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. 2026 Apr 29;32:e70152. doi: 10.1111/ijn.70152

Development and Preliminary Testing of the Healthy Transition Scale for Patients Undergoing Haemodialysis

Ae‐Kyung Chang 1, Min‐Kyung Kim 1, Woo‐Jung Hong 1, Yeon‐Kyung Cho 1, Ah‐Young Kim 2,✉
PMCID: PMC13128539  PMID: 42056020

ABSTRACT

Purpose

This study aimed to develop a scale to measure healthy transitions in patients undergoing haemodialysis.

Methods

Twenty‐seven preliminary items of the Healthy Transition Scale to Haemodialysis (HTS‐HD) were identified through a literature review and in‐depth interviews with patients undergoing haemodialysis. Of these, 25 items demonstrated content validity. To verify the reliability and validity of the preliminary scale, questionnaires were administered to 234 in‐centre patients undergoing haemodialysis. The data were analysed using item analysis, exploratory factor analysis, convergent and discriminant validity and concurrent validity. Internal consistency and reliability were tested using Cronbach's α coefficient.

Results

The final version of HTS‐HD consisted of 19 items. Four factors were extracted: independent participation, subjective well‐being, acceptance and integration and active information seeking and coping. These were verified through convergent and discriminant validity. The concurrent validity was confirmed using the Psychological Adaptation Scale (PAS). The overall Cronbach's α was 0.88.

Conclusion

Since the developed scale is valid and reliable, the HTS‐HD can be used to develop nursing interventions to improve the healthy transition of patients undergoing haemodialysis.

Keywords: health transition, instrumentation, psychometrics, renal dialysis

Summary

What Is Already Known About This Topic?

  • Patients initiating haemodialysis undergo a rapid transition process encompassing physical, emotional and social aspects.

  • The transition process for patients undergoing haemodialysis determines whether they experience a healthy transition, characterized by adapting to a new lifestyle, cultivating positive relationships and integrating dialysis into their lives with optimism for the future and improved quality of life.

  • Assessing the patient's transition levels in clinical practice and offering patient‐specific interventions during haemodialysis requires reliable and valid measures to facilitate the transition effectively.

What This Paper Adds?

  • The Haemodialysis Transition Scale for Patients undergoing Haemodialysis was developed in this study, and its validity and reliability were validated.

  • The Haemodialysis Transition Scale for Patients undergoing Haemodialysis Scale can be to evaluate the haemodialysis healthy transition levels, which has multidimensional attributes.

The Implications of This Paper

  • Evaluating individuals' perception of transition and assessing the quality of transition with this scale represent crucial first steps for nurses to develop tailored nursing care plans and interventions for individuals navigating through transition.

  • This scale can be used in future studies that are planned to understand the transition in patients undergoing haemodialysis, identify the level of transition and factors affecting transition,

1. Introduction

Approximately 4 million patients worldwide are diagnosed and treated for end‐stage renal failure. Haemodialysis is the most common renal replacement therapy, and it is used by more than 80% of patients with end‐stage renal failure (Bello et al. 2022; Korean Society of Nephrology 2020). For patients with chronic kidney failure, the initiation of haemodialysis is a change in treatment and physical health (Fex et al. 2011; English; Hassani et al. 2017), lifestyle changes due to strict dietary restrictions and self‐care (Wai et al. 2020; English) and a change in social organization due to 2–3 weekly hospital visits (Oliveira et al. 2020). As a result of these life‐altering changes, patients undergoing early haemodialysis experience negative psychological states, such as anxiety, panic and fear (Allen et al. 2022; Jones et al. 2021). This process of change from one state or condition to another is called ‘transition’ (Bridges and Bridges 2019; Schumacher and Meleis 1994). Meleis et al. (2000) defined health‐related transitions from a nursing perspective as ‘a change from a healthy state to a sick state or from one stage of life to another’.

However, not all the changes are negative transitions. Depending on the outcome of the interaction between an individual facing the change and his/her environment, the direction of the transition can be positive (Sturesson and Ziegert 2014). A positive transition to haemodialysis begins with the individual accepting and facing the physical, mental and social changes induced by haemodialysis (Fex et al. 2011; English; Holvoet et al. 2020). To cope with these changes, individuals then engage in self‐management behaviours and adaptive efforts, such as seeking information regarding the disease, haemodialysis and adhering to dialysis treatments, until they come to accept haemodialysis as part of their daily routine (Hassani et al. 2017; Oliveira et al. 2020). Thus, depending on how they go through the transition process, patients experience a healthy or unhealthy transition (Hassani et al. 2017). A healthy transition involves the subjective perception of well‐being, the mastery of new behaviours and the establishment of good interpersonal relationships (Meleis 2010). For patients undergoing haemodialysis, a healthy transition refers to learning a new normal lifestyle, developing positive relationships with others and integrating dialysis into their lives with hope for the future and improved quality of life (Fex et al. 2011; English; Oliveira et al. 2020; Kim and Yang 2021; Cervantes et al. 2021). However, if a healthy transition does not occur, the patient is unable to adapt to the new changes, feels helpless and continues to live a life dependent on a dialysis machine (Oliveira et al. 2020). Patients undergoing long‐term haemodialysis are exposed to transition situations as they are constantly experiencing new change factors such as dialysis‐related complications, job loss, financial burden due to long‐term treatment and family caregiving burnout (Hassani et al. 2017; Jablonski 2004); hence, promoting a healthy transition for patients undergoing early haemodialysis can be the cornerstone of a successful transition to maintenance dialysis.

To facilitate this transition, it is important to assess the patient's transition levels in clinical practice and provide patient‐specific interventions accordingly (Oliveira et al. 2020). This requires valid and reliable measures to assess the transition of patients undergoing haemodialysis (Meleis 2010). However, few valid scales are available to measure this transition in patients undergoing early haemodialysis.

The Starting Dialysis Questionnaire (SDQ) has been used as an instrument for patients undergoing early haemodialysis (Moore et al. 2020). The SDQ consists of three subscales—expectations of dialysis treatment, acceptance of dialysis and dyadic relationships—which reflect the nature of the interactions in which patients accept haemodialysis and cooperate with others. However, this scale is limited in its ability to measure healthy transitions in patients undergoing haemodialysis since it only measures the patient's emotional and interpersonal readiness before initiation of haemodialysis.

In addition, early haemodialysis studies measured concepts similar to transition, such as psychological adaptation, in chronically ill patients (Kim and Joung 2020), as haemodialysis transitions. Adaptation refers only to the outcome of a response to change at a particular point in time, whereas transition is a more encompassing concept that emphasizes both the process and the outcome of readjusting one's life by interacting with a changing environment (Kralik et al. 2006). Measuring transition with scales that measure readiness for transition or adaptation as a result of transition has limitations, especially because not all transitions lead to adaptation (Sturesson and Ziegert 2014), and healthy transitions can occur at any point in the transition process experienced by patients (Meleis 2010).

Through the theory of transition, Meleis suggests both process indicators that occur in the middle of the transition process and outcome indicators that occur at the end of the transition (Meleis 2015). The healthy transition of patients undergoing haemodialysis occurs when individuals experiencing extensive changes face and accept the haemodialysis situation, strive for self‐management and integrate haemodialysis and daily life (Hassani et al. 2017; Allen et al. 2022; Sturesson and Ziegert 2014). Therefore, in this study, using Meleis' transition theory (Meleis et al. 2000) as a theoretical framework, we aimed to develop a measure of healthy transition of patients undergoing haemodialysis that includes process factors and outcome factors among the response dimensions of transition theory to measure healthy transitions of patients undergoing haemodialysis and to verify its reliability and validity.

2. Methods

2.1. Study Design

This methodological study aimed to develop the Healthy Transition Scale for Patients undergoing Haemodialysis (HTS‐HD) for maintenance haemodialysis treatment. The research procedure followed the scale development and validation guidelines proposed DeVellis and Thorpe (2021).

2.2. Instrument Development

2.2.1. Create a Conceptual Framework and Item Generation

Using the definition and attributes of healthy transition proposed in Meleis' (Meleis et al. 2000) transition theory as a conceptual framework, a preliminary questionnaire was constructed through a literature review and in‐depth interviews with patients undergoing haemodialysis.

Transition theory (Meleis et al. 2000) states that a healthy transition should include the attributes of subjective well‐being, role mastery and well‐being relationships. To identify the attributes of the concept of healthy transition experienced by patients undergoing haemodialysis, we conducted a literature review of transitions in haemodialysis and conducted in‐depth interviews with patients undergoing haemodialysis.

For the comprehensive literature review, we searched articles in three international databases, CINAHL, Pubmed and PsycINFO, and two Korean databases, RISS and DBpia, using ‘h(a)emodialysis’, ‘renal dialysis’ and ‘transition’ as keywords. A total of 4987 articles were identified from the literature search, and 53 articles were extracted after removing duplicates and checking the titles and abstracts. Finally, 19 research articles that fit the concept of haemodialysis transition were selected and analysed for their attributes by checking the full text.

In‐depth interviews were conducted between 13 December 2021 and 31 January 2022, with 16 patients aged 19 and older who were receiving haemodialysis treatment in the artificial kidney units of two dialysis hospitals in Korea. The number of interviews per participant was one–two, and the duration of the interviews was 30–60 min. Because of the difficulty of face‐to‐face meetings with participants due to COVID‐19, we collected data through telephone interviews. With the participants' informed consent, the interviews were recorded and transcribed on the day of the interview and analysed through repeated readings. The main interview questions were as follows: ‘What was your experience in transitioning to hemodialysis?’ ‘What changed before and after hemodialysis?’‘What are the positive changes since you started hemodialysis?’ ‘What aids in a smooth transition to hemodialysis’ ‘How are you doing on hemodialysis?’ ‘Who and how did you receive support to make a good transition after starting hemodialysis?’ ‘How do you currently perceive your overall condition?’ and ‘In what situations do you feel that you manage hemodialysis well on your own?’ The interviewees were six women and 10 men, with a mean age of 58.4 years and a mean haemodialysis duration of 13.9 months. The data collected during the interviews were analysed using a deductive approach following the qualitative content analysis method (Elo and Kyngäs 2008).

The literature review and in‐depth interviews were combined to create tentative attributes of the concept of healthy transition in patients undergoing haemodialysis, along with an initial preliminary tool item.

2.2.2. Content Validity Test

The content validity of the preliminary tool items was evaluated using elements from the COSMIN checklist (Terwee et al. 2018). The relevance and comprehensiveness of patient‐reported outcome measures were quantitatively assessed to determine how well each item related to the concept being measured. Consequently, an expert panel evaluated the relevance and comprehensiveness of each item, using the Item‐Content Validity Index (I‐CVI) to confirm if they met the threshold for validity. This panel, formed according to Lynn (1986), included two nephrology professors, two nursing professors with expertise in scale development and two nephrology nurses with over a decade of clinical experience. Items rated on a 4‐point scale and scoring ≥ 0.80 were considered valid (Davis 1992). Expert feedback was instrumental in refining item clarity and relevance. Additionally, a Korean literature expert reviewed the items for linguistic accuracy.

Assessing comprehensibility is crucial to determine how respondents understand the questions. Therefore, a face validity test involving 20 haemodialysis patients was conducted to evaluate comprehension, response time and potential issues in survey administration. Open‐ended responses were collected to ensure that respondents understood the questions and response options as intended.

3. Psychometric Tests

3.1. Evaluation of the Healthy Transition Scale for Haemodialysis

HTS‐HD was evaluated using item and exploratory factor analyses to identify factors, convergent validity, discriminant validity and reliability.

3.1.1. Study Participants and Data Collection

Data collection for this study was conducted from 1 June 2022 to 1 February 2023, in the artificial kidney units of three dialysis hospitals in Korea. Based on previous literature (Moos 2012), it was observed that it takes approximately 3 years to enter a period of long‐term adaptation after the start of haemodialysis treatment in patients who were receiving regular haemodialysis at least 2–3 times a week for 36 months or less after the start of haemodialysis. Accordingly, convenience sampling was carried out in these hospitals. The inclusion criteria were patients who were 20 years of age or older, able to communicate, understand and respond to the questionnaire, understood the purpose of the study and agreed to participate.

According to the sample size guidelines for exploratory factor analysis, at least five to 10 times the number of survey questions is appropriate (Fabrigar and Wegener 2012). A total of 270 questionnaires were distributed, accounting for a dropout rate of 10%. Of these, 238 questionnaires were returned. However, four questionnaires with insufficient responses were excluded, resulting in 234 data points for the final analysis.

3.1.2. Measures

To verify the validity of the HTS‐HD, the Psychological Adaptation Scale (PAS) (Biesecker et al. 2013) was adapted to Korean (Kim and Joung 2020) and the Korean version of the Psychological Adaptation Scale (K‐PAS), which has been validated for validity and reliability among Korean patients undergoing haemodialysis, was used in our study. The PAS instrument was developed based on cognitive adaptation theory and stress‐coping theory, and it consisted of 15 items in four subdomains: coping efficacy, self‐esteem, social integration and spiritual and existential well‐being (Biesecker et al. 2013). Each item was measured on a 5‐point Likert scale ranging from ‘not at all true’ to ‘very true’, with higher scores indicating higher levels of psychological adaptation. The reliability of the Korean adaptation of the instrument was Cronbach's α 0.94, and in this study, Cronbach's α was 0.94.

3.1.3. Data Analysis

The collected data were analysed using the IBM SPSS ver. 28.0 program (IBM Corp., Armonk, NY, USA). The general characteristics of the participants were calculated according to frequencies, percentages, means and standard deviations. Item analysis was conducted by examining item‐total correlations, and items with an overall correlation coefficient of 0.35 or less were reviewed and deleted accordingly (Cristobal et al. 2007). To examine construct validity, exploratory factor analysis (EFA) was conducted to identify the underlying factor structure of the instrument. The Kaiser‐Meyer‐Olkin (KMO) measure and Bartlett's test of sphericity were employed to ensure that the collected data were suitable for factor analysis. For factor extraction, varimax rotation was applied to simplify the factor structure and enhance interpretability by maintaining orthogonal interrelationships between factors (Lee 2016). The number of factors was determined based on eigenvalues greater than 1.0, factor loadings of 0.40 or more and a cumulative percentage of variance explained by the factors of 50% or more (Noh 2014). To check the convergent and discriminant validity of the developed items, a multi‐trait, multi‐item matrix analysis was conducted subsequently. Convergent validity was determined by checking whether the correlation coefficient calculated after controlling for overlapping items was greater than 0.40, and discriminant validity was determined by checking whether the correlation coefficient of each item with the subscale to which it belonged was greater than the correlation coefficient of the other subscale to which it did not belong (Ware and Gandek 1998). To verify concurrent validity, the correlation between the scores of the instrument developed in this study and the K‐PAS instrument (Kim and Joung 2020) was analysed using the Pearson correlation coefficient. The reliability of the instrument was evaluated by calculating the internal consistency reliability coefficient (Cronbach's alpha).

3.1.4. Ethical Considerations

All stages of this study were reviewed and approved by the Institutional Review Board to protect the rights of the study participants. Informed written consent was obtained from the participants after the purpose and methods of the study and their rights and privacy were explained to them. They were assured of their ability to withdraw from the study at any time, and the anonymous storage of data was guaranteed.

4. Results

4.1. Instrument Development

4.1.1. Item Generation

Through a comprehensive comparison and analysis of findings from the literature review and in‐depth interview data, four attributes of the concept of healthy transition for patients undergoing haemodialysis were identified, along with the initial item pool of the HTS‐HD. The preliminary scales consisted of four subdomains: (1) ‘Accepting the change’, which contained 5 items, (2) ‘Active information seeking and support’, which contained 6 items, (3) ‘Harmonious integration’, which contained 7 items and (4) ‘Perceived well‐being’, which contained 7 items. The 27 preliminary scales of the HTS‐HD were measured with a 5‐point Likert scale (1 = strongly disagree to 5 = strongly agree).

4.1.2. Content Validity Test

The content validity evaluation led to the removal of the item ‘I try to control my food and fluids’ due to its redundancy with ‘I try to follow my healthcare provider's prescription’, as reflected by an I‐CVI of 0.67. Since the I‐CVI value was below the threshold of 0.80, it was rated as insufficient (−) according to the COSMIN checklist's relevance rating, resulting in the deletion of this item. Consequently, 25 items were retained for further study.

To assess comprehensibility, a face validity test was conducted with 20 haemodialysis patients, which yielded an average Content Validity Index (CVI) of 0.96. This high score indicates that the questions were clear and easily understood. The mean completion time for the questionnaire was 8.5 min. Open‐ended responses confirmed that all scale items and response options were understandable and appropriate, resulting in all items being rated as sufficient (+) for comprehensibility according to the COSMIN checklist.

4.2. Psychometric Tests

4.2.1. General Characteristics of Participants

The average age of the participants was 49.35 years, with 47.9% aged 50 or older, and most of the participants were men (n = 126, 53.8%). The majority, 181 (77.4%) had a current spouse. Regarding education, 132 (56.4%) were college graduates or higher, 92 (39.3%) were high school graduates, seven (3.0%) were middle school graduates and three (1.3%) were elementary school graduates. More than half had a current job (n = 133, 56.8%), and 162 (69.2%) reported their subjective economic status as moderate. The average dialysis duration was 14.64 months, with 117 (50.0%) patients reporting a duration of 12 months or less (Table 1).

TABLE 1.

General Characteristics of participants (N = 234).

Characteristics Categories n (%) M ± SD
Age (year) ≤ 39 37 (15.8) 49.35 ± 11.49
40–49 85 (36.3)
50–59 73 (31.2)
≥ 60 39 (16.7)
Gender Male 126 (53.8)
Female 108 (46.2)
Education Under middle school 10 (4.3)
High school 92 (39.3)
≥ Bachelor 132 (56.4)
Marital status Single 53 (22.6)
Married 181 (77.4)
Occupation No 101 (43.2)
Yes 133 (56.8)
Perceived economic status High 10 (4.3)
Middle 162 (69.2)
Low 62 (26.5)
Education experience about HD No 91 (38.9)
Yes 143 (61.1)
HD vintage (month) 1–12 117 (50.0) 14.64 ± 9.13
13–24 82 (35.0)
25–36 35 (15.0)
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Abbreviations: HD, haemodialysis; M, mean; SD, standard deviation.

4.2.2. Construction of a Validity Test

4.2.2.1. Item Analysis

The item analysis of the preliminary tool showed that the mean value of each item ranged from 3.15 to 4.40 with a standard deviation of 0.70 to 1.08. The item‐total correlation coefficients for ‘My relationships with my family and close friends have not changed’ (factor loadings of 0.28), ‘I accept dialysis treatment with the support of family and friends’ (factor loadings of 0.30) and ‘I am supported by my social activities (occupation, hobbies, etc.) that have changed due to haemodialysis’ (factor loadings of 0.32) were below 0.35, indicating low contribution to the scale. The remaining items showed adequate correlations between 0.41 and 0.65 (Table 2). When examining the internal consistency and reliability of item deletions, we observed that none of the items increased the Cronbach's α value above 0.88. Therefore, we removed three items (3, 5 and 9) with item‐total correlations below 0.35, resulting in 22 items.

TABLE 2.

Item analysis (N = 234).

Item contents M ± SD item‐total correlation Cronbach's α if item is deleted
1. I know that haemodialysis is important for my survival and health. 4.33 ± 0.73 0.41 0.88
2. I feel mentally better after haemodialysis. 3.50 ± 0.95 0.51 0.88
3. My relationships with my family and close friends have not changed. 3.52 ± 1.03 0.28 0.88
4. I accept the changes in my role within the family due to haemodialysis. 3.79 ± 0.82 0.54 0.88
5. I accept dialysis treatment with the support of family and friends. 3.71 ± 1.02 0.30 0.88
6. I search for information about haemodialysis. 4.07 ± 0.88 0.42 0.88
7. I am satisfied with the haemodialysis treatment method. 4.05 ± 0.77 0.50 0.88
8. I modify my overall lifestyle to accommodate haemodialysis treatment. 4.16 ± 0.77 0.52 0.88
9. I am supported by my social activities (occupation, hobbies, etc.) that have changed due to haemodialysis. 3.55 ± 1.08 0.32 0.88
10. I can access local community social welfare services when I need help. 3.39 ± 0.95 0.48 0.88
11. I can share information and get support with other haemodialysis patients. 3.59 ± 0.93 0.49 0.88
12. I actively participate in haemodialysis treatment without missing sessions. 4.21 ± 0.87 0.44 0.88
13. I try to adhere to the healthcare providers' prescriptions. 4.33 ± 0.72 0.53 0.88
14. I have a good relationship with my healthcare providers. 4.08 ± 0.73 0.53 0.88
15. I feel better physically after dialysis. 3.85 ± 0.82 0.55 0.88
16. I accept the physical changes (arteriovenous fistula, appearance, etc.) due to haemodialysis. 3.76 ± 0.84 0.50 0.88
17. I accept myself for continuing to live with haemodialysis. 3.74 ± 0.88 0.58 0.87
18. I integrate haemodialysis into my daily life. 3.88 ± 0.72 0.53 0.88
19. I can accept the emotional changes (worry, anxiety, etc.) caused by haemodialysis. 3.68 ± 0.85 0.50 0.88
20. I feel confident in managing self‐care (fluid restriction, weight control, dietary adjustments, arteriovenous fistula care) effectively. 3.58 ± 0.92 0.63 0.87
21. I know I can cope with haemodialysis complications. 3.55 ± 0.92 0.56 0.88
22. I know I can ask my healthcare providers for help when I need it. 4.04 ± 0.72 0.54 0.88
23. I am generally satisfied with my life. 3.25 ± 1.05 0.55 0.87
24. I feel that my life is meaningful. 3.55 ± 0.96 0.65 0.87
25. I accept reality and think positively about the future. 3.55 ± 0.94 0.63 0.87
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Abbreviations: M, mean; SD, standard deviation.

4.2.2.2. Exploratory Factor Analysis

The KMO and Bartlett's tests of sphericity were conducted to assess the fit of the model before exploratory factor analysis of the 22 items that were observed to be appropriate through item analysis. The KMO value was 0.85, indicating the existence of a common latent factor among the items and that the number of items and samples was appropriate. Bartlett's test for sphericity was statistically significant with a chi‐square value of 1720.67 (p < 0.001), indicating that the 22 items were suitable for factor analysis; therefore, a factor analysis using varimax was conducted. As a result of factor extraction, four factors were extracted from 22 questions. The factor loadings for the items ‘I am satisfied with the haemodialysis treatment method’, ‘I can access local community social welfare services when I need help’ and ‘I feel confident in managing self‐care (fluid restriction, weight control and dietary adjustments, arteriovenous fistula care) effectively’ were observed to be less than 0.40 and thus, these items were deleted.

The final 19 items were subjected to a secondary factor analysis, and four factors were extracted, as in the first‐factor analysis, which explained more than 58.81% of the variance of each item (Table 3). The communality of all items was above 0.35, and the factor loadings of all items ranged from 0.41 to 0.82, meeting the criterion of 0.40 or higher. Factor 1 had six items with factor loadings ranging from 0.52 to 0.74, Factor 2 had five items with factor loadings ranging from 0.45 to 0.82, Factor 3 had five items with factor loadings ranging from 0.41 to 0.74, and Factor 4 had three items with factor loadings ranging from 0.54 to 0.64. The explanatory power of each factor was 27.51% for factor 1, 13.04% for factor 2, 10.63% for factor 3 and 7.63% for factor 4, respectively. The final questionnaire consisted of 19 items across four factors.

TABLE 3.

Exploratory factor analysis for the healthy transition scale to patients undergoing haemodialysis (N = 234).

Factor Item no. Factor loading Communality
1 2 3 4
Independent participation 12 0.74 0.01 0.17 −0.14 0.59
1 0.70 0.03 0.03 0.04 0.49
8 0.66 0.01 0.10 0.31 0.54
22 0.57 0.09 0.19 0.14 0.49
13 0.57 0.11 0.09 0.22 0.49
14 0.52 0.16 0.13 0.26 0.48
Subjective well‐being 23 −0.13 0.82 0.20 0.10 0.74
25 0.08 0.64 0.41 0.08 0.59
24 0.09 0.62 0.31 0.23 0.55
2 0.16 0.48 0.12 0.16 0.43
15 0.32 0.45 0.05 0.19 0.44
Acceptance and integration 16 0.15 0.12 0.74 0.01 0.58
19 0.01 0.31 0.61 0.01 0.47
17 0.11 0.36 0.52 0.11 0.42
4 0.37 0.06 0.49 0.13 0.40
18 0.33 0.18 0.41 0.12 0.48
Active information seeking and coping 21 −0.01 0.44 0.06 0.64 0.61
6 0.29 0.05 0.05 0.57 0.46
11 0.19 0.25 0.08 0.54 0.49
Eigen value 5.25 2.48 2.02 1.45
Explained variances (%) 27.51 13.04 10.63 7.63
Accumulative variances (%) 27.51 40.55 51.18 58.81
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Note: KMO = 0.85, Bartlett test of sphericity = 1720.67 (p < 0.001).

Factor 1 had the highest explanatory power of 27.51% with a total of six items, and it had high factor loadings in the following order: ‘I actively participate in haemodialysis treatment without missing sessions’, ‘I know that haemodialysis is important for my survival and health’, ‘I modify my overall lifestyle to accommodate haemodialysis treatment’, ‘I know I can ask my healthcare providers for help when I need it’, ‘I try to adhere to the healthcare providers' prescriptions’ and ‘I have a good relationship with my healthcare providers’. This factor was named ‘independent participation’ since it included items such as taking an active role in the treatment process, adhering to healthcare providers' prescriptions and modifying one's life to accommodate treatment.

Factor 2 consisted of five items: ‘I am generally satisfied with my life’, ‘I accept reality and think positively about the future’, ‘I feel that my life is meaningful’, ‘I feel mentally better after haemodialysis’ and ‘I feel better physically after dialysis’ and it had an explanatory power of 13.04%. Factor 2 was named ‘subjective well‐being’ since it referred to awareness of the physical and mental effects of dialysis treatment and how these effects explained positive attitudes toward life.

Factor 3 consisted of five items, and it had an explanatory power of 10.63%. The items included ‘I accept the physical changes (arteriovenous fistula, appearance, etc.) due to haemodialysis’, ‘I can accept the emotional changes (worry, anxiety, etc.) caused by haemodialysis’, ‘I accept myself for continuing to live with haemodialysis’, ‘I accept the changes in my role within the family due to haemodialysis’ and ‘I integrate haemodialysis into my daily life’. Factor 3 was named ‘acceptance and integration’ since it involved the positive acceptance of the various changes brought by haemodialysis and the desire to integrate them into daily life.

Factor 4, consisting of three items, had an explanatory power of 7.63%. ‘I know I can cope with haemodialysis complications’, ‘I search for information about haemodialysis’ and ‘I can share information and get support with other haemodialysis patients’, which represented self‐seeking of information regarding haemodialysis and belief in their ability to cope with complications. Factor 4 was named Active information seeking and coping.

4.2.2.3. Validate Convergent and Discriminant Validity

A multi‐trait–multi‐item matrix analysis was conducted to check the convergent and discriminant validity of the developed tool items, and the results are shown in Table 4. The convergent validity of the items was checked by the correlation coefficient calculated after controlling for items that overlapped with the subscale to which each item belonged, which ranged from 0.44 to 0.66, all of which were greater than 0.40, confirming convergent validity. In addition, the discriminant validity of the items was verified by demonstrating that the correlation coefficient of each item with its own subfactor was at least twice the standard error greater than the correlation coefficient with other subfactors (Ware and Gandek 1998). In this study, the discriminant validity of the items was successfully established, as the difference in correlation coefficients was approximately twice the standard deviation for all items.

TABLE 4.

Item convergent and Item discriminant validity (N = 234).

Factor Item no. Independent participation Accepting and integration Active information seeking and coping Subjective well‐being
Independent participation 12 0.60 0.13 0.31 0.06
1 0.61 0.13 0.22 0.18
8 0.62 0.17 0.28 0.37
22 0.57 0.21 0.35 0.26
13 0.56 0.23 0.28 0.33
14 0.51 0.28 0.31 0.39
Subjective well‐being 23 0.02 0.66 0.36 0.32
25 0.21 0.64 0.53 0.32
24 0.24 0.63 0.46 0.43
2 0.20 0.50 0.32 0.31
15 0.35 0.45 0.29 0.33
Acceptance and integration 16 0.26 0.35 0.63 0.14
19 0.14 0.44 0.53 0.14
17 0.22 0.48 0.54 0.24
4 0.43 0.28 0.47 0.25
18 0.40 0.32 0.43 0.25
Active information seeking and coping 21 0.17 0.49 0.25 0.52
6 0.36 0.22 0.18 0.44
11 0.29 0.36 0.23 0.48
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4.2.2.4. Concurrent Validity

The correlation between the haemodialysis healthy transition instrument developed in this study and the K‐PAS (Table 5) showed a statistically significant positive correlation (r = 0.65, p < 0.001). According to Cohen (2013), an r value of 0.5 or above indicates a large effect size, which suggests a strong correlation. The four subscales of the Healthy Transition Instrument and the four subscales of the Psychological Adjustment Instrument were positively correlated and statistically significant, indicating that the higher the level of healthy transition among patients undergoing haemodialysis, the higher the level of psychological adjustment among patients undergoing haemodialysis.

TABLE 5.

Correlation between healthy transition scale for patients undergoing haemodialysis (HTS‐HD) and Korean version of the psychological adaptation scale (K‐PAS) (N = 234).

HTS‐HD K‐PAS Cronbach's α
F1 F2 F3 F4 Total
r (p) r (p) r (p) r (p) r (p)
Independent participation 0.34 (< 0.001) 0.14 (0.031) 0.16 (0.017) 0.15 (0.021) 0.22 (0.001) 0.82
Subjective well‐being 0.61 (< 0.001) 0.70 (< 0.001) 0.59 (< 0.001) 0.69 (< 0.001) 0.74 (< 0.001) 0.80
Acceptance and integration 0.50 (< 0.001) 0.47 (< 0.001) 0.38 (< 0.001) 0.41 (< 0.001) 0.50 (< 0.001) 0.75
Active information seeking and coping 0.42 (< 0.001) 0.35 (< 0.001) 0.36 (< 0.001) 0.37 (< 0.001) 0.42 (< 0.001) 0.67
Total 0.64 (< 0.001) 0.57 (< 0.001) 0.51 (< 0.001) 0.56 (< 0.001) 0.65 (< 0.001) 0.88
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Abbreviation: F, factor.

4.2.2.5. Internal Consistency Reliability

The internal consistency of the developed instrument was analysed, with an overall Cronbach's α of 0.88, which meets the criteria of being between 0.70 and 0.95 as suggested by Terwee et al. (2007). Factor 1 (independent participation) was 0.82, Factor 2 (subjective well‐being) was 0.80, Factor 3 (acceptance and integration) was 0.75 and Factor 4 (active information seeking and coping) was 0.67 (Table 5). Although the Cronbach's alpha for Factor 4 is 0.67, it may still be acceptable depending on the context and purpose of the instrument. In exploratory research or when dealing with new or complex constructs, a value in this range might be deemed acceptable, particularly if the subscale is part of a broader tool with overall good reliability (DeVellis and Thorpe 2021).

4.2.2.6. Final Scale

The HTS‐HD consisted of 19 items organized into four factors: independent participation, subjective well‐being, acceptance and integration and active information seeking and coping. Each question was answered on a 5‐point Likert scale, and the total score was calculated by summing the scores for strongly disagree (1), disagree (2), neutral (3), agree (4) and strongly agree (5). The cumulative score for the entire tool ranged from 19 to 95, with a higher total score indicating a healthier transition to haemodialysis. For score calculation in this psychometric instrument, responses with missing data exceeding 20% of the total items were considered insufficient.

5. Discussion

This study attempted to identify the components of healthy transition among patients undergoing haemodialysis and to develop a measure of healthy transition among patients undergoing haemodialysis based on them. Using Meleis et al. (2000) transition theory as a theoretical framework, four constructs were derived through a literature review and one‐on‐one in‐depth interviews with patients undergoing haemodialysis. Subsequently, the validity of the instrument was verified, and a 19‐item instrument was developed with four factors: ‘independent participation’, ‘subjective well‐being’, ‘acceptance and integration’ and ‘active information seeking and coping’. ‘Independent participation’ and ‘active information seeking and coping’ were consistent with the process indicators ‘locating and being situated’ and ‘developing confidence and coping skills’ of Meleis' transition theory (Meleis et al. 2000), while ‘acceptance and integration’ and ‘subjective well‐being’ were consistent with the outcome indicators ‘mastery’ and ‘fluid and integrated identities’ of transition theory.

When examining the sub‐factors of the Healthy Transition for Haemodialysis Patients instrument, factor 1, ‘independent participation’, has the highest explanatory power with six items. This is consistent with previous research (Kim and Yang 2021; Mitchell et al. 2009; English), which suggests that through a healthy transition, patients undergoing haemodialysis acquire a new lifestyle adapted to dialysis and incorporate it into their daily lives. Engagement in haemodialysis treatment refers to the active and long‐term performance of behaviours consistent with healthcare provider prescriptions, such as keeping dialysis appointments and taking medications (Yeon et al. 2012). This is consistent with the items in this tool, such as recognizing the importance of haemodialysis treatment, being actively engaged, making an effort to follow healthcare provider prescriptions and understanding how haemodialysis treatment works. We included items on modifying one's overall life to accommodate haemodialysis treatment, which is interpreted as an important factor in explaining the healthy transition of patients undergoing haemodialysis, as treatment adherence is known to be a key factor directly affecting long‐term treatment outcomes, including lower hospitalization and mortality rates (Tohme et al. 2017; Naalweh et al. 2017).

Factor 2, labelled ‘subjective well‐being’, consisted of five items and explained 13.04% of the total variance. This is consistent with Meleis (2010), who emphasized the subjective well‐being experienced by patients as an outcome measure of a healthy transition. Objective indicators such as blood tests, weight and dialysis adequacy are utilized to determine the level of health of patients undergoing haemodialysis (Daugirdas 2015; Marcelli et al. 2015), and subjective well‐being, which reflects patients' feelings, perceptions and judgements, is a major factor that directly and indirectly affects their health (Santos 2011; Pilger et al. 2017). Subjective well‐being in patients undergoing haemodialysis is a multidimensional attribute of feeling physically, mentally and socially healthy and satisfied with one's life (Santos 2011; Seraji et al. 2018), which can be measured through the questions in this tool, such as physical symptoms and mental improvement after dialysis and feeling meaning in one's life. Assessing the subjective level of well‐being of patients undergoing haemodialysis, accepting it as it is, and nursing interventions based on this assessment will have a positive impact on the transition of patients undergoing haemodialysis (Campbell‐Crofts and Stewart 2018).

The acceptance and integration factors consisted of five items. The initiation of haemodialysis does not represent a simple change in the treatment of patients with chronic kidney failure but rather a complex and simultaneous set of drastic changes, including physical and emotional (Fex et al. 2011; English; Allen et al. 2022) and socio‐organizational (Oliveira et al. 2020) changes (Holvoet et al. 2020; Santana et al. 2020). Haemodialysis transition begins with facing and accepting these comprehensive and far‐reaching physical, emotional and social changes (Fex et al. 2011; English; Hassani et al. 2017), which is reflected in questions regarding accepting physical, emotional and role changes at home. In addition, the transition includes an item on acceptance of living as a patient undergoing haemodialysis, which refers to self‐acceptance, which is known to be a key concept closely related to treatment adherence in patients undergoing haemodialysis (Wijayanti et al. 2022). Understanding the disease and the dialysis machine, education on self‐management and support from healthcare providers and family are known to be important factors in the acceptance of dialysis treatment (Hassani et al. 2017; Moore et al. 2020). A study by Karimi et al. (2020) showed that an intervention based on acceptance and commitment therapy to help patients undergoing haemodialysis accept their dialysis treatment resulted in improvements in self‐care, willingness to participate in treatment and adherence. In addition, a healthy transition results in acceptance of the reality of being on haemodialysis, hope for the future, living positively and integrating haemodialysis into daily life (Kim and Yang 2021; Cervantes et al. 2021), which can be measured by the acceptance and integration items in this tool.

Finally, factor 3, labelled ‘Active Information Seeking and Coping’, consisted of three items. This is in line with Meleis (Meleis 2010), who identified the development of confidence and coping skills as process indicators of a healthy transition. A lack of health‐related information is a barrier to a healthy transition to haemodialysis (Campbell‐Crofts and Stewart 2018) and providing clear and frank information regarding the nature and management of end‐stage renal disease, haemodialysis treatment, possible complications and how to deal with them is necessary for a stable transition (Mitchell et al. 2009; English; Schaeffner 2022). In addition, having and utilizing information regarding social services that patients can access at the appropriate time is an essential component of the haemodialysis transition (Jones et al. 2021). More than 80% of patients actively strive to improve their knowledge related to their disease after starting dialysis treatment (Ansari et al. 2016), and information sharing and interaction with fellow patients receiving haemodialysis positively influence the haemodialysis transition (Hassani et al. 2017). In addition, coping skills, which enable patients undergoing haemodialysis to understand and control their health conditions, have been suggested as factors that facilitate haemodialysis transition (Oliveira et al. 2020). Patients undergoing haemodialysis improve their quality of life through coping skills training (Mitchell et al. 2009; Silva et al. 2016). Therefore, in this study, we included a questionnaire to measure haemodialysis transition by assessing the degree of coping.

To evaluate concurrent validity, a correlation analysis was conducted with the K‐PAS tool (Kim and Joung 2020). As a result of revising the instrument, the correlation coefficient improved to 0.65, which, according to Cohen's (2013) guidelines, indicates a large effect size. This suggests that the new instrument holds significant clinical value in assessing the same construct as the K‐PAS. Additionally, the analysis showed that all attributes of the tool developed in this study positively correlated with all attributes of the K‐PAS, supporting the convergent validity by demonstrating that a higher degree of transition in patients undergoing haemodialysis is associated with a higher level of adaptation. Psychosocial adaptation to haemodialysis is considered a result of a healthy transition (Hassani et al. 2017). In addition, the convergent and discriminant validity of the instrument confirmed that the items comprising the subscales were highly correlated with each other, distinct from other attributes and measured the unique attributes of transition. In addition, the reliability test showed high internal consistency with a Cronbach's α of 0.88 (Terwee et al. 2007), confirming its suitability for measuring patients undergoing haemodialysis transition.

Assessing how individuals perceive transition and measuring the quality of transition using this tool is an important first step for nurses to determine nursing care plans and interventions for individuals experiencing transition. The tool, grounded in Meleis's theory of transition (Meleis et al. 2000) and developed from the real‐life experiences of patients undergoing haemodialysis in Korea, provides a framework to measure the multidimensional attributes of haemodialysis transition. Its design, which is patient‐friendly and concise, enhances its utility for research by allowing efficient measurement of haemodialysis transition. However, the tool's generalizability is limited, as it was initially developed for in‐centre haemodialysis patients in a specific region. To address this limitation, it is crucial to conduct further studies involving diverse patient populations, including home haemodialysis patients and those from various cultural backgrounds beyond Korea. Such studies should employ confirmatory factor analysis (CFA) to verify the tool's construct validity and extend its generalizability. This includes confirming the relationship between the 19 items and the four components of the tool across different samples.

6. Conclusions

The HTS‐HD, a measure assessing healthy transitions in patients on HD, was developed in this study, and its validity and reliability were subsequently validated. The scale was composed of 19 items in four factors, including 6 items for ‘independent participation’, 5 items for ‘subjective well‐being’, 5 items for ‘accepting and integration’ and 3 items for ‘active information seeking and coping’. Each item was measured on a 5‐point Likert scale, with a higher total score indicating a healthier transition for patients undergoing haemodialysis (Appendix 1). We recommend further research to understand the transition in patients undergoing haemodialysis, identify the level of transition and factors affecting transition and evaluate the effectiveness of transition promotion programs for patients undergoing haemodialysis.

Author Contributions

A.‐K.C. designed the study. A.‐Y.K. and M.‐K.K. collected the data. A.‐Y.K., W.‐J.H. and Y.‐K.C. analysed the data. All authors prepared the manuscript. All authors approved the final version for submission.

Funding

The present study was supported by the National Research Foundation of Korea (NRF) grant funded by the Korean government (MSIT) (grant number 2021R1F1A1050087).

Ethics Statement

All stages of this study were reviewed and approved by the K university's Institutional Review Board (IRB No.: KHSIRB‐21‐429, KHSIRB‐22‐118). Informed written consent was obtained from the participants after the purpose and methods of the study and their rights and privacy were explained to them. They were assured of their ability to withdraw from the study at any time, and the anonymous storage of data was guaranteed.

Conflicts of Interest

The authors declare no conflicts of interest.

Appendix 1. The Healthy Transition Scale for Patients Undergoing Haemodialysis (HTS–HD)

Items Strongly disagree Disagree Neutral Agree Strongly agree
1 I know that haemodialysis is important for my survival and health. 1 2 3 4 5
2 I feel mentally better after haemodialysis. 1 2 3 4 5
3 I accept the changes in my role within the family due to haemodialysis. 1 2 3 4 5
4 I search for information about haemodialysis. 1 2 3 4 5
5 I modify my overall lifestyle to accommodate haemodialysis treatment 1 2 3 4 5
6 I can share information and get support with other haemodialysis patients. 1 2 3 4 5
7 I actively participate in haemodialysis treatment without missing sessions. 1 2 3 4 5
8 I try to adhere to the healthcare providers' prescriptions. 1 2 3 4 5
9 I have a good relationship with my healthcare providers. 1 2 3 4 5
10 I feel better physically after dialysis. 1 2 3 4 5
11 I accept the physical changes (arteriovenous fistula, appearance, etc.) due to haemodialysis. 1 2 3 4 5
12 I accept myself for continuing to live with haemodialysis. 1 2 3 4 5
13 I integrate haemodialysis into my daily life. 1 2 3 4 5
14 I can accept the emotional changes (worry, anxiety, etc.) caused by haemodialysis. 1 2 3 4 5
15 I know I can cope with haemodialysis complications. 1 2 3 4 5
16 I know I can ask my healthcare providers for help when I need it. 1 2 3 4 5
17 I am generally satisfied with my life. 1 2 3 4 5
18 I feel that my life is meaningful. 1 2 3 4 5
19 I accept reality and think positively about the future. 1 2 3 4 5
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Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

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