The Caring Dimension Inventory (CDI-29): Modified Arabic Version
Majdi Alhadidi1 and Muayyad Ahmad2*
1Community Health Nursing Department, School of Nursing, The University of Jordan, Amman, Jordan
2Clinical Nursing Department, School of Nursing, The University of Jordan, Amman, Jordan
*Corresponding author: Muayyad Ahmad, Clinical Nursing Department, School of Nursing, The University of Jordan, Amman, Jordan, E-mail: firstname.lastname@example.org
Int Arch Nurs Health Care, IANHC-2-048, (Volume 2, Issue 3), Mini Review; ISSN: 2469-5823
Received: March 26, 2016 | Accepted: May 18, 2016 | Published: May 24, 2016
Citation: Alhadidi M, Ahmad M (2016) The Caring Dimension Inventory (CDI-29): Modified Arabic Version. Int Arch Nurs Health Care 2:048. 10.23937/2469-5823/1510048
Copyright: © 2016 Alhadidi M, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Purpose: This study was designed to examine the psychometric properties of modified Arabic version of the Caring Dimension Inventory.
Methods: The cross-sectional survey was conducted in Jordan in four psychiatric clinical settings. Data were collected from three psychiatric hospitals and one psychiatric ward. The sample size was 205 nurses. Ethical approval was granted to conduct this study by the relevant research ethics committees of the involved hospitals.
Results: The Exploratory Factor Analysis with principal component analysis using Varimax rotation for the CDI-29 resulted in four factors. The psychometric properties of the modified scale are well established in this study.
Conclusion: The modified scale can be used to determine caring behaviors and nurses' perceptions of the importance of caring behaviors in the Arabic culture.
CDI-29, Arabs, Nursing care, Factor analysis
Caring is the essence of nursing. It is directly connecting patients' overall fulfillment and sense of well-being [1,2]. It is reported that high level caring vitally enhances clients' emotional as well as physical health which, corresponds with the ultimate goal of achieving good mental and physical health status . Literature emphasized the importance of caring for patients' wellbeing. For example, studies indicated that a therapeutic relationship is a caring relationship, and considered an essential element in professional nursing [4,5]. In spite of a lack of consensus on caring as part of the meta-paradigms of nursing, caring has appeared during the past three decades as a dominant element in nursing profession . Caring relies on situations, and nurses should consider the various emotions for the clients when providing the necessary care . The patient must be the center of the health care focus .
Nurses working in psychiatric hospitals need to acquire the skills of therapeutic communication such as being genuine, an active listener, and being a patient advocate [8,9]. In mental health nursing, the interpersonal interaction is the core element of the practice. In order to promote the client with mental health issue, nurses caring attitude towards their patients is essential . This requires mental health nurses to recognize the necessity of caring in a client-nurse relationship .
Translating questionnaires into other languages is a common procedure these days . The underlying principle being that it is wise to use existing instruments that are proven to effectively measure variables rather than develop new tools with all the time-consuming measures that this involves. Actually, a translated instrument to evaluate different populations in new cultural setting is preferable and will support the validity of the measure [13-15]. Nationwide, mental health issues in many parts of Jordan continue to be under -discussed topic [16,17]. To the best of our knowledge, no studies have been found in the published literature that had assessed caring among nurses in mental health settings in Jordan. Therefore, this study may contribute to the body of knowledge and lead to an evaluation of the quality of nursing care provided to patients diagnosed with a mental health challenge.
This study intended to explore the fundamental structure of caring, and this was addressed by the addition of four new items to the original Caring Dimension Inventory (CDI-25). These additional items were Item 26 (assess the psychosocial aspects of the patient); item 27 (assess the patient with a high risk of suicide), item 28 (assess the patient with a high risk of violence) and item 29 (modify the environment to be more therapeutic). All the modification processes were applied according to the pre-pilot committee suggestions (Two Assistant Professor, one Lecturer, and clinical nurse specialist in Psychiatric/Mental health Nursing) and after obtaining the permission of the original author of the instrument. From the perspective of the panel, the rational for these modifications was that caring in a specialized area such as the psychiatric unit involves dealing with special situations such as violent and suicidal behaviors; thus, nurses may need to modify the environment to be more therapeutic. Therefore, the aim of this study was to examine the psychometric properties (validity and reliability) of an Arabic version of the modified CDI-29 among mental health nurses in Jordan.
The need for an instrument to measure the Caring Dimension Inventory (CDI) is vital. There are few instruments identified in the published literature that may be used to measure caring. The CDI-25 is one of these instruments which was developed by Watson in 1997 . However, the CDI-25 was not adequately developed to measure caring for the Arab world, as well as in mental health nursing. The instrument originally was designed to assess the perception of caring by asking people to indicate their agreement to statements about their nursing practice as constituting caring. Therefore, four items focusing on a safe and therapeutic environment were added to the instrument. Then, the measure was examined to establish its validity and reliability in this study.
Setting and sampling
Data were collected from three psychiatric hospitals and one psychiatric ward; "A" hospital is a government hospital with a capacity of 220 beds, "B" hospital is a government hospital with a capacity of 125 beds, "C" hospital is a private hospital with a capacity of 75 beds. The psychiatric ward is part of a large educational and multispecialty hospital with a capacity of 10 beds. According to the data obtained from the human resources departments in the selected hospitals, the total number of nurses was 260 nurses. A list with the demographics of all nurses working in the selected hospitals was checked for the inclusion criteria (to be a registered nurse and to be from one of the Arab nationalities). The total number of eligible participants for this study was 220 nurses. Those who met the inclusion criteria received a package containing the questionnaires used in the present study.
Ethical approval was granted to conduct this study by the relevant research ethics committees of the involved hospitals. The purpose, benefits, and risks were explained to the sample before they decided to participate. The participants were assured that their contribution would be completely voluntary. The expected time to complete the questionnaire was between 5 and 10 minutes.
Out of the 220 eligible nurses, 205 of them (93%) completed the survey. The mean age of the participants was 33.6 years. More than half of the participants were male (n = 110; 54%). Almost three-quarters of the participants were married (n = 150; 73%). Moreover, 135 (66%) participants held bachelor degrees with an average of seven years nursing experience in the mental-health field. Over half of the participants had some training in mental-health nursing (n = 105; 51%) and 58% (n = 118) received organizational and managerial support. The mean number of the participants' working time was 45.5 hours weekly.
Exploratory factor analysis (EFA) is used to group together the intercorrelated variables or items [19,20]. Table 1 presents the means and standard deviations for the 29 items of the CDI scale. The highest mean was (4.74) for the item "Assess the patient who high risk for suicide," and the lowest mean was (3.17) for the items "Sharing your personal problems with a patient."
Table 1: Descriptive statistics with means and standard deviations (N = 205). View Table 1
The EFA principal component analysis with Varimax rotation resulted in four latent variables with items distribution among the factors as shown in table 2. The cumulative variance for the four factors in the model was 44.67%, with the highest contribution from the first factor with 27.82%. The Cronbach's Alpha for the 29-item scale was 0.89, and it was 0.85, 0.77, 0.69, and 0.65 for the factors one to four respectively. The first factor was called "Psychosocial," and it is composed from 10 items; the second factor was called "Technical," and it is composed from eight items; the third factor was called "Professional," and it is composed from six items; and the fourth factor was called "Empathy" and is composed from five items.
Table 2: Factors loading with Varimax rotation. View Table 2
For many reasons, the Caring Dimension Inventory-25 was modified in this study. In addition to the original 25 items, the researchers added four items: Item 26 (assess the psychosocial aspects of the patient); item 27 (assess if the patient with a high risk of suicide), item 28 (assess if the patient with a high risk of violence) and item 29 (modify the environment to be more therapeutic).
Mental health nursing has been considered to be a demanding profession [21,22]. Nurses face various challenges, such as increased patient acuteness, decreased duration of stay in hospitals, and altering patient anticipations [23,24]. The primary issues that mental health nurses are experiencing while giving care includes the ability to provide a safe environment, and providing therapeutic care [16,25]. Furthermore, Rey et al. (2004) reported that patients with a mental illness lean to be more challenging, acute, and distressed . Mental health nursing responsibilities consist of assessments, establishing a safe and therapeutic environment, and promoting stabilization . On the other hand, while mental health nurses endeavor to provide a safe environment, they struggle to give therapeutic care , frequently raising nurses' burdens, and negatively influencing their capability to provide quality care  because caring in a specialized area such as the psychiatric unit involves dealing with special stressful situations such as the psychological aspects [29,30] violent or aggressive [31-33] and suicidal  behaviors.
In the Principal Components Analysis with Varimax rotation, the four-factor model accounted for 45% of the variance. Our results show that the reduced version of 29 items improves the validity of the instrument in the Arab culture. Furthermore, internal consistency coefficients were relatively high in the modified version. In conclusion, the modified 29-item CDI scale is recommended for use when determining caring behaviors and nurses' perceptions of caring behaviors in the Arabic culture. However, the psychometric properties of the modified scale needs further assessment in future studies.
• Measurement of caring is a relatively new area in the health studies literature.
• Exploratory factor analysis indicated that the 29-item scale is better than the 25-item scale in measuring caring in the Arab culture.
• The four-factor model is valid, reliable, and empirically supported.
Conflicts of Interest
The authors have no financial or any other kind of personal conflicts with this article.
Mathes S (2011) Implementing a Caring Model. Creative Nursing 17: 36-42.
Alslman E, Ahmad M, Bani Hani M, Atiyeh H (2015) Health: A Developing Concept in Nursing. International Journal of Nursing Knowledge
Drach-Zahavy A (2009) Patient-centred care and nurses' health: the role of nurses' caring orientation. J Adv Nurs 65: 1463-1474.
Watson J (2009) Caring Science and Human Caring Theory: Transforming Personal and Professional Practices Of Nursing and Health Care. J Health Hum Serv Adm 31: 466-482.
Ramjan LM (2004) Nurses and the 'therapeutic relationship': Caring for adolescents with anorexia nervosa. J Adv Nurs 45: 495-503.
Watson J (2007) Watson's theory of human caring and subjective living experiences: carative factors/caritas processes as a disciplinary guide to the professional nursing practice. TextoContextoEnferm, Florianopolislis 16: 129-35.
Ahmad M (2015) Knowledge and beliefs about Cancer Prevention and Care in Jordan. International Journal of Medicine 1: 1-5.
Ahmad M, Dardas L (2016) Jordan: Nursing in the Arab World: An Aspiration for a Culturally-Sensitive Nursing Model. In: Fitzpatrick JJ, Whall AL (Edn.) Conceptual models of nursing: Global perspectives. Upper Saddle, NJ: Pearson.
Dinga J, Karvinen M (2008) Building Therapeutic Relationships with Mental Health Clients in Primary Care Settings- A Literature Review; Helsinki Metropolia University of Applied Sciences. Finland.
Dziopa F, Ahern K (2009) What makes a quality therapeutic relationship in psychiatric/mental health nursing: A review of the research literature. Internet Journal of Advanced Nursing 10: 1-10.
Wilkin P (2003) The craft of psychiatric-mental health nursing practice. Psychiatric and mental health nursing. The craft of caring 26-33. CRC Press. Oxford, UK.
Salimi S, Azimpour A, Mohammadzadeh S, Fesharaki M (2014) Psychometric properties of Persian version of the Caring Dimension Inventory (PCDI-25). Iran J Nurs Midwifery Res 19: 173-179.
Anshasi H, Ahmad M (2016) Tool Development to Measure Dyspnea among Patients with Advanced Cancer Stage. The Journal of Middle East and North Africa Sciences 2: 9-15.
Watson R, Hoogbruin AL, Rumeu C, Beunza M, Barbarin B, et al. (2003) Differences and similarities in the perception of caring between Spanish and UK nurses. J Clin Nurs 12: 85-92.
Miro J, Huguet A (2004) Evaluation of reliability, validity, and preference for a pediatric pain intensity scale: the Catalan version of the faces pain scale--revised. Pain 111: 59-64.
Ayoub Z (2014) Understanding mental health. The Jordan Times.
World Health Organization (2011) WHO-AIMS Report of the Assessment of the Mental Health System in Jordan.
Watson R, Lea A (1997) Journal of the American Psychiatric Nurses Association Journal of the American Psychiatric Nurses Association. Journal of Advanced Nursing 25: 87-94.
Ahmad MM (2010) Validation of the Cognitive Appraisal Health Scale with Jordanian patients. Nurs Health Sci 12: 74-79.
Dardas LA, Ahmad MM (2014) Psychometric properties of the Parenting Stress Index with parents of children with autistic disorder. J Intellect Disabil Res 58: 560-571.
Edwards D, Burnard P, Coyle D, Fothergill A, Hannigan B (2000) Stress and burnout in community mental health nursing: a review of the literature. J Psychiatr Ment Health Nurs 7: 7-14.
Humpel N, Caputi P, Martin C (2001) The relationship between emotions and stress among mental health nurses. Aust N Z J Ment Health Nurs 10: 55-60.
Ahmad MM (2005) Psychometric evaluation of the Cognitive Appraisal of Health Scale with patients with prostate cancer. J Adv Nurs 49: 78-86.
Atiyeh H, Ahmad M, Alslman E, Bani Hani M (2016) The Pragmatic Utility of Watson Based-Caring Measures. Journal of Nursing Measurement.
Alasad JA, Ahmad MM, Tabar NA, Ahmad H (2015) Nursing Student's Experiences in Critical Care Course: A Qualitative Study. Journal of Intensive and Critical Care. 1: 1-7.
Rey J, Walter G, Giuffrida M (2004) Policy, structural change and quality of psychiatric services in Australia: The views of psychiatrists. Australian Psychiatry 12: 118-122.
Treatment Protocol Project. Acute Psychiatric Inpatient Care: A Source Book (1999) Darlinghurst, NSW: Collaborating Centre for Mental Health and Substance Abuse.
O'Brien L, Cole R (2003) Close-observation areas in acute psychiatric units: A literature review. International Journal of Mental Health Nursing 12: 165-176.
Moore KA, Cooper CL (1996) Stress in mental health professionals: A theoretical overview. International Journal of Social Psychiatry 42: 90-101.
Salem A, Ahmad M (2016) Maturity of the concept of the concept of coping in health research. International Journal of Applied Sciences and Innovation 2: 95-100.
Chapman R, Styles I, Perry L, Combs S (2010) Nurses' experience of adjusting to workplace violence: a theory of adaptation. Int J Ment Health Nurs 19: 186-194.
Dawson P, Kingsley M, Pereira S (2005) Violent patients with psychiatric intensive care units: Treatment approaches, resistance and the impact upon staff. Journal of Psychiatric 1: 45-53.
Dardas LA, Ahmad MM (2014) Validation of the World Health Organization's Quality of Life Questionnaire with parents of children with autistic disorder. J Autism Dev Disord 44: 2257-2263.
Kipping CJ (2000) Stress in mental health nursing. Int J Nurs Stud 37: 207-218.