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Cross-cultural validation and psychometric testing of the Swedish version of the microsocial section of the Attitudes toward Patient Advocacy Scale

Anna Josse Eklund, Kerstin Petzall, Ann Kristin Sandin-Bojo, Bodil Wilde-Larsson


Rationale, aims and objectives: Patient advocacy can be defined as a process for maintaining and monitoring patients’ rights, values and best interests. To measure attitudes toward patient advocacy, Bu and Wu (2008) developed the Attitudes toward Patient Advocacy Scale (APAS), which required further testing and refining in different contexts. This two-phased study aimed to: (1) translate and cross-culturally validate the APAS section for microsocial patient advocacy (AMIA) in accordance with the Swedish context and (2) test the instrument’s psychometric properties in the community care of older patients.

Methods and results: The first phase consisted of back-translation and cultural validation of the APAS-AMIA in accordance with the Swedish context and resulted in a 39-item Swedish version of the APAS-AMIA. In the second phase, data were collected using the 39-item APAS-AMIA in 2009 from a sample of 230 registered nurses and nurse managers covering 16 communities. Subsequently, psychometric testing was conducted with exploratory factor analysis and reliability analysis in a final sample of 201 RNs. The exploratory factor analysis revealed a 4-factor structure, explaining 52.1% of the total scale variance in a 33-item instrument called the APAS-AMIA/SE. The Cronbach’s alpha for the APAS-AMIA/SE was 0.92 and varied between 0.82 and 0.88 for the factors.

Conclusion: When the APAS-AMIA/SE semantic and conceptual equivalence to the APAS-AMIA, its distinct factor structure, internal consistency values and theoretical attachment are all added together, the conclusion is that the APAS-AMIA/SE is an acceptably reliable and valid instrument.


Community care, exploratory factor analysis, nursing, older patients, patient advocacy, person-centered medicine, psychometric testing

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Woods, M. (1999). A nursing ethic: The moral voice of experienced nurses. Nursing Ethics 6 (5) 423-433.

Dictionary of Nursing. (2007). London: A & C Black Publishers Ltd 2nd ed.

Gilkey, M.B., Earp, J.A.L. & French E.A. (2008). What is patient advocacy? pp. 3-28. In: Patient advocacy for health care quality: Strategies for achieving patient-centered care. (Gilkey, M.B., Earp, J.A.L. & French E.A. eds). Sudbury, Massachusetts: Jones and Bartlett Publishers.

Huber, R., Nelson, W.H., Netting, E.F. & Borders, K.W. (2008). Elder Advocacy. Essential Knowledge & Skills Across Settings. Belmont CA: Thomson, Brooks/Cole.

Caffrey, R.A. (2005). Community Care Gerontological Nursing. The independent nurse’s role. Journal of Gerontological Nursing 31 (7) 18-25.

Edberg, A-K., Bird, M., Richards, D.A., Woods, R., Keeley, P. & Davis-Quarell, V. (2008). Strain in nursing care of people with dementia: Nurses’ experience in Australia, Sweden and United Kingdom. Aging & Mental Health 12 (2) 236-243.

Gustafsson, C., Asp, M. & Fagerberg, I. (2009). Municipal Night Nurses’ Experience of the Meaning of Caring. Nursing Ethics 16 (5) 599-612.

Walent, R.J. & Kayser-Jones, J. (2008). Having a Voice and Being Heard. Nursing home residents and In-House Advocacy. Journal of Gerontological Nursing 34 (11) 34-42.

Vaartio, H. & Leino-Kilpi, H. (2005). Nursing advocacy – a review of the empirical research 1990-2003. International Journal of Nursing Studies 42, 705-714.

Foley, B. J., Minick, P. & Kee, C. (2000). Nursing advocacy during a military operation. Western Journal of Nursing Research 22 (4) 492-507.

O’Connor, T. & Kelly, B. (2005). Bridging the gap: A study of general nurses’ perceptions of patient advocacy in Ireland. Nursing Ethics 12 (5) 453-467.

Kubsch, S.M., Sternard, M.J., Hovarter, R. & Matzke, V (2003). A holistic model of advocacy: factors that influence its use. Complementary Therapies in Nursing & Midwifery 10, 37-45.

Vaartio, H., Leino-Kilpi, H., Suominen, T. & Puukka, P. (2008). The content of advocacy in procedural pain care- patients’ and nurses’ perspectives. Journal of Advanced Nursing 64 (5) 504-513.

Bu, X. & Wu, Y.B. (2008). Development and Psychometric Evaluation of the Instrument: Attitude Toward Patient Advocacy. Research in Nursing & Health 31 (1) 63-75.

Bu, X. & Jezewski, M.A. (2007). Developing a mid-range theory of patient advocacy through concept analysis. Journal of Advanced Nursing 57 (1) 101-110.

Ajzen, I. & Fishbein, M. (1980). Understanding Attitudes and Predicting Social behavior. Englewood Cliffs: Prentice Hall.

Eliopoulos, C. (2010). Gerontological Nursing .7th ed. Philadelphia: Wolters Kluwer Health, Lippincott Williams & Wilkins.

Brislin, R.W. (1970). Back-Translation for cross-cultural research. Journal of Cross-Cultural Psychology 1 (3) 185-216.

Streiner, D.L. & Norman, G.R. (2008). Health Measurement Scale- A practical guide to their developement and use.4th ed. Oxford: Oxford University Press.

Field, A. (2009). Discovering Statistics Using SPSS. 3rd ed. Thosand Oaks CA: Sage.

Pallant, J. (2010). SPSS. Survival Manual. 4th. ed. Milton Keynes: Open University Press.

Hair, J.F., Black, W.C., Babin, B.J., Anderson, R.E. &Tatham, R.L. (2006). Multivariate Analysis. 6th ed. New Jersey: Pearson Prentice Hall.

Costello, A.B. & Osborne, J.W. (2005). Best practices in expolaratory factor analysis: Four recommendations for getting the most from your analysis. Practical Assessment, Research & Evaluation 10 (7) 1-9.

Statistics Sweden. (2004). Utbildning och arbete. Tillskott och rekryteringsbehov för olika utbildningsgrupper till 2010. (Education and employment. Input and recruitment needs for different educational groups). Retrieved from on 28 of April 2012. (In Swedish).

The National Board of Health and Welfare. (2010). Årsrapport NPS 2010. En analys av barnmorskors, sjuksköterskors, läkares, tandhygienisters och tandläkares arbetsmarknad.(An analysis of midwives’, registered nurses’, physicians’, dental hygienists’ and dentists’ employment market). In Swedish.

Velicer, W.F. & Jackson, D.N. (1990). Component analysis versus common factor analysis: Some issues in selecting an appropriate procedure. Multivariate Behavioral Research 25 (1) 1-28.

Child, D. (2006). The Essentials of Factor Analysis. 3rd ed. London: Continuum International Publishing Group.

Ministry of Health and Social Affairs. (1982). The Health and Medical Services Act. (SFS 1982:763). (In Swedish).



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