Development and Validation of Caregivers Perspectives Questionnaire in Comatose Patients
A. Mostafa Shokati,
Safar Ali Esmaeili Vardanjani
The caregivers perspective about care in comatose patients is different among different caregivers, and thus the question is how it is perceived by caregivers. Among the health staff and family members, perspective of caring is obviously different. Thus, the current study was carried out to develop a valid and reliable instrument to assess of caregivers perspective in comatose patient care. For gathering the data used from the questionnaire consisted of items of Van Manens hermeneutic phenomenology, then these items combined and validated by content, face and construct validity and by split half and Cronbach α coefficient for reliability. The results showed that the four factors were labeled living with client, efforts for survival, professional conscience and responsibility and respect of human dignity. The perspective of caring of comatose patient questionnaire had 32 items and 4 dimension and showed validity and reliability, but it need to test more and more to multiplication of its' validity and reliability.
to cite this article:
A. Mostafa Shokati, Parkhideh Hasani, Houman Manoochehri, Ebrahim Hajizadeh, Safar Ali Esmaeili Vardanjani and Yaser Moradi, 2013. Development and Validation of Caregivers Perspectives Questionnaire in Comatose Patients. Journal of Applied Sciences, 13: 178-182.
Received: July 21, 2012;
Accepted: November 21, 2012;
Published: February 01, 2013
Caregivers of comatose patients are considered as the perspective of health
care systems. They have positive effect on caring and play a key role in improvement
of caring of comatose patients (Villanueva, 1997). Moreover,
they are in charge of providing care to comatose patients without any prejudice
and judgment. Respecting peoples rights and treating people with regard
to their dignity is an inseparable part of heath care systems (Menck,
1998). To direct the caring and experience, a sensitive perspective is needed;
thus it is an important item for health care providers (Dahlqvist
et al., 2009). Caregivers perspective is the foundation of
caring and influences private and professional life (Sanea
Pour, 2010). Perspective originates from the living experience and is a
part of our daily and professional life (Johnston, 2006).
An interview with nurses showed that when they are asked to narrate the challenges
in comatose patient care situations, they mostly refer to their perspectives.
The caregivers perspective precludes them from some acts and orders them
to do some acts and they have to assess themselves and their acts. While talking
about lived experience in comatose patients caring, we should consider
that perspective is different among different individuals and thus the question
is how perspective is perceived by caregivers. This perspective is related to
the qualities and acts of caring and how the individuals encountered with the
origin of lived experience. Depending on the perspective of caring, some caregivers
opt out of their job, and some experience long-term distress but some manage
these stresses. It is necessary to know the viewpoints of caregivers on the
caring of comatose patients, the quality and acts of perspective (Johnston,
2006). Dahlqvist et al. (2009) showed that
the perspective of caring was significantly different among the Swedish health
care staff and by main component analysis, they found that perspective of caring
can be considered as the authority and alarming signal that is the required
sensitivity for nursing and perceived asset and burden and depends on the individual
cultural background. In other hand, it was showed that perspective of caring
plays a role in the caregivers acts, which affects the comatose patients
caring. It sometimes directs the acts of nurses toward good values and thus
perceived as a motivation act in an attempt to provide high quality care and
sometimes limits low quality acts. In an attempt to provide high quality care,
it is necessary to be aware of the effect of perspective of caring on caregivers
activities. However, there is not enough information about the perspective of
caring in comatose patients and there is no validated and culturally adapted
instrument in this regard. Thus, the current study was carried out to develop
a valid and reliable instrument to assess of caregivers perspective in
comatose patient care.
The caregivers perspective about care in comatose patients is the most significant criteria for evaluation of nursing experiences because this is important and very effective on caring process as they said, therefore, of this the aim study was to validate the perspective of caregivers of comatose patients.
MATERIALS AND METHODS
All teaching hospitals in Iran have only registered nurse, from novice to expert, according to the Iranian ministry of health, even in critical care units specially in caring of comatose patients; in addition, many patients have nursing care from the teaching health care facilities. On the one hand, hard working conditions and units overcrowding result in nurses lack of experience in comatose caring patients. On the other hand, expert nurses who cannot transfer any caring experiences to novice nurses are employed in critical care units.
In addition to our professional grounding; Approximately, I spent 1 month in caring for my terminally ill wife and my father until they died of traumatic coma in 2008 and 2009. I also have experience in caring for comatose patients at ICUs for 4 years between 2003 and 2007. This interest eventually led to my doctoral studies and to my choice for the topic of study.
For development questionnaire, a quantitative methodological research was carried
out in two steps. First, the items of questionnaire were determined and then
the questionnaire was validated. The items of phenomenological study (it carried
out in another study) added to systematic review and existing questionnaire
items. The items extracted based phenomenological study that made a 127 items
questionnaire and then similar items were deleted or combined and used for psychometric
process. For determination of validity, content, face and construct validity
were used. The Waltz and Basel index for content validity were used and the
sum of scores were calculated for every item (Polit et
al., 2005), then the items above 75% maintained (held) and the items
under the 75% deleted. In the first step based on nature of the research, different
experts were participated. The 12 professors of nursing, 10 caregivers of comatose
patients and 2 Ph.Ds of psychology completed Waltz and Basel index for relevancy,
clearance and simplicity. Each item took a score from 1 for least relevancy
to 4 for best relevancy. Then the sum of scores divided on possible sum of scores.
The score of each item determined and recommendation for every item considered.
In next steps the questionnaire completed by 8 nursing teachers for judging
about content based on Waltz and Basel index. The scores above 75% maintained
(held) and the items under the 75% deleted, however the items took scores over
the 90%. For face validity, plus to appropriate face of questionnaire, the opinion
of nursing teachers were used and the questionnaire completed by 20 nurses for
content, clearance and simplicity and these opinions were considered. By using
version 16 of SPSS software, the factor analysis was done. Based on Nunnally
and Bernstein (1994) recommendations, the exploratory factor analysis was
used and the Kayser-Meyer-Olkin (KMO) and Bartletts Test of Sphericity
were done before factor analysis. The KMO index is between 0 and 1 and numbers
closest to 1 represent model of correlation and factor analysis is fit to be
doing (Hutcheson and Sofroniou, 1999). The 268 caregivers
of comatose patients completed questionnaire for factor analysis. After factor
analysis, the items with coefficient correlation lower than 40% were deleted.
The Cronbach Alpha and split-half were done for reliability too.
After content validity, the 48 items questionnaire was made. Then the opinion of nurses and experts were considered for face validity and the questionnaire corrected based on their opinion. Before factor analysis, the internal consistency calculated and the items lower than 40% were deleted and hence the items decreased to 32 items. Content validity was calculated by Cronbach Alpha, again (Table 1). The KMO test showed 0/872 and Bartletts test of Sphericity was significant p≤0.001.
Then, item weighting was done. Factor analysis showed 4 dimensions (Factors)
of questionnaire. The 62% of total variance of questionnaire covered by these
4 factors and 38% were covered by 12 remaining factors. For determination of
background dimensions, the orthogonal varimax was done and item weighting between
each item and factors calculated. Dimensions of questionnaire named based on
items. The first dimension was living with client and consisted of 12 items
and 43% of total variance was covered by this factor. The second dimension was
efforts for survival and consisted of 9 items and 7% of total variance was covered
by this factor. The third dimension was professional conscience and responsibility
and consisted of 7 items and 6% of total variance was covered by this factor.
The fourth dimension was respect of human dignity and consisted of 3 items and
6% of total variance was covered by this factor.
|| Item weighting and Cronbach alpha if item deleted
|| Result of factor extraction rotated component matrix
The result of reliability by Cronbach Alpha showed r = 0.945 for internal consistency
and the Guttmans split-half coefficient for this criteria was r = 0.906
and correlation coefficient between forms showed the internal consistency of
component of questionnaire, r = 0.848. Spearman-Brown and Guttman split-half
coefficient showed internal consistency of questionnaire, r = 0.917. Finally,
Cronbach Alpha coefficient showed internal homogeneity for each factor of questionnaire,
r = 0.945 (Table 2).
Unfortunately, there is not any instrument or study like our study and we couldnt
compare our findings with them. By the way, the results showed 4 dimensions
(factor) of questionnaire. The first dimension was living with client. This
dimension emphasis on every task and duties in caring of comatose patients,
each caregiver lives with comatose patients and in every place and every time,
they think about their patients. The caregivers have a closest fleeing and believe
that their patients are themselves. This fleeing is origin of caring or necessary
for doing every thing. With this concept, the caregivers can feel and percept
the comatose patients, understand their needs, meet them and evaluate the outcomes.
The caregivers are instead of their patients and live with them. The second
dimension was efforts for survival. Each caregiver of comatose patients tries
to rescue and survive her or his patient and he or she does any thing for rescue
of them. Each caregiver believes that the comatose patients are on terminal
line in life and they are between life and death so he or she has to do any
thing for rescue of them. This caring process is much exhausted but the caregivers
are hopeful and effort for life. The third dimension was professional conscience
and responsibility. Norberg named conscience as metaphors such as internal voice
and voice. These voices experienced from numinous (Norberg,
2002) and most inner nucleus and sanctuary of human being that sanctum with
its god and reflect from inner, as Hoose (1999) said it
is conscience and claims every person has overlord rules that carving on the
heart and determined by conscience. However conscience described as inductor
of self developer and protector of self integrity. When caring of patients,
the conscience must be referred as consultant (Childress,
1979). Von Post said that conscience is critical for human being and is
alarming for hurting others (Von Post, 1998). The items
of this dimension had theoretical bases and in the single questionnaire there
are some similar sentences.
The fourth dimension was respect of human dignity and consisted of concepts
such as commitment to care, sensitive to patients needs and closing to
patient. This dimension is expected from caregivers to do works ethically. Nursing
literature stresses on this dimension. No doubtfully, nursing is an ethical
commitment and cant been done in without ethics space. All nursing procedures
have ethical importance and potential dangerous ethical results (Johnston,
2006). Nurses as participating in dynamic profession have ethical choices
that impact on the profession (Thompson et al., 2006).
All nursing procedures need to ethic and respect and must be motivated in professional
subjects (costing) and respecting to self and others, self evaluation and continuous
learning, appropriate communication with clients, having a sense of responsibility
and responsiveness in nursing role, helping others and health promotion had
defined as professional ethics (Vanaki and Memarian, 2009).
Ethical challenge in caring of comatose patients makes an ethical subject and
caregivers like to do works that are good and consonant with their conscience
(Juthberg et al., 2007). Caring dimension of
conscience and respect to patients dignity is the fundamental of nursing
and stressed on by nursing literature.
The caregivers of comatose patients present their perspective in a range from living with patients, efforts for survival, professional conscience and responsibility and respect of human dignity that caregivers percept meanwhile caring of comatose patients. The caregivers perspective of caring of comatose patient questionnaire showed degrees of validity and reliability, nevertheless, more validation of questionnaire and more studies about similar concepts such as moral sensitivity, resiliency and burnout is needed.
The authors wish to thank all of the critical care nurses for their sincere cooperation during the completion of the research. In addition, we want to recognize the all family members and academic persons for giving the experiences and guiding us in the present study.
The research team wants to thanks all professors that accepted to read and comment in the content and face validity step. Also we appreciated the participation of caregivers in content, face and construct validity and completion of questionnaire.
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