ORIGINAL ARTICLE

Psychometric evaluation of a new instrument to measure disease

self-management of the early stage chronic kidney disease patients
Chiu-Chu Lin, Chia-Chen Wu, Li-Min Wu, Hsing-Mei Chen and Shu-Chen Chang

Aims and objectives. This study aims to develop a valid and reliable chronic kidney disease self-management instrument (CKD-
SM) for assessing early stage chronic kidney disease patients’ self-management behaviours.
Background. Enhancing early stage chronic kidney disease patients’ self-management plays a key role in delaying the pro-
gression of chronic kidney disease. Healthcare provider understanding of early stage chronic kidney disease patients’ self-
management behaviours can help develop effective interventions. A valid and reliable instrument for measuring chronic kidney
disease patients’ self-management behaviours is needed.
Design. A cross-sectional descriptive study collected data for principal components analysis with oblique rotation.
Methods. Mandarin- or Taiwanese-speaking adults with chronic kidney disease (n = 252) from two medical centres and one
regional hospital in Southern Taiwan completed the CKD-SM. Construct validity was evaluated by exploratory factor analysis.
Internal consistency and test–retest reliability were estimated by Cronbach’s alpha and Pearson correlation coefficients.
Results. Four factors were extracted and labelled self-integration, problem-solving, seeking social support and adherence to
recommended regimen. The four factors accounted for 60Æ51% of the total variance. Each factor showed acceptable internal
reliability with Cronbach’s alpha from 0Æ77–0Æ92. The test–retest correlations for the CKD-SM was 0Æ72.
Conclusion. The psychometric quality of the CKD-SM instrument was satisfactory. Research to conduct a confirmatory factor
analysis to further validate this new instrument’s construct validity is recommended.
Relevance to clinical practice. The CKD-SM instrument is useful for clinicians who wish to identify the problems with self-
management among chronic kidney disease patients early. Self-management assessment will be helpful to develop intervention
tailored to the needs of the chronic kidney disease population.

Key words: chronic kidney disease, exploratory factor analysis, instrument development, psychometric evaluation, self-
management

Accepted for publication: 7 November 2011

leading cause of mortality (>60%) in the world. In the USA,

Introduction
CKD has increased 20–25% over the last decade which
According to the World Health Organization, chronic represents greater than a threefold population increase in
diseases, including chronic kidney disease (CKD), are the recognised CKD patients in the Medicare system (USRDS

Authors: Chiu-Chu Lin, PhD, RN, Associate Professor, College of
Nursing, Kaohsiung Medical University, Kaohsiung; Chia-Chen Wu,
RN, MSN, Lecturer, School of Nursing, Fooyin Technology
University, Pingtung; Li-Min Wu, PhD, RN, Assistant Professor,
Kaohsiung Medical University, Kaohsiung; Hsing-Mei Chen, PhD,
RN, Assistant Professor, Kaohsiung Medical University, Kaohsiung;
Shu-Chen Chang, RN, MSN, Director of Nursing Department,
Changhua Christian Hospital, Lugang, Taiwan
Correspondence: Chiu-Chu Lin, Associate Professor, College of
Nursing, Kaohsiung Medical University, No. 100, Shih-Chuan 1st
Road, Kaohsiung City 807, Taiwan.
Telephone: +886 7 3121101.
E-mail: chiuchu@kmu.edu.tw

Ó 2012 Blackwell Publishing Ltd

Journal of Clinical Nursing, doi: 10.1111/j.1365-2702.2011.04048.x 1
C.-C. Lin et al.
2009). In Taiwan, CKD ranked tenth as the leading cause of
death in 2008 (Taiwan Department of Health 2010).
Untreated CKD progresses to end stage renal disease and
affected patients require dialysis. The incidence and preva-
lence rate of end stage renal disease in Taiwan has become
the highest in the world (USRDS 2007). In 2008, dialysis
patients in Taiwan accounted for 0Æ26% of the total insured
population, while the medical expense for dialysis treatment
was 8% of the total insured expenditure (Bureau of National
Health Insurance 2010a,b). The increased CKD population
and expenditure due to CKD is becoming a major health
problem not only in Taiwan, but also in the world; and this
predicament will increase as the population ages if not
resolved effectively.
CKD is a preventable disease; the progress of the CKD
can be interrupted by identifying patients with early stage
CKD. To delay the progress or avoid the deterioration of
CKD, patients must be able to self-manage the disease.
Because of the chronic nature of CKD, patients are
responsible for the daily management of their condition.
Accordingly, successful disease management depends lar-
gely on patients’ self-management efforts rather than the
direct care of healthcare providers (Funnell & Anderson
2000). In other words, patients’ self-management behav-
iours is exceedingly important than the care of healthcare
providers.
The research literature indicates that when patients are
more involved with their own chronic illness management,
health outcomes improve (Bodenheimer et al. 2002, Heisler
et al. 2003). Consequently, self-management of CKD patient
will play a key role in controlling ongoing symptoms and
unwanted sequelae of CKD. To measure the impact of
interventions designed to assist CKD patients in managing
their illness, a valid and reliable measurement of self-
management behaviour is needed.
Self-management includes the full range of activities
undertaken by a person with a chronic condition, ranging
from the preventive activities undertaken by healthy people
home to the day-to-day tasks undertaken by an individual
to manage symptoms, treatments, consequences and life-
style changes associated with chronic conditions (Barlow
et al. 2002). Patients adapt to their chronic condition by
integrating the recommended regimen into their daily lives
to prevent complications, maintain optimum health status
and minimise the intrusion of the disease into their
preferred life-styles (C.C. Lin, University of Michigan,
Ann Arbor, MI, unpublished doctoral dissertation). Accord-
ingly, self-management should be approached as a multi-
dimensional concept that combines biological,
psychological and social activities (Barlow et al. 2002).
2 Journal of Clinical Nursing
Research regarding self-management among patients with
chronic illness has targeted several facets such as self-
integration, self-care, problem-solving, social support,
adherence, communication and partnership in care (Gallant
2003, Hill-Briggs 2003, Curtin et al. 2005). Lorig and
Holman (2003) defined self-management as encompassing
three essential components including medical management,
which involves adhering to treatment regimens; role man-
agement, which clients seek to maintain or create new life
tasks; and emotional management, which entails coping
with the feelings a life-threatening chronic illness evokes.
People with chronic illness must develop skills as follows:
problem-solving including identifying symptoms and deter-
mining possible causes for each symptom; decision-making
involving symptom management using many different
techniques and employing resources; establishing health
care provider partnerships where clients are taught how to
access and use medical care in their community (Hill-Briggs
2003, Lorig & Holman 2003).
The first author of this study in her doctoral dissertation
identified the dimensions of self-management as illness
adaptation, decision making and illness control through
concept synthesis (C.C. Lin, University of Michigan, Ann
Arbor, MI, unpublished doctoral dissertation). Based on
these three dimensions, Lin et al. (2008) developed and
tested an instrument to measure diabetes self-management.
They confirmed the dimensions of self-management for
diabetic patients through the confirmatory factor analysis
as follows: self-integration, self-regulation, interaction with
health professionals and significant others, self-monitoring
of blood glucose and adherence to recommended regimen.
The above indicates that self-management is a complex
concept.
In the present study, we identified six dimensions for CKD
self-management behaviours based on the dimensions devel-
oped by Lin et al. (2008), literature (Gallant 2003, Hill-
Briggs 2003, Lorig & Holman 2003, Curtin et al. 2005) and
clinical experience. The six dimensions used to further
generate the item pool as follows: learning skills and
knowledge about disease; interaction with health profession-
als and significant others; problem-solving, self-care; self-
integration; and emotion management.
Healthcare providers that gain a better understanding of
CKD patients’ self-management behaviours can develop
effective interventions to prevent the CKD deterioration.
There was no relevant instrument found in the published
paper to assess the problems with self-management faced by
patients with CKD. Thus, the aim of this study was to
develop and test an instrument of CKD patients’ self-
management behaviours.
Ó 2012 Blackwell Publishing Ltd
Original article
Methods
Instrument development
Fifty-nine candidate items were generated to form an initial
draft of the CKD-SM. The draft was then evaluated for
content validity. An expert panel consisted of eight experts
including nephrologists, dietitian, case manager and nurse
educators those who specialise in CKD practice were invited
to assess the content validity. The expert panel reviewed the
initial set of 59 items and rated each item for relevance to its
associated concept dimension based on the conceptual
definition provided. The panel assessed each item using a
four-point Likert scale to score the degree of agreement
ranged from (1) relevant, (2) somewhat relevant, (3) quite
relevant and (4) very relevant. If an expert rated any item
below 4, the expert was asked to provide his or her
suggestions for modifying or eliminating the item. The
content validity index (CVI) analysed the level of experts’
agreements. The CVI for an item is the proportion of experts
who rate it as 3 or 4 (Waltz et al. 2005). The expert panel’s
evaluation resulted in a total CVI score of 0Æ89. Nine
additional items were added to the initial draft of CKD-SM
based on recommendations from the experts. Furthermore,
problematic items were revised or reworded based on the
suggestions from the expert panel. The finalised draft of
CKD-SM contained 68 items.
To evaluate the face validity of the 68-item CKD-SM, 15
CKD patients were invited to pilot test the instrument for
clarity, reading levels, precision, comprehension and ease of
response. The CKD-SM was revised based on the pilot
study. The CKD-SM contained 68 items using response
options from 1 (never) to 4 (always) with 18 negatively
worded items. Total possible scores ranged from 68–272,
with higher scores indicating greater CKD self-manage-
ment.
Data collection procedure
Before data collection, human participant approval was
obtained from the Kaohsiung Medical University Institu-
tional Review Board. At the request of study primary
investigator, nephrologists or case managers at each of the
data collection sites referred potential subjects from the CKD
outpatients’ clinic to the investigators for recruitment. Fer-
ketich (1991) suggested that at least 200 research participants
are needed to achieve a high reliability of new instruments.
We recruited 252 patients with CKD stages 1–3 who were
willing to participate in the study from two medical centres
and one regional hospital in the southern Taiwan. Patients
Ó 2012 Blackwell Publishing Ltd
Journal of Clinical Nursing
Chronic kidney disease self-management (CKD-SM) instrument
provided written informed consent and completed the study
questionnaires in a private room.
Data analysis
Data were analysed using SPSS 16.0 (SPSS Inc., Chicago, IL,
USA). Descriptive statistics were generated for demographic
variables and individual item scores. Internal consistency was
assessed by determining Cronbach’s alpha coefficients for
overall scale and subscales. Cronbach’s alpha coefficients
above 0Æ70 were considered satisfactory (Polit & Beck 2006).
Exploratory factor analysis (EFA) using principal compo-
nent analysis (PCA), an essential tool in instrument develop-
ment, was used to determine the number and content of
factors underlying the initial set of items. The Kaiser–Meyer–
Olkin test of sampling adequacy and Bartlett’s test of
Sphericity were performed. The number of factors to be
retained was determined by a convergence of criteria includ-
ing eigenvalues >1, the scree plot and theoretical interpret-
ability of the resulting factor structure. Items were selected
according to four criteria: factor loading above 0Æ5, minimum
factor membership of three items, no cross-factor loaded
items and conceptual coherence of items with the individual
factor.
Results
Sample characteristics
Among the 252 subjects, 59Æ9% (n = 151) were male and
ranged from 24–90 years old (mean = 61Æ0, SD 14Æ2). The
majority of the subjects (81Æ7%, n = 206) were married and
more than half of them were educated in high school (56Æ1%,
n = 141). Most subjects (90Æ9%) were stage 2 or 3 of chronic
kidney disease.
Factorial validity
The internal structure of the 68 items CKD-SM was analysed
with a sample of 252 adults with CKD using principal
components to extract factors. The Kaiser–Meyer–Olkin
(KMO) values was 0Æ92, indicating excellent sampling
adequacy and relatively compact patterns of correlation,
such that factor analysis should produce distinct and reliable
factors (Field 2000). Bartlett’s test of Sphericity was signif-
icant (v2 = 10280Æ2, df = 2278, p < 0Æ001), indicating that
there were some relationships between the variables (Field
2000). Oblique promax rotation procedures were used as the
method of factor rotation because CKD self-management
factors were assumed to be correlated.
3
C.-C. Lin et al.

Thirty-six items were eliminated from the final draft of
68-item CKD-SM because of factor loading less 0Æ5, or cross-
factor loaded items. A four-factor solution for the 32
remaining items provided the most meaningful factor pattern.
Factors were labelled ‘self-integration’, ‘problem-solving’,
‘seeking social support’ and ‘adherence to recommended
regimens’. Because the conceptual meaning of three items did
not fit their corresponding factor, one item of Factor 1 ‘social
support’ and two items of Factor 4 ‘adherence to recom-
mended regimens’ were deleted, leaving 29 items of the CKD-
SM (Table 1). The factor structure was described as follows.
Factor 1 named ‘self-integration’ includes 11 items with
factor loadings ranging from 0Æ57–0Æ83 and accounted for
40Æ65% of the variance. The factor focuses on patients’
adjustment to their life style and implementation of
recommended regimens and self-care activities to achieve
a balance life. Factor 2 has nine items, called ‘problem-
solving’ with factor loadings ranging from 0Æ62–0Æ87,
accounting for 8Æ72% of the variance. This factor reflects
the patient’s ability to seek the resources and actively learn
disease-specific knowledge and skills. Factor 3 is ‘seeking
social support’. Factor 3 contains 5 items with factor
loadings ranging from 0Æ65–0Æ78, accounting for 6Æ17% of
the variance. The factor reflects patient’s actions to seek
resources or support from significant others to cope with
their disease and the negative emotions evoked by their
illness. Factor 4 is composed of 4 items with factor
loadings ranging from 0Æ69–0Æ78, accounting for 4Æ97% of

Table 1 Descriptive statistics, factor loading and Cronbach’s alpha for the 29-item CKD-SM

Factor loading
Cronbach’s
Item M SD Factor 1 Factor 2 Factor 3 Factor 4 alpha

Factor 1: self-integration 0Æ92

Heeding habits that may affect kidney function 3Æ29 0Æ76 0Æ84 0Æ05 0Æ05 0Æ13
Managing food portions and choices in social activity 2Æ96 0Æ81 0Æ83 0Æ17 0Æ11 0Æ02
Managing food followed to care providers’ suggestion 3Æ00 0Æ82 0Æ81 0Æ08 0Æ08 0Æ14
Giving up bad habits harmful for kidney 3Æ16 0Æ89 0Æ79 0Æ11 0Æ14 0Æ14
Adjusting CKD care to fit new situation 2Æ97 0Æ86 0Æ76 0Æ02 0Æ00 0Æ01
Managing food to avoid harm for kidney 2Æ88 0Æ93 0Æ73 0Æ23 0Æ15 0Æ12
Managing CKD to stay healthy 3Æ22 0Æ80 0Æ66 0Æ24 0Æ02 0Æ04
Merging CKD management into daily life 3Æ15 0Æ84 0Æ62 0Æ19 0Æ00 0Æ00
Adjusting lifestyle to maintain the best condition 3Æ10 0Æ79 0Æ62 0Æ25 0Æ07 0Æ05
Participating selectively in social activities 2Æ84 0Æ94 0Æ61 0Æ06 0Æ08 0Æ11
Changing lifestyle to avoid worse of kidney function 3Æ14 0Æ82 0Æ57 0Æ23 0Æ10 0Æ06
Factor 2: problem solving 0Æ91
Actively seeking information about kidney disease 2Æ39 1Æ02 0Æ12 0Æ87 0Æ01 0Æ08
Actively seeking resources to better control 2Æ65 0Æ95 0Æ06 0Æ82 0Æ01 0Æ08
Utilizing different ways to clarify questions about treatment plan 2Æ55 1Æ00 0Æ06 0Æ80 0Æ02 0Æ04
Utilizing different ways to solve problems 2Æ54 0Æ96 0Æ04 0Æ75 0Æ11 0Æ05
Finding out reasons for signs and symptoms 2Æ8 0Æ91 0Æ18 0Æ73 0Æ07 0Æ12
Thinking over reasons about bad laboratory data 2Æ61 0Æ91 0Æ01 0Æ73 0Æ05 0Æ05
Finding out possible reasons about high BP value 2Æ65 0Æ89 0Æ10 0Æ66 0Æ08 0Æ01
Actively understanding the meaning of laboratory data 2Æ64 0Æ97 0Æ01 0Æ64 0Æ15 0Æ10
Actively understanding risk factors of CKD 2Æ95 0Æ90 0Æ29 0Æ62 0Æ08 0Æ05
Factor 3: seeking social support 0Æ84
Sharing experience with other patients 2Æ08 1Æ03 0Æ13 0Æ14 0Æ78 0Æ09
Sharing helpless and frustrated feeling with other patients 1Æ84 0Æ99 0Æ19 0Æ21 0Æ78 0Æ01
Asking family or friends for help when helpless or frustrated 2Æ62 0Æ96 0Æ25 0Æ11 0Æ74 0Æ06
Discussing with family or friends while questioning or worrying 2Æ44 0Æ82 0Æ13 0Æ16 0Æ72 0Æ03
Telling family or friends about treatment plan 2Æ58 0Æ91 0Æ14 0Æ09 0Æ65 0Æ06
Factor 4: adherence to recommended regimen 0Æ77
Don’t follow care providers’ suggestion to adjust diet habit* 3Æ46 0Æ75 0Æ17 0Æ03 0Æ10 0Æ78
Don’t follow care providers’ suggestion to control weigh* 3Æ58 0Æ70 0Æ09 0Æ13 0Æ07 0Æ77
Don’t follow care providers’ suggestion to exercise* 3Æ42 0Æ83 0Æ18 0Æ04 0Æ16 0Æ74
Don’t follow the dieticians’ suggestion to choose food* 3Æ52 0Æ74 0Æ22 0Æ01 0Æ08 0Æ69
Total scale 0Æ95

*Representing reverse-worded item.

Bold values highlight the factor loading of each factor.

Ó 2012 Blackwell Publishing Ltd

4 Journal of Clinical Nursing
Original article
the variance and is labelled ‘adherence to recommended
regimens’. The factor represents how a patient follows the
treatment regimen to control kidney disease.
Reliability
Cronbach’s alpha was used to assess the internal consistency
reliability of the total scale and sub-scales. As shown in
Table 1, Cronbach’s alpha for the 29-item version of the
CKD-SM total scale was 0Æ95. The sub-scale coefficients
alphas ranged from 0Æ77–0Æ93. The stability of the CKD-SM
was assessed using Pearson correlation coefficient for mea-
suring 2-week test–retest reliability. The test–retest correla-
tions for the CKD-SM was 0Æ72 (p < 0Æ001, n = 26).
Discussion and conclusion
An instrument to measure self-management behaviours
among adults with early stage CKD was developed and
tested. EFA identified four factors with 29 items. Although
these four factors did not exactly match the dimensions from
the six a priori hypothesised dimensions (i.e. learning skills
and knowledge about disease, interaction with health pro-
fessionals and significant others, problem-solving, self-care,
self-integrations and emotion management), the four factors
identified from the empirical data are theoretically closely
related to the six dimensions proposed in the initial stage of
instrument development. For example, Factor 1 ‘self-integra-
tion’ consisted of the items from the original dimensions of
‘self-care’ and ‘self-integration’. According to the meaning of
items appeared in the Factor 1, self-integration covers the
dimension of self-care. Self-integration reflects patients with
chronic illness had the abilities to integrate treatment
regimens and self-care activities benefit to their disease
control to their daily life to achieve a more balanced life.
Accordingly, the dimension of self-integration is more
appropriate to reflect the construct of self-management.
For patients with chronic illness, they may be faced with a
variety of problems related to the disease, treatment, or
personal life. It is important for patients to identify their
problems and determine possible causes through seeking
resources or applying the knowledge and skills they learned.
The problem-solving model proposed by Hill-Briggs (2003)
may explain the rationale for the original dimension of
‘actively learning skills and knowledge about disease’ was
combined to the factor of ‘problem-solving’ after conducting
the factor analysis.
As suggested by Gallant (2003) who reviewed 29 studies,
social support is an important component for chronic illness
self-management. That is, patients with chronic illnesses need
Ó 2012 Blackwell Publishing Ltd
Journal of Clinical Nursing
Chronic kidney disease self-management (CKD-SM) instrument
support from health professionals or significant others, to
help them cope with their disease and emotions resulting
from the disease. This reflects the result that the original
dimension of ‘emotion management’ was combined with the
original dimension ‘interaction with health professionals and
significant others’ to form the dimension of ‘social support’ in
the final version of CKD-SM. To maintain disease control,
patients was often instructed to adhere to therapeutic
regimens. Thus, Factor 4 ‘adherence to recommended regi-
mens’ was extracted. The above indicated the four conceptual
dimensions verified from empirical data in this study appear
to be specifically applicable in the clinical settings and also to
reflect the construct of self-management presented in the
theoretical literature.
The homogeneity or uni-dimensionality of items is a major
issue in assessing the psychometric properties of an instru-
ment. In this study, the Cronbach’s alpha coefficient for the
CKD-SM was 0Æ95 and each of the four subscales ranged
from 0Æ77–0Æ92 indicating good internal consistency for this
newly constructed instrument. According to Devellis (1991),
the results of the reliability of the CKD-SM were satisfactory.
In addition, the result of test–retest analyses indicated the
CKD-SM was relatively stable over a 2-week period.
This study provides support for the content and construct
validity as well as the internal consistency and retest
reliability of the CKD-SM in Taiwanese populations. The
CKD-SM should be tested in other patient populations rather
than generalizing from these results since linguistic, cultural
and health system differences may exist, including patient
and healthcare provider expectations and methods of self-
management implementation.
Self-management is a complex concept. To investigate
clinical questions about self-management, there is a need for
valid and reliable measures that provide empirical data. The
CKD-SM developed in this study can be used to assess how
patients self-manage their chronic conditions and to develop
more relevant, patient-centred teaching and implement
interventions tailored to the needs of individual patients.
Implications to clinical practice
Early detection and treatment can halt the progression of
CKD. To our knowledge, the CKD-SM developed in this study
is the first one for measuring self management behaviours
among early stage CKD patients. The results obtained from
the present study provided acceptable level of reliability and
validity for this new instrument with early stage CKD patients
in Taiwan. CKD is a preventive disease. The CKD-SM could
be used as an assessment tool to help recognise those early
CKD patients who are unable to manage their disease well. By
5
C.-C. Lin et al.

better understanding patients’ self-management behaviours Contributions

the healthcare providers can further develop the better
Study design: CCL, CCW; data collection and analysis: CCL,
intervention tailored to the needs of the CKD population.
CCW, LMW, HMC and manuscript preparation: CCL,
CCW, LMW, SCC.
Acknowledgements
This study was funded by National Science Council, Taiwan Conflict of interest
(NSC 95-2314-B-037-052-MY3). We would like to thank the
None.
participants who participated in the study.

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6 Journal of Clinical Nursing
Original article Chronic kidney disease self-management (CKD-SM) instrument

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