Aims and objectives. This study aims to develop a valid and reliable chronic kidney disease self-management instrument (CKD-
SM) for assessing early stage chronic kidney disease patients’ self-management behaviours.
Background. Enhancing early stage chronic kidney disease patients’ self-management plays a key role in delaying the pro-
gression of chronic kidney disease. Healthcare provider understanding of early stage chronic kidney disease patients’ self-
management behaviours can help develop effective interventions. A valid and reliable instrument for measuring chronic kidney
disease patients’ self-management behaviours is needed.
Design. A cross-sectional descriptive study collected data for principal components analysis with oblique rotation.
Methods. Mandarin- or Taiwanese-speaking adults with chronic kidney disease (n = 252) from two medical centres and one
regional hospital in Southern Taiwan completed the CKD-SM. Construct validity was evaluated by exploratory factor analysis.
Internal consistency and test–retest reliability were estimated by Cronbach’s alpha and Pearson correlation coefficients.
Results. Four factors were extracted and labelled self-integration, problem-solving, seeking social support and adherence to
recommended regimen. The four factors accounted for 60Æ51% of the total variance. Each factor showed acceptable internal
reliability with Cronbach’s alpha from 0Æ77–0Æ92. The test–retest correlations for the CKD-SM was 0Æ72.
Conclusion. The psychometric quality of the CKD-SM instrument was satisfactory. Research to conduct a confirmatory factor
analysis to further validate this new instrument’s construct validity is recommended.
Relevance to clinical practice. The CKD-SM instrument is useful for clinicians who wish to identify the problems with self-
management among chronic kidney disease patients early. Self-management assessment will be helpful to develop intervention
tailored to the needs of the chronic kidney disease population.
Key words: chronic kidney disease, exploratory factor analysis, instrument development, psychometric evaluation, self-
management
Authors: Chiu-Chu Lin, PhD, RN, Associate Professor, College of Changhua Christian Hospital, Lugang, Taiwan
Nursing, Kaohsiung Medical University, Kaohsiung; Chia-Chen Wu, Correspondence: Chiu-Chu Lin, Associate Professor, College of
RN, MSN, Lecturer, School of Nursing, Fooyin Technology Nursing, Kaohsiung Medical University, No. 100, Shih-Chuan 1st
University, Pingtung; Li-Min Wu, PhD, RN, Assistant Professor, Road, Kaohsiung City 807, Taiwan.
Kaohsiung Medical University, Kaohsiung; Hsing-Mei Chen, PhD, Telephone: +886 7 3121101.
RN, Assistant Professor, Kaohsiung Medical University, Kaohsiung; E-mail: chiuchu@kmu.edu.tw
Shu-Chen Chang, RN, MSN, Director of Nursing Department,
2009). In Taiwan, CKD ranked tenth as the leading cause of Research regarding self-management among patients with
death in 2008 (Taiwan Department of Health 2010). chronic illness has targeted several facets such as self-
Untreated CKD progresses to end stage renal disease and integration, self-care, problem-solving, social support,
affected patients require dialysis. The incidence and preva- adherence, communication and partnership in care (Gallant
lence rate of end stage renal disease in Taiwan has become 2003, Hill-Briggs 2003, Curtin et al. 2005). Lorig and
the highest in the world (USRDS 2007). In 2008, dialysis Holman (2003) defined self-management as encompassing
patients in Taiwan accounted for 0Æ26% of the total insured three essential components including medical management,
population, while the medical expense for dialysis treatment which involves adhering to treatment regimens; role man-
was 8% of the total insured expenditure (Bureau of National agement, which clients seek to maintain or create new life
Health Insurance 2010a,b). The increased CKD population tasks; and emotional management, which entails coping
and expenditure due to CKD is becoming a major health with the feelings a life-threatening chronic illness evokes.
problem not only in Taiwan, but also in the world; and this People with chronic illness must develop skills as follows:
predicament will increase as the population ages if not problem-solving including identifying symptoms and deter-
resolved effectively. mining possible causes for each symptom; decision-making
CKD is a preventable disease; the progress of the CKD involving symptom management using many different
can be interrupted by identifying patients with early stage techniques and employing resources; establishing health
CKD. To delay the progress or avoid the deterioration of care provider partnerships where clients are taught how to
CKD, patients must be able to self-manage the disease. access and use medical care in their community (Hill-Briggs
Because of the chronic nature of CKD, patients are 2003, Lorig & Holman 2003).
responsible for the daily management of their condition. The first author of this study in her doctoral dissertation
Accordingly, successful disease management depends lar- identified the dimensions of self-management as illness
gely on patients’ self-management efforts rather than the adaptation, decision making and illness control through
direct care of healthcare providers (Funnell & Anderson concept synthesis (C.C. Lin, University of Michigan, Ann
2000). In other words, patients’ self-management behav- Arbor, MI, unpublished doctoral dissertation). Based on
iours is exceedingly important than the care of healthcare these three dimensions, Lin et al. (2008) developed and
providers. tested an instrument to measure diabetes self-management.
The research literature indicates that when patients are They confirmed the dimensions of self-management for
more involved with their own chronic illness management, diabetic patients through the confirmatory factor analysis
health outcomes improve (Bodenheimer et al. 2002, Heisler as follows: self-integration, self-regulation, interaction with
et al. 2003). Consequently, self-management of CKD patient health professionals and significant others, self-monitoring
will play a key role in controlling ongoing symptoms and of blood glucose and adherence to recommended regimen.
unwanted sequelae of CKD. To measure the impact of The above indicates that self-management is a complex
interventions designed to assist CKD patients in managing concept.
their illness, a valid and reliable measurement of self- In the present study, we identified six dimensions for CKD
management behaviour is needed. self-management behaviours based on the dimensions devel-
Self-management includes the full range of activities oped by Lin et al. (2008), literature (Gallant 2003, Hill-
undertaken by a person with a chronic condition, ranging Briggs 2003, Lorig & Holman 2003, Curtin et al. 2005) and
from the preventive activities undertaken by healthy people clinical experience. The six dimensions used to further
home to the day-to-day tasks undertaken by an individual generate the item pool as follows: learning skills and
to manage symptoms, treatments, consequences and life- knowledge about disease; interaction with health profession-
style changes associated with chronic conditions (Barlow als and significant others; problem-solving, self-care; self-
et al. 2002). Patients adapt to their chronic condition by integration; and emotion management.
integrating the recommended regimen into their daily lives Healthcare providers that gain a better understanding of
to prevent complications, maintain optimum health status CKD patients’ self-management behaviours can develop
and minimise the intrusion of the disease into their effective interventions to prevent the CKD deterioration.
preferred life-styles (C.C. Lin, University of Michigan, There was no relevant instrument found in the published
Ann Arbor, MI, unpublished doctoral dissertation). Accord- paper to assess the problems with self-management faced by
ingly, self-management should be approached as a multi- patients with CKD. Thus, the aim of this study was to
dimensional concept that combines biological, develop and test an instrument of CKD patients’ self-
psychological and social activities (Barlow et al. 2002). management behaviours.
Instrument development
Data analysis
Fifty-nine candidate items were generated to form an initial
draft of the CKD-SM. The draft was then evaluated for Data were analysed using SPSS 16.0 (SPSS Inc., Chicago, IL,
content validity. An expert panel consisted of eight experts USA). Descriptive statistics were generated for demographic
including nephrologists, dietitian, case manager and nurse variables and individual item scores. Internal consistency was
educators those who specialise in CKD practice were invited assessed by determining Cronbach’s alpha coefficients for
to assess the content validity. The expert panel reviewed the overall scale and subscales. Cronbach’s alpha coefficients
initial set of 59 items and rated each item for relevance to its above 0Æ70 were considered satisfactory (Polit & Beck 2006).
associated concept dimension based on the conceptual Exploratory factor analysis (EFA) using principal compo-
definition provided. The panel assessed each item using a nent analysis (PCA), an essential tool in instrument develop-
four-point Likert scale to score the degree of agreement ment, was used to determine the number and content of
ranged from (1) relevant, (2) somewhat relevant, (3) quite factors underlying the initial set of items. The Kaiser–Meyer–
relevant and (4) very relevant. If an expert rated any item Olkin test of sampling adequacy and Bartlett’s test of
below 4, the expert was asked to provide his or her Sphericity were performed. The number of factors to be
suggestions for modifying or eliminating the item. The retained was determined by a convergence of criteria includ-
content validity index (CVI) analysed the level of experts’ ing eigenvalues >1, the scree plot and theoretical interpret-
agreements. The CVI for an item is the proportion of experts ability of the resulting factor structure. Items were selected
who rate it as 3 or 4 (Waltz et al. 2005). The expert panel’s according to four criteria: factor loading above 0Æ5, minimum
evaluation resulted in a total CVI score of 0Æ89. Nine factor membership of three items, no cross-factor loaded
additional items were added to the initial draft of CKD-SM items and conceptual coherence of items with the individual
based on recommendations from the experts. Furthermore, factor.
problematic items were revised or reworded based on the
suggestions from the expert panel. The finalised draft of
Results
CKD-SM contained 68 items.
To evaluate the face validity of the 68-item CKD-SM, 15
Sample characteristics
CKD patients were invited to pilot test the instrument for
clarity, reading levels, precision, comprehension and ease of Among the 252 subjects, 59Æ9% (n = 151) were male and
response. The CKD-SM was revised based on the pilot ranged from 24–90 years old (mean = 61Æ0, SD 14Æ2). The
study. The CKD-SM contained 68 items using response majority of the subjects (81Æ7%, n = 206) were married and
options from 1 (never) to 4 (always) with 18 negatively more than half of them were educated in high school (56Æ1%,
worded items. Total possible scores ranged from 68–272, n = 141). Most subjects (90Æ9%) were stage 2 or 3 of chronic
with higher scores indicating greater CKD self-manage- kidney disease.
ment.
Factorial validity
Data collection procedure
The internal structure of the 68 items CKD-SM was analysed
Before data collection, human participant approval was with a sample of 252 adults with CKD using principal
obtained from the Kaohsiung Medical University Institu- components to extract factors. The Kaiser–Meyer–Olkin
tional Review Board. At the request of study primary (KMO) values was 0Æ92, indicating excellent sampling
investigator, nephrologists or case managers at each of the adequacy and relatively compact patterns of correlation,
data collection sites referred potential subjects from the CKD such that factor analysis should produce distinct and reliable
outpatients’ clinic to the investigators for recruitment. Fer- factors (Field 2000). Bartlett’s test of Sphericity was signif-
ketich (1991) suggested that at least 200 research participants icant (v2 = 10280Æ2, df = 2278, p < 0Æ001), indicating that
are needed to achieve a high reliability of new instruments. there were some relationships between the variables (Field
We recruited 252 patients with CKD stages 1–3 who were 2000). Oblique promax rotation procedures were used as the
willing to participate in the study from two medical centres method of factor rotation because CKD self-management
and one regional hospital in the southern Taiwan. Patients factors were assumed to be correlated.
Thirty-six items were eliminated from the final draft of adjustment to their life style and implementation of
68-item CKD-SM because of factor loading less 0Æ5, or cross- recommended regimens and self-care activities to achieve
factor loaded items. A four-factor solution for the 32 a balance life. Factor 2 has nine items, called ‘problem-
remaining items provided the most meaningful factor pattern. solving’ with factor loadings ranging from 0Æ62–0Æ87,
Factors were labelled ‘self-integration’, ‘problem-solving’, accounting for 8Æ72% of the variance. This factor reflects
‘seeking social support’ and ‘adherence to recommended the patient’s ability to seek the resources and actively learn
regimens’. Because the conceptual meaning of three items did disease-specific knowledge and skills. Factor 3 is ‘seeking
not fit their corresponding factor, one item of Factor 1 ‘social social support’. Factor 3 contains 5 items with factor
support’ and two items of Factor 4 ‘adherence to recom- loadings ranging from 0Æ65–0Æ78, accounting for 6Æ17% of
mended regimens’ were deleted, leaving 29 items of the CKD- the variance. The factor reflects patient’s actions to seek
SM (Table 1). The factor structure was described as follows. resources or support from significant others to cope with
Factor 1 named ‘self-integration’ includes 11 items with their disease and the negative emotions evoked by their
factor loadings ranging from 0Æ57–0Æ83 and accounted for illness. Factor 4 is composed of 4 items with factor
40Æ65% of the variance. The factor focuses on patients’ loadings ranging from 0Æ69–0Æ78, accounting for 4Æ97% of
Table 1 Descriptive statistics, factor loading and Cronbach’s alpha for the 29-item CKD-SM
Factor loading
Cronbach’s
Item M SD Factor 1 Factor 2 Factor 3 Factor 4 alpha
the variance and is labelled ‘adherence to recommended support from health professionals or significant others, to
regimens’. The factor represents how a patient follows the help them cope with their disease and emotions resulting
treatment regimen to control kidney disease. from the disease. This reflects the result that the original
dimension of ‘emotion management’ was combined with the
original dimension ‘interaction with health professionals and
Reliability
significant others’ to form the dimension of ‘social support’ in
Cronbach’s alpha was used to assess the internal consistency the final version of CKD-SM. To maintain disease control,
reliability of the total scale and sub-scales. As shown in patients was often instructed to adhere to therapeutic
Table 1, Cronbach’s alpha for the 29-item version of the regimens. Thus, Factor 4 ‘adherence to recommended regi-
CKD-SM total scale was 0Æ95. The sub-scale coefficients mens’ was extracted. The above indicated the four conceptual
alphas ranged from 0Æ77–0Æ93. The stability of the CKD-SM dimensions verified from empirical data in this study appear
was assessed using Pearson correlation coefficient for mea- to be specifically applicable in the clinical settings and also to
suring 2-week test–retest reliability. The test–retest correla- reflect the construct of self-management presented in the
tions for the CKD-SM was 0Æ72 (p < 0Æ001, n = 26). theoretical literature.
The homogeneity or uni-dimensionality of items is a major
issue in assessing the psychometric properties of an instru-
Discussion and conclusion
ment. In this study, the Cronbach’s alpha coefficient for the
An instrument to measure self-management behaviours CKD-SM was 0Æ95 and each of the four subscales ranged
among adults with early stage CKD was developed and from 0Æ77–0Æ92 indicating good internal consistency for this
tested. EFA identified four factors with 29 items. Although newly constructed instrument. According to Devellis (1991),
these four factors did not exactly match the dimensions from the results of the reliability of the CKD-SM were satisfactory.
the six a priori hypothesised dimensions (i.e. learning skills In addition, the result of test–retest analyses indicated the
and knowledge about disease, interaction with health pro- CKD-SM was relatively stable over a 2-week period.
fessionals and significant others, problem-solving, self-care, This study provides support for the content and construct
self-integrations and emotion management), the four factors validity as well as the internal consistency and retest
identified from the empirical data are theoretically closely reliability of the CKD-SM in Taiwanese populations. The
related to the six dimensions proposed in the initial stage of CKD-SM should be tested in other patient populations rather
instrument development. For example, Factor 1 ‘self-integra- than generalizing from these results since linguistic, cultural
tion’ consisted of the items from the original dimensions of and health system differences may exist, including patient
‘self-care’ and ‘self-integration’. According to the meaning of and healthcare provider expectations and methods of self-
items appeared in the Factor 1, self-integration covers the management implementation.
dimension of self-care. Self-integration reflects patients with Self-management is a complex concept. To investigate
chronic illness had the abilities to integrate treatment clinical questions about self-management, there is a need for
regimens and self-care activities benefit to their disease valid and reliable measures that provide empirical data. The
control to their daily life to achieve a more balanced life. CKD-SM developed in this study can be used to assess how
Accordingly, the dimension of self-integration is more patients self-manage their chronic conditions and to develop
appropriate to reflect the construct of self-management. more relevant, patient-centred teaching and implement
For patients with chronic illness, they may be faced with a interventions tailored to the needs of individual patients.
variety of problems related to the disease, treatment, or
personal life. It is important for patients to identify their
Implications to clinical practice
problems and determine possible causes through seeking
resources or applying the knowledge and skills they learned. Early detection and treatment can halt the progression of
The problem-solving model proposed by Hill-Briggs (2003) CKD. To our knowledge, the CKD-SM developed in this study
may explain the rationale for the original dimension of is the first one for measuring self management behaviours
‘actively learning skills and knowledge about disease’ was among early stage CKD patients. The results obtained from
combined to the factor of ‘problem-solving’ after conducting the present study provided acceptable level of reliability and
the factor analysis. validity for this new instrument with early stage CKD patients
As suggested by Gallant (2003) who reviewed 29 studies, in Taiwan. CKD is a preventive disease. The CKD-SM could
social support is an important component for chronic illness be used as an assessment tool to help recognise those early
self-management. That is, patients with chronic illnesses need CKD patients who are unable to manage their disease well. By
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