Development and Validation of a Meta-Instrument for the Assessment of Functional Capacity, the Risk of Falls and Pressure Injuries in Adult Hospitalization Units (VALENF Instrument) (Part II)
Abstract
:1. Introduction
2. Materials and Methods
2.1. Design and Setting
2.2. Participants and Sample
2.3. Variables, Instruments and Data Collection
2.4. Validation and Data Analysis Procedures
3. Results
3.1. Content Validity
3.2. Construct Validity, Internal Consistency and Inter-Observer Reliability
3.2.1. Descriptive Analysis of the Samples
3.2.2. Exploratory and Confirmatory Factorial Analysis
3.3. Reliability
3.3.1. Internal Consistency
3.3.2. Inter-Observer Reliability
4. Discussion
5. Conclusions
Supplementary Materials
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
References
- Ministerio de Sanidad, Política Social e Igualdad. Estrategia de Seguridad del Paciente del Sistema Nacional de Salud. Periodo 2015–2020; Spain, 2016. Available online: https://www.seguridaddelpaciente.es/resources/documentos/2015/Estrategia%20Seguridad%20del%20Paciente%202015-2020.pdf (accessed on 20 December 2022).
- Zsifkovits, J.; Zuba, M.; Geibler, L.; Pertl, D.; Kernstock, E. Costs of Unsafe Care and Cost Effectiveness of Patient Safety Programmes; European Comisión: 2016. Available online: https://ec.europa.eu/health/sites/health/files/systems_performance_assessment/docs/2016_costs_psp_en.pdf (accessed on 20 December 2022).
- Ministerio de Sanidad y Consumo. Proyecto SENECA. Estándares de Calidad de Cuidados para la Seguridad del Paciente en los Hospitales del SNS; Spain, 2009. Available online: https://www.sanidad.gob.es/organizacion/sns/planCalidadSNS/docs/SENECA.pdf (accessed on 20 December 2022).
- Córcoles-Jiménez, M.P. Deterioro funcional asociado a la hospitalización en pacientes mayores de 65 años. Enf. Clín. 2016, 26, 121–128. [Google Scholar] [CrossRef] [PubMed]
- Hershey, K. Culture of Safety. Nurs. Clin. 2015, 50, 139–152. [Google Scholar] [CrossRef] [PubMed]
- Palese, A.; Colognese, S.; Pellicciari, C.; Mecugni, D.; VISPA’s Group. Implemetation strategies of measurement instruments and their validity as adopted in Italian hospital nursing practice: An Italian cross-sectional study. Int. J. Nurs. Knowl. 2012, 23, 75–85. [Google Scholar] [CrossRef]
- Higgins, L.W.; Shovel, J.A.; Bilderback, A.L.; Lorenz, H.L.; Martin, S.C.; Rogers, D.J.; Minnier, T.E. Hospital Nurses’ Work Activity in a Technology-Rich Environment: A Triangulated Quality Improvement Assessment. J. Nurs. Care Qual. 2017, 32, 208–217. [Google Scholar] [CrossRef] [PubMed]
- Westbrook, J.I.; Duffield, C.; Li, L.; Creswick, N.J. How much time do nurses have for patients? A longitudinal study quantifying hospital nurses’ patterns of task time distribution and interactions with health professionals. BMC Health Serv. Res. 2011, 11, 319. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Liang, Y.W.; Chen, W.Y.; Lee, J.L.; Huang, L.C. Nurse staffing, direct nursing care hours and patient mortality in Taiwan: The longitudinal analysis of hospital nurse staffing and patient outcome study. BMC Health Serv. Res. 2012, 12, 44. [Google Scholar] [CrossRef] [Green Version]
- Kim, S.J.; Lee, J.Y.; Lee, Y.M. Comparison of Nurses’ Job Satisfaction, Patients’ Satisfaction and Direct Nursing Time according to the Change in Grade of the Nursing Management Fee. J. Korean Crit. Care Nurs. 2017, 10, 9–18. [Google Scholar]
- Stalpers, D.; de Brouwer, B.J.; Kaljouw, M.J.; Schuurmans, M.J. Associations between characteristics of the nurse work environment and five nurse-sensitive patient outcomes in hospitals: A systematic review of literature. Int. J. Nurs. Stud. 2015, 52, 817–835. [Google Scholar] [CrossRef]
- Ilgen, J.S.; Ma, I.W.Y.; Hatala, R.; Cook, D.A. A systematic review of validity evidence for checklists versus global rating scales in simulation-based assessment. Med. Educ. 2015, 49, 161–173. [Google Scholar] [CrossRef] [PubMed]
- Shafqat, A.; Rafi, M.; Thanawala, V.; Bedforth, N.M.; Hardman, J.G.; McCahon, R.A. Validity and reliability of an objective structured assessment tool for performance of ultrasound-guided regional anaesthesia. Br. J. Anaesth. 2018, 121, 867–875. [Google Scholar] [CrossRef] [Green Version]
- Palese, A.; Marini, E.; Guarnier, A.; Barelli, P.; Zambiasi, P.; Allegrini, E.; Bazoli, L.; Casson, P.; Grassetti, L. Overcoming redundancies in bedside nursing assessments by validating a parsimonious meta-tool: Findings from a methodological exercise study. J. Eval. Clin. Prac. 2016, 22, 771–780. [Google Scholar] [CrossRef] [PubMed]
- Dante, A.; Mecugni, D.; Moga, M.M.; Graceffa, G.; Palese, A. Gli sprechi nella pratica clinica infermieristica: Risultati di uno studio fenomenologico. Ig. E Sanità Pubblica 2015, 71, 2015–2224. [Google Scholar]
- Luna-Aleixos, D.; Llagostera-Reverter, I.; Castelló-Benavent, X.; Aquilué-Ballarín, M.; Mecho-Montoliu, G.; Cervera-Gasch, Á.; Valero-Chillerón, M.J.; Mena-Tudela, D.; Andreu-Pejó, L.; Martínez-Gonzálbez, R.; et al. Development and Validation of a Meta-Instrument for Nursing Assessment in Adult Hospitalization Units (VALENF Instrument) (Part I). Int. J. Environ. Res. Public Health 2022, 19, 14622. [Google Scholar] [CrossRef] [PubMed]
- González, N.; Bilbao, A.; Forjaz, M.J.; Ayala, A.; Orive, M.; Garcia-Gutierrez, S.; Hayas, C.L.; Quintana, J.M.; OFF (Older Falls Fracture)-IRYSS Group. Psychometric characteristics of the Spanish version of the Barthel Index. Aging Clin. Exp. Res. 2018, 30, 489–497. [Google Scholar] [CrossRef]
- Moreno-Pina, J.P.; Richart-Martínez, M.; Guirao-Goris, J.A.; Duarte-Climents, G. Análisis de las escalas de valoración del riesgo de desarrollar una úlcera por presión. Enferm. Clin. 2007, 17, 186–197. [Google Scholar] [CrossRef] [PubMed]
- Bueno-García, M.J.; Roldán-Chicano, M.T.; Rodríguez-Tello, J.; Meroño-Rivera, M.D.; Dávila-Martínez, R.; Berenguer-García, N. Características de la escala Downton en la valoración del riesgo de caídas en pacientes hospitalizados. Enferm. Clin. 2017, 27, 227–234. [Google Scholar] [CrossRef] [PubMed]
- Anthoine, E.; Moret, L.; Regnault, A.; Sébille, V.; Hardouin, J.B. Sample size used to validate a scale: A review of publications on newly-developed patient reported outcomes measures. Health Qual. Life Outcomes 2014, 12, 176. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Formiga, F.; Moreno-Gonzalez, R.; Chivite, D. High comorbidity, measured by the Charlson Comorbidity Index, asso-ciates with higher 1-year mortality risks in elderly patients experiencing a first acute heart failure hospitalization. Aging Clin. Exp. Res. 2018, 30, 927–933. [Google Scholar] [CrossRef]
- Polit, D.F.; Beck, C.T. The content validity index: Are you sure you know what’s being reported? Critique and recommendations. Res. Nurs. Health 2006, 29, 489–497. [Google Scholar] [CrossRef] [Green Version]
- Efron, B.; Tibshirani, R. Improvements on cross-validation: The 632+ bootstrap method. J. Am. Stat. Assoc. 1997, 92, 548–560. [Google Scholar] [CrossRef]
- Goretzko, D.; Pham, T.T.H.; Bühner, M. Exploratory factor analysis: Current use, methodological developments and recommendations for good practice. Curr. Psychol. 2021, 40, 3510–3521. [Google Scholar] [CrossRef]
- LLoret-Segura, S.; Ferreres-Traver, A.; Hernández-Baeza, A.; Tomás-Marco, I. Exploratory item factor analysis: Practical guide revised and updated. Anales Psicol. 2014, 30, 1151–1169. [Google Scholar]
- Kline, R.B. Principles and Practice of Structural Equation Modeling; The Guilford Press: New York, NY, USA, 2015. [Google Scholar]
- Kalkbrenner, M.T. Alpha, Omega, and H Internal Consistency Reliability Estimates: Reviewing These Options and When to Use Them. Couns. Outcome Res. Eval. 2023, 14, 77–88. [Google Scholar] [CrossRef]
- Jakobsson, U.; Westergren, A. Statistical methods for assessing agreement for ordinal data. Scand. J. Caring Sci. 2005, 19, 427–431. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Mokkink, L.B.; Terwee, C.B.; Patrick, D.L.; Alonso, J.; Stratford, P.W.; Knol, D.L.; Bouter, L.M.; de Vet, H.C. The COSMIN study reached international consensus on taxonomy, terminology, and definitions of measurement properties for health-related patient-reported outcomes. J. Clin. Epidemiol. 2010, 63, 737–745. [Google Scholar] [CrossRef] [Green Version]
- Prinsen, C.A.C.; Mokkink, L.B.; Bouter, L.M.; Alonso, J.; Patrick, D.L.; de Vet, H.C.W.; Terwee, C.B. COSMIN guideline for systematic reviews of patient-reported outcome measures. Qual. Life Res. 2018, 27, 1147–1157. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Strini, V.; Schiavolin, R.; Prendin, A. Fall Risk Assessment Scales: A Systematic Literature Review. Nurs. Rep. 2021, 11, 430–443. [Google Scholar] [CrossRef]
- Conley, D.; Schultz, A.A.; Selvin, R. The challenge of predicting patients at risk for falling: Development of the Conley Scale. Medsurg. Nurs. 1999, 8, 348–354. [Google Scholar]
- Blaylock, A.; Cason, C.L. Discharge planning predicting patients’ needs. J. Gerontol. Nurs. 1992, 18, 5–10. [Google Scholar] [CrossRef]
- Aranda-Gallardoa, M.; Morales-Asenciob, J.M.; Canca-Sáncheza, J.C.; Morales-Fernándeza, A.; Enríquez de Luna-Rodrígueza, M.; Moya-Suareza, A.B.; Mora-Banderasa, A.M.; Pérez-Jiméneza, C.; Barrero-Sojoa, S. Consecuencias de los errores en la traducción de cuestionarios: Versión española del índice Downton. Rev. Calid. Asist. 2015, 30, 195–202. [Google Scholar] [CrossRef]
- Ladios-Martin, M.; Cabañero-Martínez, M.J.; Fernández-de-Maya, J.; Ballesta-López, F.J.; Belso-Garzas, A.; Zamora-Aznar, F.M.; Cabrero-Garcia, J. Development of a predictive inpatient falls risk model using machine learning. J. Nurs. Manag. 2022, 30, 3777–3786. [Google Scholar] [CrossRef] [PubMed]
- Feo, R.; Conroy, T.; Jangland, E.; Muntlin Athlin, Å.; Brovall, M.; Parr, J.; Blomberb, K.; Kitson, A. Towards a standardised definition for fundamental care: A modified Delphi study. J. Clin. Nurs. 2017, 27, 2285–2299. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Kitson, A.L.; Muntlin Athlin, A.; Conroy, T. Anything but basic: Nursing’s challenge in meeting patients’ fundamental care needs. J. Nurs. Scholarsh. 2014, 46, 331–339. [Google Scholar] [CrossRef] [PubMed]
- Törnvall, E.; Wahren, L.K.; Wilhelmsson, S. Advancing nursing documentation--an intervention study using patients with leg ulcer as an example. Int. J. Med. Inform. 2009, 78, 605–617. [Google Scholar] [CrossRef]
- Santos, W.J.; Graham, I.D.; Lalonde, M.; Demery, M.; Squires, J.E. The effectiveness of champions in implementing innovations in health care: A systematic review. Implement. Sci. Commun. 2022, 3, 80. [Google Scholar] [CrossRef]
- Müller-Staub, M.; Needham, I.; Odenbreit, M.; Lavin, M.A.; van Achterberg, T. Improved Quality of Nursing Documentation: Results of a Nursing Diagnoses, Interventions, and Outcomes Implementation Study. Int. J. Nurs. Terminol. Classif. 2007, 18, 5–17. [Google Scholar] [CrossRef]
- Colquhoun, D.A.; Davis, R.P.; Tremper, T.T.; Mace, J.J.; Gombert, J.M.; Sheldon, W.D.; Connolly, J.J.; Adams, J.F.; Tremper, K.K. Design of a novel multifunction decision support/alerting system for in-patient acute care, ICU and floor (AlertWatch AC). BMC Anesthesiol. 2021, 21, 196. [Google Scholar] [CrossRef]
- Urquhart, C.; Currell, R.; Grant, M.J.; Hardiker, N.R. WITHDRAWN: Nursing record systems: Effects on nursing practice and healthcare outcomes. Cochrane Database Syst. Rev. 2018, 5, CD002099. [Google Scholar] [CrossRef]
- McCrae, N. Whither nursing models? The value of nursing theory in the context of evidence-based practice and multidisciplinary health care. J. Adv. Nurs. 2012, 68, 222–229. [Google Scholar] [CrossRef]
- Macia Soler, M.L. Prescipción temporal de cuidados. In Un Avance para la Práctica Enfermera, 1st ed.; Elsevier: Barcelona, Spain, 2021. [Google Scholar]
Items | I-CVI 1 | |||
---|---|---|---|---|
Nursing Assessment | Functional Capacity | Risk of Pressure Injuries | Risk of Falls | |
Mobility (Barthel) | 1 | 1 | 0.93 | 1 |
Sensory Perception (Braden) | 1 | 1 | 1 | 1 |
Moisture (Braden) | 0.933 | 0.8 | 1 | 0.733 |
Mobility (Braden) | 1 | 1 | 1 | 1 |
Sensory Deficiency (Downton) | 0.933 | 0.933 | 0.8 | 0.933 |
Previous Fall (Downton) | 0.933 | 0.933 | 0.8 | 1 |
Medication (Downton) | 0.933 | 0.933 | 0.8 | 1 |
GLOBAL | 0.961 | 0.942 | 0.904 | 0.952 |
Variable | Group 1 (n = 676) | Group 2 (n = 676) | ||
---|---|---|---|---|
m (ds) 1 | m (ds) 1 | p 3 | ||
Barthel index | 78.40 (33.86) | 78.36 (33.72) | 0.956 * | |
Braden index | 19.05 (3.82) | 18.89 (3.92) | 0.826 * | |
Downton scale | 1.15 (1.23) | 1.16 (1.23) | 0.895 * | |
Age | 67.8 (18.1) | 67.6 (17.8) | 0.773 * | |
Charlson index | 1.31 (1.61) | 1.32 (1.69) | 0.608 * | |
% (n) 2 | % (n) 2 | p 3 | ||
Sex | Male | 52.07 (352) | 52.22 (353) | 0.956 ** |
Female | 47.93 (324) | 47.78 (323) | ||
Process type | Medical | 64.94 (439) | 68.93 (466) | 0.118 ** |
Surgical | 35.06 (237) | 31.07 (210) | ||
Admission type | Scheduled | 83.43 (564) | 83.43 (564) | 1.000 ** |
Emergency | 16.57 (112) | 16.57 (112) | ||
Hospitalization unit | Traumatology | 26.04 (176) | 27.08 (183) | 0.842 ** |
Surgery and gynecology | 19.82 (134) | 21.59 (146) | ||
Cardio/gastroenterology | 14.64 (99) | 14.05 (95) | ||
Neuro/pulmonology | 13.02 (88) | 13.17 (89) | ||
General surgery | 2.66 (18) | 1.92 (13) | ||
Otolaryngology/urology | 9.91 (67) | 8.14 (55) | ||
Internal medicine | 13.91 (94) | 14.05 (95) |
Items | VALENF | Barthel | Braden | Downton | |||
---|---|---|---|---|---|---|---|
Factor 1 | Factor 2 | Factor 1 | Factor 2 | Factor 1 | Factor 1 | Factor 2 | |
Mobility (Barthel) | 0.944 | 0.069 | 0.943 | −0.020 | 0.879 | 0.835 | 0.020 |
Sensory Perception (Braden) | 0.689 | 0.219 | 0.171 | 0.769 | 0.862 | 0.735 | 0.184 |
Moisture (Braden) | 0.818 | 0.045 | 0.478 | 0.408 | 0.858 | 0.892 | −0.016 |
Mobility (Braden) | 0.811 | 0.080 | 0.651 | 0.253 | 0.873 | -- | -- |
Sensory Deficiency (Downton) | 0.034 | 0.365 | 0.009 | 0.631 | -- | −0.015 | 0.420 |
Previous Fall (Downton) | 0.060 | 0.303 | -- | -- | -- | 0.048 | 0.320 |
Medication (Downton) | −0.044 | 0.817 | -- | -- | 0.299 | 0.043 | 0.720 |
Indicators of the exploratory factorial analysis | |||||||
Bartlett’s Test | p < 0.001 | p < 0.001 | p < 0.001 | p < 0.001 | |||
1 KMO | 0.885 | 0.875 | 0.860 | 0.832 | |||
% Variance | 40.5 | 15.6 | 39.3 | 32.3 | 62.1 | 36.1 | 16.1 |
% Total variance | 56.2 | 71.5 | 62.1 | 52.2 | |||
Correlation | 0.755 | 0.822 | -- | 0.742 | |||
Indicators of the confirmatory factorial analysis | |||||||
2 χ2/df (p) | 4.576 (<0.001) | 2.55 (<0.001) | 4.26 (<0.001) | 3.8 (<0.001) | |||
3 CFI | 0.980 | 0.997 | 0.991 | 0.985 | |||
4 TLI | 0.967 | 0.993 | 0.983 | 0.972 | |||
5 RMSEA | 0.072 | 0.048 | 0.069 | 0.064 |
VALENF | Barthel | Braden | Downton | |
---|---|---|---|---|
Ω * | ||||
Global | 0.869 | 0.911 | 0.882 | 0.826 |
if items are withdrawn | Ω * | |||
Mobility (Barthel) | 0.828 | 0.882 | 0.834 | 0.765 |
Sensory Perception (Braden) | 0.826 | 0.880 | 0.838 | 0.753 |
Moisture (Braden) | 0.830 | 0.884 | 0.839 | 0.762 |
Mobility (Braden) | 0.826 | 0.881 | 0.835 | |
Sensory Deficiency (Downton) | 0.884 | 0.924 | 0.803 | |
Previous Fall (Downton) | 0.886 | 0.845 | ||
Medication (Downton) | 0.858 | 0.924 | 0.847 |
Observer 2 | Observer 1 (n; %) | K (95%CI) 2 | |||||
---|---|---|---|---|---|---|---|
Independent | Needs Help | Wheelchair 1 | Immobile | Total (n; %) | |||
Mobility (Barthel) | Independent | 8 | 3 | 0 | 4 | 15 (36.6) | 0.554 (0.33–0.77) |
Needs help | 2 | 7 | 0 | 1 | 10 (24.4) | ||
Wheelchair 1 | 0 | 0 | 0 | 0 | 0 (0) | ||
Immobile | 1 | 1 | 0 | 14 | 16 (39.0) | ||
Total n (%) | 11 (26.8) | 11 (26.8) | 0 (0) | 19 (46.3) | 41 (100) | ||
Completely limited | Very limited | Slightly limited | No impairment | Total | K (95%CI) 2 | ||
Sensory Perception (Braden) | Completely limited | 0 | 1 | 1 | 0 | 2 (4.9) | 0.609 (0.43–0.77) |
Very limited | 0 | 2 | 4 | 1 | 7 (17.1) | ||
Slightly limited | 0 | 0 | 8 | 4 | 12 (29.3) | ||
No impairment | 0 | 0 | 0 | 20 | 20 (48.8) | ||
Total | 0 (0) | 3 (7.3) | 13 (31.7) | 25 (61) | 41 (100) | ||
Mobility (Braden) | Completely limited | 1 | 0 | 0 | 0 | 1 (2.4) | 0.605 (0.44–0.76) |
Very limited | 3 | 6 | 4 | 1 | 14 (34.1) | ||
Slightly limited | 0 | 2 | 5 | 5 | 12 (29.3) | ||
No impairment | 0 | 0 | 1 | 13 | 14 (34.1) | ||
Total | 4 (9.8) | 8 (19.5) | 10 (24.4) | 19 (46.3) | 41 (100) | ||
Constantly moist | Often moist | Occasionally moist | Barely moist | Total | K (95%CI) 2 | ||
Moisture (Braden) | Constantly moist | 0 | 1 | 1 | 0 | 2 (4.9) | 0.609 (0.43–0.77) |
Often moist | 0 | 2 | 4 | 1 | 7 (17.1) | ||
Occasionally moist | 0 | 0 | 8 | 4 | 12 (29.3) | ||
Barely moist | 0 | 0 | 0 | 20 | 20 (48.8) | ||
Total | 0 (0) | 0 (7.3) | 13 (31.7) | 25 (61) | 41 (100) | ||
No | Yes | --- | --- | Total | K (95%CI) 2 | ||
Sensory Deficiency (Downton) | No | 6 | 8 | --- | --- | 14 (34.1) | 0.213 (−0.9–0.52) |
Yes | 6 | 21 | --- | --- | 27 (65.9) | ||
Total | 12 (29.3) | 29 (70.7) | --- | --- | 41 (100) | ||
Previous Fall (Downton) | No | 19 | 2 | --- | --- | 21 (51.3) | 0.902 (0.77–1.00) |
Yes | 0 | 20 | --- | --- | 20 (48.8) | ||
Total | 19 (46.3) | 22 (53.7) | --- | --- | 41 (100) | ||
Medication (Downton) | No | 9 | 1 | --- | --- | 10 (24,4) | 0.752 (0.52–0.97) |
Yes | 3 | 28 | --- | --- | 31 (75.6) | ||
Total | 12 (29.3) | 29 (70.7) | --- | --- | 41 (100) |
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content. |
© 2023 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).
Share and Cite
Luna-Aleixos, D.; Llagostera-Reverter, I.; Castelló-Benavent, X.; Aquilué-Ballarín, M.; Mecho-Montoliu, G.; Cervera-Gasch, Á.; Valero-Chillerón, M.J.; Mena-Tudela, D.; Andreu-Pejó, L.; Martínez-Gonzálbez, R.; et al. Development and Validation of a Meta-Instrument for the Assessment of Functional Capacity, the Risk of Falls and Pressure Injuries in Adult Hospitalization Units (VALENF Instrument) (Part II). Int. J. Environ. Res. Public Health 2023, 20, 5003. https://doi.org/10.3390/ijerph20065003
Luna-Aleixos D, Llagostera-Reverter I, Castelló-Benavent X, Aquilué-Ballarín M, Mecho-Montoliu G, Cervera-Gasch Á, Valero-Chillerón MJ, Mena-Tudela D, Andreu-Pejó L, Martínez-Gonzálbez R, et al. Development and Validation of a Meta-Instrument for the Assessment of Functional Capacity, the Risk of Falls and Pressure Injuries in Adult Hospitalization Units (VALENF Instrument) (Part II). International Journal of Environmental Research and Public Health. 2023; 20(6):5003. https://doi.org/10.3390/ijerph20065003
Chicago/Turabian StyleLuna-Aleixos, David, Irene Llagostera-Reverter, Ximo Castelló-Benavent, Marta Aquilué-Ballarín, Gema Mecho-Montoliu, Águeda Cervera-Gasch, María Jesús Valero-Chillerón, Desirée Mena-Tudela, Laura Andreu-Pejó, Rafael Martínez-Gonzálbez, and et al. 2023. "Development and Validation of a Meta-Instrument for the Assessment of Functional Capacity, the Risk of Falls and Pressure Injuries in Adult Hospitalization Units (VALENF Instrument) (Part II)" International Journal of Environmental Research and Public Health 20, no. 6: 5003. https://doi.org/10.3390/ijerph20065003