ORIGINAL ARTICLE
The Journal of Nursing Research h VOL. 22, NO. 4, DECEMBER 2014
Psychometric Properties of the Persian Version of the Critical Care Family Needs Inventory Razieh Bandari1 & Majideh Heravi-Karimooi2* & Nahid Rejeh3 & Ali Montazeri4 Farid Zayeri5 & Majid Mirmohammadkhani6 & Mojtaba Vaismoradi7 1
MScN, Research Center for Social Determinants of Health, Semnan University of Medical Sciences, Semnan, Iran & 2 PhD, Associate Professor, Elderly Care Research Center, Shahed University, Tehran, Iran & 3PhD, Associate Professor, Elderly Care Research Center, Shahed University, Tehran, Iran & 4PhD, Professor, Mental Health Research Group, Health Metrics Research Centre, Iranian Institute for Health Sciences Research, ACECR, Tehran, Iran & 5PhD, Associate Professor, Faculty of Paramedical Sciences, Department of Biostatistics, Shahid Beheshti University of Medical Sciences, Tehran, Iran & 6PhD, MD, Assistant Professor, Research Center for Social Determinants of Health, Department of Community Medicine, School of Medicine, Semnan University of Medical Sciences, Semnan, Iran & 7PhD, Honorary Research Associate, College of Human and Health Sciences, Swansea University, Wales, United Kingdom.
ABSTRACT Background: Life-threatening illnesses and subsequent hospitalization in the intensive care unit (ICU) often occur unexpectedly. In many cases, this event is devastating for families and may lead to emotional stress, anxiety, and fear. To offer comprehensive and high-quality nursing care, critical care nurses not only provide critical care to patients but also attend to the psychological and social needs of patients and their families. Purpose: The purpose of this study was to assess the psychometric properties of the Persian version of the Critical Care Family Needs Inventory (CCFNI-P). Methods: This was a cross-sectional methodological research study. ForwardYbackward translation was used to develop the instrument. The first version was pretested with 10 families to assess face validity. The main sample consisted of 720 family members of hospitalized patients, composed of 360 admitted to ICUs and 360 admitted to general wards of hospitals in Tehran, Iran. Participants were selected randomly to evaluate the instrument in terms of known-groups, construct, and convergent validities. The internal consistency of the translated instrument was assessed using Cronbach’s alpha coefficient. Results: A significant difference was found between the scores of participants with patients in ICUs and participants with patients in the general wards (p G .001). In agreement with the original instrument, five distinct components were extracted from the CCFNI-P, which accounted for more than 52% of the total variance. The correlation between the total score for the instrument and the State-Trait Anxiety Inventory criterion was positive and significant (r = .23, p G .04). The Cronbach’s alpha coefficient for the entire instrument was .89 and more than .70 for all dimensions. Conclusions: This study confirmed the validity of the CCFNI-P in terms of face, construct, convergent, and known groups and
showed acceptable internal consistency. The CCFNI-P is valid for investigating the needs of Iranians who have a family member hospitalized in an ICU.
KEY WORDS: family, needs assessment, intensive care units, questionnaire, psychometrics, Iran.
Introduction Life-threatening illnesses and subsequent hospitalization in the intensive care unit (ICU) often occur unexpectedly, providing no time for patients and their families to prepare to face critical conditions. In many cases, this event is traumatic for families, resulting in emotional turmoil, stress, anxiety, fear, and doubt, which is understandable because of the possibility of losing a loved one (Freitas, Kimura, & Ferreira, 2007; Leske, 1986). Patients’ families may experience significant psychological tension during the early days of hospitalization, with critical care nurses often observing the devastating
Accepted for publication: August 27, 2014 *Address correspondence to: Majideh Heravi-Karimooi, Holy Shrine of Imam Khomeini-Khalij Fars Expressway, Tehran, Iran. Tel: +98 (21) 66418592; Fax: +98 (21) 66418580; E-mail: [email protected] Cite this article as: Bandari, R., Heravi-Karimooi, M., Rejeh, N., Montazeri, A., Zayeri, F., Mirmohammadkhani, M., & Vaismoradi, M. (2014). Psychometric properties of the Persian version of the critical care family needs inventory. The Journal of Nursing Research, 22(4), 259Y267. doi:10.1097/jnr.0000000000000057
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and destructive impact of the acute phase of illness not only on the patient but also on the family members (Lee & Lau, 2003). To offer comprehensive and high-quality nursing care, critical care nurses provide care not only for patients themselves but also for the psychological and social needs of patients and their families (El-Masri & Fox-Wasylyshyn, 2007). Identifying the needs of patients’ families and providing them with emotional support and a comfortable environment may significantly reduce their stress and anxiety (Curtis et al., 2012). In addition, a swift response during the critical period of illness may significantly reduce the negative impact of stress (Verhaeghe, van Zuuren, Grypdonck, Duijnstee, & Defloor, 2010). The most important needs of family members include being informed of patient hospitalization upon admission and about the patient’s condition (Horn & Tesh, 2000; Verhaeghe, Defloor, Van Zuuren, Duijnstee, & Grypdonck, 2005). Providing information is one of the most effective ways for communicating and initiating appropriate interventions for critical conditions in the ICU (Eggenberger & Nelms, 2007; Vaismoradi, Salsali, Turunen, & Bondas, 2011; Verhaeghe et al., 2005). The presence of family members during hospitalization has many advantages and may have a positive effect on patients that is similar to that of sedative drugs (Lucchese, de Albuquerque Citero, De Marco, Andreoli, & Nogueira-Martins, 2008). Identifying and planning to meet the needs of family members have been increasingly emphasized as a priority for nurses working in the ICU. However, these needs are not considered in many cases (Khalaila, 2013; Omari, 2009). Iran is now providing general and specialized services to patients hospitalized in the ICU. Iranian nurses are prepared to provide care to critically ill patients and are educated to deal with both the physiological and psychological needs of patients. Persian culture and religious doctrine recognize a strong relationship and commitment among individuals within and outside the family, with traditional habits such as visiting relatives, neighbors, and friends and showing respect for one another practiced during times of illness and death. A measurement instrument capable of identifying and determining the needs of families of ICU patients in the context of Iranian culture is critical to measuring, evaluating, and planning interventions. However, no valid measurement instrument is currently available. Because of its simple grading scale, good reliability and validity, short completion time, widespread use internationally, and applicability to different healthcare environments, the Critical Care Family Needs Inventory (CCFNI) is considered to be a suitable instrument to assess the needs of families of patients in critical care units. To use the questionnaire in Iran, a Persian version of the scale needed to be developed and tested to verify its validity and reliability for this client group and to evaluate its psychometric properties in the culture and context of Iran (Bandari et al., 2013). Therefore, the aim of this study was to translate the CCFNI into Persian and to assess the psychometric properties of the translated instrument, the CCFNI-P.
Razieh Bandari et al.
Background of the Critical Care Family Needs Inventory Molter (1979) introduced a list of 45 family needs and then, 7 years later, developed the first version of the CCFNI based on this list with Leske (1986) to assess the needs of families of patients hospitalized in the ICU. The instrument consists of 45 items with five dimensions: support (15 items), comfort (six items), information (eight items), proximity (nine items), and assurance (seven items). Each need statement is rated on a Likert scale of 1Y4 (from 1 = not important to 4 = very important). The findings of four studies have confirmed the validity and reliability of the CCFNI across a variety of cultures. Leske (1991) studied the internal consistency, reliability, and construct validity of the CCFNI with 677 family members of patients in 14 states of the United States over a 9-year period and found an overall Cronbach’s alpha coefficient of .92. Macey and Bouman (1991) assessed the content validity of the CCFNI using 16 panel experts who worked in two separate rounds with a random sample of 51 families in internal medicine and surgical ICUs. The reliabilities found in this study were between 70% and 86%, and the alpha coefficient was .90. They determined that the CCFNI was difficult to understand for people with less than a high level of literacy. A French version of the CCFNI was used in a sample group of Canadian families of ICU patients. The study involved 207 family members, and the data were collected over a 10-week period. The validity and reliability of the study were confirmed, and the Cronbach’s alpha coefficient was .91 (CoutuWakulczyk & Chartier, 1990). Chien, Ip, and Lee (2005) evaluated the psychometric characteristics of the Chinese version of the CCFNI in a sample of 200 Chinese families of ICU patients using a two-step process. First, the English version was translated into Chinese, and the similarity of the meanings between the two versions was examined. Second, the construct validity and internal consistency of the Chinese version were evaluated. The internal consistency of the Chinese version ranged from .80 to .92. Leung, Chien, and Mackenzie (2000) studied families of critically ill Chinese patients to identify their needs in the first 48Y96 hours after ICU patient admission and to compare the family needs as perceived by nurses and families. Thirty-seven Chinese families and 45 nurses completed the self-administered CCFNI, and the 10 most important and 10 least important needs expressed by families and nurses were identified. The Cronbach’s alpha coefficients ranged from .65 to .82. Lee, Chien, and MacKenzie (2000) used the CCFNI to assess the needs of 30 families of CCU patients in Hong Kong within 96 hours of hospital admission. The Cronbach’s alpha coefficient in this study was .84. Bijttebier et al. (2000) assessed the validity and reliability of the CCFNI in a Dutch-speaking Belgian sample of 200 family members visiting patients during their first 72 hours of ICU admission. Results showed an internal consistency between
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Psychometric Properties of Persian CCFNI
.62 and .80, with significant relationships among all factors. Validity and reliability were verified. Auerbach et al. (2005) investigated optimism, satisfaction with service, personal perception of the healthcare team, and emotional distress among family members during patients’ admission to the ICU. Family members of 40 patients completed a brief version of the CCFNI, the Acute Stress Disorder Scale, and the Brief Symptom Inventory promptly after admission and upon discharge from the unit. The most important need mentioned by family members was access to clear information about the patient’s condition. The Cronbach’s alpha coefficients were calculated between .80 and .90 for all three questionnaires. Go´mez-Martı´nez, Arnal, and Julia´ (2011) examined the validity and reliability of the short version of the Spanish CCFNI in 55 families of patients hospitalized in an ICU. This study used 11 questions extracted from the main questionnaire. The Cronbach’s alpha coefficient was .65 overall and .72 for subgroups. Our literature review found that the main structure of all aforementioned versions of this scale is consistent with the original scale.
Methods The Persian Version of the Critical Care Family Needs Inventory The psychometric properties of the CCFNI were assessed through a process of instrument translation and testing with 720 family members of patients (360 ICU patients, 360 general medicine patients) admitted to hospitals in Tehran, Iran. After gaining the author’s permission, two experts fluent in both languages used forwardYbackward translation to translate the text of the CCFNI from English to Persian. The two Persian translations were compared and combined to create a new version. This version was retranslated to English by two other language experts. The English-translated version was compared with the original to ensure that the main concepts were transferred into the Persian version. This version was presented to five Persian language and literature experts to revise grammar, ensure correct word usage, and correct the placement order of items in the questionnaire. The face validity of the Persian version was pretested on the family members of 10 patients hospitalized in the ICU, resulting in the final Persian version. During the translation process, there were no changes to the number of items or the content of the original questionnaire.
Sample and Setting The sample included 720 family members of hospitalized patients, composed of 360 admitted to ICUs and 360 admitted to general wards. The sample was chosen from 27 public and teaching hospitals in Tehran, with ICUs selected randomly from all areas of Tehran City. Using hospital admission data,
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one family member of each patient present on a certain day in each hospital was selected at random. The following inclusion criteria were used: Close family relationship with the patient, that is, husband, wife, child, grandchild, parent, brother, sister, son-in-law, or daughter-in-law; minimum age of 18 years; Persian speaker; and willing to participate in the study. Exclusion criteria included physical disabilities such as hearing or speech impairment and currently taking care of other family members with physical or mental problems either in hospital or at home. To maintain the predetermined sample size, if a person withdrew from the study, he or she was replaced with another qualified individual from a randomly selected hospital. In this study, eight cases were used for each item of the scale for sample size determination based on the suggestions of Waltz, Strickland, and Lenz (2005), who recommended a minimum of five cases per item to obtain valid factor analysis results. Thus, the estimated sample size in our study was 360 cases for each group.
Ethical Considerations Permission to translate the scale was obtained from the scale developer. The ethics committee affiliated with Shahed University approved the study. Official permission to recruit on site was obtained from the hospital administrators. The goals and procedures of the research were explained to all participants. They were assured of confidentiality and that they could withdraw from the study at any time. Each participant provided written informed consent before completing the instrument. Completed instruments were stored securely.
Data Collection Data were collected from January to July 2012. The participants completed the instrument under the direct instruction of one of the researchers. If the person was illiterate, an interview format was used to complete the questionnaire. The average time required to complete the questionnaire was 15 minutes.
Statistical Analysis The software SPSS v.16 (IBM, Armonk, NY, USA) was used to analyze data. Internal consistency was assessed using Cronbach’s alpha for each domain and for the overall scale, with an alpha of at least .70 required for acceptable internal consistency (Cronbach & Warrington, 1951). To evaluate construct validity, principal component analysis was conducted using varimax rotation with KaiserYMeyerYOlkin normalization, with the acceptable loading factor set at .30 (Wastell, 1981). Given normal distributions and similar variance between the two groups, an independent samples t test was used to compare groups in terms of known-group validity. 261
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To verify construct validity in terms of convergent validity, the correlation between the A-State scale of the CCFNI-P and the Iranian version of the State-Trait Anxiety Inventory (I-STAI) was investigated. The I-STAI was translated into Persian by Abdoli and Hooman. This self-report scale is used to measure respondent anxiety levels under high-stress conditions during acute hospitalization. The I-STAI involves two subscales designed to measure a temporary emotional state (A-State) and a partially stable state of anxiety (A-Trait). In the A-State scale, the respondents express their current and most recent feelings using a 4-point Likert-type scale ranging from (1) ‘‘not at all’’ to (4) ‘‘most often.’’ In the A-Trait scale, respondents express their general and common feelings using a 4-point Likert scale ranging from (1) ‘‘almost never’’ to (4) ‘‘almost always.’’ The A-State scale scores range from 20 (no anxiety) to 80 (high anxiety). The A-State scale’s Cronbach’s alpha was measured between .86 and .88 and has acceptable internal consistency (Abdoli & Hooman, 2005). The Pearson’s correlation coefficient was used to assess convergent validity.
Results Characteristics of the Sample Of the 720 participants, 424 (58. 9%) were women. In addition, 595 (82.6%) were married, and most (57.9%) had a university degree. The mean age of family members in the ICU group was 41.95 (SD = 9.33) years, with 192 (53.4%) in the age group greater than 40 years. In this group, 55.0% were women, and 44.4% were the children of the associated patient. The mean age of the sample in the general ward group was 41.56 (SD = 10.06) years, with 212 (58.8%) aged 40 years or greater, 62.8% women, and 45% the children of the patients. Slightly fewer than half (43.9%, n = 158) of patients in the ICU group and a similar percentage (45.8%, n = 323) of patients in the general ward group had been hospitalized for more than 48 hours. Table 1 shows the demographic characteristics of the study sample.
Psychometric Properties of the Persian Version of the Critical Care Family Needs Inventory A principal component analysis with varimax rotation was used to evaluate the construct validity of the questionnaire. Five factors were extracted and identified using a minimum eigenvalue of 1.0 as the factor criterion. These five accounted for 52.4% of the total variance. Table 2 shows the rotated component matrix for items of the CCFNI-P and the total variances explained by extracted components resulting from principal component analysis after rotation. Principal component analysis was conducted as put forward originally by Leske (1991) to investigate the internal structure of the scale and to evaluate
Razieh Bandari et al.
its five-factor structure. The KaiserYMeyerYOlkin value in the analysis was calculated to be .80, greater than the recommended value of .60. The Barlett’s test was statistically significant, suggesting the factorability of the correlation matrix (Stevens, 2002). To determine the known-group validity of the CCFNI-P, the scores of family members of patients admitted to the ICUs were compared with those of patients in general wards. As shown in Table 3, the total score of the scale was significantly higher for the family members of ICU patients than for those of general ward patients. This finding is true for all domains of this scale except for the domain of assurance. A significant group difference was found for the total scale scores (p G .001) for each dimension. To assess convergent validity, the correlation between the total score and the STAI score for anxiety was tested. The findings indicated a positive correlation (r = .23, p G .04). Table 4 presents the results for internal consistency as well as the correlation matrix for the scale dimensions and the Cronbach’s alpha coefficients for the total scale and its dimensions. There were positive and significant correlations between all dimensions (p G .001). The correlation coefficient was highest between the dimensions of information and proximity (r = .66) and lowest between the dimensions of comfort and assurance (r = .40). The Cronbach’s alpha coefficient for the entire scale (45 items) was .89, with all dimensions scoring more than .70.
Discussion Identifying the needs of family members of critically ill patients is a priority for critical care nurses. The purpose of this study was to assess the psychometric properties of the CCFNI-P. Five distinct components were extracted from the instrument, and over 52% of the total variance detected by the components was in agreement with the original instrument. A significant difference was found in the comparison between the scores of patients in the ICU and general wards (p G .001). The correlation between the instrument’s total score and the STAI criterion was positive and significant (r = .23, p G .04). The Cronbach’s alpha coefficient for the entire instrument was .89, whereas it was greater than .70 for all dimensions. Results confirmed the face, construct, and known-group validities of the instrument and showed that it had an acceptable internal consistency in its items. Thus, this instrument is valid for use in the investigation of Iranian family members’ needs in ICUs. It is suggested that clinical nurses use the Persian version of this inventory to assess and meet the needs of the family members of patients hospitalized in critical care units in Iran. In this study, we found that the CCFNI-P had a good level of content validity. The results showed a consistent semantic equivalence between the CCFNI-P and its original English version. In addition, results found that the selected items from the original CCFNI are valid for use in evaluating
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Psychometric Properties of Persian CCFNI
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TABLE 1.
Demographic Characteristics of Family Members and Patients, by Ward Category (N = 720) Total (N = 720) Characteristic Family members Gender Male Female Age group (years) e40 41Y60 960 Relationship Wife/husband Daughter/son Daughter/son-in-law Mother/father Sister/brother Educational level Diploma or lower Higher than diploma Marital status Married Single Patient Gender Male Female Age group (years) e40 41Y60 61Y80 980 Main cause of admission Surgical interventions Nonsurgical Duration of admission (hours) e24 48Y72
General (n = 360)
ICU (n = 360)
Count
%
Count
%
Count
%
296 424
41.1 58.9
134 226
37.2 62.8
162 198
45.0 55.0
316 396 8
43.9 55.0 1.1
148 205 7
41.1 56.9 1.9
168 191 1
46.7 53.1 0.3
189 322 21 110 78
26.2 44.7 2.9 15.3 10.8
97 162 17 49 35
26.9 45.0 4.7 13.6 9.7
92 160 4 61 43
25.6 44.4 1.1 16.9 11.9
303 417
42.1 57.9
169 191
46.9 53.1
134 226
37.2 62.8
595 125
82.6 17.4
306 54
85.0 15.0
289 71
80.3 19.7
377 343
52.4 47.6
183 177
50.8 49.2
194 166
53.9 46.1
243 200 214 63
33.8 27.8 29.7 8.8
107 105 116 32
29.7 29.2 32.2 8.9
136 95 98 31
37.8 26.4 27.2 8.6
436 284
60.6 39.4
198 162
55.0 45.0
238 122
66.1 33.9
397 323
55.2 44.8
195 165
54.2 45.8
202 158
56.1 43.9
the needs of families of hospitalized patients in ICUs in Iranian sociocultural settings. The five-factor structure of the CCFNI-P is consistent with the multidimensional nature of the English version proposed by Leske (1991) and with the other versions explored in terms of assessing the needs of families of patients hospitalized in ICUs. For example, the need for information about the patient’s condition, diagnosis, and treatment in the ICU seems to be the most important consideration for the family members of patients (Horn & Tesh, 2000). The need to be close, for example, having a family member stay with the patient for 24 hours, has been reported as one of the most critical family needs during hospitalization (Ewisn & Bryant, 1992). Social and emotional support has been reported as essential to families in terms of helping them and patients cope with
the special conditions of illness and hospitalization in the ICU (Davis-Martin, 1994). In addition to support, other aspects such as the psychological reassurance provided by experts, specialists, and other people may inspire patients and their families positively and provide a sense of security and attention (Hallgrimsdottir, 2000). In addition, the provision of the physical comfort necessary to relieve stress and meet patient needs is the ultimate goal of providing care to patients (Ruppert, Kerniki, & Dolan, 1996). This research identified five categories of needs (support, comfort, information, proximity, and assurance) as most important to the families of patients in the ICU. This research further confirmed that the CCFNI-P is able to assess and evaluate the multifaceted nature of the needs of families of critical care patients. However, factor analysis is needed to 263
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Razieh Bandari et al.
TABLE 2.
Rotated Component Matrix for Items and Total Variance Explained by Extracted Components Resulted From Principal Component Analysis After Rotation of CCFNI-P a Factor Loading
Factor and Item Support 2. To have explanations of the environment before going into intensive care unit (ICU) for the first time
.54
7. To talk about negative feelings such as guilt and anger
.47
9. To have friends nearby for support
.84
12. To have directions as to what to do at the bedside
.79
18. To have a place to be alone while in the hospital
.92
22. To have someone to help with financial problems
.83
24. To have the pastor visit
.93
25. To talk about the possibility of the patient’s death
.51
26. To have another person with you when visiting critical care unit
.61
27. To have someone be concerned with the relative’s health
.57
30. To be encouraged to cry
.43
31. To be told about other people that could help with problems
.89
33. To be alone at any time
.76
34. To be told about someone to help with family problems
.89
37. To be told about chaplain services
.47
Assurance 1. To know the expected outcome
.81
5. To have questions answered honestly
.79
14. To feel there is hope
.57
35. To have explanations given that are understandable
.79
42. To feel that hospital personnel care about patient
.90
43. To know specific facts concerning patient’s progress
.83
Proximity .53
29. To talk to the same nurse every day
.52
36. To have visiting hours start on time
.42
39. To be told about transfer plans while they are being made
.62
40. To be called at home about changes in the condition
.61
41. To receive information about patient once a day
.66
44. To see the patient frequently
.72
45. To have the waiting room near the patient
.69
Information 4. To have specific person to call at the hospital 11. To know which staff members could give what information
18.649
8.392
10.427
4.692
9.361
4.213
7.325
3.296
.57
10. To visit at any time
3. To talk to the doctor every day
Eigenvalue
.88
17. To be assured the best possible care is being given to patient
6. To have visiting hours changed for special conditions
Percentage of Variance Explained
.37 .38 .66
13. To know why things were done for a patient
.37
15. To know about the types of staff members taking care of the patient
.56 (continues)
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Psychometric Properties of Persian CCFNI
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TABLE 2.
Rotated Component Matrix for Items and Total Variance Explained by Extracted Components Resulted From Principal Component Analysis After Rotation of CCFNI-P a, Continued Factor Loading
Factor and Item 16. To know how patient is being treated medically
.49
19. To know exactly what is being done for patient
.66
38. To help with the patient’s physical care
.56
Percentage of Variance Explained
Eigenvalue
6.612
2.975
Comfort 8. To have good food available while in the hospital
.44
20. To have comfortable furniture in the waiting room
.55
21. To feel accepted by the hospital staff
.61
23. To have a telephone near the waiting room
.53
28. To be assured it is all right to leave the hospital for a while
.63
32. To have a bathroom near the waiting room
.53
Note. aKaiserYMeyerYOlkin measure of sampling adequacy = .80; Bartlett’s test of sphericity was significant (p G .001).
TABLE 3.
Comparison of Family Member Need Scores (N = 720), by Ward Category ICU (n = 360) Scale Support needs
General (n = 360)
Mean Score
SD
Mean Score
51.22
6.12
40.58
SD
p Value
7.07
.001
Comfort needs
20.61
2.21
17.469
3.65
.001
Information needs
29.15
2.29
26.38
3.06
.001
Proximity needs
32.13
2.89
28.62
3.50
.001
Assurance needs
24.55
2.85
25.05
1.95
.007
157.69
9.54
138.11
14.24
.001
Total needs
TABLE 4.
Cronbach’s Alpha Coefficients for the Total Scale and its Dimensions Regarding Family Member Needs by Ward and Their Correlation Matrix Pearson’s Correlation Coefficient
Dimension
Number of Item
Cronbach’s Alpha Coefficient
S (support)
15
.940
1
C (comfort)
6
.778
.60
1
I (information)
8
.738
.60
.54
1
P (proximity)
9
.828
.55
.60
.66
1
A (assurance)
7
.910
.51
.40
.52
.59
1
45
.886
.90
.78
.79
.80
.69
Total
S
C
I
P
A
Total
1
Note. p G .001 for all coefficients.
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gain more evidence and information about these issues. Our theoretical assessment of the relationship between the three related factors and the CCFNI provides primary evidence for convergent validity. Using principal component analysis with a varimax rotation, our survey results provided a solution with five factors, which is a finding similar to Leske (1991). Meredith, Abbott, Tsai, and Zheng (1994) posit that Chinese families express emotional concern for an individual by providing care for her or him and, unlike in Western societies, do not merely express their feelings verbally. It has been reported that Latin cultures also have a strong inclination toward nonverbal communication and toward providing physical care for patients with critical conditions, that is, physical support provided for patients by their family members was considered to be a instrument for creating a friendly and sympathetic atmosphere. All of these activities help enhance the self-confidence of patients (Morales, 1994). The results of factor analysis suggest that the Persian model of the fivefactor structured CCFNI is consistent with that conducted by Bijttebier et al. (2000) and Chien et al. (2005). The results of this study support the validity and reliability of the CCFNI-P and provide evidence of the relationship between culture and the needs of families in the hospital context. It is often observed that valid and widely used instruments are translated and used individually in such a way that the principles of etymology, translation, and cultural adaptation of words and expressions are overlooked. The first step in the process of translating a questionnaire is to respect the cultural meanings of items and sentences (Afrasibai, Yaghmaie, Abdoli, & Abed Saiedy, 2006; Rassouli, Yaghmaei, & AlaviMajd, 2010). In this study, we translated the CCFNI to Persian and verified its validity and reliability for usage in the context of Iranian culture and society. All recommended steps for translation were followed to ensure cultural agreement and symmetry for the instrument (Afrasibai et al., 2006). Findings confirmed the content validity of the CCFNI-P. The significant difference identified between the needs of the family members of ICU patients and of general ward patients showed the ability of this instrument to discriminate between the needs of families in these two clinical contexts. The high Cronbach’s alpha coefficients represent high internal consistency of the scale items. These findings are consistent with those studies conducted in other countries and reviewed in this article. Comparing the CCFNI-P and the STAI showed a positive and significant correlation between the total scores of the two instruments, indicating criterion validity. This finding is similar to that of Chien et al. (2005).
Conclusions The psychometric characteristics of the CCFNI-P were assessed in terms of face validity, construct validity, known-groups validity, and internal consistency. Intragroup demographic differences, differences in levels of emotions, and the time during hospitalization at which participants responded to
Razieh Bandari et al.
questionnaire questions represent potential limitations of this study. However, this may not have had a significant impact on the study results because of the adequate sample size. Considering the CCFNI-P’s specific features, including the simplicity of its grading, the instrument is appropriate for use in clinical practice by health service providers such as nurses. Given the shown validity and reliability of the CCFNI-P, this instrument is appropriate for application in epidemiological research and nursing practice as a helpful and user-friendly instrument to predict and address the needs of family members of patients admitted to ICUs in Persian-speaking countries.
Acknowledgments Shahed University supported this research financially. The researchers would like to thank the families of the patients for their participation in this study. It is with great sadness that we were informed of the death of our dear colleague and co-author of this article, Prof. Melanie Jasper, Head of the College of Human and Health Sciences, Swansea University, Wales United Kingdom. We acknowledge her kind efforts, expertise, and help. Her absence from the team is deeply regretted by us all.
References Abdoli, N., & Hooman, H. A. (2005). Validity of the Persian version of the Spilberger’s State-Trait test. Research Institute of Behavioral and cognitive Sciences. 36(10), 32Y40. (Original work published in Persian) Afrasibai, A., Yaghmaie, F., Abdoli, S., & Abed Saiedy, Z. (2006). Research tool translation and cross-cultural adaptation. Journal of Nursing & Midwifery, Shahid Beheshti University of Medical Sciences and Health Services, 54(16), 58Y67. (Original work published in Persian) Auerbach, S. M., Kiesler, D. J., Wartella, J., Rausch, S., Ward, K. R., & Ivatury, R. (2005). Optimism, satisfaction with needs met, interpersonal perceptions of the healthcare team, and emotional distress in patients’ family members during critical care hospitalization. American Journal of Critical Care, 14(3), 202Y210. Bandari, R., Heravi-Karimooi, M., Rejeh, N., Zayeri, F., Mirmohammadkhani, M., & Montazeri, A. (2013). Translation and validation of the critical care family needs inventory. Payesh (Health Monitor), 12(1), 89Y97. Bijttebier, P., Delva, D., Vanoost, S., Bobbaers, H., Lauwers, P., & Vertommen, H. (2000). Reliability and validity of the critical care family needs inventory in a Dutch-speaking Belgian sample. Heart & Lung: The Journal of Acute and Critical Care, 29(4), 278Y286. doi:10.1067/mhl.2000.107918 Chien, W. T., Ip, W. Y., & Lee, I. Y. M. (2005). Psychometric properties of a Chinese version of the critical care family needs inventory. Research in Nursing & Health, 28(6), 474Y487. doi:10 .1002/nur.20103 Coutu-Wakulczyk, G., & Chartier, L. (1990). French validation of the critical care family needs inventory. Heart & Lung: The Journal of Acute and Critical Care, 19(2), 192Y196. Cronbach, L. J., & Warrington, W. G. (1951). Time-limit tests: Estimating their reliability and degree of speeding. Psychometrika, 16(2), 167Y188. doi:10.1007/BF02289113
266 Copyright © 2014 Taiwan Nurses Association. Unauthorized reproduction of this article is prohibited.
Psychometric Properties of Persian CCFNI
Curtis, J. R., Ciechanowski, P. S., Downey, L., Gold, J., Nielsen, E. L., Shannon, S. E., I Engelberg, R. A. (2012). Development and evaluation of an interprofessional communication intervention to improve family outcomes in the ICU. Contemporary Clinical Trials, 33(6), 1245Y1254. doi:10.1016/j.cct.2012.06.010
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Chinese families of critically ill patients. Western Journal of Nursing Research, 22(7), 826Y840. doi:10.1177/01939450 022044782
Davis-Martin, S. (1994). Perceived needs of families of long-term critical care patients: A brief report. Heart & Lung: The Journal of Acute and Critical Care, 23(6), 515Y518.
Lucchese, A. C., de Albuquerque Citero, V., De Marco, M. A., Andreoli, S. B., & Nogueira-Martins, L. A. (2008). The needs of members of the families of general hospital inpatients. Sa˜o Paulo Medical Journal, 126(2), 128Y131. doi:10.1590/S151631802008000200013
Eggenberger, S. K., & Nelms, T. P. (2007). Being family: The family experience when an adult member is hospitalized with a critical illness. Journal of Clinical Nursing, 16(9), 1618Y1628. doi:10.1111/j.1365-2702.2007.01659.x
Macey, B. A., & Bouman, C. C. (1991). An evaluation of validity, reliability, and readability of the critical care family needs inventory. Heart & Lung: The Journal of Acute and Critical Care, 20(4), 398Y403.
El-Masri, M. M., & Fox-Wasylyshyn, S. M. (2007). Nurses’ roles with families: Perceptions of ICU nurses. Intensive and Critical Care Nursing, 23(1), 43Y50. doi:10.1016/j.iccn.2006.07.003
Meredith, W. H., Abbott, D. A., Tsai, R., & Zheng, F. M. (1994). Healthy family functioning in Chinese cultures: An exploratory study using the circumplex model. International Journal of Sociology of the Family, 24(1), 147Y157.
Ewisn, D., & Bryant, J. (1992). Relative comfort. Nursing Times, 88(52), 61Y63. Freitas, K. S., Kimura, M., & Ferreira, K. A. (2007). Family members’ needs at intensive care units: Comparative analysis between a public and a private hospital. Revista Latino-Americana de Enfermagem, 15(1), 84Y92. doi:10.1590/S0104-116920070001 00013 Go´mez-Martı´nez, S., Arnal, R. B., & Julia´, B. G. (2011). The short version of critical care family needs inventory (CCFNI): Adaptation and validation for a Spanish sample. Anales del Sistema Sanitario de Navarra, 34(3), 349Y361. doi:10.4321/S1137-66272 011000300002 (Original work published in Spanish) Hallgrimsdottir, E. M. (2000). Accident and emergency nurses’ perceptions and experiences of caring for families. Journal of Clinical Nursing, 9(4), 611Y619. doi:10.1046/j.1365-2702.2000 .00406.x Horn, E. V., & Tesh, A. (2000). The effect of critical care hospitalization on family members: Stress and responses. Dimensions of Critical Care Nursing, 19(4), 40Y49. doi:10.1097/00003465-20001904000014 Khalaila, R. (2013). Patients’ family satisfaction with needs met at the medical intensive care unit. Journal of Advanced Nursing, 69(5), 1172Y1182. doi:10.1111/j.1365-2648.2012.06109.x Lee, I. Y., Chien, W. T., & MacKenzie, A. E. (2000). Needs of families with a relative in a critical care unit in Hong Kong. Journal of Clinical Nursing, 9(1), 46Y54. doi:10.1046/j.1365-2702 .2000.00315.x Lee, L. Y., & Lau, Y. L. (2003). Immediate needs of adult family members of adult intensive care patients in Hong Kong. Journal of Clinical Nursing, 12(4), 490Y500. doi:10.1046/j.1365-2702.2003 .00743.x Leske, J. S. (1986). Needs of relatives of critically ill patients: A follow up. Heart & Lung: The Journal of Acute and Critical Care, 15(2), 189Y193. Leske, J. S. (1991). Internal psychometric properties of the critical care family needs inventory. Heart & Lung: The Journal of Acute and Critical Care, 20(3), 236Y244. Leung, K. K., Chien, W. T., & Mackenzie, A. E. (2000). Needs of
Molter, N. C. (1979). Needs of relatives of critically ill patients: A descriptive study. Heart & Lung: The Journal of Acute and Critical Care, 8(2), 332Y339. Morales, E. (1994). Meaning of touch to hospitalized Puerto Ricans with cancer. Cancer Nursing, 17(6), 464Y469. doi:10.1097/00002820199412000-00003 Omari, F. H. (2009). Perceived and unmet needs of adult Jordanian family members of patients in ICUs. Journal of Nursing Scholars, 41(1), 28Y34. doi:10.1111/j.1547-5069.2009.01248.x Rassouli, M., Yaghmaei, F., & Alavi-Majd, H. (2010). Psychometric properties of ‘‘Hopefulness Scale for Adolescents’’ in Iranian institutionalized adolescents. Payesh (Health Monitor), 9(2), 197Y204. Ruppert, S. D., Kerniki, J. G., & Dolan, J. T. (1996). Dolan’s critical care nursing: Clinical management through the nursing process (2nd ed.). Philadelphia, PA: F. A. Davis. Stevens, J. (2002). Applied multivariate statistics for the social sciences (4th ed.). Mahwah, NJ: Lawrence Erlbaum. Vaismoradi, M., Salsali, M., Turunen, H., & Bondas, T. (2011). Patients’ understandings and feelings of safety during hospitalization in Iran: A qualitative study. Nursing & Health Sciences, 13(4), 404Y411. doi:10.1111/j.1442-2018.2011.00632.x Verhaeghe, S., Defloor, T., Van Zuuren, F., Duijnstee, M., & Grypdonck, M. (2005). The needs and experiences of family members of adult patients in an intensive care unit: A review of the literature. Journal of Clinical Nursing, 14(4), 501Y509. doi:10.1111/j.1365-2702.2004.01081.x Verhaeghe, S. T., van Zuuren, F. J., Grypdonck, M. H., Duijnstee, M. S., & Defloor, T. (2010). The focus of family members’ functioning in the acute phase of traumatic coma. Part one: The initial battle and protecting life. Journal of Clinical Nursing, 19(3Y4), 574Y582. doi:10.1111/j.1365-2702.2009.02987.x Waltz, C. F., Strickland, O. L., & Lenz, E. R. (2005). Measurement in nursing and health research (3rd ed.). New York, NY: Springer. Wastell, D. G. (1981). PCA and varimax rotation: Some comments on Ro¨sler and Manzey. Biological Psychology, 13, 27Y29. doi:10 .1016/0301-0511(81)90025-9
267 Copyright © 2014 Taiwan Nurses Association. Unauthorized reproduction of this article is prohibited.
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Psychometric Properties of the Persian Version of the Critical Care Family Needs Inventory Razieh Bandari1 & Majideh Heravi-Karimooi2* & Nahid Rejeh3 & Ali Montazeri4 Farid Zayeri5 & Majid Mirmohammadkhani6 & Mojtaba Vaismoradi7 1
MScN, Research Center for Social Determinants of Health, Semnan University of Medical Sciences, Semnan, Iran & 2 PhD, Associate Professor, Elderly Care Research Center, Shahed University, Tehran, Iran & 3PhD, Associate Professor, Elderly Care Research Center, Shahed University, Tehran, Iran & 4PhD, Professor, Mental Health Research Group, Health Metrics Research Centre, Iranian Institute for Health Sciences Research, ACECR, Tehran, Iran & 5PhD, Associate Professor, Faculty of Paramedical Sciences, Department of Biostatistics, Shahid Beheshti University of Medical Sciences, Tehran, Iran & 6PhD, MD, Assistant Professor, Research Center for Social Determinants of Health, Department of Community Medicine, School of Medicine, Semnan University of Medical Sciences, Semnan, Iran & 7PhD, Honorary Research Associate, College of Human and Health Sciences, Swansea University, Wales, United Kingdom.
ABSTRACT Background: Life-threatening illnesses and subsequent hospitalization in the intensive care unit (ICU) often occur unexpectedly. In many cases, this event is devastating for families and may lead to emotional stress, anxiety, and fear. To offer comprehensive and high-quality nursing care, critical care nurses not only provide critical care to patients but also attend to the psychological and social needs of patients and their families. Purpose: The purpose of this study was to assess the psychometric properties of the Persian version of the Critical Care Family Needs Inventory (CCFNI-P). Methods: This was a cross-sectional methodological research study. ForwardYbackward translation was used to develop the instrument. The first version was pretested with 10 families to assess face validity. The main sample consisted of 720 family members of hospitalized patients, composed of 360 admitted to ICUs and 360 admitted to general wards of hospitals in Tehran, Iran. Participants were selected randomly to evaluate the instrument in terms of known-groups, construct, and convergent validities. The internal consistency of the translated instrument was assessed using Cronbach’s alpha coefficient. Results: A significant difference was found between the scores of participants with patients in ICUs and participants with patients in the general wards (p G .001). In agreement with the original instrument, five distinct components were extracted from the CCFNI-P, which accounted for more than 52% of the total variance. The correlation between the total score for the instrument and the State-Trait Anxiety Inventory criterion was positive and significant (r = .23, p G .04). The Cronbach’s alpha coefficient for the entire instrument was .89 and more than .70 for all dimensions. Conclusions: This study confirmed the validity of the CCFNI-P in terms of face, construct, convergent, and known groups and
showed acceptable internal consistency. The CCFNI-P is valid for investigating the needs of Iranians who have a family member hospitalized in an ICU.
KEY WORDS: family, needs assessment, intensive care units, questionnaire, psychometrics, Iran.
Introduction Life-threatening illnesses and subsequent hospitalization in the intensive care unit (ICU) often occur unexpectedly, providing no time for patients and their families to prepare to face critical conditions. In many cases, this event is traumatic for families, resulting in emotional turmoil, stress, anxiety, fear, and doubt, which is understandable because of the possibility of losing a loved one (Freitas, Kimura, & Ferreira, 2007; Leske, 1986). Patients’ families may experience significant psychological tension during the early days of hospitalization, with critical care nurses often observing the devastating
Accepted for publication: August 27, 2014 *Address correspondence to: Majideh Heravi-Karimooi, Holy Shrine of Imam Khomeini-Khalij Fars Expressway, Tehran, Iran. Tel: +98 (21) 66418592; Fax: +98 (21) 66418580; E-mail: [email protected] Cite this article as: Bandari, R., Heravi-Karimooi, M., Rejeh, N., Montazeri, A., Zayeri, F., Mirmohammadkhani, M., & Vaismoradi, M. (2014). Psychometric properties of the Persian version of the critical care family needs inventory. The Journal of Nursing Research, 22(4), 259Y267. doi:10.1097/jnr.0000000000000057
259 Copyright © 2014 Taiwan Nurses Association. Unauthorized reproduction of this article is prohibited.
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and destructive impact of the acute phase of illness not only on the patient but also on the family members (Lee & Lau, 2003). To offer comprehensive and high-quality nursing care, critical care nurses provide care not only for patients themselves but also for the psychological and social needs of patients and their families (El-Masri & Fox-Wasylyshyn, 2007). Identifying the needs of patients’ families and providing them with emotional support and a comfortable environment may significantly reduce their stress and anxiety (Curtis et al., 2012). In addition, a swift response during the critical period of illness may significantly reduce the negative impact of stress (Verhaeghe, van Zuuren, Grypdonck, Duijnstee, & Defloor, 2010). The most important needs of family members include being informed of patient hospitalization upon admission and about the patient’s condition (Horn & Tesh, 2000; Verhaeghe, Defloor, Van Zuuren, Duijnstee, & Grypdonck, 2005). Providing information is one of the most effective ways for communicating and initiating appropriate interventions for critical conditions in the ICU (Eggenberger & Nelms, 2007; Vaismoradi, Salsali, Turunen, & Bondas, 2011; Verhaeghe et al., 2005). The presence of family members during hospitalization has many advantages and may have a positive effect on patients that is similar to that of sedative drugs (Lucchese, de Albuquerque Citero, De Marco, Andreoli, & Nogueira-Martins, 2008). Identifying and planning to meet the needs of family members have been increasingly emphasized as a priority for nurses working in the ICU. However, these needs are not considered in many cases (Khalaila, 2013; Omari, 2009). Iran is now providing general and specialized services to patients hospitalized in the ICU. Iranian nurses are prepared to provide care to critically ill patients and are educated to deal with both the physiological and psychological needs of patients. Persian culture and religious doctrine recognize a strong relationship and commitment among individuals within and outside the family, with traditional habits such as visiting relatives, neighbors, and friends and showing respect for one another practiced during times of illness and death. A measurement instrument capable of identifying and determining the needs of families of ICU patients in the context of Iranian culture is critical to measuring, evaluating, and planning interventions. However, no valid measurement instrument is currently available. Because of its simple grading scale, good reliability and validity, short completion time, widespread use internationally, and applicability to different healthcare environments, the Critical Care Family Needs Inventory (CCFNI) is considered to be a suitable instrument to assess the needs of families of patients in critical care units. To use the questionnaire in Iran, a Persian version of the scale needed to be developed and tested to verify its validity and reliability for this client group and to evaluate its psychometric properties in the culture and context of Iran (Bandari et al., 2013). Therefore, the aim of this study was to translate the CCFNI into Persian and to assess the psychometric properties of the translated instrument, the CCFNI-P.
Razieh Bandari et al.
Background of the Critical Care Family Needs Inventory Molter (1979) introduced a list of 45 family needs and then, 7 years later, developed the first version of the CCFNI based on this list with Leske (1986) to assess the needs of families of patients hospitalized in the ICU. The instrument consists of 45 items with five dimensions: support (15 items), comfort (six items), information (eight items), proximity (nine items), and assurance (seven items). Each need statement is rated on a Likert scale of 1Y4 (from 1 = not important to 4 = very important). The findings of four studies have confirmed the validity and reliability of the CCFNI across a variety of cultures. Leske (1991) studied the internal consistency, reliability, and construct validity of the CCFNI with 677 family members of patients in 14 states of the United States over a 9-year period and found an overall Cronbach’s alpha coefficient of .92. Macey and Bouman (1991) assessed the content validity of the CCFNI using 16 panel experts who worked in two separate rounds with a random sample of 51 families in internal medicine and surgical ICUs. The reliabilities found in this study were between 70% and 86%, and the alpha coefficient was .90. They determined that the CCFNI was difficult to understand for people with less than a high level of literacy. A French version of the CCFNI was used in a sample group of Canadian families of ICU patients. The study involved 207 family members, and the data were collected over a 10-week period. The validity and reliability of the study were confirmed, and the Cronbach’s alpha coefficient was .91 (CoutuWakulczyk & Chartier, 1990). Chien, Ip, and Lee (2005) evaluated the psychometric characteristics of the Chinese version of the CCFNI in a sample of 200 Chinese families of ICU patients using a two-step process. First, the English version was translated into Chinese, and the similarity of the meanings between the two versions was examined. Second, the construct validity and internal consistency of the Chinese version were evaluated. The internal consistency of the Chinese version ranged from .80 to .92. Leung, Chien, and Mackenzie (2000) studied families of critically ill Chinese patients to identify their needs in the first 48Y96 hours after ICU patient admission and to compare the family needs as perceived by nurses and families. Thirty-seven Chinese families and 45 nurses completed the self-administered CCFNI, and the 10 most important and 10 least important needs expressed by families and nurses were identified. The Cronbach’s alpha coefficients ranged from .65 to .82. Lee, Chien, and MacKenzie (2000) used the CCFNI to assess the needs of 30 families of CCU patients in Hong Kong within 96 hours of hospital admission. The Cronbach’s alpha coefficient in this study was .84. Bijttebier et al. (2000) assessed the validity and reliability of the CCFNI in a Dutch-speaking Belgian sample of 200 family members visiting patients during their first 72 hours of ICU admission. Results showed an internal consistency between
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Psychometric Properties of Persian CCFNI
.62 and .80, with significant relationships among all factors. Validity and reliability were verified. Auerbach et al. (2005) investigated optimism, satisfaction with service, personal perception of the healthcare team, and emotional distress among family members during patients’ admission to the ICU. Family members of 40 patients completed a brief version of the CCFNI, the Acute Stress Disorder Scale, and the Brief Symptom Inventory promptly after admission and upon discharge from the unit. The most important need mentioned by family members was access to clear information about the patient’s condition. The Cronbach’s alpha coefficients were calculated between .80 and .90 for all three questionnaires. Go´mez-Martı´nez, Arnal, and Julia´ (2011) examined the validity and reliability of the short version of the Spanish CCFNI in 55 families of patients hospitalized in an ICU. This study used 11 questions extracted from the main questionnaire. The Cronbach’s alpha coefficient was .65 overall and .72 for subgroups. Our literature review found that the main structure of all aforementioned versions of this scale is consistent with the original scale.
Methods The Persian Version of the Critical Care Family Needs Inventory The psychometric properties of the CCFNI were assessed through a process of instrument translation and testing with 720 family members of patients (360 ICU patients, 360 general medicine patients) admitted to hospitals in Tehran, Iran. After gaining the author’s permission, two experts fluent in both languages used forwardYbackward translation to translate the text of the CCFNI from English to Persian. The two Persian translations were compared and combined to create a new version. This version was retranslated to English by two other language experts. The English-translated version was compared with the original to ensure that the main concepts were transferred into the Persian version. This version was presented to five Persian language and literature experts to revise grammar, ensure correct word usage, and correct the placement order of items in the questionnaire. The face validity of the Persian version was pretested on the family members of 10 patients hospitalized in the ICU, resulting in the final Persian version. During the translation process, there were no changes to the number of items or the content of the original questionnaire.
Sample and Setting The sample included 720 family members of hospitalized patients, composed of 360 admitted to ICUs and 360 admitted to general wards. The sample was chosen from 27 public and teaching hospitals in Tehran, with ICUs selected randomly from all areas of Tehran City. Using hospital admission data,
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one family member of each patient present on a certain day in each hospital was selected at random. The following inclusion criteria were used: Close family relationship with the patient, that is, husband, wife, child, grandchild, parent, brother, sister, son-in-law, or daughter-in-law; minimum age of 18 years; Persian speaker; and willing to participate in the study. Exclusion criteria included physical disabilities such as hearing or speech impairment and currently taking care of other family members with physical or mental problems either in hospital or at home. To maintain the predetermined sample size, if a person withdrew from the study, he or she was replaced with another qualified individual from a randomly selected hospital. In this study, eight cases were used for each item of the scale for sample size determination based on the suggestions of Waltz, Strickland, and Lenz (2005), who recommended a minimum of five cases per item to obtain valid factor analysis results. Thus, the estimated sample size in our study was 360 cases for each group.
Ethical Considerations Permission to translate the scale was obtained from the scale developer. The ethics committee affiliated with Shahed University approved the study. Official permission to recruit on site was obtained from the hospital administrators. The goals and procedures of the research were explained to all participants. They were assured of confidentiality and that they could withdraw from the study at any time. Each participant provided written informed consent before completing the instrument. Completed instruments were stored securely.
Data Collection Data were collected from January to July 2012. The participants completed the instrument under the direct instruction of one of the researchers. If the person was illiterate, an interview format was used to complete the questionnaire. The average time required to complete the questionnaire was 15 minutes.
Statistical Analysis The software SPSS v.16 (IBM, Armonk, NY, USA) was used to analyze data. Internal consistency was assessed using Cronbach’s alpha for each domain and for the overall scale, with an alpha of at least .70 required for acceptable internal consistency (Cronbach & Warrington, 1951). To evaluate construct validity, principal component analysis was conducted using varimax rotation with KaiserYMeyerYOlkin normalization, with the acceptable loading factor set at .30 (Wastell, 1981). Given normal distributions and similar variance between the two groups, an independent samples t test was used to compare groups in terms of known-group validity. 261
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To verify construct validity in terms of convergent validity, the correlation between the A-State scale of the CCFNI-P and the Iranian version of the State-Trait Anxiety Inventory (I-STAI) was investigated. The I-STAI was translated into Persian by Abdoli and Hooman. This self-report scale is used to measure respondent anxiety levels under high-stress conditions during acute hospitalization. The I-STAI involves two subscales designed to measure a temporary emotional state (A-State) and a partially stable state of anxiety (A-Trait). In the A-State scale, the respondents express their current and most recent feelings using a 4-point Likert-type scale ranging from (1) ‘‘not at all’’ to (4) ‘‘most often.’’ In the A-Trait scale, respondents express their general and common feelings using a 4-point Likert scale ranging from (1) ‘‘almost never’’ to (4) ‘‘almost always.’’ The A-State scale scores range from 20 (no anxiety) to 80 (high anxiety). The A-State scale’s Cronbach’s alpha was measured between .86 and .88 and has acceptable internal consistency (Abdoli & Hooman, 2005). The Pearson’s correlation coefficient was used to assess convergent validity.
Results Characteristics of the Sample Of the 720 participants, 424 (58. 9%) were women. In addition, 595 (82.6%) were married, and most (57.9%) had a university degree. The mean age of family members in the ICU group was 41.95 (SD = 9.33) years, with 192 (53.4%) in the age group greater than 40 years. In this group, 55.0% were women, and 44.4% were the children of the associated patient. The mean age of the sample in the general ward group was 41.56 (SD = 10.06) years, with 212 (58.8%) aged 40 years or greater, 62.8% women, and 45% the children of the patients. Slightly fewer than half (43.9%, n = 158) of patients in the ICU group and a similar percentage (45.8%, n = 323) of patients in the general ward group had been hospitalized for more than 48 hours. Table 1 shows the demographic characteristics of the study sample.
Psychometric Properties of the Persian Version of the Critical Care Family Needs Inventory A principal component analysis with varimax rotation was used to evaluate the construct validity of the questionnaire. Five factors were extracted and identified using a minimum eigenvalue of 1.0 as the factor criterion. These five accounted for 52.4% of the total variance. Table 2 shows the rotated component matrix for items of the CCFNI-P and the total variances explained by extracted components resulting from principal component analysis after rotation. Principal component analysis was conducted as put forward originally by Leske (1991) to investigate the internal structure of the scale and to evaluate
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its five-factor structure. The KaiserYMeyerYOlkin value in the analysis was calculated to be .80, greater than the recommended value of .60. The Barlett’s test was statistically significant, suggesting the factorability of the correlation matrix (Stevens, 2002). To determine the known-group validity of the CCFNI-P, the scores of family members of patients admitted to the ICUs were compared with those of patients in general wards. As shown in Table 3, the total score of the scale was significantly higher for the family members of ICU patients than for those of general ward patients. This finding is true for all domains of this scale except for the domain of assurance. A significant group difference was found for the total scale scores (p G .001) for each dimension. To assess convergent validity, the correlation between the total score and the STAI score for anxiety was tested. The findings indicated a positive correlation (r = .23, p G .04). Table 4 presents the results for internal consistency as well as the correlation matrix for the scale dimensions and the Cronbach’s alpha coefficients for the total scale and its dimensions. There were positive and significant correlations between all dimensions (p G .001). The correlation coefficient was highest between the dimensions of information and proximity (r = .66) and lowest between the dimensions of comfort and assurance (r = .40). The Cronbach’s alpha coefficient for the entire scale (45 items) was .89, with all dimensions scoring more than .70.
Discussion Identifying the needs of family members of critically ill patients is a priority for critical care nurses. The purpose of this study was to assess the psychometric properties of the CCFNI-P. Five distinct components were extracted from the instrument, and over 52% of the total variance detected by the components was in agreement with the original instrument. A significant difference was found in the comparison between the scores of patients in the ICU and general wards (p G .001). The correlation between the instrument’s total score and the STAI criterion was positive and significant (r = .23, p G .04). The Cronbach’s alpha coefficient for the entire instrument was .89, whereas it was greater than .70 for all dimensions. Results confirmed the face, construct, and known-group validities of the instrument and showed that it had an acceptable internal consistency in its items. Thus, this instrument is valid for use in the investigation of Iranian family members’ needs in ICUs. It is suggested that clinical nurses use the Persian version of this inventory to assess and meet the needs of the family members of patients hospitalized in critical care units in Iran. In this study, we found that the CCFNI-P had a good level of content validity. The results showed a consistent semantic equivalence between the CCFNI-P and its original English version. In addition, results found that the selected items from the original CCFNI are valid for use in evaluating
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TABLE 1.
Demographic Characteristics of Family Members and Patients, by Ward Category (N = 720) Total (N = 720) Characteristic Family members Gender Male Female Age group (years) e40 41Y60 960 Relationship Wife/husband Daughter/son Daughter/son-in-law Mother/father Sister/brother Educational level Diploma or lower Higher than diploma Marital status Married Single Patient Gender Male Female Age group (years) e40 41Y60 61Y80 980 Main cause of admission Surgical interventions Nonsurgical Duration of admission (hours) e24 48Y72
General (n = 360)
ICU (n = 360)
Count
%
Count
%
Count
%
296 424
41.1 58.9
134 226
37.2 62.8
162 198
45.0 55.0
316 396 8
43.9 55.0 1.1
148 205 7
41.1 56.9 1.9
168 191 1
46.7 53.1 0.3
189 322 21 110 78
26.2 44.7 2.9 15.3 10.8
97 162 17 49 35
26.9 45.0 4.7 13.6 9.7
92 160 4 61 43
25.6 44.4 1.1 16.9 11.9
303 417
42.1 57.9
169 191
46.9 53.1
134 226
37.2 62.8
595 125
82.6 17.4
306 54
85.0 15.0
289 71
80.3 19.7
377 343
52.4 47.6
183 177
50.8 49.2
194 166
53.9 46.1
243 200 214 63
33.8 27.8 29.7 8.8
107 105 116 32
29.7 29.2 32.2 8.9
136 95 98 31
37.8 26.4 27.2 8.6
436 284
60.6 39.4
198 162
55.0 45.0
238 122
66.1 33.9
397 323
55.2 44.8
195 165
54.2 45.8
202 158
56.1 43.9
the needs of families of hospitalized patients in ICUs in Iranian sociocultural settings. The five-factor structure of the CCFNI-P is consistent with the multidimensional nature of the English version proposed by Leske (1991) and with the other versions explored in terms of assessing the needs of families of patients hospitalized in ICUs. For example, the need for information about the patient’s condition, diagnosis, and treatment in the ICU seems to be the most important consideration for the family members of patients (Horn & Tesh, 2000). The need to be close, for example, having a family member stay with the patient for 24 hours, has been reported as one of the most critical family needs during hospitalization (Ewisn & Bryant, 1992). Social and emotional support has been reported as essential to families in terms of helping them and patients cope with
the special conditions of illness and hospitalization in the ICU (Davis-Martin, 1994). In addition to support, other aspects such as the psychological reassurance provided by experts, specialists, and other people may inspire patients and their families positively and provide a sense of security and attention (Hallgrimsdottir, 2000). In addition, the provision of the physical comfort necessary to relieve stress and meet patient needs is the ultimate goal of providing care to patients (Ruppert, Kerniki, & Dolan, 1996). This research identified five categories of needs (support, comfort, information, proximity, and assurance) as most important to the families of patients in the ICU. This research further confirmed that the CCFNI-P is able to assess and evaluate the multifaceted nature of the needs of families of critical care patients. However, factor analysis is needed to 263
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The Journal of Nursing Research
Razieh Bandari et al.
TABLE 2.
Rotated Component Matrix for Items and Total Variance Explained by Extracted Components Resulted From Principal Component Analysis After Rotation of CCFNI-P a Factor Loading
Factor and Item Support 2. To have explanations of the environment before going into intensive care unit (ICU) for the first time
.54
7. To talk about negative feelings such as guilt and anger
.47
9. To have friends nearby for support
.84
12. To have directions as to what to do at the bedside
.79
18. To have a place to be alone while in the hospital
.92
22. To have someone to help with financial problems
.83
24. To have the pastor visit
.93
25. To talk about the possibility of the patient’s death
.51
26. To have another person with you when visiting critical care unit
.61
27. To have someone be concerned with the relative’s health
.57
30. To be encouraged to cry
.43
31. To be told about other people that could help with problems
.89
33. To be alone at any time
.76
34. To be told about someone to help with family problems
.89
37. To be told about chaplain services
.47
Assurance 1. To know the expected outcome
.81
5. To have questions answered honestly
.79
14. To feel there is hope
.57
35. To have explanations given that are understandable
.79
42. To feel that hospital personnel care about patient
.90
43. To know specific facts concerning patient’s progress
.83
Proximity .53
29. To talk to the same nurse every day
.52
36. To have visiting hours start on time
.42
39. To be told about transfer plans while they are being made
.62
40. To be called at home about changes in the condition
.61
41. To receive information about patient once a day
.66
44. To see the patient frequently
.72
45. To have the waiting room near the patient
.69
Information 4. To have specific person to call at the hospital 11. To know which staff members could give what information
18.649
8.392
10.427
4.692
9.361
4.213
7.325
3.296
.57
10. To visit at any time
3. To talk to the doctor every day
Eigenvalue
.88
17. To be assured the best possible care is being given to patient
6. To have visiting hours changed for special conditions
Percentage of Variance Explained
.37 .38 .66
13. To know why things were done for a patient
.37
15. To know about the types of staff members taking care of the patient
.56 (continues)
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Psychometric Properties of Persian CCFNI
VOL. 22, NO. 4, DECEMBER 2014
TABLE 2.
Rotated Component Matrix for Items and Total Variance Explained by Extracted Components Resulted From Principal Component Analysis After Rotation of CCFNI-P a, Continued Factor Loading
Factor and Item 16. To know how patient is being treated medically
.49
19. To know exactly what is being done for patient
.66
38. To help with the patient’s physical care
.56
Percentage of Variance Explained
Eigenvalue
6.612
2.975
Comfort 8. To have good food available while in the hospital
.44
20. To have comfortable furniture in the waiting room
.55
21. To feel accepted by the hospital staff
.61
23. To have a telephone near the waiting room
.53
28. To be assured it is all right to leave the hospital for a while
.63
32. To have a bathroom near the waiting room
.53
Note. aKaiserYMeyerYOlkin measure of sampling adequacy = .80; Bartlett’s test of sphericity was significant (p G .001).
TABLE 3.
Comparison of Family Member Need Scores (N = 720), by Ward Category ICU (n = 360) Scale Support needs
General (n = 360)
Mean Score
SD
Mean Score
51.22
6.12
40.58
SD
p Value
7.07
.001
Comfort needs
20.61
2.21
17.469
3.65
.001
Information needs
29.15
2.29
26.38
3.06
.001
Proximity needs
32.13
2.89
28.62
3.50
.001
Assurance needs
24.55
2.85
25.05
1.95
.007
157.69
9.54
138.11
14.24
.001
Total needs
TABLE 4.
Cronbach’s Alpha Coefficients for the Total Scale and its Dimensions Regarding Family Member Needs by Ward and Their Correlation Matrix Pearson’s Correlation Coefficient
Dimension
Number of Item
Cronbach’s Alpha Coefficient
S (support)
15
.940
1
C (comfort)
6
.778
.60
1
I (information)
8
.738
.60
.54
1
P (proximity)
9
.828
.55
.60
.66
1
A (assurance)
7
.910
.51
.40
.52
.59
1
45
.886
.90
.78
.79
.80
.69
Total
S
C
I
P
A
Total
1
Note. p G .001 for all coefficients.
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gain more evidence and information about these issues. Our theoretical assessment of the relationship between the three related factors and the CCFNI provides primary evidence for convergent validity. Using principal component analysis with a varimax rotation, our survey results provided a solution with five factors, which is a finding similar to Leske (1991). Meredith, Abbott, Tsai, and Zheng (1994) posit that Chinese families express emotional concern for an individual by providing care for her or him and, unlike in Western societies, do not merely express their feelings verbally. It has been reported that Latin cultures also have a strong inclination toward nonverbal communication and toward providing physical care for patients with critical conditions, that is, physical support provided for patients by their family members was considered to be a instrument for creating a friendly and sympathetic atmosphere. All of these activities help enhance the self-confidence of patients (Morales, 1994). The results of factor analysis suggest that the Persian model of the fivefactor structured CCFNI is consistent with that conducted by Bijttebier et al. (2000) and Chien et al. (2005). The results of this study support the validity and reliability of the CCFNI-P and provide evidence of the relationship between culture and the needs of families in the hospital context. It is often observed that valid and widely used instruments are translated and used individually in such a way that the principles of etymology, translation, and cultural adaptation of words and expressions are overlooked. The first step in the process of translating a questionnaire is to respect the cultural meanings of items and sentences (Afrasibai, Yaghmaie, Abdoli, & Abed Saiedy, 2006; Rassouli, Yaghmaei, & AlaviMajd, 2010). In this study, we translated the CCFNI to Persian and verified its validity and reliability for usage in the context of Iranian culture and society. All recommended steps for translation were followed to ensure cultural agreement and symmetry for the instrument (Afrasibai et al., 2006). Findings confirmed the content validity of the CCFNI-P. The significant difference identified between the needs of the family members of ICU patients and of general ward patients showed the ability of this instrument to discriminate between the needs of families in these two clinical contexts. The high Cronbach’s alpha coefficients represent high internal consistency of the scale items. These findings are consistent with those studies conducted in other countries and reviewed in this article. Comparing the CCFNI-P and the STAI showed a positive and significant correlation between the total scores of the two instruments, indicating criterion validity. This finding is similar to that of Chien et al. (2005).
Conclusions The psychometric characteristics of the CCFNI-P were assessed in terms of face validity, construct validity, known-groups validity, and internal consistency. Intragroup demographic differences, differences in levels of emotions, and the time during hospitalization at which participants responded to
Razieh Bandari et al.
questionnaire questions represent potential limitations of this study. However, this may not have had a significant impact on the study results because of the adequate sample size. Considering the CCFNI-P’s specific features, including the simplicity of its grading, the instrument is appropriate for use in clinical practice by health service providers such as nurses. Given the shown validity and reliability of the CCFNI-P, this instrument is appropriate for application in epidemiological research and nursing practice as a helpful and user-friendly instrument to predict and address the needs of family members of patients admitted to ICUs in Persian-speaking countries.
Acknowledgments Shahed University supported this research financially. The researchers would like to thank the families of the patients for their participation in this study. It is with great sadness that we were informed of the death of our dear colleague and co-author of this article, Prof. Melanie Jasper, Head of the College of Human and Health Sciences, Swansea University, Wales United Kingdom. We acknowledge her kind efforts, expertise, and help. Her absence from the team is deeply regretted by us all.
References Abdoli, N., & Hooman, H. A. (2005). Validity of the Persian version of the Spilberger’s State-Trait test. Research Institute of Behavioral and cognitive Sciences. 36(10), 32Y40. (Original work published in Persian) Afrasibai, A., Yaghmaie, F., Abdoli, S., & Abed Saiedy, Z. (2006). Research tool translation and cross-cultural adaptation. Journal of Nursing & Midwifery, Shahid Beheshti University of Medical Sciences and Health Services, 54(16), 58Y67. (Original work published in Persian) Auerbach, S. M., Kiesler, D. J., Wartella, J., Rausch, S., Ward, K. R., & Ivatury, R. (2005). Optimism, satisfaction with needs met, interpersonal perceptions of the healthcare team, and emotional distress in patients’ family members during critical care hospitalization. American Journal of Critical Care, 14(3), 202Y210. Bandari, R., Heravi-Karimooi, M., Rejeh, N., Zayeri, F., Mirmohammadkhani, M., & Montazeri, A. (2013). Translation and validation of the critical care family needs inventory. Payesh (Health Monitor), 12(1), 89Y97. Bijttebier, P., Delva, D., Vanoost, S., Bobbaers, H., Lauwers, P., & Vertommen, H. (2000). Reliability and validity of the critical care family needs inventory in a Dutch-speaking Belgian sample. Heart & Lung: The Journal of Acute and Critical Care, 29(4), 278Y286. doi:10.1067/mhl.2000.107918 Chien, W. T., Ip, W. Y., & Lee, I. Y. M. (2005). Psychometric properties of a Chinese version of the critical care family needs inventory. Research in Nursing & Health, 28(6), 474Y487. doi:10 .1002/nur.20103 Coutu-Wakulczyk, G., & Chartier, L. (1990). French validation of the critical care family needs inventory. Heart & Lung: The Journal of Acute and Critical Care, 19(2), 192Y196. Cronbach, L. J., & Warrington, W. G. (1951). Time-limit tests: Estimating their reliability and degree of speeding. Psychometrika, 16(2), 167Y188. doi:10.1007/BF02289113
266 Copyright © 2014 Taiwan Nurses Association. Unauthorized reproduction of this article is prohibited.
Psychometric Properties of Persian CCFNI
Curtis, J. R., Ciechanowski, P. S., Downey, L., Gold, J., Nielsen, E. L., Shannon, S. E., I Engelberg, R. A. (2012). Development and evaluation of an interprofessional communication intervention to improve family outcomes in the ICU. Contemporary Clinical Trials, 33(6), 1245Y1254. doi:10.1016/j.cct.2012.06.010
VOL. 22, NO. 4, DECEMBER 2014
Chinese families of critically ill patients. Western Journal of Nursing Research, 22(7), 826Y840. doi:10.1177/01939450 022044782
Davis-Martin, S. (1994). Perceived needs of families of long-term critical care patients: A brief report. Heart & Lung: The Journal of Acute and Critical Care, 23(6), 515Y518.
Lucchese, A. C., de Albuquerque Citero, V., De Marco, M. A., Andreoli, S. B., & Nogueira-Martins, L. A. (2008). The needs of members of the families of general hospital inpatients. Sa˜o Paulo Medical Journal, 126(2), 128Y131. doi:10.1590/S151631802008000200013
Eggenberger, S. K., & Nelms, T. P. (2007). Being family: The family experience when an adult member is hospitalized with a critical illness. Journal of Clinical Nursing, 16(9), 1618Y1628. doi:10.1111/j.1365-2702.2007.01659.x
Macey, B. A., & Bouman, C. C. (1991). An evaluation of validity, reliability, and readability of the critical care family needs inventory. Heart & Lung: The Journal of Acute and Critical Care, 20(4), 398Y403.
El-Masri, M. M., & Fox-Wasylyshyn, S. M. (2007). Nurses’ roles with families: Perceptions of ICU nurses. Intensive and Critical Care Nursing, 23(1), 43Y50. doi:10.1016/j.iccn.2006.07.003
Meredith, W. H., Abbott, D. A., Tsai, R., & Zheng, F. M. (1994). Healthy family functioning in Chinese cultures: An exploratory study using the circumplex model. International Journal of Sociology of the Family, 24(1), 147Y157.
Ewisn, D., & Bryant, J. (1992). Relative comfort. Nursing Times, 88(52), 61Y63. Freitas, K. S., Kimura, M., & Ferreira, K. A. (2007). Family members’ needs at intensive care units: Comparative analysis between a public and a private hospital. Revista Latino-Americana de Enfermagem, 15(1), 84Y92. doi:10.1590/S0104-116920070001 00013 Go´mez-Martı´nez, S., Arnal, R. B., & Julia´, B. G. (2011). The short version of critical care family needs inventory (CCFNI): Adaptation and validation for a Spanish sample. Anales del Sistema Sanitario de Navarra, 34(3), 349Y361. doi:10.4321/S1137-66272 011000300002 (Original work published in Spanish) Hallgrimsdottir, E. M. (2000). Accident and emergency nurses’ perceptions and experiences of caring for families. Journal of Clinical Nursing, 9(4), 611Y619. doi:10.1046/j.1365-2702.2000 .00406.x Horn, E. V., & Tesh, A. (2000). The effect of critical care hospitalization on family members: Stress and responses. Dimensions of Critical Care Nursing, 19(4), 40Y49. doi:10.1097/00003465-20001904000014 Khalaila, R. (2013). Patients’ family satisfaction with needs met at the medical intensive care unit. Journal of Advanced Nursing, 69(5), 1172Y1182. doi:10.1111/j.1365-2648.2012.06109.x Lee, I. Y., Chien, W. T., & MacKenzie, A. E. (2000). Needs of families with a relative in a critical care unit in Hong Kong. Journal of Clinical Nursing, 9(1), 46Y54. doi:10.1046/j.1365-2702 .2000.00315.x Lee, L. Y., & Lau, Y. L. (2003). Immediate needs of adult family members of adult intensive care patients in Hong Kong. Journal of Clinical Nursing, 12(4), 490Y500. doi:10.1046/j.1365-2702.2003 .00743.x Leske, J. S. (1986). Needs of relatives of critically ill patients: A follow up. Heart & Lung: The Journal of Acute and Critical Care, 15(2), 189Y193. Leske, J. S. (1991). Internal psychometric properties of the critical care family needs inventory. Heart & Lung: The Journal of Acute and Critical Care, 20(3), 236Y244. Leung, K. K., Chien, W. T., & Mackenzie, A. E. (2000). Needs of
Molter, N. C. (1979). Needs of relatives of critically ill patients: A descriptive study. Heart & Lung: The Journal of Acute and Critical Care, 8(2), 332Y339. Morales, E. (1994). Meaning of touch to hospitalized Puerto Ricans with cancer. Cancer Nursing, 17(6), 464Y469. doi:10.1097/00002820199412000-00003 Omari, F. H. (2009). Perceived and unmet needs of adult Jordanian family members of patients in ICUs. Journal of Nursing Scholars, 41(1), 28Y34. doi:10.1111/j.1547-5069.2009.01248.x Rassouli, M., Yaghmaei, F., & Alavi-Majd, H. (2010). Psychometric properties of ‘‘Hopefulness Scale for Adolescents’’ in Iranian institutionalized adolescents. Payesh (Health Monitor), 9(2), 197Y204. Ruppert, S. D., Kerniki, J. G., & Dolan, J. T. (1996). Dolan’s critical care nursing: Clinical management through the nursing process (2nd ed.). Philadelphia, PA: F. A. Davis. Stevens, J. (2002). Applied multivariate statistics for the social sciences (4th ed.). Mahwah, NJ: Lawrence Erlbaum. Vaismoradi, M., Salsali, M., Turunen, H., & Bondas, T. (2011). Patients’ understandings and feelings of safety during hospitalization in Iran: A qualitative study. Nursing & Health Sciences, 13(4), 404Y411. doi:10.1111/j.1442-2018.2011.00632.x Verhaeghe, S., Defloor, T., Van Zuuren, F., Duijnstee, M., & Grypdonck, M. (2005). The needs and experiences of family members of adult patients in an intensive care unit: A review of the literature. Journal of Clinical Nursing, 14(4), 501Y509. doi:10.1111/j.1365-2702.2004.01081.x Verhaeghe, S. T., van Zuuren, F. J., Grypdonck, M. H., Duijnstee, M. S., & Defloor, T. (2010). The focus of family members’ functioning in the acute phase of traumatic coma. Part one: The initial battle and protecting life. Journal of Clinical Nursing, 19(3Y4), 574Y582. doi:10.1111/j.1365-2702.2009.02987.x Waltz, C. F., Strickland, O. L., & Lenz, E. R. (2005). Measurement in nursing and health research (3rd ed.). New York, NY: Springer. Wastell, D. G. (1981). PCA and varimax rotation: Some comments on Ro¨sler and Manzey. Biological Psychology, 13, 27Y29. doi:10 .1016/0301-0511(81)90025-9
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