Development and Validation of an Early Post-Liver Transplant Activity Knowledge, Attitude, and Practice Questionnaire for Intensive Care Unit Nurses: A Multicenter Study

Introduction

Material and Methods

Questionnaire Development and Methods

STUDY DESIGN AND VALIDATION FRAMEWORK:

This study focused on the initial development and preliminary validation phase of the KAP questionnaire. Although the hypotheses include CFA, the primary objective of this multicenter investigation was to explore the factor structure using EFA in the current sample. Consequently, CFA is not reported in this paper and is planned for future research with an independent sample to confirm the factor structure established here.

ESTABLISHMENT OF THE RESEARCH TEAM:

The team consisted of 15 members, including 4 men and 11 women, aged 34 to 55 years, mainly middle-aged medical staff with extensive experience. In terms of positions, there is 1 deputy director of the nursing department, 1 team-leading director, 1 head nurse of the department, and 2 deputies, with the remainder holding no official position. Regarding professional titles, the team included 2 associate chief physicians, 2 associate chief nurses, 1 attending physician, 2 nurse practitioners, 5 chief physicians, and 1 associate professor. The team covered multidisciplinary backgrounds such as critical care medicine, nursing science, rehabilitation medicine, and clinical medicine, with work experience ranging from 8 to 31 years. Additionally, 4 members served as master’s and doctoral supervisors, possessing comprehensive capabilities in clinical practice, teaching, and research supervision, thereby meeting the needs of multidisciplinary collaboration, medical services, and staff training. Team members were assigned clearly defined roles: the ICU director was responsible for clinical pathway review and quality control, the head nurse coordinated resource allocation and nursing practice, ICU specialists provided medical assessments and contraindication guidance, the rehabilitation physician developed mobilization programs and safety assessments, and the 4 ICU specialized nurses were divided into 2 groups for the handling of literature searches, establishment of the items pool, and preliminary surveys. The team adopted a ‘phased collaboration-focused discussion’ model, holding interdisciplinary meetings every 2 weeks to ensure efficient collaboration throughout the process from literature search and item selection to questionnaire validation. Data analysis was conducted by a doctoral-level statistician using SPSS 26.0 (IBM, Armonk, NY, USA) for item analysis and reliability and validity testing, thus ensuring methodological rigor.

ESTABLISHMENT OF THE QUESTIONNAIRE ITEMS: Figure 1 presents a flow chart of the establishment of the questionnaire for this study. The main processes involved are outlined below.

LITERATURE ANALYSIS:

The knowledge dimension focuses on ICU nurses’ comprehension of core content such as the definition, indications/contraindications, safety assessment, and emergency response of early mobilization following liver transplantation. The attitude dimension reflects nurses’ subjective tendency towards implementing early mobilization for patients who are critically ill after liver transplantation. The practice dimension measures nurses’ actual implementation behavior in early mobilization, based on their professional knowledge and attitudes.

SELECTION OF CONSULTATION EXPERTS:

Experts were selected using purposeful sampling to ensure diversity of expertise and relevance to the study topic. A total of 15 experts were selected from relevant fields, such as critical care medicine, nursing management, and rehabilitation related to liver transplantation, for consultation. The inclusion criteria for experts were: (1) at least 10 years of experience in critical care medicine, critical nursing, nursing management, rehabilitation, or related fields concerning liver transplantation; (2) bachelor’s degree or higher; (3) intermediate professional title or above; and (4) voluntary participation in this research and active cooperation in completing the expert consultation.

DEVELOPMENT OF THE EXPERT CONSULTATION QUESTIONNAIRE:

Based on the previously established item pool, a custom-designed expert consultation questionnaire was created, which included 4 parts. (1) Guidance for the consultation questionnaire: This introduced the background, purpose, and significance of the research and a description of the questionnaire. (2) Main body of the questionnaire: This contained the importance evaluation, relevance evaluation, and revision suggestion column for the KAP questionnaire items, with importance and relevance evaluated using a 5-point Likert scale with the following criteria. Importance evaluation: not important=1 point, slightly important=2 points, neutral=3 points, quite important=4 points, very important=5 points. Relevance evaluation: completely irrelevant=1 point, slightly irrelevant=2 points, somewhat relevant=3 points, completely relevant=4 points. Experts were also invited to suggest modifications or additions/deletions of items. (3) Basic information survey for experts: This included gender, age, position, title, institution, professional field, and years of work experience. (4) Self-assessment of expert authority: This was a self-assessment form regarding the basis for judgment and familiarity with the questionnaire content. Items with a mean importance score ≤3.5, a maximum score ratio ≤20%, or a CV ≥0.25 were revised or removed.

CONDUCTING EXPERT CONSULTATION:

The expert consultation was conducted between August and October 2023. In the first round, an electronic questionnaire (in Excel format) containing the research purpose, preliminary item pool, and evaluation criteria (relevance, clarity, and feasibility of each item were rated on a 5-point Likert scale: 1=strongly irrelevant/unclear/unfeasible to 5=strongly relevant/clear/feasible) was sent to 15 experts via email. They were invited to propose suggestions for item modification, addition or deletion, with a 2-week response period, and a reminder email was sent to non-respondents at 1 week. In the second round, items with a CVI <0.33 (low expert recognition) or duplicate items were first deleted based on feedback from the first round, and some items were revised to form a revised questionnaire, which was then re-sent to the same group of experts for re-evaluation. For items with discrepancies, the research team held an online consensus meeting, conducted anonymous voting combined with literature evidence (eg, the ‘Expert Consensus on Enhanced Recovery Management during the Perioperative Period of Liver Transplantation in China’) and retained items with agreement from ≥80% of experts. For items with significant controversy (eg, ‘pain management’), the principal investigator, along with 2 external experts who did not participate in the consultation, served as arbitrators. Subsequently, the expert consultation was conducted again until the coordination coefficient of expert opinions reached ≥0.70 (indicating good consistency), ensuring the clinical applicability and theoretical integrity of the items.

PRELIMINARY SURVEY:

The preliminary survey was conducted using convenience sampling, with 30 ICU nurses selected from a tertiary hospital in Beijing in November 2023. Notably, this hospital performs over 100 liver transplant surgeries annually, and the ICU nursing team has extensive experience in postoperative management, with the educational background of the nurses (85% with bachelor’s degrees) and their work experience (40% with 5 to 10 years’ experience) closely aligning with the characteristics of national multicenter samples, ensuring extrapolation of the preliminary survey results. The evaluation assessed whether the language of the questionnaire items was clear and understandable and whether the number of items was reasonable. The inclusion criteria were: (1) registered nurses currently working in the ICU; (2) directly involved in the care of patients who are critically ill following liver transplantation; (3) having at least 1 year of working experience and at least 6 months of working in the ICU; and (4) voluntary participation in this study and signing the informed consent form. The exclusion criteria were: (1) intern nurses, visiting nurses, and nurses in standardized training, and (2) nurses who have been away from their positions in the ICU for 3 consecutive months or more due to various reasons (eg, sick leave, maternity leave, out-of-town education).

FORMAL SURVEY: ICU nurses from 7 tertiary general hospitals across China that perform liver transplant surgeries were selected in January 2024 for a validity and reliability test using convenience sampling. Among the survey participants, 30 nurses were selected to complete a second questionnaire 2 weeks after the first survey to assess test–retest reliability, with the same inclusion and exclusion criteria as in the preliminary survey. The questionnaire in this study included 40 items, and the estimated sample size was 200 to 400, following the principle that the sample size required for the reliability and validity tests of the questionnaire should be at least 5 to 10 times the number of questionnaire items [15]. The survey was distributed through the Questionnaire Star platform and consisted of 3 parts: informed consent, general information, and the KAP questionnaire for ICU nurses regarding early mobilization of patients who are critically ill after liver transplantation. A total of 348 questionnaires were collected, and those with a short completion time were excluded, resulting in 334 valid questionnaires, with a valid response rate of 95.98%. This study was approved by the hospital’s ethics committee (approval no. 2022-P2-032-01).

STATISTICAL METHODS:

Data analysis was performed using IBM SPSS Statistics software (version 26.0). Frequency and percentage were used to describe the categorical variables; means±standard deviation or median (P25–75) were used to describe the continuous variables.

EVALUATION OF EXPERT CONSULTATION:

The expert consultation process was quantitatively evaluated using several key metrics: experts’ familiarity (Cs) with the topic, the theoretical and practical basis (Ca) for their judgments, and the authority coefficient (Cr), which is the arithmetic mean of Cs and Ca. The degree of consensus among experts was assessed using Kendall’s coefficient of concordance (W) and the CV. A CV <0.25 and a significant Kendall’s W (P<0.05) were considered indicative of a satisfactory level of consensus.

ITEM ANALYSIS:

Item analysis was conducted to refine the initial item pool. The critical ratio (CR) method was used to compare the total scores of the highest and lowest 27% of respondents (independent samples t test). Items with a non-significant CR (P≥0.05) were considered for removal. Additionally, the corrected item–total correlation was calculated by correlating each item’s score with the total score of its respective dimension, excluding that item. Items with a correlation coefficient <0.4 were deemed to have poor discriminative power and were eliminated.

RELIABILITY TESTING:

The reliability of the final questionnaire was evaluated primarily through internal consistency, measured by Cronbach’s α coefficient for the entire scale and for each dimension. A split-half reliability coefficient (using the Spearman-Brown formula) was also computed to further assess scale stability.

VALIDITY TESTING:

The validity of the questionnaire was examined from 2 perspectives. Content validity was quantified using the CVI, which included the item-level CVI (I-CVI), and the scale-level CVI (S-CVI), calculated as the proportion of experts who rated items 3 or 4 on a 4-point relevance scale. Structural validity was assessed using EFA. The suitability of data for EFA was confirmed via the Kaiser-Meyer-Olkin (KMO) measure (values >0.80) and Bartlett’s test of sphericity (P<0.001). Principal component analysis (PCA) with varimax rotation was used to extract factors. Factors with eigenvalues >1 were retained to reduce the data and maximize the variance explained in the observed variables, thus providing a clear and concise summary of the underlying structure during the initial exploratory phase of scale development.

For all statistical tests, a two-tailed P value <0.05 was considered statistically significant. To test the research hypotheses, a series of predefined analyses was conducted. First, to address Hypothesis 1 regarding content validity and reliability, we calculated the CVI based on expert ratings and assessed internal consistency (Cronbach’s α), split-half reliability, and test–retest reliability. Second, to address Hypothesis 2 regarding the three-factor structure, EFA was performed to determine whether the empirical data aligned with the theoretical KAP dimensions.

Results

EXPERT CONSULTATION RESULTS:

A total of 15 experts aged 34 to 55 years (mean age: 43.6±6.22 years) from Beijing, Zhejiang, Chongqing, Shanghai, Gansu, and Sichuan were invited. The average work experience of the experts was 21.27 years, and the Cr was 0.96 (Ca: 0.95, Cs: 0.97), indicating a high level of professionalism in their opinions. Among the experts, 8 held bachelor’s degrees, 3 had master’s degrees, 3 had PhDs, and 1 was a postdoctoral researcher, with 4, 5, and 5 experts holding intermediate, associate senior, and senior professional titles, respectively. The response rate for the first round of consultation was 93.75% (15/16), with familiarity level, judgment basis, and authority coefficients being 0.97, 0.95, and 0.96, respectively. Kendall’s W was 0.298 (χ²=210.255, P<0.001), suggesting low coordination in the initial opinions of the experts, possibly due to vague item descriptions or differences in professional understanding. The research team conducted anonymous voting on controversial items, resulting in the deletion of 8 items with CV ≥0.25. In the second round, the response rate was 100% (15/15), and Kendall’s W significantly improved to 0.512 (χ²=299.322, P<0.001), with CV <0.25 for all items, indicating high consistency in expert opinions following item revisions (eg, adding ‘nutritionist’ to K5, specifying ‘activities of daily living training’ in K8, and including ‘transfer training’ in K9). This change reflects the effectiveness of the Delphi method in integrating multidisciplinary perspectives and enhancing the scientific rigor of the items. Ultimately, the KAP questionnaire for ICU nurses regarding early mobilization in patients who are critically ill after liver transplantation was finalized, consisting of 3 dimensions and 40 items.

PRELIMINARY SURVEY RESULTS:

The preliminary survey included 30 ICU nurses, with an effective response rate of 93.3% (28/30). Feedback from nurses regarding their understanding of the items resulted in the original item ‘changes in consciousness’ being revised to ‘abnormal consciousness’ due to vague wording (some nurses mistakenly thought it included ‘emotional changes’). Another item, ‘safety risks include unplanned extubation’, was revised to ‘common safety risks mainly include unplanned extubation’ because it did not specify ‘common’ risks. Following these modifications, the factor loadings for the revised items in the formal survey were 0.872 (K14) and 0.890 (K12), both exceeding the critical value of 0.4, and nurses reported that “the revised items are more aligned with clinical scenarios.” Additionally, the average completion time for the preliminary survey decreased from 18 to 12 min, along with reduced redundancy of items, indicating that simplified items effectively enhanced the operability of the questionnaire.

GENERAL INFORMATION OF SURVEY PARTICIPANTS:

A total of 348 questionnaires were collected in this study, with 334 valid questionnaires, resulting in an effective response rate of 95.98%. As shown in Table 1, regarding the demographic characteristics of the respondents, there were 268 women (80.24%), and the age range was 21 to 52 years (mean age: 31.41±5.73 years). In terms of educational background, the proportion of those with a bachelor’s degree was the highest, accounting for 81.14%. Regarding professional titles, junior titles were the most dominant, accounting for 72.46%. For years of ICU work experience, the group with 10 to 15 years of experience accounted for the highest percentage (29.04%). In terms of work category, general ICU nurses constituted the largest proportion, accounting for 72.75%.

ITEM ANALYSIS RESULTS:

(1) Critical ratio method: Based on the overall score of the questionnaire, the top 27% were categorized as the high-score group and the bottom 27% as the low-score group. An independent samples t test revealed statistically significant differences between each item in the high- and low-score groups (P<0.001), indicating good discriminative ability for all items, which were retained. (2) Homogeneity test method: The correlation of each item with the corresponding dimension total score and the overall questionnaire score was calculated using Pearson’s correlation analysis. The results showed a correlation coefficient of r=0.875–0.945 for knowledge-related items corresponding to the overall knowledge score, r=0.933–0.986 for attitude-related items corresponding to the overall knowledge score, r=0.819–0.965 for practice-related items corresponding to overall knowledge score and r=0.657–0.852 for all items corresponding to the overall questionnaire score. All correlation coefficients were >0.4 (P<0.01), indicating good correlations of each item with their corresponding dimensions and the overall questionnaire score, leading to the retention of all items.

RELIABILITY AND VALIDITY ANALYSIS:

The questionnaire’s psychometric properties were systematically evaluated through content validity, structural validity, and reliability tests, with the results as follows. Content validity was assessed via the second round of expert consultation, yielding an I-CVI ranging from 0.800 to 1.000. The mean CVI values for the knowledge, attitude and practice dimensions were 0.918, 0.940, and 0.959, respectively, with an S-CVI of 0.937, indicating good content relevance. For structural validity, EFA confirmed data suitability (KMO=0.956; Bartlett’s test of sphericity: χ2=26,348.889, P<0.001). Using PCA with varimax rotation, 3 factors with eigenvalues >1 were extracted, explaining 86.852% of the total variance. All item factor loadings exceeded 0.70 (range: 0.733–0.956), indicating a well-defined structure (see Table 2 for the rotated factor matrix).

As detailed in Table 3, the questionnaire demonstrated excellent internal consistency (Cronbach’s α=0.976 overall; dimension-specific α: 0.987–0.993) and split-half reliability (0.772 overall; dimension-specific: 0.956–0.987), all exceeding the recommended threshold of 0.80 [16]. Test–retest reliability was evaluated by reassessing 30 ICU nurses after a 2-week interval (inclusion criteria excluded nurses in rotational shifts or continuing training to ensure population consistency), yielding an overall coefficient of 0.784 (knowledge=0.856, attitude=0.867, practice=0.866), which meets the psychometric requirement of >0.70 [12]. Notably, the questionnaire’s overall test–retest reliability (0.856) outperformed the pediatric ICU (PICU) nurse KAP questionnaire reported by Luo (2023) (0.742) [17], potentially due to the clarity and clinical relevance of the revised items.

Guided by KAP theory, the questionnaire was developed via 2 rounds of Delphi consultation (expert authority coefficient=0.96) and pre-survey optimization, with improved expert opinion consistency (Kendall’s W=0.298–0.512). Key psychometric tests confirmed its excellent reliability (Cronbach’s α=0.976, test–retest reliability=0.856) and validity (S-CVI=0.937; EFA extracted 3 KAP-consistent factors, cumulative variance=86.852%).

Discussion

HIGH SCIENTIFIC VALIDITY AND RELIABILITY OF THE QUESTIONNAIRE:

This study presents preliminary evidence for the psychometric properties of a newly developed KAP questionnaire for ICU nurses regarding early mobilization following liver transplantation. Guided by KAP theory, the questionnaire was developed through literature analysis, 2 rounds of Delphi expert consultation, and pre-survey optimization. Expert opinions showed increasing consistency, with all items having a CV <0.25. Reliability and validity tests confirmed the questionnaire’s excellent psychometric properties: Cronbach’s α coefficient=0.976, split-half reliability=0.772, and test–retest reliability=0.856. For validity, the I-CVI ranged from 0.800 to 1.000, with an S-CVI of 0.937. The EFA extracted 3 common factors (consistent with the KAP framework) with a cumulative variance contribution rate of 86.852%, and all item factor loadings ranged from 0.733 to 0.956 (>0.4). Although these initial findings are promising and confirm the tool’s scientific reliability in this sample, they should be considered preliminary findings pending further validation in independent cohorts using CFA.

Notably, the overall Cronbach’s α coefficient of the questionnaire reached 0.976, and the α coefficients of each dimension were as high as 0.987 to 0.993, which not only fully demonstrated strong internal consistency of the scale and high correlation between items in the same dimension but also may indicate a certain degree of item redundancy. The high item correlation may be due to the fact that some items in the knowledge and practice dimensions were designed with overlapping connotations in the process of combining clinical guidelines and expert opinions, such as the correlation between items related to ‘mobilization safety risk assessment’ and ‘mobilization suspension indications’ in the knowledge dimension. Although all items were retained following item analysis due to good discriminative ability and homogeneity, the possible item redundancy needs to be further optimized in follow-up research, such as merging items with highly overlapping connotations or deleting repetitive items on the premise of ensuring the comprehensiveness of the scale content.

UNIQUE ADVANTAGES AND SIGNIFICANCE OF THE QUESTIONNAIRE:

The primary contribution of this study lies in addressing a significant gap in the existing literature. Although previous studies have developed KAP questionnaires for early mobilization targeting general ICU patients [18] or specific populations, such as patients with trauma or those undergoing cardiac surgery [19,20], a validated tool specifically for liver transplant recipients has been notably absent. This gap is critical because the postoperative recovery trajectory of patients undergoing liver transplant is unique, involving specific risks and considerations. Our research methods and results align with the rigorous standards established in prior studies for developing disease-specific KAP questionnaires. For example, the high content validity achieved through the Delphi expert consultation method is consistent with the validation process reported in Mahaptra’s study on developing and validating a KAP questionnaire for relevant clinical scenarios [21]. This consistency underscores the importance of expert consensus-based methods in ensuring the relevance and comprehensiveness of the tool for the target clinical context, be it delirium assessment or early mobilization following liver transplantation.

Following liver transplantation, patients face various complications and recovery challenges in ICUs. In recent years, early mobilization has been gaining increasing attention as an effective nursing intervention [22,23]. The KAP theory concludes that knowledge, attitude, and practice are part of a continuously developing process, where human behavior is based on specific knowledge and attitude; the more knowledge the individual possesses, the stronger their beliefs are, and the more likely the individual is to form behavioral habits [24,25]. In this regard, the KAP of nurses when implementing nursing measures significantly impacts patient recovery outcomes [5]. Currently, despite some available assessment tools targeting ICU nurses or patients in early mobilization, their design concepts and applicability involve certain limitations. For example, the assessment tool for early mobilization participation developed by Knutsen et al (2024) focuses on the subjective experiences and physiological function indicators of patients, without addressing the knowledge reserves and behavioral practices of nursing staff [10]. Although the KAP questionnaire for PICU nurses compiled by Luo includes knowledge, attitude, and practice dimensions, its item design mainly focuses on pediatric patients who are critically ill, lacking specificity for the complex pathological characteristics and multidisciplinary collaboration needs of patients after liver transplantation [16]. Additionally, the KAP scale for deep vein thrombosis prevention developed by the Chinese scholar Wang is framed within KAP theory but focuses on managing a single complication, without systematically covering the entire assessment process of early mobilization [26].

In contrast, the questionnaire in this study offers several distinct advantages. (1) Targeted design: The items closely align with the clinical characteristics of patients who are critically ill following liver transplantation (eg, line management, postoperative complication risks, and multidisciplinary collaboration), integrating core recommendations from the ‘Expert Consensus on Enhanced Recovery Management during the Perioperative Period for Liver Transplantation in China’, ensuring the tool’s high relevance to clinical practice. (2) Multidimensional coverage: Existing tools mostly focus on a single dimension of knowledge or practice [27], whereas our questionnaire comprehensively reflects the knowledge, attitude, and practice of ICU nurses through a collaborative assessment across 3 dimensions: knowledge (17 items), attitude (10 items), and practice (13 items), which aligns more closely with the interpretation of KAP theory regarding the continuity of behavioral changes [14,22]. (3) Advantages in reliability and validity: The Cronbach’s α coefficient, CVI, and cumulative variance contribution rate of this questionnaire are higher than those of similar tools [16], indicating good measurement precision and structural stability of the scale in the preliminary validation stage.

CLINICAL SIGNIFICANCE AND APPLICATION PROSPECTS OF THE RESEARCH FINDINGS:

The formulation of this questionnaire provides scientific references for improving the quality of ICU nursing for patients undergoing liver transplantation. In addition to its rigorous psychometric properties, this questionnaire provides an important reference for clinical practice and healthcare policy in the preliminary application stage. Clinically, it can serve as a targeted assessment tool to accurately identify nurses’ knowledge gaps (eg, unclear understanding of mobilization timing following liver transplantation) and attitude barriers (eg, excessive concern about the risk of graft injury), providing a basis for developing personalized educational intervention programs and standardizing early mobilization practices. By addressing these deficiencies, the approach can indirectly improve patient outcomes, such as reducing the incidence of postoperative complications (eg, deep vein thrombosis, pulmonary infection) and shortening hospital stays, aligning closely with the goals of the Enhanced Recovery After Surgery protocol for liver transplant recipients. At the institutional and policy levels, the questionnaire can be integrated into nursing quality control systems to monitor and enhance the specialized rehabilitation nursing competence of ICU teams, offering empirical data for optimizing post-liver transplant nursing training programs and improving clinical practice guidelines. This practical relevance enhances the study’s academic value and provides robust support for advancing evidence-based improvements in specialized nursing care.

STUDY LIMITATIONS:

This study has some limitations. First, although the sample size met the statistical requirements for EFA, the surveyed population was only from tertiary hospitals performing liver transplantation in several regions of China. Moreover, the sample selection was based on convenience sampling, which led to certain regional limitations in sample representativeness and in the coverage of ICU nursing staff across different levels of medical institutions in China. Second, as this was a preliminary validation study, we conducted EFA to explore the factor structure. The absence of CFA in an independent sample means the three-factor structure requires further verification. Future research should recruit a separate, larger sample to perform CFA and cross-validate the model. Third, this study did not perform cross-cultural validation of the questionnaire, and the scale was developed based on the clinical guidelines and expert consensus of Chinese liver transplantation perioperative management; therefore, its applicability in other countries and regions with different medical systems, clinical practice norms, and nursing education backgrounds is unknown, and cross-cultural adaptation and validation are needed in the follow-up. Finally, this study only relied on the KAP model to construct the questionnaire framework, which only focuses on the continuous relationship between knowledge, attitude, and practice, and may not fully cover all the factors affecting nurses’ early mobilization practice, such as organizational management factors, resource support factors, and inter-professional collaboration factors. Future research should incorporate other theoretical models such as the TPB to complement and verify the research results.

Conclusions

This study successfully completed the preliminary development and validation of a specialized KAP assessment tool for ICU nurses regarding the early mobilization of critically ill patients after liver transplantation. The scale covers 3 dimensions – knowledge, attitude, and practice – and demonstrates satisfactory reliability and validity in the current research sample. It fills the gap in specialized assessment tools in China, addresses the limitations of traditional general tools and provides a standardized basis for accurately identifying nurses’ competency gaps, formulating targeted training programmes and optimizing the perioperative rehabilitation nursing process for liver transplantation. The tool also facilitates implementation of the patient-centred enhanced recovery concept in critical care, enriches the array of liver transplantation nursing assessment tools, and offers a reusable measurement instrument for subsequent research. Future research could expand the sample coverage to verify the tool’s cross-scenario applicability, adopt mixed research methods to analyze underlying influencing factors, develop systematic training and intervention programs based on this tool and validate their effectiveness, explore its integration with electronic nursing quality management systems, and construct a dynamic system for continuous improvement of nursing quality.