (n=114) and via social media (n=45) completed the POPAC scale. By performing confirmatory factor analysis, construct validity was tested. Cronbach’s alpha scale was utilized to establish internal consistency.\\u003c/p\\u003e\\u003cp\\u003e\\u003cstrong\\u003eResults: \\u003c/strong\\u003eThe confirmatory factor analysis showed that the comparative fit index (0.89) was slightly lower than 0.9. The root mean square error of approximation (0.075, p=0.012, CI 0.057-0.092) and the standardized root mean square residual (0.063) were acceptable, with values less than 0.08. The findings revealed a three-dimensional structure. The factor loadings (0.69-0.77) indicated that the items to be strongly associated with their respective factors. The results also indicated that deleting Item 5 improved the Cronbach’s alpha of the instrument as well as of the subscale ‘using cognitive assessments and care interventions’. Instead of deleting this item, we suggest rephrasing it into a positively worded item.\\u003c/p\\u003e\\u003cp\\u003e\\u003cstrong\\u003eConclusions:\\u003c/strong\\u003e Our findings suggest that the Dutch POPAC scale is sufficiently valid and reliable and can be utilized for assessing person-centred care in acute care hospitals. The study enables nurses to interpret and compare person-centred care levels in wards and hospital levels nationally and internationally. The results form an important basis for improving the quality of care and nurse-sensitive outcomes, such as preventing complications and hospital stay length.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Validation and psychometric evaluation of the Dutch Person-centred care of Older People with cognitive impairment in Acute Care (POPAC)\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":3,\"date\":\"2021-01-07 17:10:30\",\"doi\":\"10.21203/rs.2.22472/v3\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"checksComplete\",\"content\":\"\",\"date\":\"2020-12-24T17:28:16+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"decision\",\"content\":\"Accept\",\"date\":\"2020-12-24T00:00:00+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-health-services-research\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"bhsr\",\"sideBox\":\"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/BHSR/default.aspx\",\"title\":\"BMC Health Services Research\",\"twitterHandle\":\"BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true}},{\"code\":\"\",\"date\":\"2020-12-17 00:00:00\",\"doi\":\"\",\"editorialEvents\":[{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2020-12-17T00:00:00+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"checksComplete\",\"content\":\"\",\"date\":\"2020-12-16T23:00:00+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvited\",\"content\":\"\",\"date\":\"2020-12-16T23:00:00+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"notPreprinted\",\"content\":\"\"}],\"status\":\"timeline\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-health-services-research\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"bhsr\",\"sideBox\":\"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/BHSR/default.aspx\",\"title\":\"BMC Health Services Research\",\"twitterHandle\":\"BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true}},{\"code\":2,\"date\":\"2020-11-11 20:57:56\",\"doi\":\"10.21203/rs.2.22472/v2\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"decision\",\"content\":\"Minor revision\",\"date\":\"2020-12-03T00:00:00+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2020-11-30T00:00:00+00:00\",\"index\":1,\"fulltext\":\"Recommendation: Major revisions required\\nForm responses:\\n---\\n\\nComments to Author:\\n---\\nAbstract\\nMethods\\n- Page 2; Line 12: Perhaps just make it clear that it is n=114 and n=45 in the brackets after six hospitals and via social media to make it clear that the authors are referring to the number of nurses recruited from those sources.\\n- Page 2; Line 13: Consider removing 'the' before construct validity and internal consistency.\\nResults\\n- Page 2; Line 20: Consider changing 'improves' to 'improved'. It might also be helpful to state which subscale the authors are referring to. \\n\\nBackground\\n- Page 3; Lines 14-16: Should the start of this sentence be 'The basis of person-centred care…'? The authors might also want to consider joining these two sentences with the previous paragraph for better flow.\\n- Pages 4; Line 1: Remove the full stop after 'individualizing care'.\\n- Page 5; Line 15: Consider rephrasing to 'this study's purpose was to conduct a cross-national validation and psychometric evaluations….'.\\n\\nMethods\\n- Page 6; Lines 2-3: It is unclear what the authors mean by 'as they are on a total level'. Do the authors mean that the scores for each subscale can be summed into an overall summary score? If so, perhaps just state that a bit more clearly.\\n- Page 6; Line 13: Remove 'was made' in the sentence as the phrasing is awkward otherwise.\\n- Page 6; Lines 15-16: Awkward phrasing. Consider just stating that 'There was unanimous consensus for the final selection of all items'.\\n- Page 7; Line 2: Not sure that 'aftermath' is the appropriate word here. Perhaps it is just post-hoc analyses?\\n- Page 7: Line 9: What does Top-Clinical refer to? Perhaps there is no need to include this information in brackets.\\n- Page 7; Line 13: Perhaps make it clearer what measurements the authors are referring to - is this the POPAC measurements?\\n- Page 7; Line 25: Awkward phrasing. Consider removing 'by analyzed' and 'was employed' from the sentence. Alternatively, separate this into two different sentences - one regarding using complete cases and the other regarding the programs used for the statistical analyses.\\n- Page 7; Line 27: Change to 'reverse coded' rather than 'coded reversed'.\\n- Page 8; Lines 1-4: Are the authors able to check whether there are any differences in the demographic characteristics of the nurses who did not provide complete cases compared to those that did provide all data? If differences were minimal, this will support using just those with complete data.\\n- Page 9; Line 1: This sentence should be written in past tense (see comment below).\\n- Please check the tenses used throughout this section. As the study has been conducted, the methods section should be written in past tense rather than present tense.\\n\\nResults\\n- Page 9; Line 16: Was the score on 'skills on caring for people with dementia' skewed? If so, consider reporting median and IQR rather than average/SD.\\n- Page 10; Line 17: Remove 'the' before internal consistency in this sentence.\\n\\nDiscussion and conclusion\\n- Page 11; Lines 1-25: These two paragraphs appear to be discussing the same result - suggest that the authors consolidate the discussion into one paragraph and make it clearer the relevance of previous literature. For instance, it is unclear what the findings from the Swedish study or the Australian study mean in terms of the author's own findings.\\n\\n* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons upon publication of the manuscript. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **No**\\n* Declaration of competing interests: **I declare that I have no competing interests.**\\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please do not publish my name with my report. (default)**\\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **Yes**\\n* Are the methods sufficiently described to allow the study to be repeated?: **Yes**\\n* Is the use of statistics and treatment of uncertainties appropriate?: **Yes**\\n* Is the presentation of the work clear?: **No**\\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **Yes**\\n\"},{\"type\":\"reviewersInvited\",\"content\":\"\",\"date\":\"2020-11-11T00:00:00+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"\",\"date\":\"2020-11-11T00:00:00+00:00\",\"index\":1,\"fulltext\":\"\"},{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2020-11-05T00:00:00+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"checksComplete\",\"content\":\"\",\"date\":\"2020-11-04T23:00:00+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvited\",\"content\":\"\",\"date\":\"2020-11-04T23:00:00+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-health-services-research\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"bhsr\",\"sideBox\":\"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/BHSR/default.aspx\",\"title\":\"BMC Health Services Research\",\"twitterHandle\":\"BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true}},{\"code\":1,\"date\":\"2020-02-03 22:14:41\",\"doi\":\"10.21203/rs.2.22472/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"decision\",\"content\":\"Major revision\",\"date\":\"2020-10-14T12:00:00+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"\",\"date\":\"2020-08-02T12:00:00+00:00\",\"index\":3,\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"\",\"date\":\"2020-07-31T12:00:00+00:00\",\"index\":2,\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2020-02-16T12:00:00+00:00\",\"index\":1,\"fulltext\":\"Recommendation: Major revisions required\\nForm responses:\\n---\\n\\nComments to Author:\\n---\\nGeneral comments\\nThis article has translated and validated a Dutch version of the Person-centred care of Older People with cognitive impairment in Acute Care. It might be helpful to include the analysis undertaken in the title of the article for clarify (i.e. Confirmatory Factor Analysis). In addition, given that this is a validation study, it might be helpful for the authors to refer to the COSMIN taxonomy of measurement properties (Prinsen et al., 2018) and ensure that the terms they have used in this paper are consistent with the COSMIN terminology. Specific comments for each section are listed below.\\n\\nAbstract\\nMethods\\n- A bit more information about how the tool was translated might be helpful in this section.\\n- Suggest the authors specify exactly what type of reliability they are assessing using Cronbach's alpha (assuming that it is internal consistency reliability).\\nResults\\n- Some information about the participants included in the study would be helpful for readers to determine whether the sample a representative sample.\\n- It would be helpful to report actual results from the CFA e.g. what was the actual CFI result (including a 95% CI if available). Likewise, what was the RMSEA and SRMS residual and how did the authors determine this was an acceptable model fit?\\n- Please also report the factor correlations what was obtained - otherwise it is very unclear from the results presented how the authors came to the conclusion that item 5 could be deleted to improve reliability of the instrument. Is this because the Cronbach alpha was \\u003e0.8 which indicates item redundancy?? \\nConclusion\\n- The authors needs to be careful not to overstate their results. Given that no sample characteristics were reported in the results (and no actual results from the CFA were presented) it is difficult to determine whether the conclusions of this study are appropriate.\\n\\nIntroduction\\n- The introduction is a bit long - consider revising and presenting the information in the first two paragraphs more succinctly.\\n- A bit more information needs to be provided on the POPAC e.g. how were the items in the final scale identified? How did the instrument developers establish construct validity? How did the authors determine that the subscales can be combined into a total score? Was the instrument validated using item response theory to establish unidimensionality?\\n- Please see my comment earlier regarding using the COSMIN terminology - it will be helpful if the authors can be more specific as to what type of validity and reliability they plan to assess/address in this paper.\\n- Page 4; Line 1: Please spell out POPAC in full before using an abbreviation.\\n- Page 4; Line 20: What do the authors mean by a retest?\\n- Page 4; Lines 26-28: Be more specific here - how was the instrument evaluated in Sweden and by Grealish in Australia? Was CFA used as well or was a different analysis undertaken e.g. Rasch analysis?\\n\\nMethods\\n- Has this study been approved by an ethics committee? This information needs to be presented in the methods section.\\n- How was consent obtained from the nurses to participate in this study? It would be also be good to mention how anonymity and confidentiality of respondents were maintained.\\n- Were managers of participating wards asked to assist in distributing the survey? If so, then the authors needs to explain how they mitigated against hierarchical coercion.\\n- Were there any other demographic information that was obtained from the nurses? If so, this needs to be made clearer in the methods section.\\n- How did the authors arrive at a sample size of 150 for this study? Some justification for this sample size would be helpful.\\n- Some justification for using complete cases in the data analysis is required.\\n- Page 6; Line 1: It is unclear what discussions the authors are referring to.\\n- Page 6; Line 15: It is unclear what the difference is between an 'academic' hospital and a 'top' clinical hospital.\\n- Page 6; Lines 17-19: This appears to be the inclusion criteria for the study - perhaps consider rephrasing the way this was written so that it is clear that this refers to the eligibility criteria for the study. \\n- Page 7; Line 4: Change 'are' to 'were'.\\n- Page 7; Lines 15-16: Please refer to Cosmin taxonomy and use the same terms to improve interpretability i.e. rather than internal reliability this should be internal consistency reliability.\\n\\nResults\\n- Suggest reporting all characteristics of nurses in Table 2 - rather than just the education level.\\n- Page 8; Lines 20-29: It is not clear whether the characteristics described were just the 114 recruited from the hospitals or the total 159 recruited from both sources? It might be helpful (in Table 2) to report the characteristics of the 2 separate samples to enable the readers to determine whether there are any differences between the two groups.\\n- Page 8; Lines 26: Consider renaming this to internal consistency reliability and using that term consistently throughout the manuscript.\\n\\nDiscussion and conclusion\\n- I am not sure that by evaluating the psychometric properties of this instrument allows the authors to compare the results internationally. The importance of evaluating the psychometric properties of an instrument would be to ensure that the translated instrument can accurately measure person-centred care and the quality of care of people with dementia in acute care.\\n- Overall, the discussion needs further development. The authors appear to repeat the main results without discussing the implications of their findings.\\n- Based on the findings I am also not sure that the authors can say that their study has confirmed the validity and reliability of the POPAC as there appears to be some issues with model fit.\\n- Given that the POPAC is assessed using an ordinal scale, it is unclear how the authors made the decision that total sum scores can be used. Did the authors consider converting the scores into interval level measures using item analysis or Rasch analysis?\\n- Page 9; Line 5: Not sure what the authors mean by 'cross-national' validate - do the authors just mean that they validated the Dutch version of the POPAC in a national sample of nurses?\\n- Page 9; Lines 9-15: Some additional discussion on the relevance of this result would be helpful i.e. what are the implications of the result obtained? What does this mean in the context of using this instrument to measure person-centred care?\\n- Page 9; Lines 16-25: Again it would be helpful for the authors to discuss what the implications of their findings are? What do these results actually mean in terms of using the Dutch version of the POPAC? What does a three-factor solution mean? Does that mean the POPAC has three dimensions?\\n\\n* Are the methods appropriate and well described?: **No**\\n* Does the work include the necessary controls?: **Yes**\\n* Are the conclusions drawn adequately supported by the data shown?: **Unable to assess**\\n* Are you able to assess any statistics in the manuscript or would you recommend an additional statistical review?: **I recommend additional statistical review**\\n* Quality of written English: **Needs some language corrections before being published**\\n* Declaration of competing interests: **I declare that I have no competing interests.**\\n* I agree to the open peer review policy of the journal. I understand that my name will be included on my report to the authors and, if the manuscript is accepted for publication, my named report including any attachments I upload will be posted on the website along with the authors' responses. 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