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The Development, Refinement, and Psychometric Testing of the Attitude Toward Advanced Directive Survey in Implantable Cardioverter Defibrillator Patients

Conelius, Jaclyn PhD, FNP-BC

Journal of Cardiovascular Nursing: May/June 2013 - Volume 28 - Issue 3 - p 238–244
doi: 10.1097/JCN.0b013e31824b2105

Implantable cardioverter defibrillators (ICDs) have been the treatment of choice for those who experienced or are at risk of sudden cardiac arrest. Many patients who receive these devices experience progressive comorbid and cardiac conditions and may not want the additional survival provided by an ICD. Clinicians will need to counsel patients and families about advanced directives when their ICD is no longer beneficial, to prevent unnecessary suffering near the end of life. The Attitude Towards Advanced Directive Survey was developed to assess patients’ level of knowledge and identify the barriers that prevent them from completing advanced directives. This will help clinicians promote completion of advanced directives by addressing barriers and increasing knowledge of them. The purpose of this study was to develop and evaluate the psychometric properties of the survey and investigate reliability and validity from its use among ICD patients. A convenience sample of 200 patients who have an ICD participated in this study. Psychometric testing of the Attitude Towards Advanced Directive Survey provided evidence to support the validity and reliability of the survey. Moderate to strong factor intercorrelations and conceptual meaningfulness led to the combination of 5 factors. The 5 factors were as follows: factor 1: communication barriers; factor 2: informed confidence; factor 3: timing of discussion; factor 4: patient-family relationship; and factor 5: patient-provider relationship. Reliability coefficient α ranged from .67 to .95 for the factors and .75 for the total scale. Stability reliability of the survey was analyzed through test-retest of the survey, with a response rate of 34% (n = 68), and revealed a significant positive correlation (r = .62; P < .001) between the first and second testing. The participants reported communication barriers and demonstrated poor understanding of their medical condition/treatments and were not comfortable discussing advanced directives with their families. They preferred to discuss advanced directives when they were first diagnosed and at every office visit because they felt more comfortable discussing advanced directives with their healthcare provider. This survey has the potential to be used in clinical practice and future research.

Jaclyn Conelius, PhD, FNP-BC Assistant Professor, School of Nursing, Fairfield University, Connecticut.

The author has no funding or conflicts of interest to disclose.

Correspondence Jaclyn Conelius, PhD, FNP-BC, School of Nursing, Fairfield University, 1078 North Benson Rd, Fairfield, CT 06824 (

© 2013 Lippincott Williams & Wilkins, Inc.