Development and content validation of the Nursing Practice Environment Scale for Long-Term Care: a methodological study in Portugal

Imagine a hospital where the focus is on a single, urgent crisis: a broken bone, a sudden infection, a heart attack. The work is intense, fast-paced, and ends when the patient is stabilized. Now, imagine a different setting: a long-term care home where people live for years, often with multiple chronic conditions, needing help with daily life and medical care that evolves slowly over time. The nature of the work here is not about fixing a sudden break, but about sustaining a life, managing complex needs, and building relationships that last. For nurses, the environment in which they work—the rules, the resources, the leadership, and the support they receive—determines whether they can provide good care. If the environment is broken, the care suffers, nurses burn out, and the people they care for are left vulnerable.

For decades, researchers have tried to measure this "nursing practice environment" using tools designed for hospitals. These tools ask questions about staffing, leadership, and resources, but they were built for the world of acute care. They often miss the unique realities of long-term care, such as the need to coordinate with social services, the specific challenges of caring for people with dementia, or the regulatory frameworks that govern residential homes. Using a hospital tool to measure a long-term care home is like trying to measure the depth of a river with a ruler meant for a swimming pool; it might give you a number, but it won't tell you the whole story. This gap led a team of researchers in Portugal to ask a simple but vital question: how do we measure the working environment for nurses in long-term care in a way that actually fits?

The researchers, led by Vera Braga and her colleagues, set out to build a new measuring tool specifically for this purpose. They called it the Nursing Practice Environment Scale for Long-Term Care. Their goal was not to simply copy an existing test, but to create something from the ground up that reflected the specific conditions of long-term care in Portugal. They started by looking at the big picture of what makes nursing work well, drawing on established ideas about nursing leadership and the specific needs of integrated care systems. They identified four main areas that matter in this setting: the systems that make care possible, the actual delivery of services, how well the team performs, and the specific health and social needs of the residents.

To build the tool, the team first wrote down 56 different statements that a nurse might agree or disagree with regarding their workplace. These statements covered everything from whether the leadership supports them to whether the funding allows for quality care. They then invited a panel of 13 experts—seasoned nurses, managers, and educators with deep experience in long-term care—to review these statements. The experts were asked two simple questions: Is this statement relevant to the nursing environment in long-term care? And is it clear enough to understand?

The experts worked independently, rating each statement. The results were telling. Out of the original 56 statements, 13 were removed because the experts felt they were either not relevant enough or too confusing. Some of the removed statements dealt with complex topics like institutional partnerships or specific regulatory nuances that the experts felt were not clear or applicable enough for a general survey. After this first round of editing, the team was left with 43 statements that the experts agreed were both important and clear. The experts' agreement was very high, suggesting that these questions truly captured the essence of the nursing environment in these settings.

But a survey is only as good as the people taking it. The researchers knew that even if experts liked the questions, the nurses on the front lines might find them confusing or difficult to answer. So, they moved to the next step: a pre-test. They invited 45 nurses working in long-term care facilities across Portugal to try out the 43-item survey. Thirty-nine nurses agreed to participate, a very high response rate. They filled out the questionnaire electronically and were asked to share any thoughts they had about the instructions or the wording of the questions.

The feedback from these nurses was crucial. It helped the researchers see how the questions landed in the real world. One specific question about whether part-time versus full-time contracts affected care quality showed a strange pattern in the data. The way the question was phrased seemed to confuse the nurses, leading to answers that didn't match the rest of the survey. The researchers decided to keep this question but flip how it was scored, a common technique to catch people who might be answering without thinking, but they noted that this specific item would need more testing later. Another question about regulatory notifications was removed entirely because the nurses seemed to have little knowledge of it, suggesting it was too far removed from their daily reality.

After these final adjustments, the team arrived at a 42-item candidate version of the scale. This new tool is organized into four sections, each focusing on a different aspect of the nursing environment. The researchers tested how well the questions in each section hung together, finding that the internal consistency was strong. This means that nurses who agreed with one statement in a section tended to agree with the others in that same section, suggesting the questions were measuring a coherent concept. The overall tool showed a very high level of consistency, indicating that it was a stable instrument.

However, the researchers are careful to define what this study has and has not achieved. They have created a tool that experts agree is relevant and clear, and that nurses found understandable. They have a candidate version that is ready for the next stage. But they explicitly state that this is not yet a fully validated, final product. The study did not test whether the four sections they designed are the only way the data fits together, nor did it test if the tool works the same way in different regions or over time. The high scores they found for consistency are promising, but they are not a guarantee that the tool measures exactly what they think it measures in every situation.

The path forward is clear. Before this scale can be used to compare different care homes, to set national standards, or to make high-stakes decisions about funding and management, it needs to be tested on a much larger group of nurses across many different locations. It needs to be proven that the four sections they identified are the right ones and that the tool remains reliable when used by thousands of people. The researchers also plan to do more detailed interviews with nurses to ensure that every single question is understood exactly as intended, especially the tricky one about employment contracts.

This work represents a significant step toward understanding the unique world of long-term care nursing. By moving away from tools designed for hospitals and building something specific for the long-term reality, the researchers have provided a foundation for better measurement. They have shown that the environment in which nurses work in long-term care is distinct, complex, and worthy of its own specific attention. The tool they have developed is a candidate, a draft that has passed the first rigorous checks of experts and frontline workers. It is a promise of what could be a powerful way to improve care, but it is not yet the final answer. The work of validation continues, ensuring that when this scale is finally used, it will tell the true story of nursing in long-term care.