Journal of Gerontological Nursing

Feature Article 

Development and Psychometric Testing of the Caregiver Communication Competence Scale in Patients With Dementia

Hui-Chen Chao, MS, RN; Ya-Ping Yang, RN; Mei-Chih Huang, PhD, RN; Jing-Jy Wang, PhD, RN

Abstract

Appropriate communication skills are essential for understanding patient needs, particularly those of patients with dementia. Assessing health care providers' competence in communicating with patients with dementia is critical for planning a communication education program. However, no formally established scale can be used. The purpose of the current study was to develop a valid and reliable instrument for determining the communication competence of health care providers with patients with dementia. Through use of a literature review and previous clinical experience, an initial 28-item scale was developed to assess the frequency of use of each item by health care providers. Fourteen items were extracted and three factors were distinguished. Results indicated that the internal consistency reliability of the 14-item scale was 0.84. Favorable convergent and discriminant validities were reached. The communication competence scale provides administrators or educators with a useful tool for assessing communication competence of health care providers when interacting with patients with dementia so a suitable education program can be planned and implemented. [Journal of Gerontological Nursing, 42 (1), 32–39.]

Abstract

Appropriate communication skills are essential for understanding patient needs, particularly those of patients with dementia. Assessing health care providers' competence in communicating with patients with dementia is critical for planning a communication education program. However, no formally established scale can be used. The purpose of the current study was to develop a valid and reliable instrument for determining the communication competence of health care providers with patients with dementia. Through use of a literature review and previous clinical experience, an initial 28-item scale was developed to assess the frequency of use of each item by health care providers. Fourteen items were extracted and three factors were distinguished. Results indicated that the internal consistency reliability of the 14-item scale was 0.84. Favorable convergent and discriminant validities were reached. The communication competence scale provides administrators or educators with a useful tool for assessing communication competence of health care providers when interacting with patients with dementia so a suitable education program can be planned and implemented. [Journal of Gerontological Nursing, 42 (1), 32–39.]

According to a demographic analysis published by the Department of Statistics, Ministry of the Interior (2014), older adults comprise 12.22% of the population in Taiwan. Health problems associated with an aging population have become a common concern of developed nations worldwide. Dementia is a crucial health problem related to aging populations. Currently, the prevalence of dementia in Taiwan is 4.79% (Sun et al., 2014), indicating one in 20 adults older than 65 has been diagnosed with dementia. Statistics provided by the World Health Organization (WHO; 2012) revealed the prevalence of dementia is approximately 4% to 9% worldwide. The population diagnosed with dementia in 2010 reached 35.6 million worldwide and initial estimates have indicated that this population will double by 2030 and more than triple by 2050 (Prince et al., 2013; WHO, 2012). Regarding the constantly increasing population of patients with dementia, improvements in individual care and quality of life have become a crucial health policy topic worldwide (Alzheimer's Association, 2014; WHO, 2012).

Dementia impairs executive functions, learning and memory, language, perceptual motor skills, complex attention, and social cognition (OuYang, 2012, 2013; Remington, 2012), which deteriorates message reception and expression processes and subsequently creates numerous communication and emotional disabilities (Bourgeois, 2002). Bourgeois (2002) indicated that early signs of dementia comprise a sense of difficulty in language differentiation, comprehension of language emphasis, and complex communication and conversations. During the middle stage, patients demonstrate memory deterioration regarding terminologies and begin using inconsistent pronouns, cannot maintain a conversation topic, and struggle to comprehend complex instructions. In addition, patients' reading comprehension regresses and they present delusional oral expressions and social withdrawal signs. At the late stage, patients lose participatory and verbal communication skills (i.e., greeting responses) (Rousseaux, Sève, Vallet, Pasquier, & Mackowiak-Cordoliani, 2010). In addition, patients exhibit difficulty in converting vocabulary, words, or morphemes into meaningful information (Carlomagno, Santoro, Menditti, Pandolfi, & Marini, 2005). When clinical health care providers have limited knowledge of dementia, they cannot communicate with patients (Callone, Kudlacek, Vasiloff, Manternach, & Brumback, 2006; McCarthy, 2011). Wang, Hsieh, and Wang (2013) determined that communication failures between clinical health care providers and patients with dementia involve a lack of mutual understanding (including repetitive reactions and lack of language cohesion) and interrupted communications (including the inability to assess emotions and needs of patients). Language is a bridge for human communication and ineffective language reflects interrupted communication between caregivers and patients. This disruption results in patients' inability to express personal needs and causes social closure, which develops into numerous caring problems (Veselinova, 2014).

Miller (2008) indicated that the loss of cognitive functions in patients with dementia subsequently deteriorates their communication skills for language reception and production. When caregivers cannot successfully interpret and process the impaired language of patients with dementia, their psychosis-related behaviors increase, thereby affecting the quality of care and patients' quality of life (Beerens, Zwakhalen, Verbeek, Ruwaard, & Hamers, 2013), which burdens caregivers. Kim et al. (2014) indicated that communicating with sufficient knowledge of patients' background culture may facilitate interaction with patients and help them express their needs to caregivers. Relevant studies have focused on developing strategies and models for caregivers to communicate effectively with individuals with dementia (e.g., the FOCUSED communication strategy by Ripich, Wykle, and Niles [1995]; verification of communication skills treatment by Feil and de Klerk-Rubin [2012]; the 10 communication strategies by Small, Gutman, Makela, and Hillhouse [2003]; and the Brief, Ordinary, and Effective or brief ordinary effective communication model [Crawford, Bonham, & Brown, 2006]) (Table 1). The aforementioned studies related to communication skills have provided caregivers with interactive techniques and precautions for communicating with patients with dementia. However, Wang, Hu, and Cheng (2011) indicated that, prior to the intervention of an appropriate communication strategy for health care providers, the competence and proficiency of caregivers communicating with patients with dementia must be determined to obtain better results when planning communication training. Therefore, the basis of planning communication training programs is established through determining health care providers' competency in communicating with patients with dementia. An effective instrument for assessing communication skills of caregivers has yet to be developed. This instrument should be able to evaluate the performance of the implemented measures prior to the intervention of communication strategies. In addition, because the scale was originally adapted from four Western communication strategies/models (Crawford et al., 2006; Feil & de Klerk-Rubin, 2012; Ripich et al., 1995; Small et al., 2003), it is believed to be suitable for Western clinical implications. The purpose of the current study was to develop a competence scale for measuring caregivers' ability to communicate with individuals with dementia. The scale serves as an interactive communication indicator between caregivers and patients and may be used as a basis for communication strategies to train dementia caregivers.

Communication Strategies

Table 1:

Communication Strategies

Method

The current study was divided into two stages: (a) item development and content validity and (b) testing of psychometrics. Data were collected before conducting exploratory factor analysis (EFA), confirmatory factor analysis (CFA), and internal consistency reliability.

Stage 1: Item Development and Content Validity Establishment

Item Development. Based on the aforementioned effective communication strategies (Table 1), the initial 28 items were developed for the competence scale. The developmental procedure for this instrument was that proposed by Hinkin (1998). The original scale was divided into two parts: (a) frequency of using communication strategies, which uses a 4-point Likert scale ranging from never to always; and (b) effectiveness of using communication strategies, which uses a 4-point Likert scale ranging from ineffective to highly effective. Due to the correlation between the two parts of the scale (i.e., frequency and effectiveness) being high (r = 0.84, p < 0.05), the use results were discarded and use frequencies were retained according to the aforementioned results, and scale development experts Hung, Lu, and Chen (2002) indicated that effective methods generate high use frequencies. Hence, the self-rating scale was calculated using a 4-point Likert scale where 1 = never used, 2 = little used, 3 = occasionally used, and 4 = always used. Scores range from 14 to 56. Higher use frequency represents higher communication competency.

Because the items were originally written in Chinese for administration, they were translated by the research team and then back-translation was performed. Items were then examined by a native English speaker.

Content Validity. Content validity of the items was assessed by five experts on dementia care, including two senior long-term nursing experts, one social worker, one geriatrics physician, and one gerontological nursing professor. A 4-point Likert scale was used to evaluate clarity, appropriateness, and relevance of the items, where 1 = highly disagree and recommend deletion, 2 = disagree and requires heavy modifications, 3 = agree and requires only minor modifications, and 4 = highly agree and requires no modifications. Burns and Grove (2004) recommended verifying the items according to the content validity index (CVI) to measure clarity, appropriateness, and relevance of the items. Calculations showed that the final overall and unit question CVIs for the original scale were 0.92 and 1, respectively. Based on the experts' review, only some items were rephrased.

Stage 2: Testing of Psychometrics

Research Ethics. The current study was approved by the University's institutional review board before participant sampling and data analysis.

Participants. Through convenience sampling, individuals from 15 long-term care facilities in Southern Taiwan who had experience in caring for patients with dementia were selected to participate. Inclusion criteria were: having at least 3 months of work experience in the institution and caring for patients with dementia. A total of 200 voluntary individuals participated in the current study.

Data Collection. Fifteen supervisors of long-term care facilities in Southern Taiwan were contacted initially by phone. Fourteen supervisors of the selected facilities agreed to participate. The researcher then visited these facilities to explain the aims of the current study and obtain written consent. Supervisors arranged times for the researcher to meet with potential participants in their institutions. Subsequently, descriptions were provided to caregivers and written consent was obtained from each participant before data collection. The researcher distributed questionnaires to all individuals who agreed to participate and instructed them on how to rate each item. A return envelope was given to supervisors and then the researcher collected the questionnaires 1 week later. Anonymity was maintained in the questionnaire results, which were numbered according to the sequence in which questionnaires were returned.

Data Analysis

Content validity was adopted for the item contents (Burns & Grove, 2004), EFA and CFA were used to test construct validity, and Cronbach's alpha was used to test internal consistency. These analyses were performed using SPSS version 17 and SPSS Amos version 18.

To ensure measurement accuracy, factor loadings in the factor analyses were used to determine the relationship between items and factors. Therefore, items were deleted when communalities were <0.3 (Chiu, 2003). Principle component factoring and oblique promax rotation were applied in EFA to test the factor structure of the competence scale (Chen & Wang, 2011). In CFA, first-order one- and three-factor CFA models were used to verify structural relationships between subscales. Further explanation by using various indices was required to specify varying goodness of fit. Therefore, chi-square test, the ratio of chi-square to its degree of freedom (df), goodness of fit index (GFI), adjusted GFI (AGFI), normed fit index (NFI), comparative fit index (CFI), and root mean square error of approximation (RMSEA) were adopted as indices for goodness of fit according to Kline's (2011) suggestions.

Results

Demographic Data

All 200 distributed questionnaires received valid responses. Regarding demographics, the average age of participants was 37 (SD = 9.04 years) and all were female caregivers whose average clinical nursing experience was 11.46 years (SD = 8.54 years). Participants included senior care attendants, nurses, physicians, and social workers who had an average of 4.86 years (SD = 4.63 years) of experience in caring for patients with dementia. Among caregivers, 76 had family members with dementia and 118 received dementia-related care training, with an average of 17.79 hours (SD = 62.26 hours). The frequency of use of each communication strategy (i.e., item) is reported in Table 2.

Nurses' Frequency of Using Communication Strategies

Table 2:

Nurses' Frequency of Using Communication Strategies

Construct Validity

Questions and total scores exhibiting correlation coefficients >0.3 were retained (Chiu, 2003); otherwise, the questions were discarded (seven questions were deleted at this stage). The remaining 21 questions were used for EFA analysis. Subsequently, principle component factoring was used for factor extraction. The Kaiser–Meyer–Olkin value was 0.913, the chi-square value of the Bartlett's test of sphericity was 1072.73, and the p value was <0.005; therefore, the oblique promax rotation method was adopted (Nunnally & Bernstein, 1994). According to the criterion of an eigenvalue of >1, 14 items were extracted and three factors were distinguished: respect and tenderness (i.e., questions 1 to 9), encouragement and patience (i.e., questions 10, 11, and 13), and connection (i.e., questions 12 and 14). Total variance explained yielded 47.29% and the explained variance for the three subscales were in descending order of 25.93% for respect and tenderness, 12.89% for encouragement and patience, and 8.47% for connection.

Internal Consistency and Reliability

The contents of the 14-item competence scale were used to conduct the internal consistency reliability test. Cronbach's alphas for internal consistencies of the scale and three subscales were 0.89 and 0.88 (for respect and tenderness), 0.68 (for encouragement and patience), and 0.61 (for connection).

Confirmatory Factor Analysis

To extract the goodness of fit and factor loading of the factor structures, CFA was performed to obtain the construct validity of the scale (Hinkin, 1998). Various goodness-of-fit tests yielded values of 0.935 for GFI, 0.91 for AGFI, 0.97 for CFI, and 0.046 for RMSEA. The chi-square, df, and chi-square/df ratio were 104.74, 74, and 1.42 (p = 0.011), respectively.

Convergent and Discriminant Validity

Convergent validity was evaluated by examining the standardized regression weights and construct reliabilities from the EFA. Standardized regression weights were between 0.54 and 0.77 and construct reliabilities for the three factors (i.e., respect and tenderness, encouragement and patience, and correction) were 0.89, 0.68, and 0.63, respectively. This evidence showed that the competence scale exhibited satisfactory convergent validity.

Discriminant validity was evaluated by examining the confidence intervals (CIs) and average variance extracted (AVE) from the EFA. Data showed that the CIs of Pearson's correlation coefficient for the three factors were 0.75, 0.69, and 0.70, respectively. In addition, the AVE yielded values of 0.71, 0.65, and 0.68, respectively. This evidence showed that the 14-item competence scale demonstrated favorable discriminant validity.

Discussion

A competence scale for measuring communication between caregivers and patients with dementia was developed in the current study on the basis of literature verification and content validity. Through verifying reliability and validity, 14 items and three dimensions exhibited optimal explanatory models.

Sample size must be constantly considered when developing questionnaires. Regarding the sample size for EFA, Li (2007) considered that, as long as items remain highly correlated and EFA samples exceed 150 participants, results can be sufficiently explained. However, the number of samples must exceed 200 participants in CFA analysis. Therefore, 200 samples were collected in the current study to provide sufficient persuasiveness in the pretest, EFA, and verification of factor analyses. Subsequently, item testing and deletion were performed in EFA. The criterion for deletion is a factor loading of <0.3 (Chiu, 2003). Therefore, seven items were deleted to confirm a consistent number of factors to the original samples before CFA. During the verification process, 21 items were used for verification. This process showed that the loading coefficients for items 8, 9, 11, 20, 21, 26, and 27 were >1, suggesting the concept was similar to that in variable monitoring. Therefore, the items were deleted, resulting in a CFA involving a 14-item competence scale.

Various GFIs in the CFA model of the 14-item competence scale were compared. According to Kelloway's (1995) suggestion, goodness of fit must be tested to serve as a basis for subsequent CFA. Therefore, one- and three-dimensional models were used to compare these models and determine the significance of the chi-square tests. In addition, Schumacker and Lomax (2010) recommended a chi-square/df ratio between one and three and suggested AGFI values of >0.9, p values <0.05, and RMSEA values of >0.9 demonstrate satisfactory goodness of fit. Therefore, goodness of fit of the 14-item competence scale was measured and reached the aforementioned recommended values (GFI = 0.935, AGFI = 0.907, CFI = 0.97, RMSEA = 0.046). The exception is chi-square, which is influenced by sample size and model complexity. Increasing the number of samples yields high df, and chi-square can easily reach significant standards, causing an underestimated goodness of fit. Although the chi-square value reached significant standards, the competence scale model remained a suitable explanatory model and conformed to Kline's (2011) recommendations when other GFIs were considered.

Regarding reliability analysis, the overall Cronbach's alpha for the 14-item scale after item deletion yielded 0.89. Moreover, each subscale yielded Cronbach's alphas between 0.61 and 0.88. A reexamination of the scale item analysis and overall scores showed correlation values >0.3. The squared multiple correlation and item-deletion Cronbach's alpha values reached levels recommended in the literature (Pett, Lackey, & Sullivan, 2003). According to Henson (2001), Cronbach's alphas of 0.5 to 0.6 are considered adequate. Therefore, the aforementioned reliability measurements showed that the 14-item competence scale exhibited satisfactory reliability.

Regarding validity analysis, the internal quality of a scale model is often tested using the scale's convergent and discriminant validities. According to suggestions proposed by Hair, Black, Babin, and Anderson (2009) and Bagozzi and Yi (1988), results from the current convergent validity analysis showed that all of the standardized regression weights of the observed variables exceeded 0.5. Moreover, construct reliabilities of the three factors were >0.6. Regarding discriminant validity, the BOOTSTRAP CI method recommended by Torkzadeh, Koufteros, and Pflughoeft (2003) was adopted, and 95% CI correlation coefficients were calculated using the three dimensions. The resultant CIs excluded the value of 1, suggesting that the three dimensions exhibited satisfactory discriminant validity. According to Hair et al. (2009), the square root AVE for each dimension was calculated and compared with the correlation coefficients of each dimension, yielding square root AVEs between 0.65 and 0.71, which exceeded the numbers of correlation coefficients for each dimension. Therefore, the evidence suggested that the 14-item scale exhibited favorable convergent and discriminant validity.

Research Limitations and Recommendations

The current study was limited by three conditions. First, research variables were measured using the cross-sectional method, questionnaires were completed by participants only once, and the scale served only as a quantitative check; therefore, causal relationships and corollary results have not been proposed. Consequently, prospective efforts may focus on coordinating continuing clinical education for experimental research evaluation to investigate causal relationships. Second, score norms were not constructed for the questionnaire and the levels of competencies could not be evaluated; therefore, sample numbers can be increased and a cutoff can be established for division purposes between the introductory and advanced communication training of caregivers caring for patients with dementia. Third, social desirability may be an issue, as caregivers will want to say that they are using positive strategies. Hence, continuing education is necessary to ensure correct implementation. Construction of this scale included caregivers from long-term care facilities. Suitability of this scale for caregivers in acute care settings must be verified. In an aging society, contact with patients with dementia is common in various care facilities. Therefore, communication skills are crucial and health care providers must be proficient at effectively communicating with patients with dementia to achieve high-quality care.

Prospective Applications and Conclusion

Communication is an interpersonal process involving transmission and feedback of information and thoughts. Communication skills affect the results of communication. Clinical caregivers conventionally adopt personal rule-of-thumb and empirical communication strategies from relevant literature when managing patients with dementia. The current study showed that the 14-item communication competence scale is a reliable and valid instrument for evaluating communication skills required for long-term care providers who manage patients with dementia. Meanwhile, this scale assists nurses' self-awareness of communication barriers, which promotes their motivation for selecting appropriate strategies to communicate with individuals with dementia. Although behavioral messages of patients with dementia symbolize their needs, the ability of care providers to comprehend patients' expressive and receptive messages is the first step to obtaining high-quality care. Empirical communication strategies from various studies have not been effectively integrated into one useful tool, which can easily cause confusion and repel users because of excessive complexity, thereby resulting in user negligence on the most fundamental standard for interactive communication. Although the current scale was developed to measure the communicative competence of nurses when working with individuals with dementia, the scale items may also serve as simple and easy to implement strategies for communicating with individuals with dementia in clinical practice. The findings, with regard to use frequency, indicated that some strategies were used less than others by nurses when communicating with patients with dementia and the less commonly used strategies should be highlighted in continuous education for nurses. For example, item 13 was the least frequently used strategy. Findings from the current study provide insights regarding the development of task-oriented dementia communication programs for nurses and other health professionals. Taiwan, like many other countries, is facing critical nursing shortages and lower wages and subsequent high turnover rates among long-term care nurses makes more education and training needed for younger nurses who will care for patients with dementia. Therefore, dementia communication programs must be included in nursing curricula, as well as ways of assessing the communication competence of inexperienced nurses. Through the integration, development, and verification processes in the current study, the caregiver communication competence scale provided a practical instrument for caregivers and educators and practical applications for communicating with patients with dementia. However, the preliminary development of this instrument may need further psychometric testing, as well as evaluation guidelines for relevant training programs.

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Communication Strategies

FOCUSED Communication Strategy (Ripich, Wykle, & Niles, 1995)

F = face to face

O = orientation

C = continuity

U = unsticking

S = structure

E = exchange

D = direct

Verification of Communication Skills Treatment (Feil & de Klerk-Rubin, 2012)

Centering

Using non-threatening factual words to establish trust

Rephrasing using polarity

Imagining the opposite

Reminiscing

Maintaining genuine, close eye contact

Using a clear, low, loving tone of voice

Observing and matching the individual's motions and emotions (i.e., mirroring)

Linking the behavior with the unmet human need

Identifying and using the preferred sense

Touching

Listening to music

10 Communication Strategies (Small, Gutman, Makela, & Hillhouse, 2003)

Eliminate distractions

Approach the individual slowly and from the front and establish and maintain eye contact

Use short, simple sentences

Speak slowly

Ask one question or give one instruction at a time

Use yes/no questions instead of open-ended questions

Repeat messages by using the same wording

Paraphrase repeated messages

Avoid interrupting the individual and allow sufficient time to respond

Encourage the individual to talk about or describe the word he/she is searching for

Brief Ordinary Effective Communication Model (Crawford, Bonham, & Brown, 2006)

Apply visual reminders that contain colored signs, pictures, or posters to prompt information exchange

Pay attention to patients' focus

Be mindful that communication difficulties cause frustration and anger

Increase alertness for nonverbal communication

Be patient and listen when patients attempt to send certain messages

Approach patients head-on and establish eye contact

Call patients by their names and prevent making arbitrary changes

Use appropriate physical contact

Talk clearly and slowly

Use simple, direct language and avoid using complex language

Introduce only one task, message, idea, or concept at a time

Guide patients by using cues or indicators to provide a sense of direction

Avoid elevating the voice, which can be mistaken as aggression or a threat

Avoid baby talk

Avoid making patients believe they should appreciate you

Do not ignore what appears to be nonsense or selectively listen to preferential expressions

Prevent judgmental comments or confronting patients' faults

Prevent abrupt conversations

Do not harass patients

Nurses' Frequency of Using Communication Strategies

Communication Strategy/Item Mean (SD) Range
1. Approach patients head-on and establish eye contact; do not abruptly appear beside patients. 3.53 (0.617) 1 to 4
2. Call patients by appropriate names and introduce yourself when facing patients. 3.41 (0.586) 2 to 4
3. Establish eye contact and ensure patients are paying attention. 3.41 (0.688) 1 to 4
4. Maintain natural eye contact when talking to patients; avoid staring or glancing away. 3.45 (0.685) 1 to 4
5. Talk to patients in a peaceful, gentle, and friendly manner. 3.59 (0.604) 1 to 4
6. Adjust speed and volume of speech according to patients' conditions. 3.52 (0.702) 1 to 4
7. Use concise sentences and simple and clear words. 3.54 (0.649) 1 to 4
8. Do not interrupt when patients are talking. 3.28 (0.846) 1 to 4
9. Repeat sentences if patients do not respond. 3.28 (0.738) 1 to 4
10. Assert rather than provide options to patients (e.g., “Come, let's join an activity.”). 3.29 (0.811) 1 to 4
11. Encourage patients to express themselves by their own means. 3.28 (0.751) 1 to 4
12. Appropriately compliment or encourage patients. 3.63 (0.561) 1 to 4
13. Tirelessly attend and respond to forgetful patients who repeatedly ask the same questions. 3.27 (0.817) 1 to 4
14. Say hello or a greeting when encountering patients even when busy with work. 3.44 (0.685) 1 to 4

Keypoints

Chao, H.-C., Yang, Y.-P., Huang, M.-C. & Wang, J.-J. (2016). Development and Psychometric Testing of the Caregiver Communication Competence Scale in Patients With Dementia. Journal of Gerontological Nursing, 42(1), 32–39.

  1. An instrument was developed for determining the communication competence of health care providers with individuals with dementia.

  2. The caregiver communication competence scale assists nurses' self-awareness of communication barriers, which promotes their motivation for selecting appropriate strategies to communicate with individuals with dementia.

  3. Caregiver communication competence scale items may serve as simple and easy-to-implement strategies for communicating with individuals with dementia.

Authors

Ms. Chao is Doctoral Candidate, Ms. Yang is Doctoral Student, Dr. Huang is Professor, and Dr. Wang is Professor, Institute of Allied Health Science, College of Medicine, National Cheng Kung University, Tainan City, Taiwan. Ms. Chao is also Lecturer, Department of Nursing, College of Nursing, Fooyin University, Kaohsiung City, Taiwan. Dr. Huang is also Professor, and Dr. Wang is also Professor, Department of Nursing, College of Medicine, National Cheng Kung University, Tainan City, Taiwan.

The authors have disclosed no potential conflicts of interest, financial or otherwise. Funding was supported by the Ministry of Science and Technology in Taiwan grant (NSC 97-2628-S-006-001-MY3).

Address correspondence to Jing-Jy Wang, PhD, RN, Professor, Department of Nursing, College of Medicine, National Cheng Kung University, 1 University Road, Tainan city, 70101 Taiwan; e-mail: ns127@mail.ncku.edu.tw.

Received: February 12, 2015
Accepted: September 18, 2015
Posted Online: October 15, 2015

10.3928/00989134-20151008-36

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