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Journal of Evaluation in Clinical Practice ISSN 1356-1294

Individualized care scale nurse version: a Finnish

validation study jep_1168 145..154

Riitta Suhonen RN PhD,1 Marja-Liisa Gustafsson RN MNSc,2 Jouko Katajisto MSocSci,3

Maritta Vlimki RN PhD,4 and Helena Leino-Kilpi RN PhD5
Adjunct Professor, Quality and Development Manager, Department of Nursing Science, University of Turku, Health Care District of Forssa, Turku,
Study Advisor, Department of Nursing Science, University of Turku, Turku, Finland
Senior Lecturer, Department of Statistics, University of Turku, Turku, Finland
Professor, Nurse Manager, Department of Nursing Science, University of Turku, Hospital District of Southwest Finland, Turku, Finland
Professor and Chair, Nurse Manager, Department of Nursing Science, University of Turku, Hospital District of Southwest Finland, Turku, Finland

Keywords Abstract
individualized care, instrument development,
nursing, reliability, validity Rationale Nurses work is inextricably linked to the evaluation of the quality of care
provision in health care. Within this evaluation, individualized care is a topical theme in
Correspondence western countries. Currently, there is no suitable instrument to measure the level of
Dr Riitta Suhonen individualized care from the nurses point of view.
Department of Nursing Science Aim To report the development process of the individualized care scale nurse (ICS-
University of Turku Nurse) and to ensure its validity and reliability.
Lemminkisenkatu 1, 2nd Floor Methods A methodological design was used. Data were obtained from 544 nurses
20014 Turku (N = 923, response rate 59%) from inpatient wards in one university, two regional and two
Finland psychiatric hospitals as well as four health centres. Three expert analyses were used to
E-mail ensure content validity. Cronbachs alpha coefficients and item analysis were used to
examine internal consistency reliability. A principal components analysis, Spearmans
Accepted for publication: 19 December correlation coefficients, multiple regression analysis and structural equation modelled by
2008 LISREL were conducted to evaluate construct validity.
Results The expert analyses provided good content validity evidence. The ICS-Nurse was
easy to administer and able to be completed quickly. There were few missing data.
Cronbachs alpha coefficients ranged 0.720.84. All item-to-total correlations were accept-
able (>0.30), but some of the inter-item correlations were high. The principal components
analysis supported the three-component structure explaining 52% of the variance in ICS-
A-Nurse and 56% in ICS-B-Nurse. LISREL supported the theoretical model.
Conclusions The ICS-Nurse is a valid and reliable instrument that can be used to measure
nurses perceptions of individualized nursing care in inpatient wards. There is a need to test
instrument further, both nationally and internationally.

Individualized care has been studied and conceptualized from

Introduction both the patients [3,1114] and nurses perspective [1,1517].
Individualized approaches to patient care have gained increasing Suhonen et al. [11,18] defined individualized care as a type of
importance in the delivery of nursing care [13] and have become nursing care delivery which takes into account patients personal
a topical theme in discussions about health care systems in many characteristics in their clinical condition, their personal life situa-
western countries [4,5]. The importance of individualized care has tion and their preferences promoting patient participation in deci-
also been recognized by patients [6,7] and nurses [6,8,9]. Nurses sion making. van Servellen [15] examined individualized care
work is inextricably linked to the evaluation of the quality of care from nurses perspective in a primary nursing context. She sug-
provision in health care in terms of processes, activities and gested that individualized nursing care transforms standardized
working environments [10], which in many ways is linked to the nursing procedures and activities into personally tailored care
provision of individualized care. within the unique context of each patient situation.

2009 The Authors. Journal compilation 2009 Blackwell Publishing Ltd, Journal of Evaluation in Clinical Practice 16 (2010) 145154 145
Individualized care scale nurse R. Suhonen et al.

Clinical situation

Personal life situation

Nurses views on how
they support their patients
Decisional control individuality through
(DecA-Nurse) specific nursing activities
(ICS-A-Nurse) Individualised
care from nurses
point of view

Clinical situation
(ClinB-Nurse) Nurses views on how they
evaluate the maintenance of
individuality in care the
Personal life situation provided
(PersB-Nurse) (ICS-B-Nurse)

Decisional control

Figure 1 Theoretical background of the individualized care scale nurse (ICS-Nurse).

The content of individualized care incorporates the variety of tive. These are: (1) by exploring nurses views about how nurses
care activities that take place and develops during the nurse support their patients individuality through specific nursing
patient interaction [19]. First, nurses assess and collect informa- activities [12]; and (2) by examining how nurses evaluate the
tion about patients preferences, needs and perceptions [2022]. maintenance of individuality in care they provide [12]. These two
Second, nurses use (tailor or individualize) the information about dimensions were used to develop the two parts of the new scale,
patients characteristics and situation, reactions and responses to the ICS nurse (ICS-Nurse) (Fig. 1).
their health concerns, and the physical and socio-environmental The nursing role, encompassing surveillance, treatment and care
characteristics of the context to design activities [22,23]. Finally, over each 24-hour period in hospital, makes nurses, as a group,
patients participate in their care intervention depending on the uniquely suited to provide individualized care [15,28] and in that
patients individual expectations of the power they have to partici- way improve patient outcomes [20,22,28,29]. Patient outcomes
pate and the way the nurses encourage them during care delivery. related to nursing care are the products of the service nurses
Substantial attention has been devoted to the development of deliver and the responses from the patient. Patient outcomes
individualized care in recent years but despite this empirical evi- related to nursing care are therefore appropriate as defining criteria
dence assessing progress is limited [1,2]. Perhaps, this is because only when care is being evaluated from the patients perspective
the evaluation of the provision of nursing care is required from [30]. Therefore, the ICS-Nurse is based on and examines patient
many perspectives and in many contexts using similarly based issues about individualized patient care delivered and evaluated by
validated instruments [2426]. Although studied from nurses nurses.
point of view [1,1517], a review of the literature did not find a
suitable instrument for the measurement of nurses perceptions of
individualized care. For this gap to be filled, a suitable instrument Aim
is required that can reliably measure individualized care from the
The aim of this study was to report the development and validation
nurses perspective.
process of an instrument for the measurement of individualized
One instrument currently used to measure the level of individu-
patient care from the nurses perspective (Fig. 2). This was done in
alized care provided by nurses is the individualized care scale
two phases by (1) producing the instrument for the measurement
patient (ICS-Patient) [11,12,18]. Suhonen et al. [12,18] conceptu-
of individualized care from the nurses perspective; and (2) empiri-
alized individualized care into two dimensions: (1) nursing activi-
cally evaluating the instruments validity and reliability.
ties supporting patient individuality; and (2) perceptions of the
realization of that individuality in the care provided. Within these
two dimensions, individualized care includes the recognition of
the patients individual clinical situation, personal life situation
and the decisional control they have over their own care [3,11
Phase I: producing the ICS-Nurse
Individualized care, as seen from nurses perspective, can be The original definition of the concept of individualized care is
evaluated using these same dimensions from a different perspec- based on a concept analysis and written from the patients per-

146 2009 The Authors. Journal compilation 2009 Blackwell Publishing Ltd
R. Suhonen et al. Individualized care scale nurse

Theoretical framework of the ICS-Nurse

Phase 1 Expert analysis
Development of the 4 post-doctoral senior researchers
ICS-Nurse 35 masters degree students
9 clinical nurses

Pilot n = 41, response rate 82 %

Distributions, mean scores
Preliminary internal consistency reliability:
Cronbachs alpha coefficients, item analysis

Empirical testing
Phase 2 Data from nurses n = 544, response rate 59 %
Empirical testing of RNs n = 357, 66 %, ENs/certified nurses aids n = 161,
the reliability and 29 %, ward managers n = 26, 5 %
validity of the ICS- Distributions, missing data, mean scores
Internal consistency reliability: Cronbachs alpha
coefficients, item analysis

Construct validity, structural validity

Principal components analysis, varimax
rotation with Kaisers normalization
Multiple regression analysis
Figure 2 The process of the development
Structural equation model using LISREL
and evaluation of the individualized care scale
nurse (ICS-Nurse) instrument. RN, regis-
tered nurse.

spectives [2,11,12,18]. This same conceptualization was used to

Expert analysis to evaluate content validity
produce the items in the ICS-Nurse.
The content validity of the ICS-Nurse was evaluated using three
groups of experts: (1) post-doctoral senior researchers (n = 4);
The ICS-Nurse instrument
(2) masters degree students (n = 35); and (3) clinical nurses
The ICS-Nurse is a bipartite questionnaire designed for the (n = 9). The foci of the expert deliberations were reviews of
purpose of exploring nurses views about individualized care on item relevancy, content and clarity [3133] and measured on a
two dimensions (ICS-A-Nurse and ICS-B-Nurse). The ICS-A- 4-point Likert type scale (1 = the item is not relevant/clear,
Nurse is a 17-item 5-point Likert type scale (1 = strongly disagree, 2 = the item needs major revisions to be relevant/clear, 3 = the
2 = disagree to some extent, 3 = neither agree nor disagree, item needs minor revisions to be relevant/clear, 4 = the item is
4 = agree to some extent, 5 = strongly agree) designed to explore relevant/clear) [34]. Content validity was determined by the pro-
nurses views on how nurses support patient individuality through portion of experts who scored items as 3 or 4. The index for
nursing activities in general. The ICS-B-Nurse is also a 17-item relevancy and clarity of the items is the percentage of agreement
5-point Likert type scale exploring the extent to which nurses judged to be valid content by receiving a score of 3 or 4. Imle
perceive the care they provide to patients is individual. Both scales and Atwood [35] report that a percentage of agreement of 70%
consist of three sub-scales: (1) clinical situation (ClinA and B, is necessary, of 80%, adequate and of 90%, good. The experts
seven items); (2) personal life situation (PersA and B, four items); were also asked to suggest revisions for items where necessary
and (3) decisional control over care (DecA and B, six items). [34].

2009 The Authors. Journal compilation 2009 Blackwell Publishing Ltd 147
Individualized care scale nurse R. Suhonen et al.

used to evaluate the sample size for conducting factor analysis

Piloting the ICS-Nurse
[39]. Spearmans rho correlation coefficients were computed
The ICS-Nurse was piloted by 50 nurses working in the inpatient between the sub-scales of the ICS-Nurse to determine the exist-
wards of a regional hospital and health centre in July 2007. The ence, type and strength of the associations [40,41].
aim was to examine the reliability and clarity of the items and the Enter method multiple regression analysis was computed to
instructions given to complete the questionnaire. Preliminary examine the extent of the single-sub-scale concepts (clinical situ-
analyses included item distributions, sub-scale means, Cronbachs ation, personal life situation, decisional control) conceptualized
alpha coefficients and average inter-item as well as item-to-total individualized care in the ICS-Nurse. The analysis produces the
correlations. overall explanatory power of all predictor variables (R2) and the
relative importance of individual predictors in the analysis when
the standardized regression coefficient (beta) is inspected. Multi-
Phase II: empirical testing of the ICS-Nurse
collinearity was examined using tolerance values. Tolerance
values of 0.1 or less indicate problems with multicollinearity [42]
Design, sampling and data collection
and the variance inflation factor (VIF). Multicollinearity is a
A methodological study design was used within one university concern when the VIF exceeds 10 [43]. These indices define the
hospital district area in southern Finland between March and May proportion of variability of that variable not explained by its linear
2008. The sample was stratified on the type of health care organi- relationships with the other independent variables in the model
zation (university, regional and psychiatric hospitals, health [40]. A statistical significance level of P < 0.05 was used for all the
centres) because previous evidence identifies the effect of the tests.
working environment on nurses perceptions of care [10,36,37]. Finally, structural equation modelling (SEM) with LISREL 8.3
Within this stratification, a heterogeneous sampling frame was using the maximum likelihood estimation procedure [44] was con-
used which consisted of registered nurses (RNs), enrolled nurses ducted to investigate the construct validity of the ICS-Nurse.
(ENs), certified nurses aids and ward managers from typical Several goodness-of-fit indices (GFI) were also used: chi-squared
inpatient wards working in randomly assigned health care with degrees of freedom (d.f.) and a P-value and a relative likeli-
organizations. hood ratio (RLR), the ratio of the chi-squared value to the number
of d.f. There is no consensus on what value constitutes a good fit
[45] but RLR of ~3 or lower are considered indicative of a good fit
Ethical approval and data collection
[46]. In addition, the root mean square error of approximation
This study was conducted in accordance with the general prin- (RMSEA) was used.
ciples of research ethics [38]. Permission to conduct the study was Additional GFI were used because of the extensive data set.
obtained from the chief administrators of the hospital districts and These were the GFI and the comparative fit index. Finally, the
health centres. Research assistants provided oral information to the amount of unexplained variance, or the error, of each endogenous
nursing staff in each of the participating wards and units. They also variable was evaluated using root mean square residual (RMR)
distributed a pack which included questionnaires, an introductory and the standardized residual (SRMR). The critical N was also
letter explaining the purpose of the study, the voluntary nature of calculated.
participation in the study and how anonymity of the responses
would be maintained. There was also questionnaire completion
instructions and information about what to do with the completed
questionnaire. The completed questionnaires were placed in sealed
Content validity from three expert analyses
envelopes and posted in ward-based letter boxes provided for this
purpose. The research assistants collected the sealed envelopes for First, four post-doctoral senior researchers conducted the expert
analysis. analysis (Table 1). All experts agreed the clarity of the items giving
100% score to 15 items in the ICS-A-Nurse and to 16 items in the
ICS-B-Nurse. A 100% agreement was obtained in 15 of the items
Statistical analyses
in the ICS-A-Nurse and 16 out of 17 items in the ICS-B-Nurse.
The data were analysed using the spss 14.0 for Windows (SPSS However, in the ICS-A-Nurse, one item achieved only 67% agree-
Inc., Chicago, IL, USA). Both item and sub-scale levels were first ment on relevancy. Seven items were therefore clarified by chang-
analysed using descriptive statistics, frequencies, means and stan- ing, adding or deleting words.
dard deviations (SD). Eight sum variables (ICS-A-Nurse, ClinA- Second, masters degree students (n = 35) analysed the ICS-
Nurse, PersA-Nurse, DecA-Nurse, ICS-B-Nurse, ClinB-Nurse, Nurse. The relevancy of one item in ICS-B-Nurse was question-
PersB-Nurse and DecB-Nurse; Fig. 1) were formed by counting able, achieving 62%. Five items on the ICS-B-Nurse were clarified
the item scores and dividing the total sum by the number of items by changing the wording, altering the tense and by adding or
in each of the sub-scales to obtain average scores. The initial deleting words.
internal consistency of the ICS-Nurse was examined using Cron- Finally, nine clinical nurses evaluated the ICS-Nurse items for
bachs alpha coefficients and item analysis including inter-item, clarity and relevancy. Fourteen items in the ICS-A-Nurse and 12
average inter-item and item-to-total correlations. Construct valid- items in the ICS-B-Nurse achieved 100% agreement on clarity.
ity was investigated using the principal components analysis Eleven items in the ICS-A-Nurse and 11 items in the ICS-B-Nurse
(PCA) with Kaisers normalization and varimax rotation. The achieved 100% agreement on relevance. One item in the ICS-B-
Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy was Nurse achieved an agreement of 66%. This low agreement was on

148 2009 The Authors. Journal compilation 2009 Blackwell Publishing Ltd
R. Suhonen et al. Individualized care scale nurse

Table 1 The content validity evaluation of the individualized care scale nurse (ICS-Nurse) by three expert review groups

Expert analysis 1 Expert analysis 2 Expert analysis 3

Experts Four post-doctoral senior researchers Thirty-five masters degree students Nine clinical nurses
Age (years)
Mean 48 35 45
Standard deviation 5 6 10
Range 4151 2547 3159
Working experience (mean years) 13 12 18
Content Items (n)
ICS-A-Nurse ICS-B-Nurse ICS-A-Nurse ICS-B-Nurse ICS-A-Nurse ICS-B-Nurse
index (% of
agreement) Relevancy Clarity Relevancy Clarity Relevancy Clarity Relevancy Clarity Relevancy Clarity Relevancy Clarity

100 15 15 16 16 7 2 4 4 11 14 11 12
>90 8 11 10 7
>80 2 4 2 5 3 3 4 3
>70 1 2 1 1 1 3 1 2
>60 1 1 1

the item In providing care for the patients I took into account their
Features on score distribution
everyday activities (e.g. work, leisure activities) outside the hos-
pital. However, the content of this item is theoretically important The whole range of scale options was used in the ICS-Nurse
for individualized care and for taking into account the patients and there was very little missing data ranging 0.21.3% on the
personal life situation. The item was kept in the scale. items in the ICS-A-Nurse and 0.5% to 1.3% in the ICS-B-Nurse
(Table 2).
The ICS-A-Nurse mean score was 4.10 (SD = 0.53) out of 5.0
Pilot study and the individual mean scores ranged 3.344.59. The ICS-B-
Nurse mean score was 4.02 (SD = 0.56) and the individual mean
Pilot data were obtained from 41 nurses (response rate of 82%). scores ranged 3.574.61. Nurses perceptions of patient individu-
The mean age of the nurses was 46.2 9.3 years (ranged 2359) ality in the care received (ICS-B-Nurse) were more positive than
and all were female. The mean values for the sub-scales ranged their perceptions of support of patient individuality through
3.724.40. All possible scale options were used although the nursing activities (ICS-A-Nurse) (Table 2). At the sub-scale level,
evaluation tended to show agreement, rather than disagreement, this trend was similar suggesting that perceptions of care received
with the positively worded items. Cronbachs alpha coefficients were more positive than perceptions of nursing activities support-
for the sub-scales ranged 0.760.90 and average inter-item corre- ing patient individuality in the clinical situation, personal life
lations ranged 0.3560.528. There were two low item-to-total cor- situation and promoting patients decisional control over their
relations (r < 0.3) [47] between the items and the sub-scale PersA- care. All the items were somewhat negatively skewed, suggesting
Nurse. However, no changes were made after the pilot study. that the higher evaluations were used more often.

Main study Internal consistency reliability

Data were collected from nurses from one university, two regional The Cronbachs alpha coefficients for ICS-A-Nurse and ICS-B-
and two psychiatric hospitals as well as four primary health Nurse were 0.88 and 0.90, ranged 0.720.83 and 0.730.84,
centres. Five hundred and forty-four completed questionnaires respectively, in the sub-scales (Table 2). All item-to-total correla-
were returned (response rate 59%) including RNs (n = 357, 66%), tions in both ICS-A-Nurse and ICS-B-Nurse scales were accept-
ENs/certified nurses aids (n = 161, 29%) and ward managers able against the criteria of r > 0.3 [47]. Average inter-item
(n = 26, 5%). The mean age of the respondents was 40.7 11.1 correlations in the ICS-A-Nurse and ICS-B-Nurse ranged 0.32
years (ranged 1963) and they had 15.8 10.8 years (ranged 0.45 and 0.400.45 respectively. However, there was much more
143) of experience in health care. Most of the respondents were variation in the individual inter-item correlations (Table 2).
female (n = 495, 91%). Two-thirds (n = 539) had obtained the
matricular examination as their basic education and the rest had an
Principal components analysis
elementary school education (34%). In their professional educa-
tion, the participants had a school degree (32%, ENs), college The calculated KMO was 0.91 for the ICS-A-Nurse and 0.92 for
degree (20%, RNs), college degree with 1-year specialization the ICS-B-Nurse indicating that the sample was large enough to
(19%, RNs), polytechnic degree (28%, RNs) or university degree perform a satisfactory PCA. The PCA revealed three components
(1%, RNs). with an eigenvalue higher than 1 (Kaisers criterion, an eigenvalue

2009 The Authors. Journal compilation 2009 Blackwell Publishing Ltd 149
Individualized care scale nurse R. Suhonen et al.

Table 2 Individualized care from nurses point of view on the sub-scale level and reliability analysis of the scales

Sub-scale- Cronbachs Item-to- Average correlations
Items to-total alpha total r > 0.3 inter-item 0.30 < r < 0.70
Variable n Mean (SD) (n) Range correlation* coefficient correlations (%) correlations (%)

Nurses views on support of 546 4.02 (0.56) 17 15 0.88 0.360.68 100 0.32 103/136 (76)
patient individuality
through nursing
Patients clinical situation 546 4.26 (0.57) 7 15 0.841 0.83 0.430.64 100 0.41 19/22 (86)
Personal life situation 545 3.90 (0.87) 4 15 0.840 0.77 0.500.65 100 0.45 6/6 (100)
Decisional control 545 4.02 (0.61) 6 15 0.840 0.72 0.340.59 100 0.32 4/15 (27)
Nurses views on 544 4.10 (0.53) 17 15 0.90 0.390.67 100 0.36 90/136 (66)
maintenance of
individuality in care they
provided (ICS-B-Nurse)
Patients clinical situation 544 4.30 (0.54) 7 15 0.868 0.84 0.430.69 100 0.45 19/21 (86)
Personal life situation 544 3.73 (0.76) 4 15 0.861 0.73 0.410.61 100 0.40 6/6 (100)
Decisional control 544 4.12 (0.59) 6 15 0.859 0.78 0.370.66 100 0.40 13/15 (87)

*Spearmans rho correlation coefficient, P < 0.001.

ICS, individualized care scale; SD, standard deviation.

should be >1.00). This solution explained 52% of the total variance views about how they supported patient individuality through
in ICS-A-Nurse and 56% in ICS-B-Nurse (Table 2). The compo- nursing activities. Tolerance values of the model ranged 0.55
nents had eigenvalues from 1.11 to 6.17 in ICS-A-Nurse and 1.14 0.60, which were all at an acceptable level. In the current sample,
to 6.81 in ICS-B-Nurse, and their variances were between 6.54 the VIF of predictors ranged 1.671.81 causing no concern of
36.32 (ICS-A-Nurse) and 7.2740.0 (ICS-B-Nurse). multicollinearity.
The first component of ICS-A-Nurse and ICS-B-Nurse, clinical The model for ICS-B-Nurse was similarly statistically signifi-
situation, had loadings ranging 0.4530.797 and 0.3580.791 cant (F = 3947309.6, d.f. = 3, P < 0.001) with three sub-concepts:
respectively. The second component of ICS-A-Nurse and ICS-B- ClinB (t = 1038.87, P < 0.001), PersB (t = 859.0, P < 0.001) and
Nurse, measuring the personal life situation, had loadings ranging DecB (t = 954.8, P < 0.001) which explained 100% of the depen-
0.5920.742 and 0.3920.759 respectively. The third component dent variable changes. Tolerance values of this second model
of ICS-A-Nurse and ICS-B-Nurse, measuring patients decisional ranged 0.500.54 and the VIF ranged 1.841.99. The clinical
control, had loadings ranging 0.4390.656 and 0.4100.656 situation was also the most significant predictor of nurses views
respectively (Table 3). on the extent individuality in patient care received.
Spearmans rho correlations for the ICS-A-Nurse and ICS-B-
Nurse total scale and its sub-scales ranged 0.8400.841 and 0.859
0.868, respectively, and were all statistically significant at the level Structural equation modelling using LISREL
P < 0.001. The hypothesized model (see Fig. 1) and similarly the structure of
the questionnaire were assessed simultaneously using LISREL
SEM. All hypothesized factors were free to vary in accordance
Multiple regression
with the sample data [48]. At first, the hypothesized model was
Multiple regression analysis was conducted for both the ICS-A- assessed for its significance and overall fit using chi-squared sta-
Nurse and the ICS-B-Nurse to examine the strength of the domains tistics, the GFI and an examination of the residual covariance
in explaining the measured concepts separately. The model for matrix. The structure of the hypothetical model was not supported
ICS-A-Nurse was statistically significant (F = 841149, d.f. = 3, by the chi-squared statistics (c2 = 255.62, d.f. = 8, P < 0.0001)
P < 0.001) with three sub-concepts: ClinA (t = 496.5, P < 0.001), (Table 4). With SEM by LISREL, the aim is to find small, non-
PersA (t = 454.79, P < 0.001) and DecA (t = 458.58, P < 0.001) significant chi-squared statistics [49]. The GFI for the overall
which explained 100% of the dependent variable changes. The model was 0.86 suggesting that the model does not fit the data. The
clinical situation was the most significant predictor of nurses RMSEA was 0.24 (90% confidence intervals = 0.210.26) with a

150 2009 The Authors. Journal compilation 2009 Blackwell Publishing Ltd
R. Suhonen et al. Individualized care scale nurse

Table 3 Principal components analysis varimax rotation with Kaisers normalization

ICS-A-Nurse ICS-B-Nurse

Loadings, rotated Loadings, rotated

Item Item
number Abbreviated item Communality C1 C2 C3 number Communality C1 C2 C3

A01 Feelings about illness/health 0.656 0.797 0.071 0.122 B01 0.576 0.701 0.234 0.171
A02 Needs that require care and 0.575 0.721 0.168 0.164 B02 0.702 0.791 0.059 0.270
A03 Chance to take responsibility as far 0.417 0.524 0.282 0.250 B03 0.352 0.358 0.168 0.442
as possible
A04 Identify changes in how they have 0.399 0.570 -0.021 0.270 B04 0.602 0.743 0.072 0.211
A05 Talk with patients about fears and 0.575 0.663 0.358 0.087 B05 0.592 0.560 0.513 0.128
A06 Find out how their health 0.598 0.492 0.596 -0.024 B06 0.699 0.586 0.560 0.107
conditions affect them
A07 What the illness/health condition 0.625 0.453 0.634 0.132 B07 0.696 0.481 0.678 0.076
means to them
A08 What kinds of things they do in 0.586 0.277 0.689 0.187 B08 0.673 0.115 0.759 0.290
their everyday life
A09 Previous experiences of 0.598 0.059 0.732 0.240 B09 0.648 0.056 0.753 0.279
A10 Everyday habits 0.394 0.120 0.592 0.171 B10 0.495 0.048 0.457 0.533
A11 Family to take part in their care 0.595 0.057 0.742 0.201 B11 0.319 0.154 0.392 0.376
A12 Instructions to patients 0.260 0.300 0.113 0.397 B12 0.465 0.331 0.111 0.586
A13 What they want to know about 0.489 0.002 0.544 0.439 B13 0.383 0.348 0.306 0.410
illness/health condition
A14 Patients personal wishes with 0.543 0.424 0.113 0.591 B14 0.634 0.445 0.077 0.656
regard to their care
A15 Help patients take part in decisions 0.590 0.264 0.300 0.656 B15 0.582 0.200 0.178 0.714
A16 Encourage patients to express their 0.512 0.302 0.282 0.584 B16 0.629 0.432 0.175 0.641
A17 Ask patients at what time they 0.448 -0.012 0.162 0.649 B17 0.426 -0.093 0.261 0.591
would prefer to wash
Eigen values 6.17 1.57 1.11 6.81 1.40 1.24
Percentage of explained variance 36.3 9.3 6.5 40.0 8.2 7.3
Cumulative percentage of explained variance 36.3 45.6 52.1 40.0 48.3 55.5

The bold figures indicate that the highest loading of an item is in its theoretical component.
C1, the first component; C2, the second component; C3, the third component; ICS, individualized care scale.

P-value (for test of close fit RMSEA < 0.05) of 0.00, again sug- suggesting that the model fits the data very well and provided
gesting an unacceptable fit of the data with the model. The RMR evidence for structural validity.
(0.033) was acceptable being <0.05 [50], but the SRMR (0.061) The RMSEA of 0.062 (P = 0.24) indicates a moderate fit for the
was not acceptable. Therefore, there was a need to revise the model [40]. The residuals of the indicators were small, the RMR of
model. This was conducted theoretically by adding additional 0.0069 and SRMR of 0.015 were at an acceptable level against the
paths. As both the ICS-A-Nurse and ICS-B-Nurse share the same criteria of <0.05 [50] and adequately explaining individual obser-
conceptual base, the first revision was done by intercorrelating the vations. The critical N was 529.01. The Akaikes information
sub-concepts [12]. criterion (AIC) of 47.44 was notably lower than in the first model.
The structure of the second model was not supported by chi- The coefficients on the arrows between the latent variable and
squared statistics (c2 = 15.44, d.f. = 5, P = 0.009). However, the the empirical indicator should be approximately from 0.50 to 1.0
significance of the chi-squared value may sometimes be due to its for the indicator to be well tied to its latent variable [48]. In the
sensitivity to large sample sizes [48,49,51]. The RLR (c2/d.f. ratio) second model, the coefficients were as follows (ICS-B-Nurse in
of 3.09 indicated an acceptable degree of discrepancy. All the other parenthesis): ClinA 0.42 (ClinB 0.45), PersA 0.64 (PersB 0.58)
indices supported the second model with a close fit to the data. and DecA 0.49 (DecB 0.47). The path coefficients were evaluated
Further support for the fit of the second model to the data was for significance using Students t-test ranging 18.2120.56 for
obtained from model estimates that were less dependent on ICS-A-Nurse and 19.3921.16 for ICS-B-Nurse. Parameters with
the sample size. The index values were as follows: GFI = 0.99, t-values larger than 2.0 are generally considered significantly dif-
comparative fit index = 1.00, Normed fit index (NFI) = 0.99, ferent from 0 and therefore statistically significant [48].

2009 The Authors. Journal compilation 2009 Blackwell Publishing Ltd 151
Individualized care scale nurse R. Suhonen et al.

Table 4 LISREL model of the ICS-Nurse, n = 544 viding care for the patients, they assumed responsibility for their
care as far as they were able), B4 (In providing care for the
Model 1 Model 2
patients, I took into account the changes in how they felt) and B6
c 255.62 15.44 (In providing care for the patients, I took into account the way the
Degree of freedom 8 5 illness/health condition has affected them). These problematic
P <0.0001 0.009 items occurred in Clin A and Clin B. However, in the expert
Relative likelihood ratio (c2/degree of 31.95 3.09 analyses, some items in PersA and B were also considered unclear
freedom) and were revised during the development process. There is need to
Goodness-of-fit indices 0.86 0.99 develop new insights into the sensitivity of the items in the instru-
Comparative fit index 0.90 1.00
ment using different approaches. This could be done by conduct-
Normed fit index 0.90 0.99
ing, for example, a Rasch analysis for the evaluation of item
Root means square error of 0.24 0.062
sensitivity [54].
Close attention to construct validity is a fundamental require-
90% confidence intervals for root 0.210.26 0.0280.098
means square error of approximation
ment in nursing research, because the study variables are often
Root mean square residual 0.033 0.0069
abstract and so difficult to measure quantitatively [52]. Factor
Standardized root means square 0.061 0.015 analysis, used in this study, is an important statistical tool for
residual providing validity evidence concerning the structure of instru-
Critical N 38.30 529.01 ments [47]. Three components were extracted using a PCA which
Akaikes information criterion 281.62 47.44 explained 52% of the variance in the ICS-A and 56% in the ICS-B.
There is no gold standard for the percentage of explained variance,
but these percentages are typical of previous studies [47].
The Spearmans correlations between the sub-scales measuring
Discussion clinical situation, personal life situation and decisional control as
The evaluation of health care is important and it should be per- well as the total ICS-A-Nurse and ICS-B-Nurse correlated strongly.
formed from different perspectives [4,37]. In order to evaluate This result indicates construct validity [41,47]. However, the result
health care processes and activities as well as perceptions of both is obvious as the sub-scales represent sub-concepts of the same
providers and users, reliable and valid instruments are needed conceptualization. In multiple regression, the multiple correlation
[2426,41,47]. is tested for significance and each of the beta weights is also tested
The ICS-Nurse instrument has face validity being based on the for significance [47]. This provides information about the signifi-
concepts of the ICS-Patient version [12,18]. However, the ICS- cance of the contribution of the associated independent variable to
Patient instrument includes contents that the patients can evaluate the variance accounted for in the dependent variable. The results
and includes activities and maintenance issues that occur in the pointed out that the sub-scales, ClinA and B, were the most signifi-
patientnurse interaction. In the future, there is need for further cant contributors in the ICS-A-Nurse and ICS-B-Nurse.
testing to find out whether it would be useful to include some items A new insight was obtained by conducting confirmatory factor
which reveal the background work that nurses perform in order to analysis using LISREL for the examination of construct validity
provide individualized patient care in the ICS-Nurse version (e.g. [47,52]. SEM challenges researchers to think about how to
care plans and documentation). The content validity of the ICS- measure a theoretical construct. This construct models the hypoth-
Nurse evaluated by three different expert analyses provided many esized relationships between the theoretical constructs; therefore,
opportunities to revise and clarify the items in the scales. The if it fits the data, it supports the construct validity of the instrument
danger in this methodology is that many expert reviewers are under study. The first simple model did not fit the data. The second
needed to avoid an inflated estimate of validity that often results model, permitting error covariances between the corresponding
when experts endorse most items [34,52]. Therefore, this current sub-scales (clinical situation, personal life situation and decisional
evidence is considered indicative only. control), did not provide evidence for an adequate fit based on
The instrument was easy to administer and quick to complete. chi-squared statistics. However, chi-squared statistics have been
The few data missed were not focussed on specific questions. found to be high when used on large samples. Therefore, a variety
Cronbachs alpha values for the sub-scales were acceptable of additional GFI were examined such as GFI, NFI, RMSEA, RLR
ranging 0.720.83 (ICS-A-Nurse) and 0.730.84 (ICS-B-Nurse) and residuals. These indices provided support for the model fit, so
indicating that the items on the tool fit together conceptually. All that they supported the construct validity of the instrument.
sub-scale alpha values met the typical minimum criterion of 0.70 The significance of the ICS-Nurse in different clinical settings
[52,53]. The alpha values found for the scales in this study should remains to be seen. Theoretically strong and clinically important
also be considered indicative. More studies using different samples instruments are needed in order to evaluate and develop health care
and contexts are needed to evaluate the homogeneity of the items. delivery. Information obtained from the evaluation of nursing staff
The correlation matrix (item analysis) was evaluated in order to regarding their activities, care processes and the provision can be
find out how items related to each other. All item-to-total correla- used in developing both care outcomes and health care organiza-
tions were higher than 0.30 [47] but the inter-item correlations tions as work places. Hospitals are facing serious challenges to the
were more problematic. provision of health care that is consistently high quality, including
In the ICS-A-Nurse, the most difficult item with small inter-item the delivery of individualized patient care in rapidly changing and
correlations was A4 (I identify changes in how they have felt). In uncertain environments [10,36]. This is endorsed by nurses in
the ICS-B-Nurse, there were three problematic items: B3 (In pro- countries with distinctly different health care systems, who report

152 2009 The Authors. Journal compilation 2009 Blackwell Publishing Ltd
R. Suhonen et al. Individualized care scale nurse

similar shortcomings in their work, their working environments

and the quality of hospital care [10,36,37].
Used together with the ICS-Patient, the ICS-Nurse instrument Based on the study findings, the researchers suggest that the
provides an opportunity to evaluate the individuality of care in the 34-item ICS-Nurse is a multi-item, valid and reliable instrument
same care situation from both patients and nursing staffs per- that can be used to evaluate nurses perceptions of individualized
spectives. In turn, these instruments may provide a further oppor- nursing care in inpatient wards in health care organizations. The
tunity to develop individualized care, which is both highly valued ICS-Nurse was shown to have satisfactory content, face and con-
[69,29] and demanded [4,5]. struct validity and internal consistency reliability in a population
of Finnish nursing staff. The items of the ICS-Nurse should be
Limitations tested with different samples to determine whether the findings are
able to be replicated. This will provide further information that can
There are some limitations which need to be taken into account in
be used to develop the instrument. As Devon et al. [52] have stated
the interpretation and generalization of the results. The response
there are many methods that can be used to evaluate reliability and
rate in the study was only 59%. This is a similar response rate to
validity in the ongoing process for which there is no end point.
other research involving samples of nurses [41]. Despite the low
response rate, the sample size was large enough to conduct mul-
tivariable analyses such as SEM. Also the KMO measure of sam- Acknowledgements
pling adequacy suggested the sample size was large enough to This study was funded by the Research Foundation for Nursing
perform the PCA. Education, Kanta-Hme Hospital Districts special grant-in-aid
This study was conducted in the Finnish health care system (EVO), Forssa Health Care Districts special grant-in-aid (EVO)
which may limit the generalizability of the results and the appro- and the Finnish Cultural Federation, which are gratefully acknowl-
priateness of the use of the scale internationally. However, the edged. We wish to thank Norman Rickard, BSc(Hons) MSc RN,
sample was heterogenous including nurses of different grades for his help with the English language. We also thank the nurses
from different hospitals and health centres. The scale was therefore for their participation in this study.
evaluated in a variety of different organizations and working envi-
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154 2009 The Authors. Journal compilation 2009 Blackwell Publishing Ltd