Development and Psychometric Evaluation of the Perioperative Care Process Adherence Scale (PCPAS): A Multicenter Methodological Study

Background and Rationale

One of the key determinants of clinical outcomes in perioperative care is consistent adherence to evidence-based care processes. The Donabedian structure-process-outcome model emphasizes that process quality is closely linked to clinical outcomes, making it critical to render process performance measurable for quality management purposes (Donabedian, 1988). In the perioperative context, this process spans a multi-component chain of care encompassing operating room safety (e.g., surgical safety checklist use), early postoperative monitoring, complication prophylaxis, pain management, Enhanced Recovery After Surgery (ERAS) components such as early mobilization and early feeding, effective communication, patient education, and documentation continuity (Ljungqvist et al., 2017).

The perioperative period constitutes a high-risk, time-critical "acute vulnerability window" in which the surgical stress response, hemodynamic fluctuations, analgesia requirements, early complication development, and safety threats escalate simultaneously within a short time frame. Adherence, therefore, is not merely the existence of a protocol but the timely, correctly sequenced, and well-coordinated implementation of its components. Much of the existing literature on process performance has approached measurement through the lens of "missed nursing care" or care omission, which captures what care was not delivered but does not fully capture holistic adherence to evidence-based care (encompassing presence, timing, continuity, and coordination of care). Existing perioperative nursing scales largely measure patient experience/perception (PREMs) or general care-quality perception, or focus on competency rather than directly modeling process adherence at a performance-near level. This gap motivates the development of a new instrument capable of jointly capturing operating-room and ward-based nursing process adherence, evaluated with rigorous psychometric methods including measurement invariance testing across work settings.

Aims

The purpose of this study is to develop the Perioperative Care Process Adherence Scale (PBSUO) and to evaluate its content validity, construct validity (exploratory and confirmatory factor analysis), convergent and discriminant validity, internal consistency, and temporal reliability in a multicenter sample. Additional aims include testing measurement invariance between operating room and surgical ward nurses and confirming a second-order (hierarchical) factor structure in which sub-dimensions (e.g., operating room safety and team coordination; early monitoring and complication prevention; ERAS adherence; documentation continuity; patient education and communication) load onto a general "overall process adherence" higher-order factor.