The Open Nursing Journal




ISSN: 1874-4346 ― Volume 13, 2019
RESEARCH ARTICLE

The Development and Psychometric Evaluation of a Questionnaire on the Nurses’ Recognition of Elder Abuse by Family Caregiver



Atefeh Alipour1, Abbas Shamsalinia2, Fatemeh Ghaffari2, Zahra Fotokian2, *
1 Ramsar Student Research Committee, Nursing Care Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, I.R.Iran
2 Nursing Care Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, I.R.Iran

Abstract

Introduction:

Exploring the nurses’ recognition of elder abuse and related signs may lead to the knowledge development solutions through the In-Service programs. To develop an instrument for the assessment of nurses’ recognition of elder abuse by family caregivers within the Iranian context and psychometrically evaluate its reliability and validity.

Methods:

The sequential combination exploratory mixed methods design was used to develop the questionnaire format, which involved two sections: the quantitative and qualitative step. The qualitative step included probing the Nurses’ recognition of elder abuse by family caregivers in two steps including the literature and related tools review and semi-structured interviews with nurses. The quantitative step was accomplished in two parts. The validity of questionnaire was checked using face, content, construct, and formal validity; and the reliability was probed using cronbach’s alpha reliability. The analyzed data were categorized into 67 items (three main groups namely evident signs of abuse, elder’s potential to get abused, and family caregiver’s potential to abuse and 6 sub-groups including inadvertency, physical abuse, financial misconduct, psychological abuse, sexual abuse, and risk factors). Three components from the exploratory content analysis gained 58.8% variance totally. The cronbach’s alpha for the 3 components were 0.79, 0.76, and 0.78, respectively.

Results:

The questionnaire on the nurses’ recognition of elder abuse by family caregiver can be applied to a wide variety of settings because of the broad range of methods utilised to generate items and domains, its comprehensive consideration of the principles of elder abuse, and its initial reliability and validity.

Keywords: Nurses’ recognition, Elder abuse, Family caregivers, Designing a questionnaire, Psychometric, Elderly's properties.


Article Information


Identifiers and Pagination:

Year: 2019
Volume: 13
First Page: 66
Last Page: 74
Publisher Id: TONURSJ-13-66
DOI: 10.2174/1874434601913010066

Article History:

Received Date: 24/11/2018
Revision Received Date: 18/01/2019
Acceptance Date: 23/01/2019
Electronic publication date: 28/02/2019
Collection year: 2019

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© 2019 Alipour et al.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: (https://creativecommons.org/licenses/by/4.0/legalcode). This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


* Address correspondence to this author at the Nursing Care Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran. Postal Code: 4691714141; Tel: +98 (11) 55225151; E-mail: zfotoukian@yahoo.com




1. INTRODUCTION

Elder abuse is one of the domestic violence subcategories, which may bring irreparable damages like death [1Schofield MJ, Powers JR, Loxton D. Mortality and disability outcomes of self-reported elder abuse: A 12-year prospective investigation. J Am Geriatr Soc 2013; 61(5): 679-85.[http://dx.doi.org/10.1111/jgs.12212] ], depression, anxiety, and chronic pain [2Dyer CB, Pavlik VN, Murphy KP, Hyman DJ. The high prevalence of depression and dementia in elder abuse or neglect. J Am Geriatr Soc 2000; 48(2): 205-8.[http://dx.doi.org/10.1111/j.1532-5415.2000.tb03913.x] ], frequently referring to the treatment centers as well as hospital admission [3Cooper C, Selwood A, Livingston G. Knowledge, detection, and reporting of abuse by health and social care professionals: a systematic review. Am J Geriatr Psychiatry 2009; 17(10): 826-38.[http://dx.doi.org/10.1097/JGP.0b013e3181b0fa2e] [PMID: 19916205] ]. Besides, the treatment cost and overall budget of elder abuse treatment are considerably high with an estimation of about 5.3 billion dollars spent in the United States each year for this purpose [4Dong X. Do the definitions of elder mistreatment subtypes matter? Findings from the PINE Study 2014.[http://dx.doi.org/10.1093/gerona/glu141] , 5Mouton CP, Rodabough RJ, Rovi SL, et al. Prevalence and 3-year incidence of abuse among postmenopausal women. Am J Public Health 2004; 94(4): 605-12.[http://dx.doi.org/10.2105/AJPH.94.4.605] [PMID: 20458103] ]. Moreover, there are also social costs like prosecution, punishment, and rehabilitation of abused elder [6Anetzberger G. An update on the nature and scope of elder abuse. Generations 2012; 36(3): 12-20., 7Metlife. The MetLife study of elder financial abuse crimes of occasion, desperation, and predation against America’s elders 2011.Metlife Mature Market Institute/National Committee for Prevention of Elder Abuse/Virginia Polytechnic Institute and State University, Metlife Mature Market Institute Westport, CT]. The frequent referrals to the treatment centers as well as getting hospitalized also increase the workload of medical and nursing care. Nevertheless, to provide high quality and comprehensive care services alongside supportive, mental, and legal actions, nurses are required to have sufficient knowledge about this phenomenon [4Dong X. Do the definitions of elder mistreatment subtypes matter? Findings from the PINE Study 2014.[http://dx.doi.org/10.1093/gerona/glu141] , 8Naughton C, Drennan J, Lyons I, et al. Elder abuse and neglect in Ireland: results from a national prevalence survey. Age Ageing 2011; 41(1): 98-103.[http://dx.doi.org/10.1093/ageing/afr107] [PMID: 21997767] , 9Karimi M, Elahi N. Elderly abuse in Ahwaz city and its relationship with individual and social characteristics. Sālmand 2008; 3(1): 42-7.] as the early diagnosis of elder abuse signs and symptoms is effective in developing early medical interventions and preventing the side effects [10Kennedy RD. Elder abuse and neglect: the experience, knowledge, and attitudes of primary care physicians. Family Medicine-kansas city 2005; 37(7): 481.]. However, despite being an important member of the treatment staff, nurses’ recognition and knowledge about the subject is not enough in this context [11Mandiracioglu A, Govsa F, Celikli S, Yildirim GO. Emergency health care personnel’s knowledge and experience of elder abuse in Izmir. Arch Gerontol Geriatr 2006; 43(2): 267-76.[http://dx.doi.org/10.1016/j.archger.2005.10.013] , 12Anetzberger GJ. Elder abuse identification and referral: The importance of screening tools and referral protocols. J Elder Abuse Negl 2001; 13(2): 3-22.[http://dx.doi.org/10.1300/J084v13n02_02] ]. Mondiraghlou et al (2006) have shown that the medical and emergency ward staffs are not aware of how to recognize, report, and treat the elder abuse phenomenon and how to approach an abused elder [11Mandiracioglu A, Govsa F, Celikli S, Yildirim GO. Emergency health care personnel’s knowledge and experience of elder abuse in Izmir. Arch Gerontol Geriatr 2006; 43(2): 267-76.[http://dx.doi.org/10.1016/j.archger.2005.10.013] ]. According to another study, only 40% of 131 nurses working in the emergency wards of 5 hospitals in South Korea were aware of elder abuse [13Dong X. Medical implications of elder abuse and neglect. Clin Geriatr Med 2005; 21(2): 293-313.[http://dx.doi.org/10.1016/j.cger.2004.10.006] ].

Table 1
A sample format for defining the items of questionnaire.


Moreover, several studies have shown that the nurses’ knowledge on the elder abuse phenomenon is limited and most of the experiences are gained from the clinical settings, co-worker’s experiences, media, and social networks. For instance, 39.1% of participants gained knowledge about the phenomenon from radio and TV channels in the study conducted by Dedli et al [14Dedeli O, Kiyancicek Z, Yildiz E. Perceptions of elder abuse, neglect and attitudes toward ageism: Volunteers public non-health staff and tradesmen in Manisa/Turkey. Gerontol Geriat Res 2013; 2(2): 2-9.[http://dx.doi.org/10.4172/2167-7182.1000120] ]. Thus, lack of knowledge or having limited and false information can challenge the process of taking care of the elder.

1.1. Background

At present, the nursing curriculum in Iran offer a four year baccalaureate in nursing [15Salsali M. Evaluating teaching effectiveness in nursing education: an Iranian perspective. BMC Med Educ 2005; 5(1): 29-38.[http://dx.doi.org/10.1186/1472-6920-5-29] ]. Nursing curriculum is defined as the totality of the philosophical approaches, curriculum outcome statements, overall design, courses, teaching-learning strategies, delivery methods, interactions, learning climate, evaluation methods, curriculum policies, and resources [16Dianne R, Andrusyszyn MA, Iwasiw CL, Goldenberg D, Lever JA, Munro BH, et al. Curriculum Development in Nursing Education. Can Nurse 2005; 101(5): 11. [Statistical Methods for Health Care Research 5th ed]. [Set Me Free: Towards Reducing the Use of Physical Restraints 2nd ed].].

There is no syllabus for elder abuse, influensive factors and probable outcomes defined in the Iranian nursing curriculum. there is no in-service training provided for the nurses to receive regarding the elder abuse concept and the caring style or the case-report process neither [10Kennedy RD. Elder abuse and neglect: the experience, knowledge, and attitudes of primary care physicians. Family Medicine-kansas city 2005; 37(7): 481.]. Several studies have defined the lack of a reliable and standard instrument, as one of the most important barriers in recognizing the elder abuse cases [17Cooper C, Manela M, Katona C, Livingston G. Screening for elder abuse in dementia in the LASER-AD study: prevalence, correlates and validation of instruments. International Journal of Geriatric Psychiatry: A journal of the Psychiatry of Late Life and Allied Sciences 2008; 23(3): 283-8.[http://dx.doi.org/10.1002/gps.1875] , 18Buri HM, Daly JM, Jogerst GJ. Elder abuse telephone screen reliability and validity. J Elder Abuse Negl 2009; 21(1): 58-73.[http://dx.doi.org/10.1080/08946560802571912] [PMID: 21997767] ].

Therefor, the issue is not known as an educational priority for nurses in health care providing systems point of view while the risk of misdiagnosis and arbitrary actions of nurses increase [19Torre DM, Daley BJ, Sebastian JL, Elnicki DM. Overview of current learning theories for medical educators. Am J Med 2006; 119(10): 903-7.[http://dx.doi.org/10.1016/j.amjmed.2006.06.037] [PMID: 17000227] ]. Meanwhile nurses can play an important role in recognizing the phenomenon and deploying well-timed and appropriate interventions due to their close encounter with the elderlies. Hence, they can not be easily ignored as the factors decreasing the elder abuse side-effects and treatment costs as well as increasing quality of life for elder abuse cases [20Orfila F, Coma-Solé M, Cabanas M, Cegri-Lombardo F, Moleras-Serra A, Pujol-Ribera E. Family caregiver mistreatment of the elderly: prevalence of risk and associated factors. BMC Public Health 2018; 18(1): 167.[http://dx.doi.org/10.1186/s12889-018-5067-8] [PMID: 29357866] ]. Therefore, probing the level of nurses’ recognition of elder abuse and its signs and symptoms can be useful in providing the knowledge upgrading initiatives by the in-service programs.

Available data suggest that the overall elder abuse prevalence in Iran is 56.4% with confidence interval 95% (35.1-75.5%) [21Molaei M, Etemad K, Taheri Tanjani P. Prevalence of Elder Abuse in Iran: A Systematic Review and Meta Analysis. Iranian Journal of Ageing 2017; 12(2): 242-53.[http://dx.doi.org/110.21859/sija-1202242] ]. It is concluded that; Iranian's nurses encounter with and take care of elderlies patients who have experience abuse. In this context, using valid and reliable tools can be effective; however, existing papers and databases provide only a limited number of such tools, while most of them are made by researchers and are not psychometrically analyzed [5Mouton CP, Rodabough RJ, Rovi SL, et al. Prevalence and 3-year incidence of abuse among postmenopausal women. Am J Public Health 2004; 94(4): 605-12.[http://dx.doi.org/10.2105/AJPH.94.4.605] [PMID: 20458103] , 22Harries P, Davies M, Gilhooly K, Gilhooly M, Tomlinson C. Educating novice practitioners to detect elder financial abuse: a randomised controlled trial. BMC Med Educ 2014; 14(1): 21-30.[http://dx.doi.org/10.1186/1472-6920-14-21] [PMID: 24485005] , 23Mahmoud S. Elder Abuse Education for Nurses 2014.]. Therefore, the lack of appropriate tool has made us design and develop the questionnaire on the nurses’ recognition of elder abuse by family caregivers.

2. METHODS

The sequential exploratory mixed methods design was adopted to develop the questionnaire in this study, which involved two steps: qualitative and quantitative study. The study was conducted in Mazandaran province, Iran in 2016.

2.1. Step One: Qualitative Study

The nurses’ recognition of elder abuse by family caregivers was probed in two parts including the literature and related tools review and field work (semi-structured interviews with nurses) for the qualitative step. Several keywords, such as elderly, physical abuse, financial misconduct, psychological abuse, sexual abuse, inadvertency, misbehavior risk factors, nurses’ recognition of misbehavior and psychometrics were searched in Scopus, Ovid, Proquest, ScienceDirect, Pub Med, and CINHAL databases without setting any specific time-limit for the literature search. Finally, 82 papers were selected for the study. The textual content analysis was used for analyzing the papers. The data analysis process was started with careful papers studying. Afterwards, a list of items for the final data check was prepared. For the next step, 23 items each covering a different aspect of elder abuse were selected.

The field work step consisted of data gathering from the detailed interviews determining the nurses’ recognition of elder abuse. Five geriatric nursing masters and 3 nursing PhD were selected as participants. All the participants with sufficient subject knowledge willingly joined the study. The sampling was purposive. Participants were selected on the basis of age, gender, working experience, graduation date, and the experience in caring the elderly with different kinds of abuse to gain the maximum variability. Detailed semi-structured interviews were used for the data gathering. The interview guide questions like “What do you know about elder abuse signs and symptoms?”, “What kind of factors may put the elders at a risk of elder abuse in your opinion?”, “What are the threatening specifications of a caregiver putting the elder at a risk of abuse?”, “Can you give me some details of an elder being abused if you have the experience of threatening with such a patient?”, and “What are the actions that should be taken when a nurse faces the elder abuse phenomenon in your opinion?” were asked. In the interview, all the questions came sequentially according to the earlier response and the interview guide. Probing questions like “What do you mean?” or “Could you please give more details?” were designed, if needed. At the end, the participants were asked to state any missed detail or point, and subsequently they were informed about the possibility of further interviews. For conducting the interviews, empty rooms in a clinical set-up were selected, and the interviews lasted for 20 to 25 minutes. The data saturation appeared when the codes became repetitive, and no new category or subcategory was created. The interviews were transcribed for the data analysis, and the open coding was done by carefully reading the texts. Fifty five initial codes were extracted in this step. Categorizing and recognizing the differences and similarities were done by studying the extracted codes frequently. The relationship between the categories was determined as the data analysis proceeded. Finally, the extracted codes were organized in 3 themes.

The codes extracted from the literature review and field work were compared in the final analyzing step, and the similarities and differences between the codes were probed. Afterwards, drafting of the items according to the categories and subcategories was done to create the final concept of nurses’ recognition of elder abuse by family caregivers format Table 1.

2.2. Rigor

The data gathered in the qualitative step were carefully checked in order to fit the Guba & Lincoln criteria of credibility, dependability, confirmability, and transferability [24Guba EG, Lincoln YS. Competing paradigms in qualitative research. Handbook of qualitative research 1994; 2(163-194): 105.]. Enough sample size capable of getting the data saturation was used in both qualitative and quantitative step [25Grove SK, Burns N, Gray J. The practice of nursing research: Appraisal, synthesis, and generation of evidence 2012.].

2.3. Questionnaire’s Validation

The psychometric evaluation of 78-itemed questionnaire was done in this step, which included the validity and reliability phases. The validity phase included the validation of face, content and, construct.

2.4. Face Validity

The face validity was checked in both qualitative and quantitative methods. It is considered as a degree in which the questionnaire appears effective in terms of its stated aims qualitatively. Ten nurses were asked to comment on difficulty, relevancy, and ambiguous levels to check the face validity qualitatively. Afterwards, the item impact method was applied to decrease or remove the inappropriate items and determine each item’s important as a quantitative method. Likert 5-point scale (absolutely important to absolutely unimportant) was used to study each item, and the nurses were asked to determine the importance of each item according to their experience.

2.5. Content Validity

Both qualitative and quantitative methods were used to check the content validity. Five nursing faculty members with sufficient working experience in both the clinical and theoretical settings were asked to comment on the grammar, wording, allocation, and scaling of the items. Two indices of CVI and CVR were used to check the content validity quantitatively.

2.6. Content Validity Ratio (CVR)

Lawash model (1975) was used to determine the CVR [26Lawshe CH. A quantitative approach to content validity 1. Person Psychol 1975; 28(4): 563-75.[http://dx.doi.org/10.1111/j.1744-6570.1975.tb01393.x] ] in this study. Ten subject matter experts (nursing faculty members with the working experience in clinical settings, tool making, and teaching geriatric nursing subjects) were asked to check the necessity of items according to a 3-point scale including necessary, helpful but not necessary, and unnecessary. Later, the results were compared with the scale of Lawash. The minimum value of CVR according to the Lawash’s table and the number of experts (all responded to the questions) was set to 0.80. The item was considered necessary with a statically significant level (p<0.05) if the outcome number was larger than the table’s number. CVRstrict was used in this study meaning that only the necessary options were kept in the CVR formula.

2.7. Content Validity Index (CVI)

The CVI was promoted initially by Waltz and Bausell (1981) [27Yaghmale F. Content validity and its estimation. Journal of Medical Education 2009; 3(1): 245-54.]. Ten experts (the same people helped in CVR determination) were asked to check if each item fits in the Likert 4-point scale (from absolutely relevant to irrelevant) in order to determine the content validity of each item and to ensure whether the items were designed properly to create the constructs. In this study, the S-CVI was calculated.

2.8. Construct Validity

The construct validity is considered as a degree in determining the questionnaire’s efficiency in the created constructs [28Doward LC, Meads DM, Thorsen H. Requirements for quality of life instruments in clinical research. Value Health 2004; 7: S13-6.[http://dx.doi.org/10.1111/j.1524-4733.2004.7s104.x] [PMID: 1536 7238] ]. The factor analysis was used to study the internal relationship between the variables and explore the categories of items that were tightly related [25Grove SK, Burns N, Gray J. The practice of nursing research: Appraisal, synthesis, and generation of evidence 2012.]. Kaiser-Meyer-Olkin and Bartlett sphericity tests were used before extracting the components to ensure that the items were appropriately designed to analyze different factors. The KMO value of 0.7 or higher was considered as the condition of sample size sufficiency in the content analysis. Bartlett test of sphericity was used to check the level of correlation between the questionnaire’s items in a way that the merging of items is possible. According to the previous study, the required sample size for content analysis varies from 5 to 10 for each item [29Knapp TR, Brown JK. Ten measurement commandments that often should be broken. Res Nurs Health 1995; 18(5): 465-9.[http://dx.doi.org/10.1002/nur.4770180511] [PMID: 7676079] ]. Four hundred samples were used in this study for the exploratory content analysis. The exploratory factor analysis, analysis of the main components of Scree plot to estimate the appropriate number of factors, eigenvalues equal to and/or more than 1 and varimax rotation were used. The score of 0.5 was considered as the minimal factor load for each item of extracted components from the content analysis.

2.9. Reliability

The reliability of this study was checked using the internal consistency and stability methods. Cronbach’s alpha was used in the internal consistency method, and the minimum alpha was considered to be 0.6 [30Krishna H, Kumar K. Reliability estimation in generalized inverted exponential distribution with progressively type II censored sample. J Stat Comput Simul 2013; 83(6): 1007-19.[http://dx.doi.org/10.1080/00949655.2011.647027] ]. The Test-retest and Interclass Correlation Coefficient (ICC) were used to check the stability by asking 25 nurses to fill the questionnaire two times in two weeks interval. The acceptable minimum for ICC was set at 0.4 [31Baumgartner TA, Chung H. Confidence limits for intraclass reliability coefficients. Meas Phys Educ Exerc Sci 2001; 5(3): 179-88.[http://dx.doi.org/10.1207/S15327841MPEE0503_4] ].

3. RESULTS

Three main categories including “evident signs of abuse”, “elder’s potential to get abused”, and “family care giver’s potential for abusing” as well as 6 sub-categories including “inadvertency”, “physical abuse”, “financial misconduct”, “psychological abuse”, “sexual abuse”, and “risk factors” were extracted in the qualitative step. The 78-itemed questionnaire became a 71-itemed one after the face validity checks in which 5 qualitative and 2 quantitative items with scores less than 1.5 were eliminated .

Two items were reviewed in the content validity check and all the possible changes were applied. The quantitative survey of content validity was based on the CVR and CVI methods. Two items including “elder’s anxious look at the caregiver before answering nurse’s questions” and “elder’s race as a risk factor for being abused” were eliminated using CVR method. Two other items were also ignored after receiving a score of 0.73 and 0.75, respectively, in CVI method. The mean content validity score (S-CVI) for all the remaining items was equal to 0.91 in the next step.

A 67-itmed questionnaire based on Likert 5 point scale (5 for strongly agree and 1 for strongly disagree) was prepared for the exploratory content analysis phase. A sufficient number of samples needed for the factor analysis using KMO equal to 0.985 were included in this study, collecting enough data for the analysis. Bartlett’s test was also statistically significant with the number of 20810.938 (p<0.001) meaning that significant correlation exist between the items for the content analysis. To determine the number of components in Scree plot, eigenvalues were used. The Scree plot showed that 3 components are enough for exploring the factors affecting the nurses’ recognition of elder abuse by family caregivers (Fig. 1).

Afterwards, the extraction of the factor structure of the questionnaire by the principle component analysis using orthogonal rotation or varimax rotation (Eigen value>1) was carried out. The factor load of each item was considered to be minimum 3 in the factors matrix and rotated matrix. Three components having 58.8% variance according to the Scree plot were considered for this questionnaire.

3.1. The 1st Component

This component included 38 items related to the evident signs of abuse. The highest load factor was observed for the item “elder’s funds are managed by the caregiver, despite the elder’s ability of self-management and not having any intellectual or cognitive problem” and the minimum was for the item “elders are referred to the emergency ward repeatedly due to accidents”. The variance ratio for this component before the factor rotation was 44.186, which turned to 23.087 after it.

3.2. The 2nd Component

Twenty one items were included in this component stating the elder’s potential to get abused. The highest load factor was observed for the item “ elder has dementia or Alzheimer” and the minimum was observed for the item “elder lives in the remote areas”. The variance ratio for this component before the factor rotation was 9.106, which turned to 18.998 after it.

Fig. (1)
The screen plot.


3.3. The 3rd Component

This component included 8 items stating the family care giver’s potential for abusing. Most of the load factor in this component was related to the item “the caregiver has child abuse experience from his/her parents” and the minimum load factor was related to the item “the caregiver is not skillful enough for caring an elder”. The variance ratio for this component before the factor rotation was 3.681, which turned to 14.888 after it. All the components were named according to their items after extraction, and the level of compatibility of each with the concepts and aspects of the questionnaire was studied Table 2.

Table 2
Factors resulted from the exploratory analysis of the questionnaire on the nurses’ recognition of elder abuse by family caregivers.


Table 3
The results of internal consistency evaluation of the questionnaire on the nurses’ recognition of elder abuse by family caregivers.


The total internal consistency of the questionnaire was found to be 0.98 in the reliability check. No item was removed in checking the consistency of each item in compare to the questionnaire. The Test-retest method was used for probing the stability. The results showed that the scores of first and second tests were statistically significant (P<0.001), approving the repeatability of the subscales and the questionnaire besides showing high stability Table 3.

The questionnaire included three subscales including “evident signs of abuse”, “elder’s potential to get abused”, and “family caregiver’s potential for abusing”. The scoring scale in this questionnaire was based on the five-point Likert scale denoting strongly agree score with 5 to strongly disagree score with 1. The total score varied from 1 to 335, where the score 1-83 denoted weak recognition; 84-167 denoted medium recognition; 168-251 denoted good recognition; and 252-335 denoted excellent recognition of elder abuse by the nurses.

4. DISCUSSION

The present study involved the designing and development of a questionnaire with 67 items and three subscales on the nurses’ recognition of elder abuse by family caregivers, which was further checked for the reliability and validity. This questionnaire showed acceptable formal validity. The ratio of content validity to content validity index was also appropriate. The exploratory factor analysis was applied to all the 67 items to determine the construct validity. The KMO scale and Bartlett test also approved the factor analysis model. The eigenvalues proved the multifactorial specification of the questionnaire. Each item showed a fair relationship with one of the subscales and the structural validity degree of mean correlation seemed to be reasonable as indicated by the load factor of each item. The statistically significant relationship between the subscales and total score of the questionnaire was observed. The construct validity of the tool was approved according to the compatibility within the phrases resulted by the factor analysis and the definition and recognition aspects of the nurses’ recognition of elder abuse phenomenon by family caregivers.

Factor analysis has been used to determine the validity of the structure of elder abuse induced by family carers questionnaire by Heravi Karimavi (2010), Neale (1991), Cohen (2006) et al. [32Heravi-Karimooi M, Anoosheh M, Foroughan M, Sheykhi MT, Hajizadeh E. Designing and determining psychometric properties of the Domestic Elder Abuse Questionnaire. Sālmand 2010; 5(1): 7-21.-34Neale AV, Hwalek MA, Scott RO, Sengstock MC, Stahl C. Validation of the Hwalek-Sengstock elder abuse screening test. J Appl Gerontol 1991; 10(4): 406-18.[http://dx.doi.org/10.1177/073346489101000403] ]. Given the different definitions of the elder abuse, the number and naming of factors are different in this research, and none of the scales can distinguish between different types of abuses. Although the scale designed by Heravi et al. (2010) is somewhat in terms of dimensions similar to current study, but subscales ‘risk factors of elder abuse and sexual abuse’, has not been investigated [32Heravi-Karimooi M, Anoosheh M, Foroughan M, Sheykhi MT, Hajizadeh E. Designing and determining psychometric properties of the Domestic Elder Abuse Questionnaire. Sālmand 2010; 5(1): 7-21.]. While in current study, the items 10 and 16-12 examined the symptoms of sexual abuse. A scale developed by Cohen et al. (2006) can only identify the risk factors of elder abuse induced by family caregivers and can not identify signs of abuse in Iranian elderlies [33Cohen M, Halevi-Levin S, Gagin R, Friedman G. Development of a screening tool for identifying elderly people at risk of abuse by their caregivers. J Aging Health 2006; 18(5): 660-85.[http://dx.doi.org/10.1177/0898264306293257] [PMID: 16980634] ].

The item “elder’s funds are managed by the caregiver, despite being in good health, intellectual, and cognitive status” showed highest load factor in the first component. This may happen due to the financial problems and the economic pressure felt by the children [28Doward LC, Meads DM, Thorsen H. Requirements for quality of life instruments in clinical research. Value Health 2004; 7: S13-6.[http://dx.doi.org/10.1111/j.1524-4733.2004.7s104.x] [PMID: 1536 7238] ] or the lack of awareness regarding the fact of abusing in this case. The elder’s children may consider using their parent’s funds as a basic right, leading to seizing parent’s properties without any permission. Similar conclusion has been observed in other studies as well. Sooryanarayana et al. (2011) have shown that the most prevalent type of elder abuse in Malaysia is related to the financial aspect (6.2%) [35Sooryanarayana R, Choo WY, Hairi NN, Chinna K, Bulgiba A. Insight into elder abuse among urban poor of Kuala Lumpur, Malaysia—a middle-income developing country. J Am Geriatr Soc 2015; 63(1): 180-2.[http://dx.doi.org/10.1111/jgs.13217] [PMID: 25597571] ]. The results of Karimi & Elahi (2008) have also proved that, after negligence (31.7%), financial aspect (25%) is considered as the main reason behind elder abuse in urban areas and sanatoriums [9Karimi M, Elahi N. Elderly abuse in Ahwaz city and its relationship with individual and social characteristics. Sālmand 2008; 3(1): 42-7.]. In the 2nd component, the highest load factor was related to the item “elder has dementia or Alzheimer”. It is more usual to get abused due to the cognitive problems related to the Alzheimer and dementia, causing higher dependency on the caregivers [36Grover S, Malhotra N. Depression in elderly: A review of Indian research. Journal of Geriatric Mental Health 2015; 2(1): 4.[http://dx.doi.org/10.4103/2348-9995.161376] ].

The highest load factor in the third component was related to the item “the caregiver has child abuse experience from his/her parents”. The results of different studies have shown that elders are abused mostly by the family members and own children [37Burnight K, Mosqueda L. Theoretical model development in elder mistreatment 2011.[http://dx.doi.org/10.1037/e725722011-001] , 38Abolfathi Momtaz Y, Hamid TA, Ibrahim R. Theories and measures of elder abuse. Psychogeriatrics 2013; 13(3): 182-8.[http://dx.doi.org/10.1111/psyg.12009] ]. Rosen et al (2016) have shown that 57% of elder abuse cases are related to the family members acting as caregivers [39Rosen T, Bloemen EM, LoFaso VM, Clark S, Flomenbaum NE, Lachs MS. Emergency department presentations for injuries in older adults independently known to be victims of elder abuse. J Emerg Med 2016; 50(3): 518-26.[http://dx.doi.org/10.1016/j.jemermed.2015.10.037] [PMID: 2681 0019] ].

The second and third factor with 29 items evaluates the risk factors of elder abuse. The risk factors of elder abuse are related both to the elderly and to the family caregivers. Identifying the risk factors of elder abuse helps nurses to provide interventions to prevent elder abuse. Heravi et al (2010) only identified the symptoms of elder abuse induced by family caregivers [32Heravi-Karimooi M, Anoosheh M, Foroughan M, Sheykhi MT, Hajizadeh E. Designing and determining psychometric properties of the Domestic Elder Abuse Questionnaire. Sālmand 2010; 5(1): 7-21.]. Then identification the risk factors of elder abuse can provide an opportunity for preventive interventions by nurses.

Hwalek-Sengstock Elder Abuse screening scale is also designed to investigate the risk factors of abuse, neglect, or exploitation in the elderly. The reliability of this scale (15 items) is equal to 0.855. (Cronbach's alpha:0.632) [18Buri HM, Daly JM, Jogerst GJ. Elder abuse telephone screen reliability and validity. J Elder Abuse Negl 2009; 21(1): 58-73.[http://dx.doi.org/10.1080/08946560802571912] [PMID: 21997767] ]. This scale has no symptoms of elder abuse. It is concluded that it can not be used by caregivers as a comprehensive scale to investigate the recognition of elder abuse.

CONCLUSION

The reliability details of our study seem to be encouraging. The reliability of the scale was checked both by the internal consistency and retest methods, thus, strengthening the reliability test results. The results showed that the questionnaire has good internal consistency. However, further analysis in bigger scales may show stronger relationships. This questionnaire, which we recommend as a mini scale, can be used both in statistical and practical studies. This questionnaire can also be helpful in analyzing the situation and needs assessment during the in-service trainings and educational interventions for the nurses; therefore, providing an easier way to increase the nurses’ abilities and skills for elderly care. The Nurses' Cognition of Elder Abuse Questionnaire was designed for Iranian family Caregivers. However, more surveys are needed in order to check the reliability of this questionnaire among the nurses with different cultures.

In this study, the sensitivity and specificity of the scale and the confirmatory factor analysis were not done using the structural equation method. Nevertheless, we believe that the careful qualitative research conducted and the exploratory analysis factor used in this study, will be used this scale in nursing care for the elderly, such as a hospital or other health centers, and even in Long-term care centers.

CONTRIBUTORS

All authors conceived and designed the study. FGh and AA managed the conduction of the collected the data. ZF and FGh supervised the analytical design and analysis which was conducted by FGh. The manuscript was drafted by ZF, and all authors contributed to critical revision and approved the final manuscript.

FUNDING

The study was funded by the Babol University of Medical Sciences. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

ETHICS APPROVAL AND CONSENT TO PARTICIPATE

The main ethical considerations of this study include: receiving Babol University of Medical Sciences Ethics Committee approval, receiving informed consent, informing the participants about the aims, cooperation conditions, data gathering methods, recording the interviews and the role of both the researcher and the participant, respecting participant’s privacy, choosing the time and the place of interview according to participant’s convenience, having the right of resigning the study at any level and keeping all the data and information privately.The reference number is MUBABOL-REC 1395.34.

HUMAN AND ANIMAL RIGHTS

No animals/humans were used for studies that are the basis of this research.

CONSENT FOR PUBLICATION

Written informed consent have been revised.

CONFLICT OF INTEREST

The authors declare no conflict of interest, financial or otherwise.

ACKNOWLEDGEMENTS

This study was conducted with the support of Babol University of Medical Sciences with the ethic’s code of MUBABOL.REC.1395.34. We do appreciate all the patients, nurses, and the faculty members who helped us in designing the questionnaire.

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