Participants and procedure
A total of 160 questionnaires were distributed to nurses and midwifes working in a private general Obstetrics and Gynecology hospital in Greece. The final sample consisted of 143 participants (Response rate: 89.38%). The participants completed the questionnaires at the time of recruitment. They were informed about the aim of the study and that they could terminate their participation at any time without any consequences and that the data would be treated confidentially. Returning the questionnaire was interpreted as informed consent. The data were collected in a period of 3 months in 2018.
Ethics approval
Our study protocol was submitted and approved by the Ethics Committee of the School of Social Sciences of the Hellenic Open University (Registration number: 10–11/2017). The study was also submitted and approved by the Scientific Council of the Private Hospital “Hygeia A.E” in Athens (Registration number: 10–2/2018). All participants provided written informed consent.
Instruments
Implementation leadership scale (ILS)
The ILS is comprised of four factors including: (i) Knowledgeable leadership, (ii) Proactive leadership, (iii) Supportive leadership and (iv) Perseverant leadership [5]. Each factor is assessed with three items ranked on a 5-point scale from 0 (not at all) to 4 (to a very great extent) indicating the degree to which the supervisor performs the above behaviors. Total ILS score derives from the mean of the subscales. Total ILS score ranges from 0 to 48, while score for each sub-scale ranges from 0 to 12. Regarding the interpretation of the scale results, there are no cut-off scores. ILS items are described in Table 2.
Quality of leadership scale
The Quality of leadership dimension of the Copenhagen Psychosocial Questionnaire Version II (COPSOQ II) was used for the convergent validity assessment [9]. The initial version of the COPSOQ was developed as a tool covering a broad range of psychosocial factors, including most of the main studies dimension of occupational health psychology like job insecurity, job demands, role clarity, social support from colleagues and supervisors and possibilities for development [9]. COPSOQ II is an expanded version of the initial which was developed in order to incorporate aspects arising from the experience of use of the initial COPSOQ [9]. In total is comprised from 24 dimensions (92 items). The Quality of leadership dimension which was used in our study is comprised from seven items such as: “To what extent would you say that your immediate superior appreciates the staff and shows consideration for the individual” and “... is good at allocating the work”. Items ranked in a 5-point scale from 1 (to a very small extent) to 5 (to a very large extent). Scale score ranges from 7 to 35, while there are no cut off scores indicating high or low leadership quality. Cronbach’ s alpha of the scale was .95.
Organizational climate measure
The Organizational Climate Measure was developed by Patterson et al. [10] and it is based upon Quinn and Rohrbaugh’s Competing Values Model [11] was used for discriminant validity assessment. It is consisted from 17 subscales that describe the main four domains of competing values framework: (i) human relations, (ii) internal process, (iii) open systems and (iv) rational goal. In our study we used four subscales: (i) autonomy (from human relations domain) (5 items), (ii) formalization (from internal process) (5 items), (iii) efficiency (4 items) and (iv) performance feedback (from rational goal domain) (5 items). Items ranked in a 4-point scale from 1 (total false) to 4 (total true). Regarding autonomy, formalization and performance feedback score ranges from 5 to 20, while for efficiency score ranges from 4 to 16.Similarly to the previous scales there are no cut-off scores. Cronbach’ s alpha of the sub-scales were: 0.68 for autonomy, 0.71 for formalization, 0.62 for efficiency and 0.72 for performance feedback.
Translation procedure
Translation of the original ILS into Greek was carried out by a translation/back-translation procedure which is the most common applied process for inventories [12]. Our approach was based on the systematic approach of World Health Organization regarding translation and adaptation of research instruments [13]. Namely, forward translation, panel meeting, backward translation, pre-testing and final consensus were included in the process. In the first step two professional translators performed the forward translation of the ILS into Greek. In the second step, the forward translation drafts were checked by the three authors and one independent researcher, who checked and discuss the discrepancies between both two translations. At the end of this panel meeting a single translation of the ILS was agreed upon. In the third step, a backward translation was made by two other translators. The backward translations were compared with the initial English version for the identification of discrepancies. Since no discrepancies were identified between the back-translation and the original ILS English version a final agreement upon Greek ILS was reached. In the fourth step (pre-testing) the final Greek version was given to 9 volunteer participants for pilot testing and checking for its’ clarity and understandability. Participants filled out the scale and then they answered a number of questions about the general comprehensiveness of the instrument and the clarity and ambiguity of each separate item (e.g., if there was a word or an expression that they could not understand, what they thought that each question was asking, if they could repeat questions in their own words). In the fifth step, final corrections and alterations were made. Namely, based on the comments of the translators and the participants of the pilot study, we decided to make some slight corrections in order to improve the clarity of wording and to add a statement in the initial part of the tool (before items) clarifying the meaning of EBP, since in Greece the use of the specific terminology in not as common as in other countries.
Face validity of the scale was tested by the three researchers (authors) after discussing the comments of the translators and the participants of the pilot study. All comments discussed until a consensus was reached regarding the final scale version after all the corrections that were made in the fifth step.
Content validity was examined from the three authors and four independent researchers with relevant research experience, using the content validity index (CVI) [14]. Namely, each one of the seven researchers rated each ILS item on its relevance using a 4-point scale ranging from (4) “highly relevant” to (1) “not relevant”. Then, by dividing the number of those panelists that rated 3 or 4 to the total number of panelist, CVI was calculated. CVI > .80 indicates appropriateness [14]. The steps that were followed for the translation, adaptation and psychometric validation of ILS are presented in Fig. 1.
The same procedure (forward/backward translation) until the third step was also followed for quality of leadership dimension of COPSOQ II [9] and the four sub-scales of Organizational Climate Measure [10], that are not validated in Greece and they were used for the examination of convergent and discriminant validity.
Statistical analysis
Confirmatory Factor Analysis (CFA) was applied to test how well the dimensions of ILS fit the data. The fit of the model was assessed with the comparative fit index (CFI), the goodness of fit index (GFI) and the root mean square error of approximation (RMSEA) [15]. For CFI and GFI, values close or greater to 0.95 show good data fit and for RMSEA values less than 0.05 indicate good fit, while values as high as 0.08 indicate a reasonable fit [16]. Pearson coefficients were used to explore convergent and discriminant validity. Cronbach alpha and Guttman Split Half coefficients were applied to estimate internal consistency. Data were analyzed using SPSS software (Statistical Package for the Social Sciences, version 20; IBM, Armonk, NY, USA) and AMOS (SPSS, Chicago, IL, USA) statistical software.