Validation to Spanish of the Caring Assessment Tool (CAT-V)

Resume Objective: to translate and validate to Spanish the Caring Assessment Scale tool, CAT-V, by Joanne Duffy, within the framework of Jean Watson; as a secondary objective, it is proposed to evaluate its psychometric properties. There are tools designed to measure the patient’s perception of provided cares, including CAT-V, the subject of our interest, in a way that it can be used in Spanish-speaking patients. Methods: to meet the objectives, it was performed sequential translation and retro-translation of the scale to be validated, through a standardized procedure. The final version of that scale was validated in a sample of 349 patients from four public and two private hospitals in Madrid, Spain. Results: The instrument was translated and validated with high internal consistency (Cronbach’s alpha .953). The subsequent factor analysis revealed a three-factor structure, not coincident with the data from the US population. Conclusion: it is considered that the translation of CAT-V is a suitable instrument to be used in the evaluation of patient care in Ibero-american health centers whose language is Spanish.

For the elderly, the Caring Behaviors Inventory instrument of 28 items was developed. Although easier to use than the CARE-Q, it is limited in terms of the population that can be subject to that assessment (8) .
After an evaluation of aspects of other instruments already used previously in research and applicable in the clinical settings, we considered the CAT-V questionnaire can be an ideal tool to evaluate the perception of the caring behaviors in the Spanish population, given its object of study, which is not so much the overall patient satisfaction with care, but focuses on the human aspects of such assistance provided by the nursing staff.
The assessment of behavior is based on a theoretical model widely supported, as is the Theory of Human Care (9)(10) . It is an easy applicable tool with patients, with an average length, and easily understandable short items. Internationally there have been several studies that define nursing care as an interactive and intersubjective process that occurs in moments of shared vulnerability between the nurses and the patients.
They are intended to provide patients' comfort and this only occurs when nurses respond to patients in a care situation (8,(11)(12)(13)(14) . Studies were conducted in Spain to research the patients' perceptions regarding nursing professionals from an ethical point of view (15) . The results showed the importance of personal relationships to patients, they expressed their perceived satisfaction when they were treated by nurses as human beings in all their dimension and felt they respected their privacy, also adding that nurses passed them safety and confidence. Most patients expressed the desire to receive information on the development of their disease and future expectations. Other authors conducted a study with the aim of knowing the perception of patients about what they consider important in relation to health care (16) . They concluded that patients perceived a wellbeing feeling if they had been well treated, in spite that they considered the technical aspects as important.
The Caring Assessment Tool (CAT) was developed to assess the perception that patients have on nursing care behaviors (17)(18)(19) . Originated from the Theory of Human Care (12) , several items that correspond with each "care factor" were designed. However, no deep evaluation of psychometric properties was performed. Subsequently, the number of items was reduced in order to make it more feasible to use in care settings, and was presented in its CAT-IV version, consisting of 36 items. To perform validation and explore its psychometric properties, five hospitals in the United States were selected. Its target population consisted of inpatients with at least two days in hospital, ensuring that there had been enough interaction with the nursing staff. This instrument had an internal consistency of 0.96, and an internal structure of eight factors that allowed grouping items under new dimensions provided with a theoretical basis. However, in a subsequent study with a larger sample size and the participation of 12 hospitals in four different areas of the Fernández-Ayuso RM, Morillo-Velázquez JM, Fernández-Ayuso D, de la Torre-Montero.
United States, with greater heterogeneity of patients, this internal structure was not kept stable, since the model with best fit was the instrument with a single factor (20) . This latter study allowed to check the burden presented to care staff by the administration and collection of the questionnaire CAT-IV, although there were benefits perceived by nurses e.g. how these professionals learned to recognize and educate themselves on the caring behaviors, taking the patients into consideration. The fact that 36 items still made the instrument too long, led to propose a reduction, discarding those items that have saturations of at least 0.70 and item-total correlations of at least 0.70. Thus, the resulting new version of 27 items has been called CAT-V, whose reliability (Cronbach's alpha, 0.967) and internal structure of a single factor has been proven. This is the instrument that will be studied in the present research. We can state the hypothesis of this paper as: the CAT-V scale translated will meet internal consistency characteristics suitable for its use in Spanish-speaking population, and will present a uni-dimensional structure similar to the original in English.

Method
To carry out the process of standardized translation and adaptation of this research, we have followed recommendations of several authors with extensive experience in this field, following guidelines referring to direct and reverse translation of the tool (21) . Two professionals, both in the field of language teaching with Spanish as their mother tongue, and deep knowledge of English, one of them related to health sciences, and one without deep knowledge of health, were provided with the original scale to carry out, independently, the translation into Spanish. They were provided with a template to point out the difficulties or ambiguities that could be found in the translation of a particular item. They were asked to prioritize the equivalence of the concepts with the original English version, and not a literal translation.
For the reverse translation of the tool we relied on the collaboration of two professionals with American English as their mother tongue and with identical characteristics as the previous experts. Once these translations were completed, a joint meeting with all the translation team was convened to conduct a detailed study of each item Given that the scale has 27 items, and that the recommendations regarding the sample size indicate that there is need of a ratio of 10 subjects per item in order to be able to carry out an exploratory factor analysis, we planned to have a minimum of 270 subjects (22)(23)(24) . The collected data were entered into CAT-V scale, and then obtaining the mean and standard deviation for each item in these percentiles. Finally we confirmed that there were statistically significant differences between these percentiles by applying the Student t test for independent samples, establishing a significance level of p <0.05. For the analysis of internal consistency, Cronbach's alpha coefficient and item-total correlation was calculated. Finally, the structure of factors was analyzed by an exploratory factor analysis with Varimax rotation.

Discussion
There were not validated instruments available in Spain, capable to measure these aspects and able to be applied systematically to hospitalized patients. While There is a previous version in US-Latino Spanish, which has not been previously validated (20) . including the electronic forms (24) , with data analysis in real time. The current trend, patient-centered care (25) indicates that these tools are useful for both patients and professionals who want to develop specific questionnaires on the needs of patients about themselves in different settings and people in different situations (26)(27)(28) . Finally, it is crucial to stress the importance of assessing care, to measure its quality from the point of view of the patient, within the vision of personalized nursing, where the patient is the protagonist of the process (29) . Knowing the basics of care, help us to provide better health service (30) .

Conclusion
The objective of this research has been completed,