656450
research-article2016

JFNXXX10.1177/1074840716656450Journal of Family NursingKiriake and Moriyama

ArticleDevelopment andTesting of thePartnership Scalefor Primary Family
Caregivers Caring for
Patients With Dementia

Journal of Family Nursing
﻿1­–29© The Author(s) 2016
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DOI: 10.1177/1074840716656450
jfn.sagepub.com

Ayumi Kiriake, RN, PhD1,
and Michiko Moriyama, RN, MSN, PhD2

Abstract
This article reports the development and preliminary testing of a new scale
named “Partnership Scale for Primary Family Caregivers Caring for Patients
With Dementia” that measures the ability of primary family caregivers toestablish partnerships while providing care for patients with dementia in Japan.
The first draft of the scale was developed using qualitative data from interviews
with five primary family caregivers; a pool of 39 items was created through areview process with dementia care experts and researchers. An exploratory
factor analysis and confirmatory factor analysis were conducted with data from261 primary family caregivers who completed the instrument. This resulted
in a multidimensional scale that consists of three factors with 13 items. The
suitability of the model and intraclass correlation coefficient (ICC) values (1, 1)
obtained by the test–retest method satisfied statistical standards. The criterionrelated validity of the scale was significantly correlated to an external reference,
which was the desired outcome. However, some subscales exhibited low
internal consistency, demonstrating the need for further research.
1Kurume University, Japan
2Hiroshima University, Japan

Corresponding Author:
Ayumi Kiriake, Associate Professor, School of Nursing, Kurume University, 777-1 HigashiKushiharamachi, Kurume, Fukuoka 830-0003, Japan.
Email: kiriake_ayumi@med.kurume-u.ac.jp

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Keywords
instrument development, primary family caregivers, family members,
partnerships, patients with dementia, Japan
In Japan, both the aging population and the number of people diagnosed withdementia are increasing at rates exceeding government predictions (Asada,2013). In-home care has been promoted as a way for patients to continue living in familiar surroundings (Ministry of Health, Labour, and Welfare,
Dementia Policy Research Project Team, 2012). Although this policy is
expected to prevent excessive increases in medical expenses for long-termcare, and to improve the quality of life of patients with dementia, it may resultin an increased burden for primary family caregivers.
Providing high-quality dementia care requires support and collaboration
among all involved individuals, including the patient, health care providers,and family caregivers. Building partnerships is critical to establish these collaborations, and it is important that partnerships extend beyond mere consent
to include respect for and sharing of experiences and knowledge (Adams &Clarke, 1999/2006). The ability to build partnerships is considered essential
for any person providing care to a patient with dementia. Therefore, theinstrument developed in this study focused on the ability of primary family
caregivers to build partnerships that form the nucleus of support for patientswith dementia.
The behavioral and psychological symptoms caused by dementia increase
the burden on primary family caregivers (Onishi et al., 2003) and negatively
affect their relationships with the patient (Kishimoto et al., 2013; Perren,
Schmid, Herrmann, & Wettstein, 2007). In addition to the primary symptomsof impaired memory and decreased cognitive function, other behavioral andpsychological symptoms manifest include hallucinations, delusions, and irritability. Family members who knew the patient before the onset of symptoms
of dementia may find it difficult to cope with and accept such changes in apatient, and thus family relationships may suffer (Kimura, 2008). Moreover,behavioral and psychological symptoms may interfere with the provision ofcare and further increase the burden on family caregivers (Kamiya, Sakurai,
Ogama, Maki, & Toba, 2014). These situations can worsen the psychologicalconditions of primary family caregivers (Cooper, Blanchard, Selwood,
Walker, & Livingston, 2010) and lead to strained relationships (Ueda, 2000).
When primary family caregivers are involved in relationships with others,
conflicts between primary family caregivers and other family members may
arise over both major and minor issues (Scharlach, Li, & Dalvi, 2006).
Yamamoto (1995) argued that the reason for these differences emerges from

Kiriake and Moriyama

3

the perceptions of primary family caregivers who have lived with andobserved the patient for a long time versus family members who have not.
The gap between these perceptions contains a greater potential for domestic
misunderstanding and conflict. Conflict between primary family caregivers
and other family members has been reported to strongly influence symptoms
of depression and the perception that caregiving is a burden among family
caregivers (Semple, 1992).
The lack of support from immediate family members also creates stressfor caregivers. Based on an attitude survey of primary family caregivers inJapan and the United Kingdom, Japanese caregivers reported a higher awareness of their duty to physically support elderly parents but a low recognitionof the need for collaboration among family members in providing care
(Maeda, Mizushima, & Saito, 2004). This attitude is influenced by social
norms, such as filial piety and traditional stereotypical female roles (Lebra,1976). One result of such attitudes is that instead of family collaboration,
women (e.g., wives and daughters-in-law) bear the central and excessive burden of care (Yamamoto, 1995). Even after the introduction of the Long-TermCare insurance system in Japan, in which care of the elderly was supposedlytransferred from female family members fulfilling domestic duties to a professional care provision system, the attitudes of family members did notchange significantly; instead, the burden of care was simply delegated tosociety. Consequently, it appears that the contribution of family members to
the care process has not been fully measured.
Relationships between primary family caregivers and community
resources, including health care professionals, are also important. Even
though it has been reported that good relationships improve the primary caregivers’ health (Cooper et al., 2010; Redinbaugh, MacCallum, & KiecoltGlaser, 1995), it may be difficult to build relationships between primaryfamily caregivers and professionals because the balance of power is notequal; family caregivers are often not involved in complex decision making(Heinrich, Neufeld, & Harrison, 2003). Because social resources may not be
used by primary family caregivers, their sense of burden may increase(Maeda et al., 2004; Tanji et al., 2005). Services such as respite care to reducethe burden of caregiving, professional medical support for dementia, andfamily support groups are underutilized, even though these are provided by
the government in Japan. This gap indicates the need to foster collaboration
among caregivers, family members, and health care providers.
Nurses can support family caregivers in developing and fostering these relationships. When primary family caregivers are enabled to develop partnerships,
it can lead to effective support for providing care, which can, in turn, reduce theburden of family caregiving and promote a more positive appraisal of family

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Figure 1. Partnership of primary family caregivers caring for dementia patientsand the expected ethical considerations.

(Cooper et al., 2010; Tanaka, Hyodo, & Tanaka, 2002; Zarit, Femia, Kim, &Whitlatch, 2010). Considering such care situations from the perspective of stressand coping theory (Lazarus & Folkman, 1984), fostering such partnerships withprimary family caregivers amounts to an effective coping behavior and seems toengender the promotion of primary family caregivers’ psychological adjustment
to the provision of care (see Figure 1).
Developing these partnerships may not be easy, particularly for Japanese
primary family caregivers who may have cultural issues related to collaborating with other family members or coordinating with medical professionals, andthus may lack the ability to overcome obstacles. Some qualitative studies haveexamined families’ abilities to care for patients with dementia (Nagai, 2005)
and their appropriate communication skills (Nishida & Yamada, 2007).
However, there is a lack of quantitative studies describing the skills required forprimary family caregivers to form good relationships with patients with dementia as well as no studies on the relationship between primary family caregivers
and health care providers. Previous studies have not focused on the caregivers’
abilities to build collaborative relationships, nor is there a scale to evaluate suchskills. If these abilities can be comprehensively elucidated, it would enable
creation of an assessment instrument to identify ways to support patients withdementia and their primary family caregivers in Japan.

Definition of Terms
The terms used in this study are operationally defined as follows.

Kiriake and Moriyama

5

Partnership of Primary Family Caregivers Caring for Patients
With Dementia
Based on the notion that “families are a part of large higher-order systems
and are made up of lower-order systems” derived from systems theory(Wright & Leahey, 2013, pp. 27-28), this study focuses on the relationship ofprimary family caregivers to systems both inside and outside the family.
Moreover, the partnerships found in these relationships are operationallydefined as cooperative relationships that enable mutual respect between primary family caregivers and relevant stakeholders (persons with dementia,
other family members, professional practitioners, and neighbors) that aredeveloped through the practice of caring for the dementia patient. Furthermore,ability to establish such a relationship is the central measurement concept of
the “Partnership Scale for Primary Family Caregivers Caring for Patients
With Dementia” described in this article.

Primary Family Caregiver
A primary family caregiver is defined as the family member chiefly responsible for care provision of all family members caring for a patient withdementia. In addition, “family” is defined as a collective of individuals who
recognize each other as family, irrespective of whether they share the same
household.

Purpose of the Study
This study aimed to (a) develop a scale to measure the ability of primary family caregivers to build partnerships within inside and outside of the family
while caring for a family member (the patient) with dementia, with Japanese
primary family caregivers as participants; and (b) test its validity andreliability.

Research Methodology
Item Pool Development and Content Validity Testing
Using convenience sampling, the manager of a prefectural day care facility
focusing on persons with dementia who agreed to cooperate with theresearcher was asked to select primary family caregivers actively involved in
caring for patients with dementia. Selection focused on patients’ families andother care stakeholders with positive working relationships, and sought to6Journal of Family Nursing ﻿

avoid bias in terms of gender or the nature of relationship to the recipient ofcare. After five primary family caregivers were identified and had the study
described to them, verbal and written consent to participate were obtained.
Semistructured interviews that lasted 60 to 90 min were conducted with theparticipants. The questions focused on what they attended to in their dailycare practices to build collaborative and mutually respectful relationships
with the patients with dementia and with the family member and others
involved in providing care. The participants, three women and two men,ranged in age from 50 to 80 years. In terms of their family relationship to therecipient of care, in three cases the recipient of care was a spouse, in one casea mother-in-law, and in one case a mother. When the five interviews werecompleted, it was determined that the content had sufficient commonality
and that data saturation had occurred. Data were collected between June 2010
and September 2010.
Data from the interviews were transcribed and analyzed according to procedures for qualitative data proposed by Kayama (2007). First, those portionsof the accounts relating to the ability of the primary family caregiver to build
collaborative relationships were extracted from the data obtained from thetranscripts and summarized with attention to similarity to create 33 items. A
further 11 items were added after review of additional literature (Fallon,
Gránne, & Victor, 1993; Kitwood, 1997/2005; Nagai, 2005) to create 44
questions. Analysis of these questions resulted in the extraction of eight categories: (a) Interactions That Reassure the Patient With Dementia, (b) Coping
That Matches the Patient’s World, (c) Interactions That Bring Out the Elderly
Patient’s Strengths, (d) Comprehension and Accommodation of One’s Own
Situation, (e) Proactive Aspiration for Information and Knowledge, (f) Trust
Formation and Role Coordination, (g) Proactive Consultation and Request,and (h) Affirmation of One’s Own Opinion. After further discussion andextensive modification by doctoral students in the Division of Nursing
Science in the Hiroshima University Institute of Biomedical and Health
Sciences with respect to the words used, content, and connections between
the categories and each item, five items were eliminated, thereby yielding a
final total of 39 questions. The response format was a 5-point Likert-type
scale ranging from 0 (not at all) to 4 (extremely so).
Next, as a Content Validity Index for the question items, a questionnaire
was distributed to a group of nine dementia care experts, including day careservice managers specializing in dementia care with 10 or more years ofexperience in the provision of dementia care as well as dementia care specialist nurses certified by the Japanese Society for Dementia Care. These dementia experts possessed a wealth of knowledge concerning the abilities requiredof primary family caregivers for providing care to patients with dementia. In

Kiriake and Moriyama

7

addition, approaching the data by considering various perspectives is regarded
as a way to ensure the validity of results (Frick, 1995/2002). The survey
asked participants to rate each item on a 4-point Likert-type scale from 1 (notappropriate) to 4 (concise and appropriate). This was based on the method
proposed by Lynn (1986), wherein the percentage of experts who rated each
item as 3 or more was calculated, and items that scored 78% or higher wereconsidered appropriate. As a result, the percentage of experts that assigned arating or three or more for all items was between 78% and 100%. The survey
period was between December 2010 and January 2011. The 39 items were
proposed as the preliminary Partnership Scale for Primary Family Caregivers
Caring for Patients With Dementia.

Reliability and Validity Testing
Sample and setting. Consent to participate in the study was solicited andobtained from five facilities located in Prefecture F specializing in the provision of day care for patients of dementia. Prefecture F is a regional administrative district in Japan with approximately 5 million residents, corresponding
to approximately 4% of Japan’s total population. Approximately 23.3% of
the population were above age 65 in prefecture F in 2013, which is slightly
the national average of 25.1% (Cabinet Office, 2013). The managers of theparticipating facilities agreed to select participants for the study. The criteria
for selecting participants necessitated that they were primary family caregivers providing in-home care for patients diagnosed with dementia. Documents
explaining the purpose of the study and an anonymous self-administeredquestionnaire were distributed to 430 individuals satisfying these criteria by
the staff at the participating facilities; participants were asked to return their
responses via post. In addition, with regard to the selection of primary family
caregivers, each family was given the choice to select the one person who
was primarily responsible for care provision.
A total of 286 responses were received (66.5% response rate), of which
261 were deemed complete and suitable for analysis. The attributes of the
primary family caregivers and recipients of care are listed in Tables 1 and 2.
Data of participants were devited randomized two groups for analyze. Amongthe primary family caregivers, the majority were female, and many respondents belonged to three-generation households. Among the recipients of care,the majority were female, and these were most commonly the mothers of the
primary family caregivers. In terms of the severity of dementia among therecipients of care, many were estimated to be suffering from severe dementia.
A retest was implemented after an interval of 1 week with 50 respondents
from a participating facility. A 1-week interval was observed between the

8Journal of Family Nursing ﻿

Table 1. Characteristics of Participants (Primary Family Caregivers) Which
Debited Randomized Two Groups for EFA and CFA.
Number of people (%) or M (SD)
ItemGroup A (n = 130)Age61.0 (12.5)
GenderMale
37 (28.5)
Female93 (71.5)
Family structure
Married couple only
35 (26.9)
Nuclear family
37 (28.5)
Three-generation household
49 (37.7)
Extended family
9 (6.9)Care periodLess than 6 months
8 (6.2)6 months-1 year
10 (7.7)
1-3 years
36 (27.7)
3-5 years
29 (22.3)
5-9 years
28 (21.5)
9-12 years
10 (7.7)
12 years or more
9 (6.9)Health conditions
Healthy57 (43.9)
Neither healthy nor unhealthy
36 (27.7)
Unhealthy
36 (27.7)
Users of health and medical welfare services
Day care/day service
122 (93.8)
Short stays
39 (30.0)
Visiting care
14 (10.8)
Visiting nurse
7 (5.4)

Group B (n = 131)59.8 (10.1)
24 (18.5)
106 (81.5)
38 (29.0)
28 (21.4)
55 (42.0)
9 (6.9)8 (6.1)11 (8.4)
38 (29.0)30 (22.9)
26 (19.8)8 (6.1)6 (4.6)64 (48.9)
31 (23.7)
36 (27.4)
120 (91.6)
32 (24.4)
15 (11.5)
4 (3.1)

Note. Missing values have been redacted, so the totals of some items may not add up to 100%.
EFA = exploratory factor analysis; CFA = confirmatory factor analysis.

initial test and the retest was in order that responses would not be affected bychanges in the medical condition and care situation of the person receivingcare. In addition, by asking staff to assign code numbers to participants, andhaving participants return their questionnaires after marking their code number, code matching was carried out in a way that ensured anonymity. The
survey period was between March 2011 and July 2011.

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Kiriake and Moriyama
Table 2. Characteristics of Participants (Care Receivers) Which Debited
Randomized Two Groups for EFA and CFA.
Number of people (%) or M (SD)
ItemGroup A (n = 130)

Age
GenderMale
FemaleRelationship to primary caregiver
SpouseParentMother-in-law
Father-in-law
Sibling
Other
Dementia severity
Suspected dementia
Light dementia
Moderate dementia
Severe dementia

Group B (n = 131)

83.0 (7.8)

84.03 (6.9)

40 (30.8)
90 (69.2)

37 (28.2)
93 (71.0)

33 (25.4)
64 (49.2)
20 (15.4)
3 (2.3)3 (2.3)7 (5.4)28 (21.4)
58 (44.3)
40 (30.5)
3 (2.3)0
2 (1.5)1 (0.8)5 (3.8)45 (34.6)
79 (60.8)

5 (3.8)11 (8.4)
34 (26.0)
81 (61.8)

Note. Missing values have been redacted, so the totals of some items may not add up to 100%.
EFA = exploratory factor analysis; CFA = confirmatory factor analysis.

Measures. The following five questionnaires were administered:1.

2.

Short Japanese Version of the Zarit Caregiver Burden Interview (Arai,
Tamiya, & Yano, 2003) is composed of two factors and eight items,on the basis of 22 items and two factors of the original version (Zarit,
Reever, & Bach-Peterson, 1980); its reliability and validity has been
confirmed in Japan. The factors are as follows: (a) Factor I Personal
Strain: degree of negative feeling toward situations that require careand (b) Factor II Role Strain: degree to which the caregiver’s social
life is hindered by care. A higher score is evaluated as a greater senseof burden.
Caregiver Positive Appraisal Scale (Suyama, Kawano, & Kawano,2004): Suyama et al. (2004) considered positive feelings about care to
be influenced by the primary family caregiver’s coping behavior andthe perception of the results, and created a scale composed of 12 itemswith the following three factors: (a) Factor I Sense of fulfillment

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3.

4.

toward care situation, (b) Factor II Sense of self-growth, and (c)Factor III Sense of belonging with the elderly. A higher score is evaluated as more positive feelings toward care.
Short Japanese Version of the Multidimensional Scale of Perceived
Social Support (Iwasa et al., 2007): Social support refers to support
with an instrumental and expressive function brought about throughinterpersonal relationships. Iwasa et al. (2007) developed a shortJapanese Version of the Multidimensional Scale of Perceived Social
Support created by Zimet, Powell, Farley, Werkman, and Berkoff(1990). It is composed of seven items and the following three factors:(a) Factor I Support from family, (b) Factor II Support from significant other, and (c) Factor III Support from friends. A higher score isevaluated as receiving greater social support.
Severity Evaluation Checklist for Elderly Persons at Home (Tokyo
Metropolitan Institute of Gerontology & Social Welfare Division,1996) was used to measure dementia severity. Primary family caregivers were asked to check off the presence of symptoms in theelderly person with dementia. The more symptoms checked indicatedgreater severity of dementia.

The preliminary Partnership Scale for Primary Family Caregivers Caring
for Patients With Dementia, developed as previously described, was administered. For this survey, we accounted for issues that may affect the study if
the primary family caregivers had to respond to several surveys and if theburden to answer was high, that is, responses might be missing, or there
might be a high number of response errors. Therefore, of the 430 participantsin study, half (n = 215) were given the preliminary Partnership Scale,Multidimensional Scale of Perceived Social Support (Japanese Edition;
Iwasa et al., 2007), and Zarit’s Caregiver Burden Scale (Short Edition; Araiet al., 2003). The other half of the participants completed the Care Positivity
Scale (Suyama et al., 2004) and the preliminary Partnership Scale.

Data Analysis
Data were analyzed using SPSS Version 17.0 for Windows and Amos Version
21.0 (both by IBM, Armonk, NY, USA).
Exploratory factor analysis (EFA). For our analysis, data from 261 participants
were randomly divided into two data sets using SPSS. One of these groups(Group A, 130 members) was subjected to EFA (principal factor method by correlational matrix, Varimax rotation). The number of factors was determined byKiriake and Moriyama

11

performing parallel analysis (Horn, 1965), which has been described as deriving
an appropriate number of factors while taking sampling error into consideration.
A factor loading value of .40 or higher was considered the standard for adoption.
Furthermore, the elimination of factors with a factor load of .30 or higher (otherthan principal factors) enabled the careful selection of items with high discriminative power to identify the minimum number of items for the scale. This wasdone to select items with a specific load for each factor, and to create a modelthat has a factor structure wherein the connections between each factor and item
have a clear and concise explanatory power (Brown, 2006).
Confirmatory factor analysis (CFA). A model was constructed based on the
results obtained from the EFA, and a CFA (maximum likelihood method) was
conducted for the other group, which did not undergo EFA (Group B, 131
members). A covariance structure analysis (maximum likelihood method)
was performed by CFA using Amos. The basic model for the analysis, basedon the results of EFA, was composed of three factors (“Ability for Receptive
Coping,” “Proactive Consultation and Information-Seeking,” and “Trust Formation and Role Coordination”) and 14 items. In family systems (Wright &Leahey, 2013), the model can be interpreted as the ability of primary family
caregivers to build partnerships within systems inside and outside of the family. In the analysis, correlations were posited with each factor. In addition, toclearly show the effect of error variables on each item, the variance of error
variables only was fixed at 1. However, no restrictions were imposed on any
other value estimates. The criteria used to satisfy goodness -of- fit in the CFA
were a standardized root mean square residual (SRMR) of .08 or less (Albright& Park, 2009), comparative fit index (CFI), Tucker–Lewis index (TLI) of .95
or more (Hu & Bentler, 1999), and root mean square error of approximation(RMSEA) of .05 or less (Netemeyer, Bearden, & Sharma, 2003).
Test of internal consistency and stability. To test for internal consistency, Cronbach’s alpha coefficient (Waltz, Strickland, & Lenz, 2005) was calculated forthe scale created as a result of the CFA of Group B and its subscales. Moreover, to confirm stability, after confirming the normality of the scale scores,
the intraclass correlation coefficients (ICCs; Tsushima, 2007) were calculated for the 50 participants who were retested.

Relations to Other Scales
Kramer (1997) stated that evaluation of the role of the caregiver (burden andgain) is a factor that defines the caregiver’s well-being in response to the
influence of caregiver background, the caregiving process, and care

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performance. In addition, how this care role is important in the context ofcoping behavior has been indicated. Therefore, in this study, the ability of the
primary family caregiver to build partnerships, which has been posited as aneffective form of coping based on stress coping theory, is predicted to bestrongly associated with positive relationships with persons with dementia
and acquiring social support from people in the network of care. These results
were also hypothesized to be associated to a moderate degree with positive
feelings and a sense of burden in the primary family caregiver’s experienceof care (Figure 1). Based on these hypotheses, Zarit’s Care Burden Scale(Short Edition; Arai et al., 2003), which conforms to the predicted partnership results based on stress and coping theory (see Figure 1), as well as theMultidimensional Scale of Perceived Social Support (Japanese Edition;
Iwasa et al., 2007) and the Care Positivity Scale (Suyama et al., 2004) wereused to examine the convergent validity of the Partnership Scale. Spearman’s
correlation coefficient was calculated for the score on the Partnership Scalecreated from the results of factor analysis and these scales.

Ethical Considerations
All participants were provided a written explanation about the purpose andsignificance of the study, the measures used to ensure anonymity and confidentiality, the management of data, and the reporting of research results at
academic conferences. They were informed that participation was voluntary,and that refusal to participate would involve no penalty or loss of benefits towhich the participant was otherwise entitled. The document also included
contact information for the researchers. A consent to participate in the study
was considered obtained from all those who responded. In addition, the planof this study was submitted for review to the Ethical Review Board of theresearchers’ affiliated institution and approval was obtained (Approval
Number: 1023).

Results
EFA
EFA proceeded as follows: (a) factor analysis for all items, (b) determining thenumber of factors by parallel analysis, and (c) factor analysis following determination of the number of factors. First, as the result of EFA (principal factor
method by correlational matrix, Varimax rotation) of 39 items on the Partnership
Scale, 10 factors were extracted with eigenvalues of one or greater, and the total

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Kiriake and Moriyama

Figure 2. Results of parallel analysis using eigenvalues from research and random
data (n = 130).
Table 3. Results of Parallel Analysis Using Eigenvalues From Research andRandom Data.
Eigenvalue
Factor number
1
2
3
4
5
6
7
8
9
10

Research data (n = 130)

Random data (n = 130)10.517
4.508
2.060
1.739
1.721
1.521
1.406
1.270
1.179
1.012

2.300
2.124
1.986
1.875
1.786
1.074
1.630
1.557
1.482
1.421

Note. Eigenvalues of more than 10 factors have been omitted.

14

Note: Factor loading >.40 are in boldface.

Factor I (six items): Ability for Receptive Coping
9. I adapt my support to the condition of the person receiving care on that particular day.
16. I recognize when the person receiving care is able to do something and praise him or her.
8. When necessary, I switch scenes (such as changing the topic or the person speaking,etc.), and avoid confusion and excitement of the person receiving care.
7. Even with clumsy behavior, I value the feelings of the person receiving care and watch
over him or her as much as possible.
18. I provide positive stimulus to the person receiving care by taking advantage of things heor she enjoys.
14. I gauge the feelings of the person receiving care by his or her facial expressions and attitude.
13. Even if the person receiving care behaves incoherently, I do not scold him or her in a loudvoice.
Factor II (three items): Proactive Consultation and Information-Seeking
26. I do not hesitate to ask questions to doctors and nurses about things I do notunderstand, such as treatment objectives.
24. I actively investigate available societal resources (such as services and hospitals where
consultation can be sought).
25. I seek advice from people with care experience.
Factor III (four items): Trust Formation and Role Coordination
28. I communicate and share information about the person receiving care to the family
members who are not directly involved in the care.
30. The role of care is shared among family members.
27. I seek the opinions of other family members and match the care objectives (directions)accordingly.
37. I clearly express my opinions regarding care to surrounding family members.
Eigenvalues% of variance after rotation% of total variance accounted for

Question item

Table 4. Results of Exploratory Factor Analysis (n = 130).

.305
.490
.543
.250
.266

.067
.095
.080
.148
.196
.690
.610
.498
.465
1.437
10.265

.067
.212
−.014
.803
.628
.509
.110
.413
.032
.127
1.633
11.667

.638
.598
.152
.170
.086
.049
.000
.006
.182
3.278
23.41645.348

.178

.445

.674

.457
.366

.444

.451

.639

−.024

.127

.591
.563
.505

Communalities

.659

−.001
109
.002

Factor III

.196
.003
.178

Factor II

.743
.743
.688

Factor I

Factor loadingKiriake and Moriyama

15

variance explained by these factors was 58.7%. The Kaiser–Meyer–Olkin measure was .82, which met Kaiser’s (1974) measure of sampling adequacy. The
Bartlett sphericity test was significant (p < .001). Second, parallel analysis(Horn, 1965) was carried out. The results found that the eigenvalues of therandom correlation matrix were larger up to the fourth factor, while those of thecorrelation matrix of the participant data at the third factor exceeded the eigenvalues of random correlation matrix (see Figure 2, Table 3). Therefore, thenumber of factors was determined to be three. Because a determination ofinterpretability required that the number of necessary participants should be 20
times the number of factors (Arrindel & Van der Ende, 1985), it was determined that is was possible to undertake the analysis. Table 4 shows the resultsof an EFA (principal factor method by correlational matrix, Varimax rotation)
conducted on the preliminary Partnership Scale. The Kaiser–Meyer–Olkinmeasure was .78, and it met Kaiser’s measure of sampling adequacy. The
Bartlett sphericity test was significant (p < .001). In the process of factor analysis, 12 items with factor loadings of less than .40 were eliminated. In addition,
13 further items with factor loadings of .30 and above on factors other than theprincipal factors were eliminated. Item 30 showed a loading of .30 or higher for
Factor II as well. However, the characteristics of partnerships also include voluntary involvement and participation in the respective roles of each stakeholder
as distributed and shared abilities (Gottlieb, Feely, & Dalton, 2006). As Item 30
conformed to such a characteristic, it was therefore determined to be an important item and was not eliminated prior to analysis. Finally, 14 items with threefactors were adopted. The three factors explained 45.3% of the total variance.
Factor I was named “Ability for Receptive Coping,” Factor II “Proactive
Consultation and Information-Seeking,” and Factor III “Trust Formation andRole Coordination.”

CFA
Figures 3 to 5 show the results of the CFA (maximum likelihood method).
As a minimum of 100 to 200 participants were required to conduct the
CFA (Bentler & Chou, 1987), it was determined that the analysis could beundertaken. The following three models were considered. First, based on
the result of EFA, we considered Model A, which was calibrated with the
14 items and three factors of the Partnership Scale with correlations set
between each factor (Figure 3). However, with a CFI and TLI of .95 orabove (Hu & Bentler, 1999) and RMSEA equal to or less than .05(Netemeyer et al., 2003), the goodness-of-fit criteria were not satisfied forModel A. Thus, after checking the Amos modification indices, we createdand considered Model B, for which covariance was set between error

16

Journal of Family Nursing ﻿

Figure 3. Model A completely standardized parameter estimates from the threefactor CFA model of 14 items (n = 131).

Note. χ2(74) = 113.845, p = .002, SRMR = .073, RMSEA = .064 (90% CI = [.039, .087]) TLI =.885, CFI = .906. CFA = confirmatory factor analysis; SRMR = standardized root mean square
residual; RMSEA = root mean square error of approximation; CI = confidence interval; TLI =Tucker–Lewis index; CFI = comparative fit index.

variances for Items 18 and 16 and between Items 18 and 14 (Figure 4). The
measurement content of these items was considered to have similarities interms of active involvement to elicit the capabilities of dementia patients.
As a result of setting covariance between error variances, goodness-of-fit
criteria were satisfied for all indices. In addition, as a result of comparing
the chi-square (χ2) values for Model A and Model B with a chi-square test,Kiriake and Moriyama

17

Figure 4. Model B completely standardized parameter estimates from the threefactor CFA model of 14 items correlated error variables (n = 131).

Note. χ2(72) = 84.317, p = .152, SRMR = .071, RMSEA = .036 (90% CI = [.00, .065]) TLI =.963, CFI = .971. CFA = confirmatory factor analysis; SRMR = standardized root mean square
residual; RMSEA = root mean square error of approximation; CI = confidence interval; TLI =Tucker–Lewis index; CFI = comparative fit index.

the chi-square value for Model B was significantly smaller than that for
Model A, and it was shown that the model had adequate goodness-of-fit (p= .021). However, the standardized path coefficient for Item 18 from
Factor I (Ability for Receptive Coping) at .35 was consistently low.
Moreover, Item 18 was seen to covary between error variables with respect
to other items. Therefore, we also considered Model C in which Item 18
was eliminated (Figure 5). Consequently, the goodness-of-fit criteria for
Model C were all shown to be better than that for Model B. Accordingly,
13 items and three factors in Model C were adopted as a Partnership Scaleand used for subsequent analysis.

18

Journal of Family Nursing ﻿

Item 9

.698

Item7

.656

.724

Item 㸵
8

.690

.572
.596

Item 16.820

Item 13.803

Item 14.865

Item 26

.678

.71
.717
17
.755

Factor I

.503
.236

.735

Factor II

.227

.494

Item 25

.674

.869

Item 24.739

Item 28.817

Item 27.876

Item 30.734

Item 37

.863

.694
.576

Factor Ϫ

.482
.679
.506

Figure 5. Model C completely standardized parameter estimates from the threefactor CFA model of 13 items (n = 131).

Note. χ2(62) = 70.628, p = .212, SRMR = .064, RMSEA = .033 (90% CI = [.000, .065])
TLI = .971, CFI = .977. CFA = confirmatory factor analysis; SRMR = standardized root meansquare residual; RMSEA = root mean square error of approximation; CI = confidence interval;
TLI = Tucker–Lewis index; CFI = comparative fit index.

With regard to the respective portions of the Model C, the parameters ofeach factor and item were significant (p < .001) showing coefficients
between .48 and .75. In addition, a significant correlation was foundbetween Factor II (Proactive Consultation and Information-Seeking) andFactor III (Trust Composition and Role Coordination; p < .001). However,correlations between Factor I (Ability for Receptive Coping) and Factors II
and III were not found to be significant (p = .050, p = .070).

Kiriake and Moriyama

19

Test of Internal Consistency and Stability
Cronbach’s alpha coefficient for the Partnership Scale was .78 for all 13
items, specifically .84 for Factor I, .71 for Factor II, and .67 for Factor III.
Furthermore, the normality of the results of the 13 items on the Partnership
Scale was confirmed with the Shapiro–Wilk test resulting in p = .067.
Consequently, ICCs were calculated for the 50 participants who participatedin the retest. The ICC (1, 1) for the total score on the 13 items was .80, .83 forFactor I, .61 for Factor II, and .68 for Factor III.

Relations to Other Scales
The Cronbach’s alpha coefficients for each of the scales calibrated as anexternal reference were .90 for the Japanese Version of the Social Support
Scale (Iwasa et al., 2007), .89 for the Short Version of the Zarit Caregiver
Burden Interview (Arai et al., 2003), and .92 for the Caregiver Positive
Appraisal Scale (Suyama et al., 2004). Table 4 shows the correlation coefficients for these scales and the Partnership Scale scores. The score of thePartnership Scale for Primary Family Caregivers Caring for Patients With
Dementia was confirmed to have a positive correlation with the Social
Support score, a negative correlation with the Sense of Caregiver Burden
score, and a positive correlation with the Caregiver Positive Appraisal score(p < .01, p < .01, and p < .01, respectively; see Table 5).

Discussion
The Partnership Scale for Primary Family Caregivers Caring for Patients
With Dementia was considered to have a certain content validity by virtue ofthe fact that after the creation of the item pool, it was assessed to be appropriate by expert review. Furthermore, the goodness-of-fit for the three-factor
13-item model finally adopted was confirmed by CFA. Therefore, there wasconsidered to be little inconsistency between the factor structure of the scale
and actual data. While the goodness-of-fit of the three-factor 14-item modelthat set covariance between the error variances also satisfied statistical criteria, the items observed by covariance were considered to have similarities interms of active involvement to elicit the capabilities of dementia patients.
This was thought to suggest the possibility that the variety of involvementsthat were extracted and associated with receptive coping suggested the categorization by similarity in order when drafting the Partnership Scale.
Therefore, the elimination of Item 18, which had weak links to the20

Journal of Family Nursing ﻿

Table 5. Correlation Between Scale to Assess Partnership-Building Ability ofPrimary Family Caregivers of Patients With Dementia in Japan and Other Scales.

Social Support (Total Score)
Factor I (Support of Family)
Factor II (Support of Significant Other)
Factor III (Support of Friends)
Sense of Care Burden (Total Score)
Factor I (Personal Strain)
Factor II (Role Strain)
Care Positivity (Total Score)
Factor I (Sense of Fulfillment)
Factor II (Sense of Self-Growth)
Factor III (Sense of Unity with the Elderly)

Total score

Factor I

Factor II

Factor III.488**.420**.432**.457**−.334**−.274**−.348*.370**.294*.361**.356**

.194*
.178
.187*
.149
−.241**−.062−.369**.333**.222*.376**.364**.375**.276**.307**.437**−.219**−.222**−.166*
.196*
.152
.181
.173

.542**.473**.489**.465**−.226**−.303**
−.128
.176
.138
.168
.167

Note. Social Support = Short Japanese Version of the Multidimensional Scale of Perceived Social Support(Iwasa et al., 2007); Sense of Care Burden = Short Japanese Version of the Zarit Caregiver BurdenInterview (Arai, Tamiya, & Yano, 2003); Care Positivity = Caregiver Positive Appraisal Scale (Suyama,
Kawano, & Kawano, 2004).
Spearman’s correlation coefficient: *p < .05. **p < .01.

main factors and was seen to share covariance between error variances, wasconsidered to have led to the careful selection of unique question items that
did not overlap the measurement content of other scale items. The factor
structure of the three factors (“Ability for Receptive Coping,” “Proactive
Consultation and Information-Seeking,” and “Trust Formation and Role
Coordination”), which was obtained as a result of the 13-item model andbased on the notion of family systems (Wright & Leahey, 2013), suggests thepossibility of interpreting the ability of primary family caregivers of persons
with dementia to build partnerships in care and in systems inside and outsideof the family, including with dementia patients.
In terms of the evaluation of each part of the 13 items with three-factor
model, while all factor and item coefficients were found to be significant, thecorrelation between Factor I (Ability for Receptive Coping) and the otherfactors was not significant. In other words, it is thought that receptive coping
ability is in a different dimension than other factors and that this is a multidimensional scale. It was presumed that this may have resulted from the factthat primary family caregivers’ abilities to establish partnerships with patientswith dementia differed in character from their ability to establish partnerships
with other people involved in dementia care. Gottlieb et al. (2006) indicatedthe possibility of establishing partnerships even with those with decreased
cognitive function and limited communication skills. However, the authors
state that this differs considerably in character from establishing partnerships

Kiriake and Moriyama

21

with those who can adequately communicate. From the above results, it
seems that the factor structure of the Partnership Scale, along with the relationships between each item and the relationships between factors, is boththeoretically open to interpretation and a valid fit with real-world data.
Nonetheless, this study was conducted at facilities that agreed to cooperatewith the researchers, and participants were selected using convenience sampling. Approximately 60% of participants were observed to have been caring
for patients who identified as being in a severe state of dementia. Accordingly,
it is possible that the results of this study may have been biased due to participant characteristics. In future, based on the results of this study, the sample
should be recruited using either quota techniques or random sampling toobtain the necessary larger sample considering the statistical power for confirmation of the goodness-of-fit of the factor structure.
Cronbach’s alpha coefficient was calculated as a reliability check for all
items on the scale and for each subscale to verify the scale’s internal consistency. As a result, the Cronbach’s alpha coefficient for the entire scale is .78,
confirming that it maintained a certain level of internal consistency. However,Cronbach’s alpha coefficient for the items related to the “Trust Formation andRole Coordination” subscale, which was aimed at families, was .67, consistently low. One possible reason for this is that “Trust Formation and Role
Coordination” extracted a wide range of approaches, such as sharing information, consensus building, and role allocation, to measure a family’s cooperation toward care. We presume that the internal consistency dropped
because all of these approaches are being measured with a minimal numberof items. We considered adding items such as “Verbally Expressing Gratitude
for Collaboration” to raise the internal consistency. The expression of positive emotion for specific actions is the most powerful drive for behavioral
change (Falloon, Laporta, Fadden, & Graham-Hole, 1993/2000). The expression of gratitude for collaboration may increase mutually desirable behavioral patterns, and may be an effective skill for strengthening domestic
collaboration. However, this will be an issue for future research as it was notpossible to continue further analysis of this topic in this study.
The scale’s stability was confirmed by the test–retest method, and the ICC(1, 1) was found to be .80 for the entire scale, and .61 to .83 for each of thesubscale scores. According to Fleiss’s (1986) standards, scale reliability isevaluated as excellent if the ICC is greater than .75, and fair to good if
between .40 and .75. On this basis, we confirmed that scale stability was
mostly favorable.
Regarding the relationship of the Partnership Scale with external criteria,
the expected results were obtained. First, the fact that there was a correlation
between the scores on the Partnership Scale and the Social Support Scale

22

Journal of Family Nursing ﻿

could indicate that primary family caregivers’ abilities to establish partnerships is connected to their ability to receive social support. In addition, asignificant, although slightly weaker correlation was also found between primary family caregivers’ abilities to establish partnerships and their knowledge with respect to care situations, namely, the sense of care burden andpositive feelings about care. Sense of care burden and positive feelings aboutcare have been reported to be influenced by multiple factors, including economic conditions and the situation of the care receiver (Kajiwara & Ykoyama,
2007; Kramer, 1997; Suyama et al., 2004). It was considered that such entanglements with other factors may have affected the results. As describedabove, the convergent validity of this scale is demonstrated by the fact that,as hypothesized, a significant association was seen to exist between thePartnership Scale and external factors.
Finally, we will discuss the methods of analysis used in this study. In thisstudy, when drafting the Partnership Scale, CFA (maximum likelihood
method) was conducted in addition to EFA (principal factor method by correlational matrix, Varimax rotation). Although there are several factor estimation methods within factor analysis, the principal factor method andmaximum likelihood method have been widely used. In addition, of these,
the maximum likelihood method is highly precise (Brown, 2006). However,in this study, the maximum likelihood method became unsuitable as a solution at the stage of EFA when all items were entered. This was presumably
because the model was not sufficiently sophisticated at the draft stage of thePartnership Scale and that there were strong correlations among several
items. Therefore, we proceeded with analysis by using the principal factor
method (by correlational matrix), which enabled us to seek a solution. The
fact that there were some differences in the sequence of the size of estimatedvalues for CFA as well as in factor loads for the exploratory analysis for each
item appears to be an effect of using different factor estimation methods.
The number of factors was determined to be three using parallel analysis,
and because it was possible to obtain a degree of fit for statistical tolerance
in the results of CFA (maximum likelihood method) once items were eliminated, it is thought that the selection of scale items had been appropriately
conducted.
In addition, in the process of these factor analyses, there were many items
that were deleted from the draft Partnership Scale for statistical reasons. The
majority of these were items relating to receptive coping toward dementia
patients, which is conceivably due to the fact that many individual coping
responses were extracted as individual items. As a result, the scale that was
finally adopted had fewer items, and even slight modifications had a major
effect on goodness-of-fit. Accordingly, regarding the investigation ofKiriake and Moriyama

23

subscale items that are considered necessary for improving the reliability of
future scales, it was shown that there is a need to select and add items carefully to improve the validity of factor structure.

Implications for Practice
The Partnership Scale for Primary Family Caregivers Caring for Patients
With Dementia comprehensively reflects the ability of primary family caregivers caring for patients with dementia to create collaborative relationships
with other people involved in dementia care, including the patients themselves. The content of the scale includes “Ability for Receptive Coping” withpatients, “Proactive Consultation and Information-Seeking” with specialists,and “Trust Composition and Role Coordination” with families. Abilities thatvary in target and character have been identified.
In “Ability for Receptive Coping,” receptive coping was identified, which
included behaviors related to respecting and protecting the patient’s will, or
making environmental adjustments to keep the patient’s behavioral and psychological condition from worsening. This Ability for Receptive Coping isuniversally necessary for primary family caregivers in building partnerships
with patients. These caregiving skills are important in maintaining positive
interactions with patients with dementia (Kitwood, 1997/2005). In “Proactive
Consultation and Information-Seeking,” the attitude of actively cooperatingwith specialists was identified. In “Trust Composition and Role Coordination,”the primary family caregiver’s proactive attitude toward sharing information
and allocating roles related to the patient with dementia, mainly within thefamily, was identified. In Japan, where stem-family households are decreasing and family structures are diversifying, the ability of primary family caregivers to create supportive connections that involve the extended family will
become even more important. Furthermore, a partnership formed by primaryfamily caregivers who attend to patients with dementia based on these threefactors corresponds to the risk factors in care, including the patient’s symptoms, domestic conflict, and lack of professional support (Zarit et al., 2010).
Therefore, while this scale may have a small number of items, we believe it
accurately measures the ability of primary family caregivers to form partnerships that are necessary for patients with dementia and primary caregivers toexist in a state of well-being together. In addition, this scale measures theability of primary family caregivers to establish relationships, thereby
enabling interpretation of results based on three factors. The measurement
results of this scale indicate a concrete direction for family support.
In addition, this scale was developed with the aim of measuring the abilityof primary family caregivers to establish necessary partnerships when caring

24

Journal of Family Nursing ﻿for patients with dementia. Improvement of participants’ abilities was regarded
as an important outcome when investigating support for families. In previous
studies, outcomes of support programs for primary family caregivers ofpatients with dementia were determined using sense of care burden, depressive symptoms, and symptoms of dementia (Ostwald, Hepburn, Caron, Burns,& Mantell, 1999; Steaven et al., 2006). These indices, in terms of stress andcoping theory (Lazarus & Folkman, 1984), demonstrate the effect of coping
and require the evaluation using a long-term perspective. Supplementing thesewith the additional outcome of primary family caregivers’ abilities to establish
partnerships as a coping behavior augments the possibility of conducting amore sensitive evaluation of primary family caregiver support.
However, one point that must be kept in mind during evaluation is thatprimary family caregivers’ abilities to establish partnerships will also beaffected by other factors. From the results of this study, it is possible to confirm the impact on each item from error variances in CFA. Accordingly, whenusing this scale to assess primary family caregivers’ abilities to establish partnerships, it is also necessary to collect information on environmental aspects
that are likely to affect its power and use this scale when conducting assessment and support. Considering the factors that have such impacts represents
a future challenge.

Conclusion
This psychometric study developed the Partnership Scale for Primary Family
Caregivers Caring for Patients With Dementia that comprehensively measures the ability of primary family caregivers in Japan to establish partnerships when caring for patients with dementia. This study focused on
partnerships built in the provision of care by primary family caregivers whocare for dementia patients in an attempt to develop a scale that was able tocomprehensively measure the strength to build partnerships of primary family caregivers caring for persons with dementia in Japan. The scale was madeup of three factors (“Ability for Receptive Coping,” “Proactive Consultation
and Information-Seeking,” and “Trust Formation and Role Coordination”)
and 13 items, and it was revealed to be multidimensional in nature. In addition, scores on this scale were found to have a significant association withprimary family caregivers’ awareness of care and acquisition of social support. Accordingly, a primary family caregiver’s ability to establish partnerships was considered important for the well-being of both primary family
caregivers and patients with dementia.
A limitation is that the study recruited participants using conveniencesampling techniques. The internal consistency of some of the subscales wasKiriake and Moriyama

25

low, which sets the stage for further testing. In the future, it will be necessary
to add subscale items based on the results of this study to secure new participants in consideration of statistical detectability and to ensure the reliability
and validity of factor structure. Moreover, investigating reactivity and sensitivity will also be ongoing challenges.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research,authorship, and/or publication of this article.

Funding
The author(s) disclosed receipt of the following financial support for the research,authorship, and/or publication of this article: This work was supported by JSPS
KAKENHI Grant-in-Aid for Scientific Research (C) Grant Number 25463604.

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Author Biographies
Ayumi Kiriake, RN, PhD, is an associate professor, Department of Adult HealthNursing, School of Nursing, Kurume University, Japan. Her research and clinicalinterests focus on Family Systems Nursing and families coping with chronic illness.
Her recent publications include “Ninchishou wo yuusuru hito wo kaigosuru kazokukaigosya no pa-tona-shippu wo kizuku tikara no koujyouwo mezasita kyouiku
puroguramu no kouka no kentou [Effects of an Educational Program Aimed to
Improve Partnership-Building Ability of Family Caregivers Caring for Persons With
Dementia]” in Journal of Japan Academy of Nursing Science (2016, with M.
Moriyama), and “Ninchishoukoureisya no kazokukaigosya no seikatusien [Support
for Family Caregivers Caring for Patients With Dementia]” in The Japanese Journalof Clinical Dialysis (2016).
Michiko Moriyama, RN, MSN, PhD, is a professor, Department of Nursing Science
Graduate School of Health Sciences, Hiroshima University, Japan. Her research andclinical interests focus of chronic care and family nursing, and her research projects
are frequently conducted with communities to improve population health. She served
as a chair of the 10th International Family Nursing Conference held in Kyoto, Japan,
in 2011. Her contributions to family nursing were honored with an Innovative
Contribution to Family Nursing Award at the 7th International Family Nursing
Conference in 2005. Her recent publications include “Efficacy of a Disease
Management Program Focused on Acquisition of Self-Management Skills in PreDialysis Patients With Diabetic Nephropathy: 24 Months Follow-Up” in Journal of
Nephrology (2015, with K. Kazawa, Y. Takeshita, N. Yorioka, & M. Moriyama) and“The Effect of Educational Intervention Regarding Advance Care Planning for
Advance Directives” in Health (2015, with Y. Takeshita, M. Ikeda, S. Sone, & M.
Moriyama).