Journal of Family Nursing

Volume 14 Number 1
February 2008 97-117
© 2008 Sage Publications
10.1177/1074840707312716
Families’ Importance http://jfn.sagepub.com
hosted at
in Nursing Care http://online.sagepub.com

Nurses’ Attitudes—An Instrument

Development
Eva Benzein, PhD, RNT
Pauline Johansson, PhD student, RN
Kristofer Franzén Årestedt, PhD, RN
School of Human Sciences,
Kalmar University, Kalmar, Sweden
Agneta Berg, PhD, RNT
Department of Health Sciences, Kristianstad University,
Kristianstad, Sweden
Britt-Inger Saveman, PhD, RNT, FEANS
School of Human Sciences,
Kalmar University, Kalmar, Sweden

This article describes the development and testing of a research instrument,

Families’ Importance in Nursing Care–Nurses’Attitudes (FINC-NA), designed
to measure nurses’ attitudes about the importance of involving families in
nursing care. The instrument was inductively developed from a literature
review and tested with a sample of Swedish nurses. An item-total correlation
and a first principal component analysis were used to validate the final instru-
ment, including a second principal component analysis to analyze dimen-
sionality, and Cronbach’s alpha was used to estimate internal consistency.
The instrument consists of 26 items and reveals four factors: families as a
resource in nursing care, family as a conversational partner, family as a bur-
den, and family as its own resource. Cronbach’s alpha was 0.88 for the total
instrument and 0.69 to 0.80 for the subscales. The instrument requires further
testing with other nurse populations.

Keywords: attitudes; family nursing; instrument development; nurses

T raditionally, the individual patient has been considered by nurses to be

the unit of care. Increasingly, nurses encounter families in hospitals and
the families’ homes. Is the nurse prepared to meet these families and

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98 Journal of Family Nursing

acknowledge them? Is the nurse able to recognize families not only as care
providers to their ill family member but as important to include as the unit
of care? If nurses are to acknowledge the family experience of health and ill-
ness, their attitude toward families is of great importance. In our attempt to
explore nurses’ attitudes about caring for families in a randomly chosen
national sample of Swedish nurses, we found no adequate existing instru-
ment; therefore, this article presents the psychometric development of such
an instrument.

Measurement of Nurses’ Attitudes

Toward Caring for Families

In recent years, the nurses’ relationships with families have been inves-
tigated in various health care contexts and with various methods. A variety
of terms have been used to capture the cognition, affect, and behavior of
nurses about families, including nurses’ views (Astedt-Kurki, Paavilainen,
Tammentie, & Paunonen-Ilmonen, 2001a; Jansson, Petersson, & Udén,
2001), perceptions (Ryan & Scullion, 2000), experiences (Berterö, 2002),
experiences and perceptions (Clarke, 2000; Hallgrimsdottir, 2000), views
and experiences (Hertzberg, Ekman, & Axelsson, 2003), and perspectives
(Astedt-Kurki, Paavilainen, Tammentie, & Paunonen-Ilmonen, 2001b;
Wright, 2002). The existing research has also been conducted in very con-
text-specific nursing settings such as critical care (Fulbrook & Albarran,
2005; Hallgrimsdottir, 2000), intensive care (Clarke, 2000; Söderström,
Benzein, & Saveman, 2003), surgical care (Astedt-Kurki et al., 2001b),
internal medical care (Astedt-Kurki et al., 2001a), long-term care (Ryan &
Scullion, 2000), primary-based palliative care (Berterö, 2002; Wright,
2002), and pediatric care (Jansson et al., 2001). Variability in the findings
from this review of literature indicate that although nurses claim that
families are important, this belief is not always supported by the evidence.
Findings from Hallgrimsdottir (2000), Jansson et al. (2001), Astedt-Kurki

Authors’ Note: We would like to thank all participants in the study and the staff at the
Swedish Association of Health Professionals (SAHP) for their cooperation. We also would like
to thank our students and colleagues at the School of Human Sciences, Kalmar University,
Sweden, for fruitful discussions throughout the whole process of the study, and to Mr. Alan
Crozier for revising the English. The study was funded by Kalmar University and SAHP.
Please address all correspondence to Eva Benzein, School of Human Sciences, Kalmar
University, SE-391 82, Kalmar, Sweden; e-mail: eva.benzein@hik.se.
 Benzein et al. / Families’ Importance in Nursing Care 99

et al. (2001a, 2001b), Berterö (2002), and Wright (2002) found that nurses
consider it important to establish a good relationship with the family.
However, nurses hold constraining and facilitative beliefs about including
families in nursing care (Benzein, Johansson, & Saveman, 2004; Hertzberg
et al., 2003; Leahey & Harper-Jaques, 1996).
There are a variety of instruments and questionnaires which measure
nurses’ attitudes about families (see Table 1). For example, one instru-
ment focuses on nurses in accident and emergency care, measuring their
attitudes toward and experiences of nursing care of families when one
family member is injured, critically ill, or dies suddenly (Hallgrimsdottir,
2000). Another example is the National Survey of Critical Care Nurses
Regarding End-of-Life, which involves nurses in intensive care and their
experiences of facilitating and constraining factors in nursing care of
patients and their families, but it is specific for end-of-life care (Kirchhoff
& Beckstrand, 2000). The Family-Centred Care Questionnaire measures
staff perceptions and implementation of family-centered pediatric care
(Bruce et al., 2002; Caty, Larocque, & Koren, 2001). Some instruments
measure nurses’ attitudes toward family needs in intensive care; the
Needs of Relatives of Critically Ill Patients Questionnaire (O’Malley et
al., 1991) is an example of one such instrument, whereas another mea-
sures nurses’ attitudes toward family needs when a family member has
died suddenly (Tye, 1993).
Some instruments measure nurses’ attitudes to family participation in
nursing care: For example, one instrument for long-term care staff mea-
sures their attitudes toward family participation (Ryan & Scullion, 2000).
In pediatric care, two instruments aim at comparing nurses’ and parents’
attitudes toward which caring activities the parents can carry out (Blower &
Morgan, 2000; Kristensson-Hallström & Elander, 1994). In summary, we
found instruments that either measure nurses’ attitudes toward families in
specific contexts (especially in intensive and pediatric care) or that measure
families’ needs and family participation; however, we did not find any
instrument measuring nurses’ attitudes about the importance of caring for
families from a generic nursing perspective.

Aim

The aim of this study was to develop a generic instrument to measure

nurses’ attitudes about the importance of families in nursing care and to test
its psychometric properties.
 Table 1

100
Existing Instruments From the Family Nursing Literature Search
Reference Participant Instrument Measurement Focus Context

Blower & Morgan Nurses (n = 40) and parents A checklist with 15 caring Attitude to family participation Pediatric care
(2000) (n = 40) of children activities in nursing care
0-5 years
Bruce et al. (2002) Health professionals The Family-Centered Care Perceptions and implementation Pediatric care
(n = 483) Questionnaire (FCCQ-R), of family-centered care
45 items
Caty, Larocque, & Health professionals The Family-Centered Care Perceptions and implementation Pediatric care
Koren (2001) (n = 338) Questionnaire (FCCQ-R), of family-centered care
45 items
Hallgrimsdottir Nurses (n = 54) A questionnaire, 64 items Attitude to and experiences of Accident and
(2000) nursing care of families when emergency care
one family member is critically
ill/injured or suddenly dies
Hammond (1995) Nurses (n = 27) and family A questionnaire and a checklist Attitude toward the provision of Intensive care
members (n = 20) with participatory care care by relatives to their
activities; the instrument was critically ill loved one
not shown in the article
Kirchhoff & Nurses (n = 199) The National Survey of Critical Experiences of facilitating and Intensive care
Beckstrand Care Nurses Regarding End- constraining factors in nursing
(2000) of-Life Care, 64 items care and specific for end-
of-life care
Kristensson- Staff members (n = 44) and A list with 37 aspects of caring Attitude to caring activities the Pediatric care
Hallström & parents (n = 40) of activities parents can carry out
Elander (1994) children 0-5 years

(continued)
 Table 1 (continued)
Reference Participant Instrument Measurement Focus Context

O’Malley et al. Nurses (n = 126) The Needs of Relatives of Attitude to family needs in Intensive care
(1991) Critically Ill Patients critical care
Questionnaire, 44 items
Maxton (1997) Staff members (n = 72) A questionnaire; the instrument Perceptions of families in Intensive care
was not shown in the article intensive care
Pfiel (1997) Nurses (n = 64) The European Charter for Opinion, feelings and Pediatric care
Children in hospital; the perceptions regarding their
instrument was not shown in own and the parents’ role in
the article nursing care
Plowright (1998) Nurses (n = 68) A questionnaire, 20 items; the Beliefs and attitudes regarding Intensive care
instrument was not shown in visiting critically ill patients
the article
Ryan & Scullion Family carers (n = 44) and A list of 100 tasks of family Attitude to family participation Long-term care
(2000) nursing home staff (n = 78) participation in nursing care
Tye (1993) Nurses (n=52) A questionnaire, 37 items Attitude to family needs when a Accident and
family member has suddenly died emergency care
Åstedt-Kurki et al. Nursing staff (n = 155) A questionnaire, 28 items; the View of how interaction between Hospital care
(2001a) instrument was not shown in staff and family members is
the article realized
Åstedt-Kurki et al. Nursing staff (n = 320) A questionnaire, 28 items; the View of how interaction between Hospital care
(2001b) instrument was not shown in staff and family members is
the article realized

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Methodology

Construction of the Instrument

The process of constructing the instrument, Families’ Importance in
Nursing Care–Nurses’ Attitudes (FINC-NA), was guided by the ideas of
Streiner and Norman (2003). We conducted a literature review, devised
items and scaling responses, selected items, reorganized items, and then
conducted several panel reviews with academic and practicing nurses to
establish content validity.
A comprehensive literature review was first step of the instrument
development process. During the spring of 2003, a manual search was con-
ducted and the following databases were used: Academic Research Library,
CINAHL, EBSCO, Libris, Medline, Science Citation, Social Science, and
SweMed+. This review was updated in the spring of 2004. Initially, the litera-
ture search focuses on nurses’ attitudes about the importance of families in
nursing care using the following search terms separately or in combination:
attitude, view of, beliefs, perceptions, family, family nursing, family centred
care, nurse, district nurse, health personnel, questionnaires, structured
questionnaires, nursing, nursing role, and professional. The literature search
included articles published after 1990, written in English, Swedish,
Norwegian, or Danish. The literature search resulted in 134 articles, which
were screened and reviewed by all authors in order to understand the topic.
Twenty-three articles were chosen as relevant for measuring nurses’ attitudes
toward families’ importance in nursing care, that is, areas such as nurses’ work
situation, emotional reactions, family compliance and beliefs, interactions
between nurses and families, family members’ participation, information,
nurses as a resource and family members’ resources, family structure, and the
influence of the disease on family members. These articles were used to con-
struct the initial 117 items of the first draft of instrument. Eight researchers
with expertise in family nursing were invited to discuss and critique the first
draft of the instrument. As a result, some items were excluded either because
their meaning was ambiguous or because they were difficult to understand.
Identical or similar items were then either sorted out or reconstructed to
make them less ambiguous (n = 35). This resulted in an 82-item instrument.
Response alternatives were constructed as a 4-point Likert scale (Likert,
1932). The score for each item was 1 (strongly disagree), 2 (disagree), 3
(agree), and 4 (strongly agree). This even number of scaling was chosen as we
wanted the nurse respondents to clearly express their attitude, either positive
or negative (Streiner & Norman, 2003). This second version of the instrument
 Benzein et al. / Families’ Importance in Nursing Care 103

was critically appraised and discussed at a meeting with nine researchers

(some of whom were present at the first meeting). These researchers who had
expertise in family nursing and expertise with instrument development pro-
vided further critique of both the items and the response alternatives.
The items were then sorted into cognitive, affective, and behavioral
dimensions. Each item was constructed as “I think . . .” within the cognitive
dimension, “I feel . . .” within the affective dimension, and “In my work . . .”
within the behavioral dimension. To obtain a wider variety of response alter-
natives, we decided to use a 6-point Likert scale with the alternatives totally
disagree, strongly disagree, disagree, agree, strongly agree, and totally agree.
In addition, a demographics section in the instrument was developed to
account for age, gender, and number of years of experience in nursing. We
also accounted for a broader definition of families to include emotional rela-
tionships, in addition to those individuals related by bloodlines or by law.
Content validity (refer to Streiner & Norman, 2003) was established by two
groups of nurses: a group of academic nurses and doctoral students and a group
of practicing nurses. Nine academic faculty members and doctoral students
with expertise in family nursing research and education were invited to review
the instrument. All of them agreed that the items of the instrument were rele-
vant to examining nurses’ attitudes about caring for families. From their cri-
tique of the items, 4 items were deleted, resulting in a 78-item instrument.
The instrument was also examined for content validity by a group of prac-
ticing nurses. Nineteen Registered Nurses (RNs) who attended postgraduate
courses at our university reviewed the instrument. In an accompanying letter,
information was given about the development of the instrument with a
request for comments about the construction of the items, choice of words,
and suggestions for changes. The response rate was 63% (n = 12). The RNs
had been nurses for 3 to 30 years, worked in hospital care (n = 5), primary
care (n = 4), community care (n = 1), or in other places (n = 2). Half of the
nurses had received some education about family nursing. The nurses agreed
that items which focused mainly on nurses’ experiences or knowledge of
meeting families were not relevant for the instrument. They also agreed that
there were too many response alternatives, and that the choices were hard to
differentiate. As a result of these comments, 19 items were excluded (leaving
59 items), and the response alternatives were altered to Yes and No, thereby
replacing the Likert scale construction.
The instrument was then sent by internal post delivery to all faculty
members in Nursing at Kalmar University in Sweden (n = 31) with the
same background information about the instrument and requests for feed-
back as given to the practicing nurses. Twenty-one (68%) faculty members
104 Journal of Family Nursing

responded. This group had been registered nurses for 10 to 37 years, and
most of them had previously worked at hospitals. The faculty provided few
comments about the content of the items, but 96% agreed the response alter-
natives Yes and No were too limiting. They offered comments such as
“Families are unique” and “Depends on the situation.” As a result, the
response alternatives were switched back to a 4-point Likert scale. This final
version of FINC-NA was now ready to receive psychometric testing with a
larger sample. The specific layout of the instrument followed the guidelines
offered by Pett, Lackey, and Sullivan (2003).

Psychometric Testing
Data collection. Approximately 90% (n = 74,174) of all Swedish RNs are
members of the Swedish Association of Health Professionals (SAHP) and are
listed in their register. Ninety-three percent of these members are women.
Using the register, a computer-generated, random sample of 1,000 RNs was
chosen for this phase of psychometric testing. Twenty-one RNs who did not
fulfill the inclusion criteria (working as a nurse) were excluded from the sam-
ple, leaving a sample size of 979 RNs. In May 2004, personnel from SAHP
mailed the coded FINC-NA questionnaire to the RN sample, along with a
return envelope. An accompanying letter informed the RNs that their partici-
pation was voluntary and anonymous, and they were requested to answer the
questionnaire from their view as professional nurses. SAHP sent two mailed
reminders to nonrespondents within 3 months. When the questionnaires were
returned to SAHP, 11 were missing answers and these were sent back to the
RNs for completion. SAHP personnel delivered all of the completed ques-
tionnaires to the researchers, thus ensuring anonymity of the participants. In
accordance with Swedish policy, no ethical approval was needed for this kind
of study.

Data analysis. Descriptive statistics were used to analyze the demographic

characteristics of the respondents. Nonparametric statistics (Altman, 1991)
were used to analyze the responses to the instrument. A low rate of internal
missing values (< 1%) was dealt with by imputing the mean value of each
item (Downey & King, 1998). Prior to the analysis, negative statements
were recoded to positive values.
The analysis of the psychometric properties of FINC-NA was carried out
using item analysis (Spector, 1992) and principal component analysis
(Fayers & Machin, 2000) to develop an internally consistent scale. The two
approaches were first used to reduce items. Item-total correlations adjusted
 Benzein et al. / Families’ Importance in Nursing Care 105

for overlaps below r < 0.3 were used to reduce items in the first item analysis
(Nunnally & Bernstein, 1994). In addition, items increasing Cronbach’s
alpha if deleted were excluded from the scale (Spector, 1992). Items with
weak factor loadings (< 0.4) and communality values (< 0.3) in the first
principal component analysis were also deleted.
The final version of the instrument was then validated using a second
principal component analysis based on Hair, Anderson, Tatham, and Black
(1998), with the aim of analyzing the dimensionality of the scale as a way to
test for construct validity. The analysis was judged appropriate for the data
based on Barlett’s test of sphericity (p < .001) and Kaiser-Meyer-Olkin
(KMO) statistic (0.904). A scree plot was used to decide the number of fac-
tors to be extracted. The analysis was performed with an orthogonal varimax
rotation to simplify the interpretation of items and factors. This procedure is
in accordance with psychometric tests as suggested by Spector (1992) and
Fayers and Machin (2000). Finally, the factor structure was cross-validated
by randomly splitting the sample into two equal samples, which were then
reanalyzed and compared with the original analysis (Hair et al., 1998).
For the item analysis of the final instrument, item-total correlations for
both the whole scale as well as for the subscales were performed. All item-
total correlations were adjusted for overlaps (Fayers & Machin, 2000). The
distribution of the response alternatives was analyzed by calculating the
share of persons who scored the weakest and strongest possible values on
each item.
A correlation analysis was performed with Spearman’s rank correlation
between the scales in FINC-NA to evaluate convergent and discriminant
validity, based on the hypothesis that the correlation between each subscale
and the total scale should be stronger than the correlations between the sub-
scales (Fayers & Machin, 2000).
Cronbach’s alpha reliability coefficient was used to estimate internal
consistency (Cronbach, 1951). The overall statistical significant level was
set at p < .05. Data were analyzed using SPSS for Windows (release 12.0.1,
2003, Chicago, SPSS Inc.).

Results

Sample Characteristics
In total, 688 instruments were returned, of which 54 were returned but
unanswered. Thus, the response rate was 65% (n = 634). The RN respondents
106 Journal of Family Nursing

ranged in age from 23 to 66 years (M = 45, SD = 11), and 594 were female
and 40 were male. They had been RNs on average 17 years (SD = 12, range =
0 to 41) and worked in the following settings: institutional care (66%), pri-
mary care (18%), community care (13%), or other care organizations such as
private care (3%).

Item Reduction
All 59 items of the instrument were analyzed in the first item-total cor-
relation analysis, after which 31 items were excluded due to weak correla-
tions (< 0.3) to the whole scale. In addition, they increased Cronbach’s
alpha when deleted. To further develop an internally consistent scale, a first
principal component analysis was performed. Two items showed both weak
factor loadings (< 0.4) and communality values (< 0.3) and were therefore
deleted. One item (discussions with family members during the first care
contact saves time in my future work) came very close to the cut-off value
for communality (0.293), but was still included due to its theoretical sig-
nificance. Thus, the final version of the FINC-NA consists of 26 items.

Validation of the Final Scale

The principal component analysis on the final version of the FINC-NA
resulted in four factors, explaining 44.9% of the total variance (see Table
2). Seventeen items loaded significant at one factor whereas 9 items loaded
significantly on two factors. Twenty-five items loaded > 0.4 and 1 item (dis-
cussions with family members during the first care contact saves time in my
future work) loaded < 0.4 (0.380). Because the items loading in the first
factor focused on a positive attitude toward families and the value of their
presence in nursing care, this factor was labeled families as a resource in
nursing care (Fam-RNC). The second factor items focused on the impor-
tance of acknowledging the patient’s family members and having a dia-
logue with them, so this factor was labeled family as a conversational
partner (Fam-CP). The third factor items were negative statements about
the family, so they were labeled family as a burden (Fam-B). The fourth
factor items focused on acknowledging families as having their own
resources for coping; this factor was labeled family as its own resource
(Fam-OR). The cross-validation of the principal component analysis
showed the same factor structure as the original analysis.
The item analysis of the final scale showed a ceiling effect for the major-
ity of the items and the total scale and the subscales were negatively skewed
 Table 2
The Principal Component Analysis (orthogonal-varimax rotation) for the Families’
Importance in Nursing Care–Nurses’ Attitudes (FINC-NA)
Factor

Item I II III IV h2

1. The presence of family members eases my workload 0.620 0.068 0.323 0.129 0.510
2. The presence of family members gives me a feeling of security 0.607 0.133 0.185 0.077 0.426
3. The presence of family members is important to me as a nurse 0.592 0.152 0.159 0.179 0.431
4. Family members should be invited to actively take part in the patient’s nursing care 0.579 0.214 0.068 0.111 0.398
5. Family members should be invited to actively take part in planning patient care 0.568 0.273 0.013 -0.102 0.408
6. A good relationship with family members gives me job satisfaction 0.531 0.138 –0.038 0.147 0.324
7. Getting involved with families gives me a feeling of being useful 0.521 0.071 –0.042 0.389 0.429
8. I gain a lot of worthwhile knowledge from families which I can use in my work 0.461 0.167 0.002 0.356 0.367
9. The presence of family members is important for the family members themselves 0.460 0.129 0.227 0.192 0.317
10. It is important to spend time with families 0.447 0.181 0.130 0.414 0.421
11. I invite family members to have a conversation at the end of the care period 0.128 0.701 0.104 0.090 0.527
12. I ask family members to take part in discussions from the very first contact, when a 0.172 0.681 0.131 0.103 0.522
patient comes into my care
13. I always find out what family members a patient has 0.028 0.646 0.097 0.266 0.498
14. I invite family members to speak about changes in the patient’s condition 0.182 0.636 –0.018 0.092 0.446
15. I invite family members to speak when planning care 0.361 0.517 0.017 –0.151 0.420
16. It is important to find out what family members a patient has 0.187 0.496 0.004 0.253 0.345

(continued)

107
108
Table 2 (continued)
Factor

Item I II III IV h2

17. I invite family members to actively take part in the patient’s care 0.347 0.495 0.142 0.193 0.423
18. Discussion with family members during first care contact saves time in my future work 0.380 0.354 0.074 0.135 0.293
19. The presence of family members makes me feel that they are checking up on me –0.014 0.111 0.795 0.045 0.646
20. The presence of family members makes me feel stressed 0.049 0.084 0.790 0.049 0.636
21. The presence of family members holds me back in my work 0.201 0.000 0.656 0.114 0.484
22. I don’t have time to take care of families 0.214 0.121 0.523 0.116 0.347
23. I encourage families to use their own resources so that they have the optimal 0.028 0.187 0.115 0.734 0.588
possibilities to cope with situations by themselves
24. I see myself as a resource for families so that they can cope as well as 0.263 0.200 0.097 0.633 0.520
possible with their situation
25. I consider family members as cooperating partners 0.347 0.084 0.137 0.533 0.431
26. I ask families how I can support them 0.113 0.493 0.165 0.477 0.511
Eigenvalue (after rotation) 3.740 3.286 2.333 2.308
Total variance (%) 14.385 12.637 8.975 8.878 44.875

Note: h2 = communality value.

 Benzein et al. / Families’ Importance in Nursing Care 109

(see Table 3). All subscales except the Fam-OR included items with ceiling
effects more than 50%, and the items with the most skewed distribution
were shown in Fam-RNC. No items with floor effect were demonstrated in
any subscales. The item-total correlation between items and the total scale
was moderate, varying between 0.313 and 0.565. Six items showed item-
total correlations < 0.4 and the 4 items in the Fam-B were most weakly cor-
related to the total scale. The item-total correlations for each subscale were
in general stronger, but still moderate. The item-total correlations for each
subscale were 0.418 to 0.553 (Fam-RNC), 0.397 to 0.585 (Fam-CP), 0.361
to 0.559 (Fam-B), and 0.450 to 0.524 (Fam-OR).
The analysis of the correlations between subscales and total scale is pre-
sented in Table 4. As hypothesized, the strongest correlations were dis-
played between the subscales and the total scale. The Fam-RNC correlated
most strongly with the total scale (0.840), whereas Fam-B correlated most
weakly with the total scale (0.620). The strongest correlation between sub-
scales was shown between the Fam-RNC and Fam-CP (0.579), whereas the
weakest correlation was between Fam-CP and Fam-B (0.298).
The Cronbach’s alpha reliability coefficient was 0.88 for the whole
FINC-NA with 26 items and varied between 0.69 and 0.80 for the four sub-
scales (see Table 3).

Discussion

This research focused on the development and psychometric testing of

the FINC-NA instrument, which measures nurses’ attitudes about the
importance of families in nursing care. A comprehensive literature review
was the foundation for the construction of FINC-NA, as emphasized by
Polit and Beck (2004). The development process was rigorous, involving
several steps to enhance validity (Streiner & Norman, 2003), clarity, and
respondents’ ability to give information as well as to minimize bias (Polit
& Beck, 2004). The purposive sampling of practicing RNs and academic
faculty members not only helped to ensure face validity but was valuable in
further refining the instrument. The psychometric testing with a large, ran-
dom sample of RNs allowed the instrument to be shortened to 26 items,
making the instrument more user-friendly. In addition, the items target
nurses’ attitudes about the interaction between nurses and families and are
not specific to the context of the nursing practice; this makes the FINC-NA
different from existing instruments.
(text continues on page 113)
110
Table 3
Item Analysis for the Final Version of the Families’ Importance in
Nursing Care–Nurses’ Attitudes (FINC-NA)
Item-Total
Distributiona Correlationb

Possible Median Floor Ceiling Total Cronbach’s

Scale and Item Variation (q1–q3) Effects (%) Effects (%) Scale Subscales Alpha

Family as a resource in nursing care (Fam-RNC) 10–40 36 (33–38) 0.805

1. The presence of family members eases my workload 1–4 3 (3–4) 3 28 0.533 0.536
2. The presence of family members gives me a feeling of security 1–4 3 (3–3) 3 23 0.487 0.512
3. The presence of family members is important to me as a nurse 1–4 4 (3–4) 1 58 0.517 0.553
4. Family members should be invited to actively take part in the 1–4 4 (3–4) 1 62 0.483 0.484
patient’s nursing care
5. Family members should be invited to actively take part in 1–4 4 (3–4) 0 70 0.405 0.418
planning patient care
6. A good relationship with family members gives me job 1–4 4 (4–4) 0 89 0.391 0.438
satisfaction
7. Getting involved with families gives me a feeling of 1–4 3 (3–4) 3 46 0.437 0.494
being useful
8. I gain a lot of worthwhile knowledge from families which 1–4 4 (3–4) 0 64 0.466 0.470
I can use in my work
9. The presence of family members is important for the family 1–4 4 (3–4) 1 63 0.459 0.452
members themselves
10. It is important to spend time with families 1–4 4 (4–4) 0 79 0.534 0.516

(continued)
 Table 3 (continued)
Item-Total
Distributiona Correlationb

Possible Median Floor Ceiling Total Cronbach’s

Scale and Item Variation (q1–q3) Effects (%) Effects (%) Scale Subscales Alpha

Family as a conversational partner (Fam-CP) 8–32 27 (24–29) 0.785

11. I invite family members to have a conversation at the end 1–4 3 (2–3) 10 22 0.487 0.573
of the care period
12. I ask family members to take part in discussions from the 1–4 3 (2–4) 10 27 0.516 0.585
very first contact, when a patient comes into my care
13. I always find out what family members a patient has 1–4 4 (3–4) 2 51 0.463 0.518
14. I invite family members to speak about changes in the 1–4 3 (3–4) 3 43 0.440 0.520
patient’s condition
15. I invite family members to speak when planning care 1–4 4 (3–4) 3 64 0.396 0.397
16. It is important to find out what family members a 1–4 4 (4–4) 0 77 0.437 0.446
patient has
17. I invite family members to actively take part in the 1–4 3 (2–4) 6 26 0.565 0.509
patient’s care
18. Discussion with family members during first care contact 1–4 4 (3–4) 1 59 0.449 0.398
saves time in my future work
Family as a burden (Fam-B) 4–16 13 (11–15) 0.692
19. The presence of family members makes me feel that they 1–4 3 (3–4) 2 50 0.313 0.541
are checking up on me

(continued)

111
112
Table 3 (continued)
Item-Total
Distributiona Correlationb

Possible Median Floor Ceiling Total Cronbach’s

Scale and Item Variation (q1–q3) Effects (%) Effects (%) Scale Subscales Alpha

20. The presence of family members makes me feel stressed 1–4 4 (3–4) 1 53 0.340 0.559
21. The presence of family members holds me back in my work 1–4 4 (3–4) 3 51 0.361 0.456
22. I don’t have time to take care of families 1–4 3 (2–4) 2 39 0.381 0.361
Family as own resource (Fam-OR) 4–16 13 (12–15) 0.701
23. I encourage families to use their own resources so that they 1–4 3 (3–4) 1 41 0.412 0.524
have the optimal possibilities to cope with situations
by themselves
24. I see myself as a resource for families so that they can cope 1–4 3 (3–4) 1 39 0.513 0.523
as well as possible with their situation
25. I consider family members as cooperating partners 1–4 3 (3–4) 3 45 0.474 0.450
26. I ask families how I can support them 1–4 3 (3–4) 2 47 0.549 0.455
Total scale 26–104 88 (81–94) 0.882

a. The proportion of nurses who respond 0 or 4 on each item.

b. The item-total correlation (adjusted for overlaps) for the total scale and the subscales.
 Benzein et al. / Families’ Importance in Nursing Care 113

Table 4
Correlations Between the Families’ Importance in Nursing
Care–Nurses’ Attitudes (FINC-NA) Subscales and Total Scale
Fam-RNC Fam-CP Fam-B Fam-OR Total Scale

Fam-RNC 1.000
Fam-CP 0.579 1.000
Fam-B 0.393 0.298 1.000
Fam-OR 0.559 0.550 0.327 1.000
Total scale 0.840 0.824 0.620 0.740 1.000

Note: Fam-RNC = Family as a resource in nursing care; Fam-CP = Family as a conversational

partner; Fam-B = Family as a burden; Fam-OR = Family as own resource. All correlations are
significant at a level of p < .001.

FINC-NA has a high degree of structure with response alternatives con-

structed as a Likert scale. These kinds of scales often have odd numbers of
alternatives so that researchers can measure the direction and intensity of an
individual’s attitudes. Although Streiner and Norman (2003) contend there
is no general agreement about the number of options, we agree with Pett
et al. (2003) that an even number of options may be a problem if the respon-
dent is undecided. Despite our agreement with Pett et al., however, we
chose an even number of responses to avoid some respondents’ tendencies
not to take sides (Polit & Beck, 2004).
The response rate of 65% was acceptable; Polit and Beck (2004) con-
sider a 50% response rate to be satisfactory. It was not possible to perform
a complete dropout analysis, but when the respondents’ demographic char-
acteristics were compared with the total population of Swedish RNs, there
were almost identical in terms of age, gender, and number of years of nurs-
ing experience. This strengthens the generalizability of the results.
The large random sample size (n = 634) meets the sample sizes recom-
mended in the literature for conducting factor analysis. Hair et al. (1998)
suggest as a general rule having at least five times as many observations as
there are items, Pett et al. (2003) suggest 10 to 15 subjects per item, and
Comrey and Lee (1992) argue that more than 500 observations is “very
good.” Our large random sample size strengthens the reliability of the factor
analysis. Reliability may also be determined by the magnitude of the factor
loadings. Multiple loadings occurred for nine items. There is no consensus
in the literature on how to deal with multiple loadings. Some researchers rec-
ommend eliminating such items and others (e.g., Hair et al., 1998), suggest
114 Journal of Family Nursing

that the meaning of the item should determine whether to eliminate the item.
Due to theoretical coherence, items were placed in the factor with the
strongest loading, except for Items 18 and 26, which were placed in factors
based on theoretical significance. However, these items showed similar fac-
tor loadings on the target factor, and this treatment was therefore not judged
as problematic, according to the rule of the strongest. This was a way logi-
cally to interpret the results in relation to the construction of the instrument.
Due to the large sample size (n = 634), practical and statistical significance
is reached with factor loadings 0.3 and above (Hair et al., 1998).
An important condition for using summated scales is the demand of uni-
dimensionality (Streiner & Norman, 2003). The factor analysis revealed four
subscales in the final version of FINC-NA, indicating that the instrument
measures four aspects of nurses’ attitudes about the importance of families in
nursing care. The correlation analysis of the subscales and the total scale sup-
ports this conclusion, which shows that the correlations between all subscales
and the total scale were stronger than the correlations between just the sub-
scales. The items correlating so similarly between the total scale and the sub-
scales indicate that a total score for the whole instrument can be used. Thus,
the analyses support the use of a total score and the four subscales. However,
even if the cross-validation of the factor structure strengthens and confirms
the dimensionality, the principal component analysis is an exploratory
approach and does not answer the question of how well the factor solution fits
the data (Bryant & Yarnold, 1995). Therefore, to clarify the instrument’s use
as a total score and/or as subscales, a confirmatory factor analysis is recom-
mended to further evaluate the FINC-NA (Hair et al., 1998).
It is worth noting the low degree of response distribution on the 4-point
scale, with highest frequencies on agree and strongly agree response alterna-
tives. One problem with floor and/or ceiling effects is that this reduces the abil-
ity to discriminate, causing reduced sensitivity and responsiveness. Another
consequence is that low variance of the items gives weaker correlations and
Cronbach’s alpha reliability values (Fayers & Machin, 2000). Thus, the low
variance in the items can probably explain why the items only moderately cor-
relate with the subscales and the total scale in the item-total correlation analy-
sis. Furthermore, even though some subscales showed weak Cronbach’s alpha
values, especially FamB, it is more likely that these alpha values are the result
of the items’ low variance rather than a deficient internal consistency.
The lack of a test-retest design is a limitation of the FINC-NA’s psycho-
metric properties. Test-retest was not conducted because of administrative
and financial reasons.
 Benzein et al. / Families’ Importance in Nursing Care 115

Conclusion

We inductively developed the FINC-NA, which shows promise as a tool

for measuring RNs’ attitudes about the importance of families in nursing
care. The instrument needs to be tested in other countries to refine and ana-
lyze its international relevance, and to facilitate comparisons with other
nurse populations. Researchers can obtain the FINC-NA and instructions
for its analysis from the authors.

References
Altman, D. (1991). Practical statistics for medical research. London: Chapman & Hall.
Astedt-Kurki, P., Paavilainen, E., Tammentie, T., & Paunonen-Ilmonen, M. (2001a).
Interaction between adult patients’ family members and nursing staff on a hospital ward.
Scandinavian Journal of Caring Sciences, 15, 142-150.
Astedt-Kurki, P., Paavilainen, E., Tammentie, T., & Paunonen-Ilmonen, M. (2001b).
Interaction between family members and health care providers in an acute care setting in
Finland. Journal of Family Nursing, 7, 371-390.
Benzein, E., Johansson, B., & Saveman, B.-I. (2004). Families in home care—A resource or
a burden? District nurses’ beliefs. Journal of Clinical Nursing, 13, 867-875.
Berterö, C. (2002). District nurses’ perceptions of palliative care in the home. American
Journal of Hospice and Palliative Care, 19, 387-391.
Blower, K., & Morgan, E. (2000). Great expectations? Parental participation in care. Journal
of Child Health Care, 4, 60-65.
Bruce, B., Letourneau, N., Ritchie, J., Larocgue, S., Dennis, C., & Elliott, M. (2002). A mul-
tisite study of health professionals’ perceptions and practices of family-centered care.
Journal of Family Nursing, 8, 408-829.
Bryant, F. B., & Yarnold, P. R. (1995). Principal-component analysis and exploratory and con-
firmatory factor analysis. In L. A. Grim & P. R. Yarnold (Eds.), Reading and understand-
ing multivariate statistics (pp. 99-136). Washington, DC: American Psychological
Association.
Caty, S., Larocque, S., & Koren, I. (2001). Family-centered care in Ontario general hospitals:
The views of pediatric nurses. Canadian Journal of Nursing Leadership, 14, 10-18.
Clarke, C. M. (2000). Children visiting family and friends on adult intensive care units: The
nurses’ perspective. Journal of Advanced Nursing, 31, 330-338.
Comrey, A. L., & Lee, H. B. (1992). A first course in factor analysis. Hillsdale, NJ: Lawrence
Erlbaum.
Cronbach, L. J. (1951). Coefficient alpha and the internal structure of tests. Psychometrika, 16,
297-334.
Downey, R. G., & King, C. V. (1998). Missing data in Likert ratings: A comparison of replace-
ment methods. Journal of General Psychology, 125, 175-192.
Fayers, P. M., & Machin, D. (2000). Quality of life: Assessment, analysis and interpretation.
London: John Wiley & Sons.
116 Journal of Family Nursing

Fulbrook, P., & Albarran, J. W. (2005). A European survey of critical care nurses’ attitudes and
experiences of having family members present during cardiopulmonary resuscitation.
International Journal of Nursing Studies, 42, 557-568.
Hair, J. F., Anderson, R. E., Tatham, R. L., & Black, W. C. (1998). Multivariate data analysis
(5th ed.). Upper Saddle River, NJ: Prentice-Hall.
Hallgrimsdottir, E. M. (2000). Accident and emergency nurses’ perceptions and experiences of
caring for families. Journal of Clinical Nursing, 9, 611-619.
Hammond, F. (1995). Involving families in care within the intensive care environment: A
descriptive survey. Intensive and Critical Care Nursing, 1, 256-264.
Hertzberg, A., Ekman, S.-L., & Axelsson, K. (2003). Relatives are a resource, but . . . :
Registered nurses’ views and experiences of relatives of residents in nursing homes.
Journal of Clinical Nursing, 12, 431-441.
Jansson, A., Petersson, K., & Udén, G. (2001). Nurses’ first encounters with parents of new-
born children—Public health nurses’ views of a good meeting. Journal of Clinical
Nursing, 10, 140-151.
Kirchhoff, K. T., & Beckstrand, R. L. (2000). Critical care nurses’ perceptions of obstacles and
helpful behaviors in providing end-of-life care to dying patients. American Journal of
Critical Care, 9, 96-105.
Kristensson-Hallström, I., & Elander, G. (1994). Parental participation in the care of hospital-
ized children. Scandinavian Journal of Caring Science, 8, 149-154.
Leahey, M., & Harper-Jaques, S. (1996). Family-nurse relationships: Core assumptions and
clinical implications. Journal of Family Nursing, 2, 133-152.
Likert, R. (1932). A technique for the measurement of attitudes. Archives of Psychology No.
140 (pp. 5-55). New York: Columbia University.
Maxton, F. (1997). Old habits die hard: Changing pediatric nurses perceptions of families in
ICU. Intensive and Critical Care Nursing, 13, 145-150.
Nunnally, J. C., & Bernstein, I. H. (1994). Psychometric theory (3rd ed.). New York: McGraw-
Hill.
O’Malley, P., Favaloro, R., Anderson, B., Anderson, M. L., Siewe, S., Benson-Landau, M.,
et al. (1991). Critical care nurse perceptions of family needs. Heart & Lung, 20, 189-201.
Pett, M. A., Lackey, N. R., & Sullivan, J. J. (2003). Making sense of factor analysis. Thousand
Oaks, CA: Sage.
Pfeil, M. (1997). Team players or rivals in caring. Journal of Child Health Care, 1, 6-10.
Plowright, C. I. (1998). Intensive therapy unit nurses beliefs about and attitude towards visit-
ing in three district general hospitals. Intensive and Critical Care Nursing, 14, 262-270.
Polit, D. F., & Beck, C. T. (2004). Nursing research: Principles and methods (7th ed.). New
York: Lippincott Williams & Wilkins.
Ryan, A., & Scullion, H. (2000). Family and staff perceptions of the role of families in nurs-
ing home. Journal of Advanced Nursing, 32, 626-634.
Söderström, I.-M., Benzein, E., & Saveman, B.-I. (2003). Nurses’ experiences of interactions
with family members in intensive care units. Scandinavian Journal of Caring Sciences, 17,
185-192.
Spector, P. E. (1992). Summated rating scale construction: An introduction. Newbury Park,
CA: Sage.
Streiner, D. L., & Norman, G. R. (2003). Health measurement scales: A practical guide to
their development and use (3rd ed.). New York: Oxford University Press.
 Benzein et al. / Families’ Importance in Nursing Care 117

Tye, C. (1993). Qualified nurses’ perceptions of the needs of suddenly bereaved family
members in the accident and emergency department. Journal of Advanced Nursing, 18,
948-956.
Wright, K. (2002). Caring for the terminally ill: The district nurse’s perspective. British
Journal of Nursing, 11, 1180-1185.

Eva Benzein, PhD, RNT, is an associate professor at Kalmar University, Sweden. Her
research is devoted to examining family-focused nursing and palliative care. At the Family
Care Unit at Kalmar University, which she has established, she offers families health-foster-
ing conversations with the aim of alleviating suffering and promoting hope and well being.

Pauline Johansson, PhD student, RN, is a lecturer at the School of Human Sciences, Kalmar
University, Sweden, and a doctoral student at the eHealth Institute and the School of Pure and
Applied Natural Sciences, Kalmar University, Sweden. Her clinical work and research
focused on families in palliative care and informatics related contents, functions, and usabil-
ity of Personal Digital Assistants for nurses.

Kristofer Franzén Årestedt, PhD, RN, is a lecturer at the School of Human Sciences, Kalmar
University, Sweden. His research and clinical interest is focused on health-related quality of
life and nutrition among persons with heart failure as well as development of quality of life
measures for research and clinical practice.

Agneta Berg, PhD, RNT, is an assistant professor at Department of Health Sciences,

Kristianstad University, Sweden, and Forsteamanuensis at Faculty of Social Sciences,
University of Stavanger, Norway. Her research and clinical interest is in the areas of clinical
nursing supervision and individualized nursing care, including family nursing.

Britt-Inger Saveman, PhD, RNT, FEANS, is a professor in nursing at Kalmar University

and also a guest professor at Umeå University, the Division of Surgery, Department of Surgical
and Perioperative Sciences, both in Sweden. Her research emphasis is family-focused nursing and
elder abuse. She has provided leadership for the development of family-focused nursing in
Sweden and has established the Family Care Unit at Kalmar University.