Development and validation of the Hospitality Axiological Scale for Humanization of Nursing Care

ABSTRACT Objective: to develop and validate a scale to evaluate nursing attitudes in relation to hospitality for the humanization of nursing care. Participants: the sample consisted of 499 nursing professionals and undergraduate students of the final two years of the Bachelor of Science in Nursing program. Method: the instrument has been developed and validated to evaluate the ethical values related to hospitality using a methodological approach. Subsequently, a model was developed to measure the dimensions forming the construct hospitality. Results: the Axiological Hospitality Scale showed a high internal consistency, with Cronbach’s Alpha=0.901. The validation of the measuring instrument was performed using factorial, exploratory and confirmatory analysis techniques with high goodness of fit measures. Conclusions: the developed instrument showed an adequate validity and a high internal consistency. Based on the consistency of its psychometric properties, it is possible to affirm that the scale provides a reliable measurement of the hospitality. It was also possible to determine the dimensions or sources that embrace it: respect, responsibility, quality and transpersonal care.


Introduction
Hospitality is an ethical value that guides the actions in the nursing profession in order to ensure an adequate care for patients, providing them quality care and comfort (1) . It is also an essential value for the adaptation of individuals to their stay in hospitals or in any area where health care is provided (2) .
Hospitality or receptivity is empirically associated with humanization of care (3)(4) . It implies an altruistic attitude based on humanitarian understanding of the practice of the nursing profession, which is committed to transpersonal care (5) .
It has been suggested that hospitality is influenced by several factors such as behavior, product and environment and, of these, those relate to behavior have been identified as the most important ones (6) .
Hospitality or receptivity represents, in theoretical terms, significant advancement of humanization in health care, since providing hospitality attitudes is important for the curing process (7) . Implementation in the health care practice, both the ethics of hospitality of Derrida and the ethics of alterity proposed by Levinas, provide a possibility to increase the moral quality of the relationships between health professionals and patients (8) . However, there is still a need to clarify the theoretical construction of hospitality, so that it is conceptually defined in all its fullness. Therefore, the academic world should render its contribution to this process by carrying out studies on this subject and disseminating their results to society (9) .
The nursing model based on the tradition that comes from the figure of Saint John of God (10) goes beyond the understanding that other authors have had about receptivity or hospitality in the health sphere. This model emphasizes hospitality as a receptivity paradigm, which encompasses a set of sub-values necessary for a humanized patient care: respect, responsibility, quality and spirituality. The humanistic and anthropological philosophy of the Hospitaller Order of the Brothers of Saint John of God (OHSJD acronym in Spanish) has a key role in the value hospitality, because for them this term means alterity or humanization of the personal relationships of professionals and patients, as well as the social collectivity, i.e., the mutual concern for the each other.
For the OHSJD, hospitality means receptivity, effective physical, moral, psychological and social support, valuing the multiple aspects of human needs (11) .
The culture of an institution is based on the values that are translated into reality of its functioning and dynamism. Previous studies have demonstrated how it is possible to estimate the axiological utility of the professional values of the codes of professional conduct in the health sphere through Likert-type scales (12)(13) .  Likert-type scale, where 0 indicates "no importance" and 7 indicates "maximum importance". Based on the analysis of the data and results obtained, the study of the reliability and validity of the scale was carried out.

Analysis
The validation of the measuring instrument

Reliability and exploratory factor analysis (EFA)
In the EFA carried out on the final prototype of the 30-item scale, it was observed that the most significant The results of the second order EFA reflected a unidimensional factorial structure (Table 2).
Consequently, a second order factor emerged as a factorial synthesis of the twenty-three indicators, which explained 44.7% of the variance, and was theoretically interpreted as construct "Hospitality".

Confirmatory factor analysis
In order to confirm the underlying structure, two rival measurement models that were plausible from the theoretical and empirical point of view were used. Chi-square value (2.14) was within the recommended levels (17) . Regarding fit indexes, the Normalized Fit Index  (19) was 0.048, all indicating a satisfactory fit with values ranging from 0.9 to 1 (20) . It can be concluded that all goodness of fit indexes calculated show an acceptable fit between the postulated theoretical model and the sample data, so it has not been possible to prove that the model is incorrect and it has been proven to be one of the possible acceptable models (21) .
In a more detailed analysis of the values, which resulted in the standardized solution for the proposed model (Figure 1), it was observed that all parameters have positive and significant estimates.
The indicators show an adequate reliability, with factor loads higher than 0.50 and R 2 values higher than 0.30, except for the item "altruism", which shows R 2 =0.294, very close to the recommended minimum.
Composite reliability was estimated for each construct with values ranging from 0.71 to 0.81, above the recommended minimum (21) .
Regarding the convergent validity of the constructs, the mean variance estimated from the first order factors assumed values ranging from 0.39 to 0.68.
Finally, it was verified that the root mean square calculated for each construct showed a value higher than the correlation presented by each one of them in relation to all the other ones, which evidences the discriminant validity (22) .

Discussion
The improvement of the practices of receptivity or hospitality are now a challenge for health services (23) .
Nursing professionals are able to identify how the reception should be carried out through qualified listening, humanization, responsibility and commitment to the needs of the other. However, in practice, so that these actions are recognized as nursing care, the nurses should focus on relational care (24) .Hospitality generates attitudes based on professional values (25) , as it is capable of promoting the relational bond between professionals and users, allowing to stimulate personal care, improve understanding of the disease and promote co-responsibility during treatment. It also enhances universal access, strengthens multidisciplinary and intersectional work, qualifies care, humanizes practices and encourages actions aiming to combat injurious (26) .  (27) .
In the literature, no other scales to estimate the construct Hospitality or receptivity were found since the scale proposed here is an original and innovative contribution in this field of study, which can be applied to the development of the organizational culture in order to promote humanization of nursing care and health improvement.
Although an exact equivalence between the values selected for the scale and those professed by the OHSJD has not been achieved, the values of each dimension of the scale adequately represent those values explicitly professed by the OHSJD (28) .
One limitation of the study is that of the four declared values, spirituality is the least represented value in the AHS. However, spirituality is included in the AHS from the perspective of Transpersonal Care, which ultimately presupposes a transcendent approach of a professional activity that is not focused on itself but on the patient and family. This projection is an expression of otherness and has a spiritual meaning in that it is transcendent.
In fact, the spiritual care of the patient and his family has as fundamental expression the transpersonal care performed by the health professionals (29) .
A second limitation of this scale is that the sample used to carry out the validation consists of professionals and students of an institution with a culture of values that incorporates in its tradition the value hospitality and gives it an internal validity. In order to corroborate the external validity of the scale, it would be necessary to extend this study to samples from other organizations outside the OHSJD context, in order to verify that validity.

Conclusion
In this study, it was analyzed the development of an instrument that allows measuring the behavior in relation to the construct Hospitality according to the perception of the nursing professionals and students in the context studied.
The scale showed a high internal consistency index (0.901) and the subscales showed reliability coefficients higher than 0.70. Validation using the EFA and CFA methods has allowed to confirm the factorial structure of the scale and to demonstrate its validity. The results obtained in the CFA allow postulating that the construct Hospitality encloses four dimensions: "Respect"; "Responsibility"; "Quality" and "Transpersonal Care".
Regarding the psychometric characteristics of the Axiological Hospitality Scale, it has been possible to confirm its factorial structure by a measurement model that has shown satisfactory goodness of fit measures, so that it can be affirmed that the scale has allowed evaluating the perception of Hospitality with an appropriate level of reliability and validity.
These results corroborate the usefulness of this tool considering the scarcity of instruments to evaluate the construct hospitality in nursing professionals and students.

Acknowledgments
To the Hospitaller Order of the Brothers of Saint John of God for its effective commitment to Hospitality and the way of transmitting it through the nursing practice over the five centuries of history, generation after generation to the present day.
To the centers, professionals and students participating in this study, who have made this study possible with their support and contribution.