Validity evidence of the Brazilian version of the Post-Discharge Coping Difficulty Scale - Adult Form

Trindade, Clediane Rita Portalupi da; Lima, Maria Alice Dias da Silva; Acosta, Aline Marques; Santos, Mariana Timmers dos; Zanon, Cristian

doi:10.37689/acta-ape/2025AO0003481

Abstract

Objective To identify validity evidence of the Brazilian version of the Post-Discharge Coping Difficulty Scale - Adult Form.

Methods This methodological study was carried out by means of the stages of translation, back-translation, evaluation by a committee of experts, pre-testing, and validation. Content validation was carried out by a committee of six experts, who evaluated semantic, idiomatic, experimental, and conceptual equivalence. To verify validity evidence, the scale was applied to 100 adult clinical and surgical patients. Principal component analysis was carried out with varimax rotation. Reliability was checked using Cronbach’s alpha, stability using test-retest, and equivalence using inter-rater reliability. The scale’s predictive validity was verified in relation to emergency service use and readmission.

Results In the expert committee’s assessment, adjustments were made, and all the items obtained a Content Validity Index higher than 0.80. In the validation stage, the principal component analysis revealed that the best solution would be unifactorial, according to the original scale. The scale’s internal consistency was satisfactory. Test-retest and inter-rater reliability showed no statistical difference (P > 0.05).

Conclusion The Brazilian version of the 10-item Post-Discharge Coping Difficulty Scale shows good evidence of validity and reliability. It proved to be easy to understand by the participants and represents a useful tool for professionals and researchers in the practice of care.

Resumo

Objetivo Identificar evidências de validade da versão brasileira da Post-Discharge Coping Difficulty Scale - Adult Form.

Métodos Estudo metodológico desenvolvido por meio das etapas de tradução, retrotradução, avaliação por comitê de especialistas, pré-teste e validação. A validação de conteúdo foi realizada por comitê de seis especialistas, os quais avaliaram as equivalências semântica, idiomática, experimental e conceitual. Para verificar as evidências de validade, a escala foi aplicada a 100 pacientes adultos clínicos e cirúrgicos. Foi realizada a análise de componentes principais, com rotação varimax. A confiabilidade foi verificada por meio do Coeficiente Alfa de Cronbach, quanto à estabilidade, por meio do Teste-Reteste e quanto à equivalência por meio de Confiabilidade Interavaliadores. Verificou-se a validade preditiva da escala em relação à utilização de serviço de emergência e readmissão.

Resultados Na avaliação do comitê de especialistas foram realizadas adequações e todos os itens apresentaram um Índice de Validade de Conteúdo superior a 0,80. Na etapa de validação, a análise de componentes principais revelou que a melhor solução seria unifatorial, conforme a escala original. A consistência interna da escala foi satisfatória. A confiabilidade teste-reteste e interavaliadores não mostraram diferença estatística (P > 0,05).

Conclusão A versão brasileira da Escala de Dificuldade de Enfrentamento Pós-alta com 10 itens apresenta boas evidências de validade e confiabilidade. Mostrou ser de fácil compreensão pelos participantes e representa uma ferramenta útil para os profissionais e pesquisadores na prática do cuidado.

Cuidado transicional; Alta do paciente; Continuidade da assistência ao paciente; Estudo de validação

Resumen

Objetivo Identificar las evidencias de validez de la versión brasileña de la Post-Discharge Coping Difficulty Scale - Adult Form.

Métodos Estudio metodológico llevado a cabo mediante las etapas de traducción, retrotraducción, revisión por comité de especialistas, prueba piloto y validación. La validación de contenido se realizó por un comité de seis especialistas, que evaluaron las equivalencias semánticas, idiomáticas, experimentales y conceptuales. Se aplicó la escala a 100 pacientes adultos clínicos y quirúrgicos para verificar las evidencias de validez. Se realizó el análisis de los componentes principales con rotación varimax. La fiabilidad se verificó mediante el coeficiente Alfa de Cronbach, la estabilidad con el test-retest y la equivalencia mediante la fiabilidad entre evaluadores. Se verificó la validez predictiva de la escala con relación a la utilización del servicio de emergencia y readmisión.

Resultados Se realizaron adaptaciones en la etapa de revisión del comité de especialistas, y todos los ítems presentaron un índice de validez de contenido superior a 0,80. En la etapa de validación, el análisis de los componentes principales reveló que la mejor solución era unifactorial, según la escala original. La consistencia interna de la escala fue satisfactoria. La fiabilidad test-retest y entre evaluadores no mostraron diferencia estadística (P > 0,05).

Conclusión La versión brasileña de la Escala de Dificultad de Enfrentamiento Posalta, que tiene 10 ítems, presenta buenas evidencias de validez y fiabilidad. Demostró ser de fácil comprensión por parte de los participantes y representa una herramienta útil para los profesionales e investigadores de la práctica del cuidado.

Cuidado de transición; Alta del paciente; Continuidad de la atención al paciente; Estudio de validación

Introduction

Patients’ transition between different services or levels of health care represents a vulnerable period for continuity of care. Changes in health status, diagnosis, treatment, or functional status can affect the individuals’ ability to manage their personal conditions outside the healthcare environment, leaving them susceptible to a greater risk of adverse events.(¹,²)

In this context, hospital discharge is a complex transitional phase in which patients and their families need to adjust to new challenges related to acute or chronic health conditions,(¹) which involve changes and adjustments to the family structure and organization in order to integrate the role of caregivers and establish a safe care environment.(¹,³)

Difficulties after hospital discharge refer to the physical, emotional, and environmental challenges faced by individuals and include aspects related to stress, recovery, self-care, emotional support, the ability to take care of one’s own health needs, adaptation to the home after hospitalization, among others.(⁴)

The causes or contributing factors to negative experiences after discharge are diverse and permeate the phases of transition. Problems such as lack of patient and caregiver involvement in discharge planning and care plans; insufficient information to participate in decisions; lack of guidance on who to contact after discharge; lack of understanding about medication use, health condition, risks, and aggravating factors; and failures in communication and coordination between different health services increase patients’ difficulties and hinder continuity of care.(⁵-⁷)

In the United States, scales have been developed and validated to evaluate different phases and aspects of transition at hospital discharge, including the Post-Discharge Coping Difficulty Scale (PDCDS), used to evaluate the difficulties faced by patients after discharge. The validation study involved a large sample of patients who had been discharged from hospital to home, including clinical-surgical adults, parents of hospitalized children, and puerperal women, resulting in specific scales for each group.(⁸) The adult version was used in a study to evaluate clinical-surgical patients who had been discharged from inpatient units to home, within three weeks of discharge.(⁹)

The PDCDS-Adult Form instrument has been used in different contexts to understand patient outcomes after discharge and identify opportunities to qualify this transition.(³,⁴,¹⁰) No validated instruments were found in the literature in Brazil to evaluate issues related to the post-discharge period.

Having a validated instrument that makes it possible to understand the difficulties faced by patients after hospital discharge can provide information to guide future care transition strategies in order to improve patient outcomes in terms of safety and continuity of care. Therefore, this study aims to identify validity evidence of the Brazilian version of the Post-Discharge Coping Difficulty Scale - Adult Form.

Methods

A methodological study for cross-cultural adaptation and validation of an instrument was carried out in a public university hospital with 850 beds in the south of Brazil. Authorization for the process of cross-cultural adaptation and validation of the PDCDS-Adult Form(¹⁰) was granted by e-mail by the author of the instrument.

The scale has 11 items related to difficulties in recovery, self-care, managing health conditions, difficulties for family members or close people, the need for help, emotional support and adaptation to the home.(⁸,⁹) Each item is answered on a scale of 0 to 10 points. The first 5 items are supplemented with open-ended questions. Item 6 is made up of sub-items 6a “How much help have you needed to look after yourself?” and 6b “How much help did you think you would need?”, but 6b is not included in the total score. Items 8, 9, and 10 are reversely scored. The final score is the average of the items and ranges from 0 to 10. There is no cut-off point, the higher the score, the greater the difficulty after discharge.(⁸,⁹,¹¹)

The process of cross-cultural adaptation followed the stages of translation by two independent translators; synthesis of the translations; back-translation by two independent native English-speaking translators; evaluation by a committee of six experts; pre-testing; and submission to the author of the instrument for approval.(¹²) The experts were selected intentionally, according to the inclusion criteria: being a health professional with knowledge of the subject and methodology of the study, or being a linguistics professional.(¹²,¹³) Five nurses and one linguistics professional participated.

The relevance and semantic, idiomatic, experimental, and conceptual equivalence of each item in the instrument were evaluated using a 4-point Likert scale. The Content Validity Index (CVI) was calculated to assess agreement between the experts, considering the ratings of each item as 3 or 4 (relevant and extremely relevant). Values equal to or greater than 0.80 were considered satisfactory.(¹⁴)

For the pre-test, 30 adult clinical and surgical patients in the hospitalization units were selected for convenience. All the items were evaluated by the participants for clarity and understanding, using a 5-point Likert scale: 1= I didn’t understand it; 2= I understood it a little; 3= I somewhat understood it; 4= I understood it; and 5= I understood it a lot, with a field for suggestions. The percentage of clarity for each item was calculated considering ratings 4 and 5. A clarity rate of 80% or more was considered adequate.(¹⁵)

To assess the psychometric properties of the scale, it was applied to 100 adult clinical and surgical patients who had been discharged from hospital. The sample size was calculated considering the proportion of 10 participants for each quantitative item in the instrument.(¹⁶) Patients aged 18 or over, with a minimum hospital stay of 48 hours and who had been discharged home were included, and patients unable to answer were excluded.

Data was collected by the research team by telephone, during business hours or according to the participant’s availability, between two and three weeks after discharge,(¹⁷) lasting an average of 10 minutes. Sociodemographic data (age, gender, marital status, occupation, and presence of a caregiver) was surveyed during the calls. Clinical data (diagnosis or reason for hospitalization, comorbidities, and length of stay) was obtained from a report provided by the hospital.

Reliability was assessed in terms of internal consistency and stability, predictive validity, and factor analysis for the 10 quantitative items of the scale. For the qualitative items, the content validation obtained in the expert committee evaluation and pre-test stages was considered.

The internal structure was evaluated using principal component analysis with Varimax rotation. Kaiser-Meyer-Olkin (KMO) and Bartlett’s sphericity tests were carried out to investigate the suitability of the correlation matrix for the analysis. The criteria of eigenvalue greater than one, together with the visual inspection of the Scree test (looking for the last substantial drop in eigenvalues) were used to determine the number of factors retained. Sub-item 6b was excluded from the evaluation as it was not part of the overall score.

Reliability was assessed in terms of the internal consistency of the items using Cronbach’s alpha coefficient, stability using test-retest and equivalence using inter-rater reliability. For the retest, the scale was reapplied to 20 patients by the same interviewer over a period of 7 to 15 days. To assess inter-rater reliability, the scale was reapplied to 20 patients by a second interviewer at intervals up to 7 days.(¹⁸)

Predictive validity was checked to assess whether the scale’s median score is related to the use of emergency services or readmission within 30 days. This data was verified using reports provided by the hospital.

Quantitative variables were described by mean and standard deviation or median and range of variation and qualitative variables by absolute and relative frequencies. The Mann-Whitney test was used to compare medians between groups. The Intraclass Correlation Coefficient (ICC) was applied to verify test-retest and inter-rater agreement, considering a minimum of 0.70 to be satisfactory.(¹⁸) The significance level adopted was 5% and the analyses were carried out using the Statistical Package for the Social Sciences (SPSS)® version 28.0 program.

The project was approved by the institution’s Research Ethics Committee, under Opinion No. 4.951.34. All the participants in the various stages of the research gave their consent through a free and informed consent form, obtained at the first contact made (Certificate of Presentation for Ethical Appraisal no. 49987721.0.0000.5327).

Results

There were minimal differences in the initial translations, which were resolved between the researchers and the translators. Complementary adjectives were added to the response scale (e.g. “not at all difficult/no difficulty and very difficult/extremely difficult”) to improve comprehension. The terms “medical condition” and “medical needs” were translated into “health condition” and “health needs”, taking into account the cultural and language context. During the expert committee’s evaluation, a number of changes were made to the translated version by consensus.

All the items had a CVI greater than 0.80 and the preliminary version of the scale was obtained in Portuguese. As for the pre-test participants (n=30), 17 were women, the average age was 53 (±14.3) years, and 23 were clinical admissions. The time taken to apply the scale, including that for providing guidance, ranged from 10 to 20 minutes. The items were considered easy to understand, reaching a rate over 80%. At the end of this stage, content-related validity was obtained and the pre-final version of the scale in Portuguese, called Escala de Dificuldade de Enfrentamento Pós-Alta© Formulário para adultos (Post-Discharge Coping Difficulty Scale© Form for adults), was created. Regarding the participants in the psychometric properties evaluation stage (n=100), 51% were men, the average age was 53.6 (±16.5) years, 65% were married or living with a partner, 54% were retired/pensioners, 58% had a formal or informal caregiver, 65% had been admitted to a surgical unit, 88% were admitted through the Unified Health System, and the median length of stay was 4.5 (2-9) days. The main comorbidities were neoplasms (23%), and diseases of the genitourinary tract (21%) and the circulatory system (15%). The PDCDS application obtained a median total score of 3 (1.3 - 4.8) and an average score of 3.1 (±2.0), with scores ranging from 0 to 6.9. The item with the highest score was “How much emotional support have you needed?”. Other items that indicated above-average coping difficulties were related to stress, the need for help with self-care, difficulty with recovery, difficulty managing the health condition, and difficulty with family members or people close to them. Table 1 shows the median (interquartile range), mean (standard deviation) and factor loading values for each item.

Thumbnail

Table 1
Median, mean, and factor loading values of the items in the Post-Discharge Coping Difficulty Scale

As for internal consistency reliability, the overall Cronbach’s alpha of the scale was 0.85. Test-retest and inter-rater reliability showed no statistical difference (P>0.05), with ICC of 0.90 and 0.91, respectively. As for predictive validity, there was no significant difference (p=0.448) between the median of the scale and the use of emergency services or readmission within 30 days. The KMO index was 0.776 and Bartlett’s test of sphericity was significant (p <0.001), indicating the adequacy of the correlation matrix. The result of the factor analysis indicated two factors with eigenvalues ≥ 1. However, due to the sharp drop observed in the Scree test, it was considered that the solution of one factor with an eigenvalue of 4.2, explaining 42% of the total variance, would be satisfactory for this set of items (Figure 1). The Brazilian version of the Post-Discharge Coping Difficulty Scale - Form for adults is shown in Figure 2.

Figure 1
Scree plot of the components of the Post-Discharge Coping Difficulty Scale

Figure 2
Brazilian version of the Post-Discharge Coping Difficulty Scale - Form for adults

Discussion

The cross-cultural adaptation process followed an internationally recognized methodological framework(¹²) that has been used in Brazilian studies.(¹⁹,²⁰) Throughout the adaptation process, several adjustments were made so that the scale was appropriate for the Brazilian context and consistent with the original version.

Through back-translation, it was possible to compare it with the original scale and check whether there were no significant changes to the items. This stage is considered essential to detect inconsistencies or conceptual errors in the translation and the extent to which the translated version reflects the content of the items in the original instrument. It is also a tool for communicating with the authors of the original instrument.(²⁰)

During the meeting with the experts, each item was analyzed, and the preliminary version was defined by consensus among the participants, who considered the equivalence of the translated version to the original scale to be adequate. This process makes it possible to evaluate the concepts present in the instrument, adapt the items to the cultural context, and check for content validity.(¹⁹,²⁰)

The factor analysis showed that the single-factor solution was the most suitable, corroborating the findings of the original study. As for internal consistency reliability, the Cronbach’s alpha of 0.85 was close to the result of 0.87 in the original study,(⁹) indicating that the scale has good internal consistency, since the higher the reliability, the greater its accuracy.(¹⁸,²¹)

As in the validation study of the Chinese version of the Ped-PDCDS for parents of hospitalized children,(²¹) test-retest reliability indicated that the scale has good temporal stability. Application by different interviewers also showed equivalence.

According to the original scale and the Chinese version of the Ped-PDCDS, the open-ended questions were kept, considering the possibility of broadening knowledge about the stressors and difficulties faced by patients. The analysis of the results of these items will depend on the objectives and design of the research. If the aim is to gain an in-depth understanding of the participants’ perspectives and experiences, a qualitative analysis of the answers is recommended. If the research is quantitative, it is recommended to categorize the content of the responses and present the frequency or proportion within the categories.(²¹) For the purposes of analysis, it is recommended to tabulate the number of respondents for each thematic content area.(¹¹,²¹)

The mean score of the scale (3.1±2.0) was similar to that of a Chinese study with patients with esophageal cancer after an esophagectomy (3.08±1.39). The three items with the highest scores were related to emotional support, stress, and the need for help with self-care. A Chinese study that assessed the difficulties of puerperal women after discharge, using a specific version of the PDCDS, also scored higher on the items related to emotional support and the need for help.(²²)

The difficulty score may be related to the preparation patients received for discharge and the non-association with readmission and emergency department attendance within 30 days. Studies have identified that patients prepared for discharge tend to have fewer difficulties after leaving hospital and therefore have better health outcomes, including lower readmission rates.(³,⁹,²²,²³) However, results related to preparation were not assessed in this study, indicating a possibility for future research.

In addition, most of the participants were married or lived with a partner and had a formal or informal caregiver available. Studies indicate that sociodemographic factors, such as home and family context, social support network, schooling, and socioeconomic status influence outcomes after discharge.(²⁴) Therefore, adequate preparation for discharge helps to reduce readmission rates and emergency room visits.(²⁵)

Limitations include the lack of cross-cultural adaptation studies and evidence of the validity of the PDCDS-Adult Form published in other countries, as well as studies using the scale in languages other than the original, which is a restriction for cross-cultural comparisons. The lack of other similar scales validated in Brazil is another limitation, as it does not allow comparisons between measures. In addition, readmission and care in the emergency department were verified through electronic records provided by the study hospital, and possible delivery of care and hospitalization in other services were not verified.

Conclusion

The Brazilian version of the PDCDS for adults showed semantic, idiomatic, experimental, and conceptual equivalence with the original scale. The scale proved to be easy to understand by the participants and quick to fill in, so it represents a useful tool for professionals and researchers in care, management, and research. Knowing the difficulties faced by patients after discharge is essential for assessing the transition of care and proposing strategies to improve discharge preparation, coordination, and continuity of care. Although the results show satisfactory reliability and validity, it is recommended that studies be carried out with a larger sample of participants, including in different regions of the country, in order to strengthen the evidence of validity and applicability of the scale in the Brazilian cultural context.

Acknowledgments

To the Coordination for the Improvement of Higher Education Personnel - Brazil (CAPES) - Funding Code 001 and financial support from the National Council for Scientific and Technological Development (CNPq), Process No. 433997/2018-4.

References

¹ Gheno J, Weis AH. Care transtion in hospital discharge for adult patients: integrative literature review. Texto Contexto Enferm. 2021;30:e20210030.
² Sousa LS, Pontes ML, Pereira RR, Leite MA, Vila Nova FA, Monteiro EA. Older adult transition from hospital to home from caregivers'/older adults' perspective: a scoping review. Acta Paul Enferm. 2023; 36:eAPE03631.
³ Yu Q, He LJ, Zhong JD, Zhang JE. Readiness for hospital discharge and its association with post-discharge outcomes among oesophageal cancer patients after oesophagectomy: A prospective observational study. J Clin Nurs. 2024 Feb 7. doi: 10.1111/jocn.17055.
» https://doi.org/10.1111/jocn.17055
⁴ Opper K, Beiler J, Yakusheva O, Weiss M. Effects of Implementing a Health Team Communication Redesign on Hospital Readmissions Within 30 Days. Worldviews Evid Based Nurs. 2019;16(2):121-30.
⁵ Polisaitis A, Malik AM. Cuidados continuados: uma falha na malha da rede de serviços de saúde. Tempus Actas de Saúde Coletiva. 2019;13(2):105.
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⁷ Acosta AM, Lima, MA, Pinto IC, Weber LA. Care transition of patients with chronic diseases from the discharge of the emergency service to their homes. Rev Gaúcha Enferm 2020;41(esp):e20190155. Portuguese.
⁸ Weiss ME, Piacentine LB. Psychometric properties of the Readiness for Hospital Discharge Scale. J Nurs Meas. 2006;14(3):163-80.
⁹ Weiss ME, Piacentini LB, Lokken L, Ancona J, Archer J, Gresser S, et al. Perceived readiness for hospital discharge in adult medical-surgical patients. Clin Nurse Spec. 2007;21(1):31-42.
¹⁰ Wallace AS, Pierce NL, Davisson E, Manges K, Tripp-Reimer T. Social resource assessment: application of a novel communication tool during hospital discharge. Patient Educ Couns. 2019;102(3):542-9.
¹¹ Fitzgerald Miller J, Piacentine LB, Weiss M. Coping difficulties after hospitalization. Clin Nurs Res. 2008;17(4):278-96.
¹² Beaton, D. et al. Recommendations for the cross-cultural adaptation of the DASH & QuickDASH outcome measures. Rosemond: AAOS; 2007.
¹³ Fortes CP, Araújo AP. Check list para tradução e adaptação transcultural de questionários em saúde. Cad Saude Colet. 2019;27(2):202-9.
¹⁴ Polit DF, Beck CT. The content validity index: are you sure you know what's being reported? Critique and recommendations. Res Nurs Health. 2006;29(5):489-97.
¹⁵ Sousa VD, Rojjanasrirat W. Translation, adaptation and validation of instruments or scales for use in cross-cultural health care research: a clear and user-friendly guideline. J Eval Clin Pract. 2011;17(2):268-74.
¹⁶ Hair JF Jr, Black WC, Babin BJ, Anderson RE. Multivariate data analysis. 7th ed. London: Pearson; 2014.
¹⁷ Weiss M, Johnson NL, Malin S, Jerofke T, Lang C, Sherburne E. Readiness for discharge in parents of hospitalized children. J Pediatr Nurs. 2008;23(4):282-95.
¹⁸ Terwee CB, Bot SDM, de Boer MR, van der Windt DAWM, Knol DL, Dekker J, et al. Quality criteria were proposed for measurement properties of health status questionnaires. J Clin Epidemiol. 2007;60(1):34-42.
¹⁹ Jamas MT, Ferretti-Rebustini RE, Rebustini F, Gonçalves IR, Gouveia LM, Hoga LA. Validity evidence of the Bienestar Materno en Situación de Parto scale. Acta Paul Enferm. 2021; 34:APE02843.
²⁰ Dal Pizzol FL, Predebon ML, Day CB, Bierhals CC, Machado DO, Aires M, et al. Adaptation and Validation of the Capacity Scale for Informal Caregivers of Elderly Stroke Patients to be used in Brazil. J Nurs Meas. 2020;28(1):23-42.
²¹ Liu J, Gong J, Shen Q, Si Z, Gao J, Xu L, et al. Reliability and validity of the Chinese post-discharge coping difficulty scale-parent form in parents of premature infants: a multicenter cross-sectional study. Front Psychol. 2023;14:1095485.
²² Li W, Zhang Y, Wei L. Postdischarge coping difficulties and influencing factors of pregnant women with gestational diabetes mellitus: A cross-sectional study. Nurs Open. 2022;9(3):1625-34.
²³ Siow E, Lo SM, Yeung KL, Yeung RS, Choi KC, Chair SY. Factors and post-discharge outcomes associated with patients' readiness for discharge from the emergency medicine ward: A prospective study. Int Emerg Nurs. 2019;46:100773.
²⁴ Santos JL, Pedreira LC, Amaral JB, Silva VA, Pereira A, Aguiar AC. Adaptation of long-lived elders at home after hospitalization in the intensive care unit and hospital discharge. Texto Contexto Enferm. 2019;28:e20180286.
²⁵ Weiss ME, Lerret SM, Sawin KJ, Schiffman RF. Parent readiness for hospital discharge scale: psychometrics and association with postdischarge outcomes. J Pediatr Health Care. 2020;34(1):30-7.

Edited by

Associate Editor:
Edvane Birelo Lopes De Domenico (https://orcid.org/0000-0001-7455-1727) Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, SP, Brazil

Publication Dates

Publication in this collection
02 Dec 2024
Date of issue
2025

History

Received
27 Dec 2023
Accepted
17 June 2024

This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

[1] ¹ Gheno J, Weis AH. Care transtion in hospital discharge for adult patients: integrative literature review. Texto Contexto Enferm. 2021;30:e20210030.

[2] ² Sousa LS, Pontes ML, Pereira RR, Leite MA, Vila Nova FA, Monteiro EA. Older adult transition from hospital to home from caregivers'/older adults' perspective: a scoping review. Acta Paul Enferm. 2023; 36:eAPE03631.

[3] ³ Yu Q, He LJ, Zhong JD, Zhang JE. Readiness for hospital discharge and its association with post-discharge outcomes among oesophageal cancer patients after oesophagectomy: A prospective observational study. J Clin Nurs. 2024 Feb 7. doi: 10.1111/jocn.17055.
» https://doi.org/10.1111/jocn.17055

[4] ⁴ Opper K, Beiler J, Yakusheva O, Weiss M. Effects of Implementing a Health Team Communication Redesign on Hospital Readmissions Within 30 Days. Worldviews Evid Based Nurs. 2019;16(2):121-30.

[5] ⁵ Polisaitis A, Malik AM. Cuidados continuados: uma falha na malha da rede de serviços de saúde. Tempus Actas de Saúde Coletiva. 2019;13(2):105.

[6] ⁶ da Costa LP, Pinheiro EA, Siqueira RM, Dobashi BF, Pompílio MA, de Matos VT. Integrated continuous care: implementation in Mato Grosso do Sul, Brazil. Biosci J. 2020;36(2):628-35.

[7] ⁷ Acosta AM, Lima, MA, Pinto IC, Weber LA. Care transition of patients with chronic diseases from the discharge of the emergency service to their homes. Rev Gaúcha Enferm 2020;41(esp):e20190155. Portuguese.

[8] ⁸ Weiss ME, Piacentine LB. Psychometric properties of the Readiness for Hospital Discharge Scale. J Nurs Meas. 2006;14(3):163-80.

[9] ⁹ Weiss ME, Piacentini LB, Lokken L, Ancona J, Archer J, Gresser S, et al. Perceived readiness for hospital discharge in adult medical-surgical patients. Clin Nurse Spec. 2007;21(1):31-42.

[10] ¹⁰ Wallace AS, Pierce NL, Davisson E, Manges K, Tripp-Reimer T. Social resource assessment: application of a novel communication tool during hospital discharge. Patient Educ Couns. 2019;102(3):542-9.

[11] ¹¹ Fitzgerald Miller J, Piacentine LB, Weiss M. Coping difficulties after hospitalization. Clin Nurs Res. 2008;17(4):278-96.

[12] ¹² Beaton, D. et al. Recommendations for the cross-cultural adaptation of the DASH & QuickDASH outcome measures. Rosemond: AAOS; 2007.

[13] ¹³ Fortes CP, Araújo AP. Check list para tradução e adaptação transcultural de questionários em saúde. Cad Saude Colet. 2019;27(2):202-9.

[14] ¹⁴ Polit DF, Beck CT. The content validity index: are you sure you know what's being reported? Critique and recommendations. Res Nurs Health. 2006;29(5):489-97.

[15] ¹⁵ Sousa VD, Rojjanasrirat W. Translation, adaptation and validation of instruments or scales for use in cross-cultural health care research: a clear and user-friendly guideline. J Eval Clin Pract. 2011;17(2):268-74.

[16] ¹⁶ Hair JF Jr, Black WC, Babin BJ, Anderson RE. Multivariate data analysis. 7th ed. London: Pearson; 2014.

[17] ¹⁷ Weiss M, Johnson NL, Malin S, Jerofke T, Lang C, Sherburne E. Readiness for discharge in parents of hospitalized children. J Pediatr Nurs. 2008;23(4):282-95.

[18] ¹⁸ Terwee CB, Bot SDM, de Boer MR, van der Windt DAWM, Knol DL, Dekker J, et al. Quality criteria were proposed for measurement properties of health status questionnaires. J Clin Epidemiol. 2007;60(1):34-42.

[19] ¹⁹ Jamas MT, Ferretti-Rebustini RE, Rebustini F, Gonçalves IR, Gouveia LM, Hoga LA. Validity evidence of the Bienestar Materno en Situación de Parto scale. Acta Paul Enferm. 2021; 34:APE02843.

[20] ²⁰ Dal Pizzol FL, Predebon ML, Day CB, Bierhals CC, Machado DO, Aires M, et al. Adaptation and Validation of the Capacity Scale for Informal Caregivers of Elderly Stroke Patients to be used in Brazil. J Nurs Meas. 2020;28(1):23-42.

[21] ²¹ Liu J, Gong J, Shen Q, Si Z, Gao J, Xu L, et al. Reliability and validity of the Chinese post-discharge coping difficulty scale-parent form in parents of premature infants: a multicenter cross-sectional study. Front Psychol. 2023;14:1095485.

[22] ²² Li W, Zhang Y, Wei L. Postdischarge coping difficulties and influencing factors of pregnant women with gestational diabetes mellitus: A cross-sectional study. Nurs Open. 2022;9(3):1625-34.

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Items	Median (P25-P75)	Mean (SD)	Factor loading
1. How stressful has your life been?	4 (0 – 7)	4.2(±3.1)	0.595
2. How much difficulty have you had with your recovery?	3 (0 – 7)	3.8(±3.1)	0.744
3. How much difficulty have you had taking care of yourself?	2 (0 – 6)	3.0(±3.3)	0.691
4. How difficult have you found it to manage your health condition?	3 (0 – 6)	3.5(±3.3)	0.826
5. How difficult has this period been for your family or other close people?	3 (0 – 7)	3.5(±3.4)	0.741
6a. How much help have you needed to take care of yourself?	4 (0 – 8)	4.1(±3.6)	0.661
7. How much emotional support have you needed?	5 (0 – 8)	4.5(±3.9)	0.617
8. How confident have you felt about your ability to take care of yourself?	1 (0 – 3)	1.8(±2.2)	-0.494
9. Have you been able to take care of your health-related needs, such as medication or treatment?	0 (0 – 2)	1.2(±2.5)	-0.519
10. How well have you adapted at home since your discharge from hospital?	0 (0 – 2)	1.3(±2.2)	-0.436