Abstract
Background:
Nurses’ knowledge, attitudes, and practices (KAP) regarding external ventricular drainage (EVD) significantly impact patient care quality.
Purpose:
The study aimed to develop and validate a suitable questionnaire for assessing neurosurgical nurses’ KAP regarding EVD care.
Methods:
This study developed a questionnaire from a literature review, semi-structured interviews, team discussions, and 2 Delphi rounds, then administered it to 841 neurosurgical nurses to assess its psychometric properties, including content validity, structural validity, and reliability.
Results:
The final 40-item questionnaire had a Cronbach’s α of 0.871, split-half reliability of 0.820, test-retest reliability of 0.853, with the content validity index ranging from 0.861 to 1.000. Exploratory factor analysis revealed 11 factors, collectively accounting for 64.17% of the total variance.
Conclusions:
The developed questionnaire can serve as a useful tool for assessing neurosurgical nurses’ knowledge, attitudes, and practices regarding EVD care.
Keywords: external ventricular drainage, neurosurgery, nursing, questionnaire development
INTRODUCTION
External ventricular drainage (EVD) involves the continuous closed drainage of cerebrospinal fluid (CSF) from the brain’s ventricles to the outside of the body and is recognized as a widely utilized therapeutic intervention in neurosurgery.1 The use of EVD is demonstrated to effectively lower intracranial pressure, enhance cerebral tissue oxygenation, and reduce the incidence or mitigate the progression of cerebral herniation.2 EVD is primarily indicated for the management of hydrocephalus and intracranial hemorrhage following severe cranial trauma.3-6 Guidelines for the management of craniocerebral trauma have been established by authoritative bodies such as the Brain Trauma Foundation, the American Heart Association/American Stroke Association, and the Congress of Neurological Surgeons in collaboration with the American Association of Neurological Surgeons.3,5,7
However, postoperative EVD management presents significant challenges. Insufficient drainage may lead to increased intracranial pressure and severe cerebral herniation. Excessive or rapid drainage of CSF may lead to intracranial hypotension headache, subdural hematoma, subdural effusion, and aneurysm re-rupture.3 Additionally, complications such as infection, hemorrhage, and catheter obstruction can occur post-EVD, posing a significant risk to patients’ clinical outcomes and quality of life.8,9
Presently, the domain of EVD care remains nascent.10 The capacity of nursing professionals to identify abnormalities in patients with EVD expeditiously and to implement suitable clinical interventions is critical to enhancing patients’ clinical outcomes.2,11 The theory of knowledge, attitudes, and practices (KAP) posits that individuals gain knowledge and form attitudes, which then motivate the performance of actions, facilitating the translation of cognitive understanding into tangible practices.12,13 Assessing the current state of nurses’ knowledge, attitudes, and practices in EVD care will aid in identifying and fortifying areas for improvement and is essential to enhance nurses’ professional proficiency and elevate the standard of patient care.14,15 The Canadian researcher Alrashidi examined nurses’ EVD-related knowledge and comfort levels through a survey on EVD nursing practices, but the study did not assess their attitude or practice aspects.10
This study aimed to develop a tool to assess knowledge, attitudes, and practices regarding EVD nursing care given the absence of existing instruments in this domain. The tool’s psychometric properties were evaluated among neurosurgical nurses. This questionnaire will enable nurse administrators to assess nurses’ knowledge, attitudes, and practices regarding EVD care, facilitating targeted interventions to enhance care quality, reduce patient complications, and improve outcomes for patients with EVD.
METHODS
Design
This study was conducted in 2 phases. Phase 1 focused on the development of the questionnaire, which included the establishment of a research team, literature review, semi-structured interviews, Delphi expert consultations, and a pilot survey. Phase 2 involved a formal survey to validate the psychometric properties of the questionnaire, content and structural validity, as well as reliability.
Questionnaire development
Establishment of the research team
The research team included 6 members: 1 neurosurgeon, 1 nursing administrator, 1 nursing educator, 2 clinical nurses, and 1 nursing Master’s student. The team’s main task was to conduct a literature review, conduct semi-structured interviews, develop the questionnaire, prepare an expert consultation form, select experts, and collect and analyze data. This study was approved by the Ethics Committees of the First Hospital of Jilin University.
Literature review
The research team conducted a systematic literature review using PubMed, Web of Science, Embase, Cochrane Library, China National Knowledge Infrastructure (CNKI), Wanfang, Wipu, and China Biomedical Literature Database. The keywords included EVD, management of EVD, and EVD nursing care. The search covered records from each database’s inception to November 30, 2023. Inclusion criteria were reports of adult patients receiving EVD treatment or focus on EVD management, with literature types including clinical guidelines, evidence summaries, expert consensus, and systematic reviews. The identified references were classified according to the KAP framework, with scale items independently extracted by the research team. Discrepancies were resolved through group discussions to develop the item pool.
Semi-structured interviews
Five neurosurgical nurses from a tertiary hospital in Jilin Province were selected via purposive sampling for semi-structured interviews. The interview outline included: (1) What do you think are the key points and difficulties in the nursing care of EVD? (2) What do you think are the factors affecting the quality of nursing care of EVD? (3) What do you think are key points about EVD that nurses should be knowledgeable about? (4) Talk about your attitude toward caring for patients with EVD; and (5) What do you think can be done to improve the quality of care for EVD? Interviews lasted 20 to 30 minutes and were conducted in a quiet setting. During the interviews, the interviewer listened attentively and recorded the responses accurately using an audio recorder. Data were transcribed and analyzed to extract key themes, which were then incorporated into our item pool. These themes included (1) controlling the amount of CSF drainage, (2) adjusting the height of the EVD collection system, and (3) preventing ventriculostomy-associated infection.
Delphi method with expert correspondence
A Delphi expert consensus method was employed to solicit expert opinions for reaching consensus on the pre-established item pool. Experts were recruited nationwide and were required to possess a high level of academic and practical experience in the field of neurosurgery. Additionally, they had to have a comprehensive understanding of the study and participate voluntarily. Typically, the optimal number of experts is 10 to 15.9
A total of 15 experts, including 14 nursing experts and 1 medical expert, from Beijing, Shanghai, Jilin, Liaoning, Heilongjiang, Hunan, Sichuan, and Guangdong, were invited to participate in 2 rounds of correspondence. Detailed demographic information about the experts is presented in Table 1.
Table 1.
Demographic Characteristics of Experts Included in the Delphi Method (N = 15)
| Variable | n (%) |
|---|---|
| Gender | |
| Female | 12 (80.0%) |
| Male | 3 (20.0%) |
| Age, y | |
| 30-40 | 2 (13.3%) |
| 41-50 | 5 (33.3%) |
| >50 | 8 (53.3%) |
| Education | |
| Bachelor degree | 3 (20.0%) |
| Master’s degree | 12 (80.0%) |
| Professional area | |
| Nursing Education | 3 (20.0%) |
| Clinical Nursing | 4 (26.7%) |
| Clinical Medicine | 1 (6.7%) |
| Nursing Management | 7 (46.6%) |
| Clinical experience, y | |
| 10-20 | 3 (20.0%) |
| 21-30 | 5 (33.3%) |
| 31-40 | 4 (26.7%) |
| >40 | 3 (20.0%) |
The expert consultation questionnaire consisted of 3 sections. The first section introduced the study’s background, objectives, and informed consent. The second section used a 5-point Likert scale (1 = very unimportant to 5 = very important) to rate the importance of each item. Experts were also invited to provide suggestions for the modification or deletion of specific items. The third section collected basic information about the experts, including their familiarity with EVD care and the rationale for their judgments.
After obtaining expert consent, the questionnaires were distributed via WeChat or email. Following the first round of consultation, the research team analyzed the results, summarized expert opinions, and revised the questionnaire items accordingly to form the second-round questionnaire. After 2 rounds, expert opinions converged, concluding the correspondence.
Items with a mean importance rating ≥3.5 and a coefficient of variation ≤0.25 were retained. Based on these criteria and expert feedback, the research team formed an updated draft of the item pool, which comprised 14 knowledge items, 10 attitude items, and 28 practice items, totaling 52 items.
Pilot survey
Convenience sampling was employed to select 15 neurosurgical nurses from a tertiary hospital in Jilin Province in January 2024 for a pilot study to evaluate the fluency of the items. Inclusion criteria to participate in the voluntary pilot survey included having ≥1 year of experience in neurosurgery; all participants signed an informed consent form. The exclusion criteria included nurses who were undergoing standardized training. Cognitive interviews were conducted to identify any difficulties the nurses encountered while reading and understanding the items. Pilot survey results confirmed the linguistic and logical clarity of the items. As a result, we did not make any changes to the item pool and all 52 items were retained for the formal survey.
Formal survey
Study participants
A multi-center, cross-sectional study design was employed to collect data for psychometric analyses, reliability, and validity testing. Using purposive sampling, neurosurgical nurses were selected from 15 hospitals across 10 provinces in China for the formal survey. With 52 questionnaire items and accounting for 20% invalid responses, the sample size requirement was 312 to 624.13 The inclusion criteria for participants were nurses who worked in a neurosurgery unit, had at least 1 year of clinical experience, held a valid nursing license, and provided informed consent. The exclusion criteria included nurses who were undergoing standardized training, as well as those who were studying overseas, were on maternity leave, or were on sick leave during the study period.
A total of 931 questionnaires were distributed, with 925 recovered and 841 valid (recovery rate 99%, effective rate 90%). Participant characteristics are shown in Table 2. Most were female (93.0%, n = 782) and had a university education (85.9%, n = 722). The majority were aged 31 to 35 years (39.0%, n = 328) and had 11 to 20 years of experience (40.5%, n = 341). Over half worked in neurosurgical wards (67.4%, n = 567), and a large proportion (75.5%, n = 635) had received training in standardized EVD nursing care.
Table 2.
Demographic Characteristics of Participants (N = 841)
| Variable | n (%) |
|---|---|
| Gender | |
| Female | 782 (93.0%) |
| Male | 59 (7.0%) |
| Education | |
| College | 96 (11.4%) |
| Bachelor’s degree | 722 (85.9%) |
| Master’s degree | 23 (2.7%) |
| Age, y | |
| ≤25 | 43 (5.1%) |
| 26-30 | 162 (19.3%) |
| 31-35 | 328 (39%) |
| 36-40 | 173 (20.6%) |
| ≥41 | 135 (16.1%) |
| Clinical experience, y | |
| <3 | 45 (5.4%) |
| 3-5 | 86 (10.2%) |
| 6-10 | 253 (31.1%) |
| 11-20 | 341 (40.5%) |
| 21-30 | 90 (10.7%) |
| >30 | 26 (3.1%) |
| Departments | |
| Neurosurgical Ward | 567 (67.4%) |
| Neurosurgical Intensive Care Unit | 274 (32.6%) |
| Trained in standardized EVD nursing care | |
| Yes | 635 (75.5%) |
| No | 206 (24.5%) |
EVD, external ventricular drainage.
Measurements
The questionnaire was provided via an online platform and included 4 parts: (1) demographic information of nurses including gender, age, years of work experience, educational level, and hospital level; (2) knowledge related to EVD with 14 multiple choice questions each with 5 options, 1 point for a correct answer and 0 points for a wrong answer or “not sure” for a total of 14 points; (3) attitudes related to EVD with 10 questions rated on a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree) with total scores ranging from 10 to 50; and (4) practice related to EVD with 28 questions rated on a 5-point Likert scale (1 = never to 5 = always) with total scores ranging from 28 to 140. The total score for the 3 dimensions ranged from 38 to 204, with higher scores indicating higher levels of knowledge, attitudes, and practices of nurses regarding the nursing care of adults with EVD.
Statistical analysis
Data entry and analysis were performed using Microsoft Excel 2016 (Microsoft Corporation, Redmond, Washington, USA) and IBM SPSS Statistics 26.0 (IBM Corporation, Armonk, New York, USA). Categorical data were presented as frequencies and percentages. Expert reliability was evaluated through coefficients of familiarity, judgment basis, and authority. The degree of consensus among experts was quantified using Kendall’s W coefficient. Statistical significance was set at P < .05.16
RESULTS
Delphi method
In the first Delphi round, 17 questionnaires were sent with 15 returned and 44 recommendations made by 11 experts. In the second round, 15 questionnaires were distributed and all were returned, with 6 recommendations from 2 experts. The expert positive coefficients were 88.2% and 100% in the 2 rounds, respectively, indicating high expert motivation.
During the 2 rounds of correspondence, the familiarity levels (Cs) were 0.88 and 0.91, the coefficients of judgment basis (Ca) were 0.95 and 0.96, and the authority coefficients (Cr) were 0.92 and 0.93, respectively. These values indicate a high level of expert authority. The importance ratings of the items ranged from 3.4 to 5.0 and from 3.53 to 5.0, with coefficients of variation (CV) ranging from 0.052 to 0.365 and from 0 to 0.236, respectively. Kendall’s coefficient of concordance was 0.249 and 0.252, respectively, both with P < .001.
Item analysis
The discriminatory power and differentiation of each item were tested by the critical ratio method and correlation coefficient method.17 The total scores of the questionnaire items were sorted in descending order, with the top 27% forming the high-score group and the bottom 27% forming the low-score group. Items were compared between the 2 groups. Those with composite reliability of <0.3 were excluded.17 The correlation coefficients between each item and the total questionnaire score were assessed, and items with a coefficient of <0.4 were removed.17
The questionnaire item decision values ranged from 7.164 to 17.808, with significant differences (P < .001), demonstrating good discrimination. Correlation analysis revealed that the correlation coefficients between items B1, B3, B8, and B10 in the attitude dimension and item C19 in the practice dimension were all < 0.4. These items were therefore removed, leaving 47 items for further examination.
Validity assessment
Exploratory factorial analysis
Exploratory factor analysis was conducted to assess the questionnaire’s structural validity. Bartlett’s sphericity test (P < .05) and Kaiser-Meyer-Olkin (KMO) value >0.80 determined its suitability for factor analysis.18 Factors were retained using orthogonal rotation via principal component analysis and maximum variance method, based on eigenvalues >1, cumulative variance contribution >60%, factor loadings ≥0.5, and the scree plot test.19
Exploratory factor analysis results showed a KMO value was 0.905, and Bartlett’s sphericity test χ2 value was 16 200.309 (P < .001), indicating suitability for factor analysis. The analysis was conducted using principal component analysis and varimax rotation. During factor analysis, items A4, A5, A12, C9, C11, C13, and C15 failed to load significantly on any factors (loading threshold <0.4). After discussion among the research team members, these 7 items were subsequently removed. The final analysis yielded a KMO value of 0.905, Bartlett’s χ2 was 14 861.35 (P < .001), and 11 factors were extracted by principal component analysis with eigenvalues >1 and cumulative variance contribution of 64.169%. Detailed EFA results are displayed in Supplemental Digital Content, Table 1, http://links.lww.com/JNCQ/B416. Factor loadings ranged from 0.508 to 0.851. Among them, factors 6, 8, 9, and 10 included 11 items related to the knowledge dimension; factor 3 included 6 items related to the attitude dimension; and factors 1, 2, 4, 5, and 7 included 23 items related to the practice dimension. No cross-factor loadings were observed, and the 11 factors were retained and categorized into the predefined 3 dimensions. The final questionnaire included 40 items across the knowledge dimension (items A1-A11), attitude dimension (items B1-B6), and practice dimension (items C1-C23) (Supplemental Digital Content, Table 2, http://links.lww.com/JNCQ/B417).
Content validity analysis
We invited 15 experts who participated in both rounds of the Delphi survey to evaluate the content validity of the 40-item questionnaire developed. Content validity was assessed using the item-level content validity index (I-CVI). Experts rated item relevance on a 4-point Likert scale (1 = not relevant to 4 = highly relevant). The predetermined cutoff for satisfactory content validity was an I-CVI > 0.8.20
This study showed that the questionnaire I-CVI ranged from 0.86 to 1.000, indicating good content validity of the questionnaire.
Reliability assessment
Cronbach’s α coefficient and split-half reliability were used to test the reliability of the questionnaire. A Cronbach’s α coefficient of each dimension of the questionnaire and the total questionnaire >0.7 and a split-half reliability coefficient >0.7 are considered to indicate high reliability.
The knowledge dimension items were not measured using a Likert scale and thus were not analyzed for reliability. The total questionnaire’s Cronbach’s α was 0.871, with attitude and practice dimensions ranging from 0.872 to 0.873. Item deletion analysis revealed that removing any single item would not significantly improve the α coefficients. The split-half reliability coefficient was 0.82 for the total scale, with values ranging from 0.798 to 0.892 for the attitude and practice dimensions.
Two weeks after the formal survey, we recruited 20 nurses meeting the predefined inclusion/exclusion criteria for test-retest reliability evaluation. The test-retest reliability of the questionnaire was 0.853, indicating good reliability.21
DISCUSSION
Scientific reliability of the questionnaire
Using KAP theory, this study constructed a comprehensive questionnaire item pool through a systematic literature review, clinical practice insights, and group discussions. The pool included 40 items covering topics such as EVD assessment, nursing priorities, abnormality identification, and complication prevention, ensuring broad content coverage.
In this study, 15 neurosurgery experts from 8 provinces and cities participated in 2 rounds of Delphi correspondence. Their high positive coefficient and authority indicated reliable results. Subsequently, 841 nurses from 15 hospitals across 10 provinces and cities were surveyed to test the questionnaire’s reliability. Item analysis deleted 5 items with a coefficient of variation >0.25, and exploratory factor analysis removed 7 items due to insufficient factor loadings.
Exploratory factor analysis extracted 11 metrics with factor loadings >0.4 and no multiple loadings, yielding a cumulative variance contribution of 64.169%. The knowledge, attitude, and practice dimensions yielded 4, 1, and 5 latent factors, respectively, demonstrating strong alignment with the theoretical framework and good structural validity. Fifteen experts evaluated the content validity, resulting in an scale-level content validity index (S-CVI) of 0.950 and I-CVI ranging from 0.861 to 1.000. The questionnaire’s overall and dimensional Cronbach’s alpha coefficients were >0.7, split-half reliabilities were >0.8, and test-retest reliability of 0.853. These results indicate excellent internal consistency and temporal stability and confirm that the developed instrument meets scientific standards of reliability.
Usefulness of the questionnaire
The development of the Adult EVD Nursing KAP Assessment Scale addresses a critical gap in neurosurgical nursing practice. Given the significant risks associated with EVD, including the potential for intracranial infections that can prolong hospital stays and worsen patient outcomes, the need for a reliable assessment tool is evident.22 The questionnaire developed in this study was designed to be concise and user-friendly, facilitating its adoption in clinical settings. By providing an objective measure of the nursing staff’s EVD-related competencies, the tool can guide targeted interventions and educational programs. These interventions are crucial for enhancing the quality of care, reducing complications, and improving patient prognosis. Furthermore, the questionnaire’s utility extends beyond immediate clinical practice, laying the groundwork for future research in EVD nursing care, which has significant implications for advancing evidence-based practice in this area.
Limitations
This study has several limitations. First, due to the absence of a universally accepted validated questionnaire as a benchmark, our questionnaire did not undergo standard criterion-related validity testing. Second, this study was conducted within the Chinese cultural context, and its findings may exhibit limitations when generalized to other countries. Future research should translate the Adult EVD Nursing KAP Assessment Scale into multiple languages and rigorously validate it across diverse populations before broader application.
CONCLUSION
The present study successfully developed and validated the Adult EVD Nursing KAP Assessment Scale. This questionnaire can serve as a useful tool to assess neurosurgical nurses’ knowledge, attitudes, and practices regarding EVD care. This tool can help provide new insights for developing targeted interventions to enhance care quality, reduce procedure-related complications, and ultimately improve clinical outcomes in EVD management.
Footnotes
X.C. and Y.C. contributed equally to this work.
We sincerely thank all investigators and participants of this study.
The authors declare no conflict of interest.
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (www.jncqjournal.com).
Early Access: May 8, 2025
Contributor Information
Xiaohan Chen, Email: chenxh23@mails.jlu.edu.cn.
Yunbo Chi, Email: chiyb21@mails.jlu.edu.cn.
Yangyang Tian, Email: tianyangyang16@jlu.edu.cn.
Jing Zhang, Email: flyjingjing2018@jlu.edu.cn.
Jing Zhou, Email: zhou-j@jlu.edu.cn.
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