Research in Gerontological Nursing

Focus on Methods 

Psychometric Properties of the Chinese Version of the Surrogate Decision-Making Self-Efficacy Scale

Xiuli Wang, MN, RN; Ruth Palan Lopez, PhD, GNP-BC, FAAN; Anita Hendrix Rogers, MSN, RN; Yuli Li, PhD, RN; Yuezhen Ma, BS, RN; Ying Zhang, BS, RN

Abstract

Surrogate decision making for patients in the intensive care unit (ICU) can have negative physical and emotional health consequences for the decision-maker. Improving confidence and self-efficacy may reduce these consequences, but a valid instrument is necessary for reliable measurement. Using a cross-sectional design, the current study aimed to translate the Surrogate Decision-Making Self-Efficacy Scale (SDM-SES) into Chinese and evaluate its psychometric properties for surrogate decision-makers (SDMs) of patients in the ICU. The English version of the SDM-SES was translated into Chinese according to Brislin's translation guidelines and tested in 107 Chinese SDMs of patients in the ICU. Cronbach's alpha coefficient was 0.86, and a confirmatory factor analysis yielded acceptably high goodness-of-fit. Scores of the Chinese version of the SDM-SES were positively correlated with General Self-Efficacy Scale scores and 10-item Connor-Davidson Resilience Scale scores. This study indicates that the Chinese version of the SDM-SES has sufficient psychometric properties for assessing self-efficacy of SDMs for patients in the ICU. [Research in Gerontological Nursing, 14(1), 17–23.]

Abstract

Surrogate decision making for patients in the intensive care unit (ICU) can have negative physical and emotional health consequences for the decision-maker. Improving confidence and self-efficacy may reduce these consequences, but a valid instrument is necessary for reliable measurement. Using a cross-sectional design, the current study aimed to translate the Surrogate Decision-Making Self-Efficacy Scale (SDM-SES) into Chinese and evaluate its psychometric properties for surrogate decision-makers (SDMs) of patients in the ICU. The English version of the SDM-SES was translated into Chinese according to Brislin's translation guidelines and tested in 107 Chinese SDMs of patients in the ICU. Cronbach's alpha coefficient was 0.86, and a confirmatory factor analysis yielded acceptably high goodness-of-fit. Scores of the Chinese version of the SDM-SES were positively correlated with General Self-Efficacy Scale scores and 10-item Connor-Davidson Resilience Scale scores. This study indicates that the Chinese version of the SDM-SES has sufficient psychometric properties for assessing self-efficacy of SDMs for patients in the ICU. [Research in Gerontological Nursing, 14(1), 17–23.]

Surrogate decision-makers (SDMs) are expected to make health and health care decisions on behalf of critically ill patients who are unable to express their treatment preferences (Cohen et al., 2005; Nelson et al., 2017; Song et al., 2012). Facing complex decisions, SDMs are often fraught with emotional and cognitive difficulties while making decisions in intensive care units (ICUs) (Majesko et al., 2012). If SDMs lack the necessary confidence or self-efficacy for making decisions related to their loved ones with cognitive impairment or who are in a coma, they will have more psychological symptoms, such as anxiety, depression, and posttraumatic stress (Song et al., 2012). However, no measure exists to assess self-efficacy for surrogate decision making in China.

Background

In the ICU, SDMs are often spouses, children, parents, or other relatives of critically ill patients. These SDMs are tasked with the responsibility to make life-sustaining or life-limiting decisions congruent with patients' preferences (Hickman et al., 2010). SDMs for incapacitated adults have reported psychological stress, physical and emotional fatigue, role discomfort, helplessness, and feelings of inferiority (Bradley & Green, 2018; Buckey & Molina, 2012; Hickman et al., 2010; Su et al., 2014). Buckey and Molina (2012) found that watching a loved one undergo extensive tests and prolonged treatments, a deterioration of health status, and loss of quality of life is emotionally difficult and stressful. These negative effects have been found to last from months to even several years in some cases (Wendler & Rid, 2011).

Reports of psychological stressors often emanated from having to understand complex medical terminology, weighing the prospective choices, and making a determination based on the patient's preferences (Hickman et al., 2010). Specific to patients in the ICU, Schenker et al. (2013) found that the desire for more information actually conflicted with SDMs' desire to maintain hope, resulting in underlying tension. For many, balancing a fear of harm versus honoring the patient's prior expressed wishes was found to be emotionally burdensome (Buckey & Molina, 2012). Many SDMs find they are not psychologically prepared to make end-of-life decisions (Tseng et al., 2018). Adding to SDMs' burden was the perception that treatment decisions often had to be made under time constraints (de Boer et al., 2015). Traditional ethics and morality are the core of traditional Chinese culture. For example, filial piety is an important part of Chinese traditional culture, and adult children acting as SDMs may face high stress or distress when making decisions for their parents in the ICU. Hence, Chinese SDMs for critically ill patients also need a certain level of self-efficacy for decision making.

Moreover, SDMs have less self-efficacy in making surrogate decisions. Self-efficacy refers to individuals' beliefs about their capacity to exercise control over events that affect their lives and influence how they feel, think, and act (Bandura, 1990). Moreover, Bandura's (1991) self-efficacy theory demonstrated that a strong sense of efficacy enhances personal well-being and enables individuals to approach threatening situations with assurance, thereby reducing stress and lowering vulnerability to depression. However, limited instruments have been developed to measure perceived self-efficacy for surrogate decision-making.

The Surrogate Decision-Making Self-Efficacy Scale (SDM-SES), developed by Lopez and Guarino (2013), was tailored to test SDMs' beliefs regarding their capability to make surrogate decisions for people with advanced dementia. The SDM-SES describes five dimensions of self-efficacy for decision making: (a) knowing when to make decisions, (b) ability to obtain information to make informed decisions, (c) ability to weigh risks and benefits of treatment options, (d) ability to make the best treatment decisions, and (e) knowing what treatment options the individual with memory impairment would select. The original instrument was used to measure self-efficacy for SDMs of individuals unable to make decisions due to advanced dementia. In other words, it can be hypothesized that the instrument might be applicable to assess self-efficacy of SDMs who are required to make decisions for any individuals who are unable to express their preferences due to critical illness or memory impairment. Middle-aged and older adult patients in the ICU are frequently not able to express their preferences for care as they have delirium or are in a comatose state. However, there are limited instruments used to measure SDMs' self-efficacy in making decisions for older adults in the ICU, which limits geriatric nurses in providing holistic care for older adults and their family members in China. Therefore, with the permission of the original authors, the SDM-SES was applied to measure the self-efficacy for surrogate decision-making among SDMs for critically ill patients. Moreover, there are no reliable or valid measures of surrogate decision-making self-efficacy for Chinese patients in the ICU. Therefore, the purpose of the current study was to translate the SDM-SES (Lopez & Guarino, 2013) into Chinese and assess its psychometric properties among Chinese SDMs of patients in the ICU.

Method

Study Design and Sample

In the current cross-sectional study, an online questionnaire survey was conducted from January to May 2019 in Shandong Provincial Third Hospital, Jinan City, China. The sample was obtained from the ICU and the head nurse agreed that we could investigate SDMs who provided written and oral informed consent. Inclusion criteria were as follows, SDMs: (a) of patients in the ICU with memory impairment or coma diagnosed by a physician; (b) of patients who were unable to communicate; (c) could read, speak, and understand Chinese; (d) could use a smartphone to complete the online questionnaires; and (d) age ≥18 years. SDMs who themselves had a severe or acute disease were excluded from the study. SDMs completed all questionnaires in the hospital conversation room after visiting patients. Moreover, all online questions had to be answered. SDMs were prompted to complete missing questions by the system before submission of the questionnaire. Thus, the questionnaire recovery rate was 100%.

Translation Procedure

With the original authors' permission, we translated the English version of the SDM-SES into Chinese and revised the items to measure self-efficacy of SDMs of patients in the ICU. The SDM-SES was translated into Chinese using Brislin's (1986) forward and backward translation method. The translation was first performed by two independent and professional translators (A and B) on the research team. The two translated versions (SDM-SES[A] and SDM-SES[B]) were merged into a single forward translation version (SDM-SES[C]) by a third professional and native Chinese speaker (C) and the items were revised. For example, the original item “I am confident that I know I need to make decisions for the individual with memory impairment,” was revised to “I am confident that I know I need to make decisions for the individual with memory impairment or in a state of unconsciousness in the ICU.” This version was then translated back into English by a fourth, bilingual researcher (D) who was not exposed to the scale previously. Discrepancies between the original and back-translated versions were reviewed for equivalence of meaning. Finally, the Chinese version of the SDM-SES was modified and refined (Table A, available in the online version of this article).

Instruments

SDM-SES. The SDM-SES is a self-report scale that measures self-efficacy among SDMs (Lopez & Guarino, 2013). The SDM-SES has five items scored on a 4-point Likert-type scale, where 1 = strongly disagree and 4 = strongly agree. Total score ranges from 5 to 20, with higher scores indicating greater perceived self-efficacy for surrogate decision making.

General Self-Efficacy Scale (GSES). The GSES was developed to measure individuals' beliefs in their ability to cope with a variety of situations in life (Schwarzer & Jerusalem, 1995). The GSES is a self-report 10-item measure scored on a 4-point Likert-type scale, where 1 = totally incorrect and 4 = totally correct. Total score ranges from 10 to 40, with higher scores indicating a higher level of self-efficacy. High validity and reliability of the scale have been demonstrated in many studies across various research contexts and populations (Luszczynska et al., 2005), and the psychometric properties of the Chinese version of the GSES have been well documented (Shen & Tang, 2004). Cronbach's alpha coefficient for the current sample was 0.85. The GSES has been widely used to assess health beliefs and previously adapted for use in the Chinese population. The GSES was selected for the current study to test the convergent validity of the SDM-SES.

Connor-Davidson Resilience Scale (CD-RISC). The CD-RISC comprises 10 self-rated items that measure individual resilience (Campbell-Sills & Stein, 2007). Resilience is the ability to adapt and cope with adverse events and can help decision-making abilities. The Chinese version of the CD-RISC was used in the current study with the permission of Dr. Davidson. The CD-RISC is scored on a 5-point Likert-type scale from 0 = never to 4 = almost always, with higher scores indicating greater resilience. The scale's reliability and validity with the Chinese population have been well documented (Wang et al., 2010). Cronbach's alpha coefficient of the overall scale in the current study was 0.92. The CD-RISC was used to examine the criterion-related validity of the SDM-SES.

Data Analyses

Prior to analysis, all SDM-SES items were examined through SPSS 20.0 for accuracy of data entry, missing values, and fit between their distribution and the assumptions for analysis. Face validity was measured by asking three expert ICU nurses to review the five items for clarity, comprehension, and relevance. Readability was assessed using the Flesch-Kincaid grade level formula. Internal consistency was assessed using Cronbach's alpha coefficient (Polit & Beck, 2012). Single factor construct validity was evaluated through a confirmatory factor analysis (CFA) using Amos 24.0 Maximum Likelihood Program. The convergent validity between the SDM-SES and other measures (i.e., GSES and CD-RISC) was evaluated using Spearman's rank correlation coefficients, as the variances were all in skewness distributions.

Ethics

This study was conducted according to the principles outlined in the Declaration of Helsinki and was approved by the Medical Ethics Committee. The questionnaires were completed voluntarily, and oral informed consent was obtained from all participants.

Results

A total of 107 participants answered the questionnaire (return rate = 100%). SDMs' mean age was 31.02 (SD = 14.22 years, range = 18 to 65) and patients' mean age was 55.55 (SD = 16.63 years, range = 50 to 94). The majority of SDMs (76.6%) were female, and all were Han nationality. Ninety-eight (91.6%) had a close family relative (i.e., spouse, sibling, adult child, or parent) with memory impairment or who was in a coma in the ICU. The majority (71%) of SDMs had an educational level of college or above, and 73.8% of SDMs had part- or full-time jobs (Table 1).

Participant Characteristics (N = 107)

Table 1:

Participant Characteristics (N = 107)

Face Validity

The agreement among the three expert ICU nurses achieved a Fleiss's kappa of 0.88. They reported that the scale appeared to be credible, accurate, and a relevant measure of self-efficacy for surrogate decision making. The three SDMs who pilot tested the scale reported that it was easy to use, and the instructions were clear and readable.

Internal Consistency

Table 2 shows the means, standard deviations, 95% confidence intervals, and skewness for the five items of the SDM-SES. Internal consistency achieved a Cronbach's alpha coefficient of 0.86. This internal consistency suggests that the five items all measured the same underlying construct (Polit & Beck, 2012). Table 2 also presents the corrected-to-total correlation. All items were >0.60, which indicates the item's homogeneity in measuring the concept of self-efficacy for surrogate decision making. Nevertheless, the Cronbach's alpha coefficient of the Chinese version of the SDM-SES did not increase by more than 0.10 upon deletion of any item.

Item Analysis of the Chinese Version of the Surrogate Decision-Making Self-Efficacy Scale (N = 107)

Table 2:

Item Analysis of the Chinese Version of the Surrogate Decision-Making Self-Efficacy Scale (N = 107)

Construct Validity

Construct validity was evaluated using CFA. Although the chi-square value for the one-factor model was significant (χ2/df = 3.54, p = 0.003), the comparative fit index, Tucker Lewis index, and normal fit index yielded acceptably high goodness-of-fit indices (0.95, 0.89, and 0.93, respectively). In addition, all items loaded statistically significantly and practically on the single-factor model, ranging from 0.70 to 0.85 (Figure 1).

Factor loading of the Surrogate Decision-Making Self-Efficacy Scale (SDM-SES) items. Note. e = error; Q = question.

Figure 1.

Factor loading of the Surrogate Decision-Making Self-Efficacy Scale (SDM-SES) items. Note. e = error; Q = question.

Convergent and Criterion-Related Validity

Convergent validity was assessed by comparing the Chinese version of the SDM-SES with the GSES and CD-RISC. The total score of the Chinese version of the SDM-SES was positively correlated with the GSES (r = 0.29, p < 0.01) and CD-RISC (r = 0.35, p < 0.01) (Table 3).

Concurrent Validity and Cronbach's Alpha Coefficients of the Chinese Version of the Surrogate Decision-Making Self-Efficacy Scale (SDM-SES)

Table 3:

Concurrent Validity and Cronbach's Alpha Coefficients of the Chinese Version of the Surrogate Decision-Making Self-Efficacy Scale (SDM-SES)

Discussion

In the current study, we adapted Lopez and Guarino's (2013) SDM-SES for Chinese SDMs of patients in the ICU and found that the Chinese version had sufficient psychometric properties for assessing the perceived self-efficacy of SDMs.

The ethical and legal problems raised by the evaluation of decision-making capacity are brought into sharp focus in the ICU. Traditional ethics and morality are the core of traditional Chinese culture. Filial piety is an important part of Chinese culture, and adult children acting as SDMs may face high stress or distress when making decisions for their parents. However, improving their self-efficacy or ability to make decisions could diminish their distress. Previous studies have demonstrated that perceived self-efficacy is an important concept in understanding the experiences and health-related outcomes of decision-makers or family caregivers for individuals with dementia (Lopez & Guarino, 2011). The current study also verified the hypothesis that the instrument might be applicable to assess self-efficacy for SDMs who are required to make decisions for any individuals in the ICU who are unable to express their preferences due to critical illness or memory impairment. Delirium is particularly prevalent among hospitalized older patients in the ICU, particularly those presenting with impaired memory or attention (Martin et al., 2012). People with delirium in the ICU cannot think clearly and have trouble paying attention. Hence, most of the clinical decisions need to be made by family members or significant others. The Chinese version of the SDM-SES would be a reliable instrument for geriatric nurses in the ICU to measure the self-efficacy of SDMs and explore the factors related to self-efficacy.

In addition, the current study showed a positive relationship between SDMs' self-efficacy and individual resilience. This result indicated that the Chinese version of the SDM-SES had good criterion-related validity and that SDMs with higher levels of individual resilience will more effectively make surrogate decisions for their family members. A resilient person displays a quick adaptive response to extreme changes, experiences life as a series of challenges, brings stability to a crisis, and maintains inner calm even in stressful situations (Kumar et al., 2019). Moreover, the relationship between individual resilience and surrogate decision-making self-efficacy indicates that resilience-based interventions might help facilitate SDMs' self-efficacy for patients in the ICU. General self-efficacy positively associated with surrogate decision-making self-efficacy indicated a good convergent validity of the Chinese version of the SDM-SES. Although general self-efficacy refers to our overall belief in our ability to succeed, and surrogate decision-making self-efficacy is more specific, they both conform to the same basic theory—Bandura's (1994) Self-Efficacy Theory. Bandura (1999) proposed that perceived self-efficacy influences what coping behavior is initiated when an individual is met with stress and challenges. Thus, SDMs' self-efficacy will help in making decisions for critically ill patients.

Strengths and Limitations

Prior to the current study, there were no specific instruments for measuring the self-efficacy of SDMs for Chinese patients in the ICU. Thus, the SDM-SES will be a useful tool for clinical staff to help evaluate the self-efficacy of SDMs with family members in the ICU, assisting them in providing targeted health support for these individuals. However, there were limitations in this study. First, more detailed sociodemographic variables need to be surveyed in future studies. Second, the test–retest reliability coefficients need to be measured. Finally, a larger sample and more randomized sampling methods should be considered in future studies to verify the reliability and validity of the Chinese version of the SDM-SES.

Conclusion

The Chinese version of the SDM-SES has good psycho-metric properties for assessing self-efficacy among SDMs of patients in the ICU in China. Thus, this tool will help Chinese ICU nurses measure SDMs' self-efficacy and explore relationships between self-efficacy of surrogate decision-making and the psychological well-being of SDMs of ICU patients, which in turn will help clinical nurses improve SDMs' self-efficacy for surrogate decision making.

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Participant Characteristics (N = 107)

Characteristicn (%)
Sex
  Female82 (76.6)
  Male25 (23.4)
Residence
  Urban46 (43)
  Rural35 (32.7)
  Sub-rural26 (24.3)
Educational level
  Primary7 (6.5)
  Middle24 (22.4)
  College or above76 (71)
Working status
  Part-time49 (45.8)
  Full-time30 (28)
  Unemployed/retired28 (26.2)
Relation to critically ill patient
  Child54 (50.5)
  Spouse36 (33.6)
  Other relative9 (8.4)
  Parent8 (7.5)

Item Analysis of the Chinese Version of the Surrogate Decision-Making Self-Efficacy Scale (N = 107)

Item NumberMean (SD)95% CISkewnessCorrected Item–Total CorrelationCronbach's Alpha if Item Deleted
13.09 (0.64)[2.97, 3.22]−0.300.660.84
23.07 (0.58)[2.96, 3.19]−0.300.630.84
33.02 (0.66)[2.89, 3.14]−0.420.760.81
43.01 (0.64)[2.89, 3.13]−0.010.700.83
52.98 (0.67)[2.85, 3.11]−0.550.640.84

Concurrent Validity and Cronbach's Alpha Coefficients of the Chinese Version of the Surrogate Decision-Making Self-Efficacy Scale (SDM-SES)

SDM-SES TotalGSES TotalCronbach's Alpha
SDM-SES total0.86
GSES total0.29**0.94
CD-RISC total0.35**0.54*0.93
Authors

Ms. Wang is Director, Quality Management Department, Ms. Ma is Head, Nursing Department, and Ms. Zhang is Head Nurse, Shandong Provincial Third Hospital, Jinan, China; Dr. Lopez is Jacques Mohr Professor of Geriatric Nursing Research and Associate Dean for Research, MGH Institute of Health Professions, Boston, Massachusetts; Ms. Rogers is PhD Candidate, University of Tennessee, Knoxville, Tennessee; and Dr. Li is Associate Research Professor, School of Nursing and Rehabilitation, Cheeloo College of Medicine, Shandong University, Jinan, China.

The authors have disclosed no potential conflicts of interest, financial or otherwise. This work was supported by the Shandong Provincial University Science and Technology Development Project (J17KA241) and the Fundamental Research Funds of Shandong University (2019GN089).

The authors thank all study participants.

Address correspondence to Yuli Li, PhD, RN, Associate Research Professor, School of Nursing and Rehabilitation, Cheeloo College of Medicine, Shandong University, No. 44, West Wenhua Road, 250012 Jinan, China; email: liyuli2019@sdu.edu.cn.

Received: May 06, 2020
Accepted: August 14, 2020

10.3928/19404921-20201109-01

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