The Italian version of the Care Recipient Behavior Assessment Scale (Careba): validation in Italian on patients with dementia
10.54103/dn/18991
INTRODUCTION: The international literature shows that 20-40% of patients with cognitive impairment, hospitalized in long-term facilities, may react during nursing care with aggressive behaviors such as screaming, threats, kicks, punches and scratches. The objective of this study is to validate in Italian the "Care Recipient Behavior Assessment Scale" (CAREBA), an assessment tool designed to measure physical and verbal aggression of the person with dementia.
METHODS: The CAREBA was back-translated through an observational study. It was administered to a sample of dementia patients with physical and/or verbal aggressive behaviors, conducted in a hospital in Northern Italy . Reliability and validity were assessed.
RESULTS: The scale shows satisfactory internal consistency (Cronbach's Alpha = 0.79) and content validity (CVI-S= 90%).
CONCLUSIONS: The CAREBA scale is a valid and reliable tool to detect aggression in patients with dementia.
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Giada Cocciolo
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Dissertation Nursing
infermiere
La versione italiana della Care Recipient Behavior Assessment Scale (Careba): validazione in italiano su pazienti con demenza
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2022-11-09
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DN
Giada Cocciolo
2023/01/30
10.54103/dn/18991
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Lmu Klinikum Grosshadren, Munich
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78
Polit, D.F., Beck, C.T., Owen, SV. (2007). Is the CVI an acceptable indicator of content validity? Appraisal and recommendations. Res Nurs Health, 30(4):459–467.
La versione italiana della Care Recipient Behavior Assessment Scale (Careba): validazione in italiano su pazienti con demenza
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                                                                                                                DOI: 10.54103/dn/18991




             DISSERTATION NURSING
             Journal Homepage: https://riviste.unimi.it/index.php/dissertationnursing

Validation Study

The Italian version of the CAre REcipient Behavior Assessment
  scale (Careba): validation in Italian on patients with dementia
                  1
Giada Cocciolo
1 Lmu   Klinikum Grosshadren, Munich



Findings:                                         ABSTRACT
In this study, a scale (CAREBA) designed
                                                  BACKGROUND:
to assess the aggressiveness of the person with
dementia is translated and validated.             The international literature shows that 20-40% of patients with cognitive
                                                  impairment, hospitalized in long-term facilities, may react during nursing care
                                                  with aggressive behaviors such as screaming, threats, kicks, punches and
                                                  scratches.

                                                  AIM:
                                                  The objective of this study is to validate in Italian the "Care Recipient
                                                  Behavior Assessment Scale" (CAREBA), an assessment tool designed to
                                                  measure physical and verbal aggression of the person with dementia.

                                                  METHODS:
                                                  The CAREBA was back-translated through an observational study. It was
                                                  administered to a sample of dementia patients with physical and/or verbal
                                                  aggressive behaviors, conducted in a hospital in Northern Italy. Reliability
                                                  and validity were assessed.

                                                  RESULTS:
                                                  The scale shows satisfactory internal consistency (Cronbach's Alpha = 0.79)
                                                  and content validity (S-CVI= 90%).

                                                  CONCLUSIONS:
                                                  The CAREBA scale is a valid and reliable tool to detect aggression in
                                                  patients with dementia.




                KEYWORDS: Dementia, Nurse, Assessment, Aggressive Behaviours, Aggressiveness



         Corresponding author:                                      71                                 Submission received: 09/11/2022
         Giada Cocciolo: giadacocciolo88@hotmail.com                                            End of Peer Review process: 12/12/2022
         Lmu Klinikum Grosshadern Marchioninistrasse 15,                                                         Accepted: 16/12/2022
         Munich, Germany
                                                                             This work is licensed under a Creative Commons
          Dissertation Nursing V.2, N.1 (30/01/2023)                         Attribution-NonCommercial-NoDerivatives 4.0 nternational
                                                                                                               DOI: 10.54103/dn/18991




             DISSERTATION NURSING
             Journal Homepage: https://riviste.unimi.it/index.php/dissertationnursing

Studio di Validazione
        La versione italiana della CAre REcipient Behavior Assessment
        scale (Careba): validazione in italiano su pazienti con demenza
                  1
Giada Cocciolo
1 Lmu   Klinikum Grosshadren, Munich



Riscontri:                                       ABSTRACT
In questo studio viene tradotta e validate una   INTRODUZIONE:
scala (CAREBA) progettata per valutare
l’aggressività della persona con demenza.        La letteratura internazionale mostra che il 20-40% dei pazienti con
                                                 deterioramento cognitivo, ricoverati in strutture a lungo termine, può reagire
                                                 durante l'assistenza infermieristica con comportamenti aggressivi come urla,
                                                 minacce, calci, pugni e graffi.

                                                 OBIETTIVO:
                                                 L'obiettivo di questo studio è quello di validare in italiano la "Care Recipient
                                                 Behavior Assessment Scale" (CAREBA), uno strumento di valutazione
                                                 progettato per misurare l'aggressività fisica e verbale della persona con
                                                 demenza.

                                                 METODI:
                                                 La CAREBA è stata ritradotta attraverso uno studio osservazionale. È stato
                                                 somministrato a un campione di pazienti affetti da demenza con
                                                 comportamenti aggressivi fisici e/o verbali, in un ospedale del Nord Italia.
                                                 Sono state valutate l'affidabilità e la validità.

                                                 RISULTATI:
                                                 La scala mostra una consistenza interna soddisfacente (Alpha di Cronbach =
                                                 0,79) e una validità di contenuto (CVI-S= 90%).

                                                 CONCLUSIONI:
                                                 La scala CAREBA è uno strumento valido e affidabile per rilevare
                                                 l'aggressività nei pazienti con demenza.




            KEYWORDS: Demenza, Infermiere, Valutazione, Comportamento Aggressivo, Aggressività



         Corresponding author:                                     72                                 Submission received: 09/11/2022
         Giada Cocciolo: giadacocciolo88@hotmail.com                                           End of Peer Review process: 12/12/2022
         Lmu Klinikum Grosshadern Marchioninistrasse 15,                                                        Accepted: 16/12/2022
         Munich, Germany
                                                                            This work is licensed under a Creative Commons
          Dissertation Nursing V.2, N.1 (30/01/2023)                        Attribution-NonCommercial-NoDerivatives 4.0 nternational
                                                                                                                   DOI: 10.54103/dn/18991




            DISSERTATION NURSING
            Journal Homepage: https://riviste.unimi.it/index.php/dissertationnursing



BACKGROUND                                                                 behaviors into account. The CAREBA scale does not
                                                                           yet exist in Italian in Italy.
Within two years of a dementia diagnosis, 20% of
patients experience psychobehavioral symptoms. As                          MATERIALS AND METHODS:
the condition progresses, this proportion rises to
80%. (1-3). Caregiver and medical staff find it difficult                  From June to October 2018, a study was carried out

to control agitation and violence in dementia patients,                    in two dementia-specific surgery rooms at a private

which has an immediate negative impact on the staff                        hospital in Northern Italy. We enrolled individuals
                                                                           with dementia (both Alzheimer's disease and non-
members and the organization (4-6).
                                                                           disease) with "moderate" or "severe" cognitive
According to the research, 20–40% of patients with                         impairment, a Mini Mental State Examination score
cognitive impairment who are admitted to long-term                         of 19 or above, a PAINAD score of 4, and a history
facilities may respond aggressively during nursing                         of      physically       or     verbally         aggressive      conduct,.
treatment, including yelling, threatening, kicking,                        Alzheimer's Excluded patients included those with
punching, and scratching (7-9).                                            delirium as their major diagnosis, those who were

Currently,           both          pharmaceutical              and         unconscious or comatose, those with alcohol-related

nonpharmacological therapy are available to treat                          dementia or psychotic illnesses as their primary

psychobehavioral disorders (10-12). According to                           diagnosis, those with an MMSE > 19 and "moderate"

studies, antipsychotics are used to treat agitation and                    cognitive impairment, and those with PAINAD 4.

violence in anywhere between 21% and 46% of                                The hospital is not a member of any external bodies
situations (13-15). The most popular antipsychotics to                     and does not have an internal ethics committee. In
lessen      agitation     and     aggression      are      atypical        accordance with the ethical precepts of the
antipsychotics (16,17). However, most patients do not                      Declaration of Helsinki, members of hospital
respond well to these drugs (18), which has negative                       leadership, including nurses, doctors, and managers,
effects (19,20), including an increased risk of falls and                  address ethical concerns. The study was carried out in
fractures (21), the onset of cerebrovascular accidents,                    accordance with hospital ethical guidelines, and all
a lower quality of life, and a higher mortality rate (22-                  required approvals were received. Before starting the
25). The Care Recipient Behavior Assessment Scale                          translation of the treatment recipient behavior rating
(CAREBA scale), developed in 2004 by Sloane et al.,                        scale     (CAREBA              scale),       we       obtained     written
allows for the evaluation of the patient's level of                        permission from the author, who confirmed that no
hostility (11). When assessing behavioral distress in a                    other Italian author was working on this instrument.
dementia patient, it takes hostile verbal and physical                     The scale, shown in Appendix 1, has 9 items, each

         Corresponding author:                                        73                                  Submission received: 09/11/2022
         Giada Cocciolo: giadacocciolo88@hotmail.com                                               End of Peer Review process: 12/12/2022
         Lmu Klinikum Grosshadern Marchioninistrasse 15,                                                            Accepted: 16/12/2022
         Munich, Germany
                                                                                This work is licensed under a Creative Commons
          Dissertation Nursing V.2, N.1 (30/01/2023)                            Attribution-NonCommercial-NoDerivatives 4.0 nternational
                                                                                                            DOI: 10.54103/dn/18991




            DISSERTATION NURSING
            Journal Homepage: https://riviste.unimi.it/index.php/dissertationnursing



corresponding to the patient's behavior, which may or                instrument as a whole (CV-S) was calculated and the
may not be present. The scale is considered positive                 Content Validity Index of each subject (CVI-I) was
even with an "attempt" of aggressive behavior toward                 evaluated (32). Cronbach's alpha was used to assess
the operator. The scale was administered to all                      internal consistency. Exploratory factor analysis was
patients until reaching the sample size for the study                used to study the scale construct, after checking for
we did literature indicating a minimum sample size of                sample      adequacy           with       the      Kaiser-Meyer-Olkin
100 patients to obtain a reliable factor analysis. This              measure and Bartlett's test of sphericity. The Varimax
was necessary to obtain a reliable factor model as                   algorithm was used to rotate the factor model. The
recommended by the reference textbooks (31). The                     eigenvalues of the correlation matrix and factor
scale was translated using the back-translation                      loadings were maintained according to Kaiser's and
method in order to ensure cultural and linguistic                    Steven's criteria, respectively. All calculations were
overlap of the instrument. The translation was carried               performed by a statistician using SAS software for
out in two distinct phases: in a first phase, the                    MacOS.
translation (from English to Italian) was carried out
                                                                     RESULTS
independently by two nurses (experts in this field and
in possession of advanced certifications in English).                Face validity was satisfactory: the scale had a content
The     two      versions       later     compared       were        validity index (S-CVI) of 0.94. Internal consistency
superimposable and there were no differences in                      was good (Cronbach's Alpha 0.79). The average time
content; this allowed the drafting of a single shared                to complete the CAREBA scale was less than 1
text that was later retranslated by a third English                  minute. Factor analysis showed only one factor, as in
native speaker. The final retranslated version was sent              the original scale. All items on the scale have
to    the    original    author     who      confirmed    the        satisfactory loadings, meaning that each item on the
correspondence of content and the reliability of the                 instrument contributes substantially to describing the
translation to the original. Data collection was                     patient's situation. The analysis was initially conducted
performed by a single nurse, who was the project                     on all variables; because very few patients spit or
manager and had direct contact with the author of the                threw objects during basic nursing care, the loadings
instrument.                                                          of these two variables are small (0.17 and 0.22,
                                                                     respectively). The situations investigated by these two
At a later date, content and face validity of the
                                                                     items may actually occur, so it makes sense to retain
CAREBA scale was tested by administering it to six
                                                                     these two scale questions. From a mathematical point
nurses with 5 or more years of experience in this area.
                                                                     of view, the analysis is repeated by eliminating these
Therefore, the content validity index of the
                                                                     two variables, obtaining for all remaining items a
       Corresponding author:                                    74                                 Submission received: 09/11/2022
       Giada Cocciolo: giadacocciolo88@hotmail.com                                          End of Peer Review process: 12/12/2022
       Lmu Klinikum Grosshadern Marchioninistrasse 15,                                                       Accepted: 16/12/2022
       Munich, Germany
                                                                         This work is licensed under a Creative Commons
        Dissertation Nursing V.2, N.1 (30/01/2023)                       Attribution-NonCommercial-NoDerivatives 4.0 nternational
                                                                                                       DOI: 10.54103/dn/18991




          DISSERTATION NURSING
          Journal Homepage: https://riviste.unimi.it/index.php/dissertationnursing



more than satisfactory result. Table 1 shows the                two items "spitting" or "throwing objects" during
loading coefficients, all of which are above the                basic nursing care are not assessable from a statistical
Stevens cut-off, which for this sample is 0.5204.               point of view, but find confirmation in clinical
                                                                practice and therefore appear worthy of inclusion in
                 ITEM                    LOADING
                                                                the instrument. The scale is easy, fast in compilation
          Colpire, spingere,
                                            0.83248             (less than one minute) and therefore a valid and
              graffiare
            Tirare calci                    0.73004             reliable tool in the assessment of aggression even in
              Mordere                       0.66688             patients with dementia. The scale is easy, fast in
        Afferrare il caregiver              0.80604
                                                                compilation (less than a minute) and therefore a valid
        Usare un linguaggio
                                            0.73842             and reliable tool in the evaluation of aggressiveness
         ostile/aggressivo
          Urlare/gridare                     0.5699             also in patients with dementia.
           Chiamare per
                                            0.52345
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      Corresponding author:                                75                                 Submission received: 09/11/2022
      Giada Cocciolo: giadacocciolo88@hotmail.com                                      End of Peer Review process: 12/12/2022
      Lmu Klinikum Grosshadern Marchioninistrasse 15,                                                   Accepted: 16/12/2022
      Munich, Germany
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        Journal Homepage: https://riviste.unimi.it/index.php/dissertationnursing



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     Corresponding author:                             76                              Submission received: 09/11/2022
     Giada Cocciolo: giadacocciolo88@hotmail.com                                End of Peer Review process: 12/12/2022
     Lmu Klinikum Grosshadern Marchioninistrasse 15,                                             Accepted: 16/12/2022
     Munich, Germany
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      Dissertation Nursing V.2, N.1 (30/01/2023)             Attribution-NonCommercial-NoDerivatives 4.0 nternational
                                                                                                 DOI: 10.54103/dn/18991




        DISSERTATION NURSING
        Journal Homepage: https://riviste.unimi.it/index.php/dissertationnursing



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  Corresponding author:                                  77                             Submission received: 09/11/2022
  Giada Cocciolo: giadacocciolo88@hotmail.com                                    End of Peer Review process: 12/12/2022
  Lmu Klinikum Grosshadern Marchioninistrasse 15,                                                 Accepted: 16/12/2022
  Munich, Germany
                                                              This work is licensed under a Creative Commons
      Dissertation Nursing V.2, N.1 (30/01/2023)              Attribution-NonCommercial-NoDerivatives 4.0 nternational
                                                                                                                                       DOI: 10.54103/dn/18991




              DISSERTATION NURSING
              Journal Homepage: https://riviste.unimi.it/index.php/dissertationnursing



APPENDIX 1: CARE RECIPIENT BEHAVIOR ASSESSMENT (CAREBA Scale) Italian Version
Questa scala è usata per valutare chiari segni di distress comportamentale nella persona ricevente le cure. Ogni comportamento verrà classificato in “SI”,
“NO”, “TENTATIVO”, “ENTRAMBI” . Se due comportamenti avvengono simultaneamente valutare con “ ENTRAMBI”, se non c’è stato contatto
con il caregiver valutare con “TENTATIVO”. Se un comportamento non è chiaro, NON valutarlo.

                                                     Manifestazioni fisiche                                    Possibili valutazioni
                                              COMPORTAMENTO (valutazioni)                              Si         No       Tentativo Entrambi
                                 Colpire, spingere, graffiare (Si, No, Tentativo e Entrambi )
                                 Tirare calci (Si, No, Tentativo e Entrambi )
                                 Mordere (Si, No, Tentativo e Entrambi )
                                 Lanciare oggetti (Si, No, Tentativo)
                                                                                                               Possibili valutazioni
                                                                                                       Si         No
                                 Afferrare il caregiver (Si, No)
                                 Sputare (Si, No)


                                                     Manifestazioni verbali                                    Possibili valutazioni
                                 COMPORTAMENTO (valutazioni)                                           Si         No
                                 Chiamare per aiuto/protestare/obiettare (Si, No)
                                 Usare un linguaggio ostile/aggressivo (Si, No)
                                 Urlare/gridare (Si, No)



    1. Manifestazioni fisiche
        COMPORTAMENTO                                                                              DESCRIZIONE
                                          Abusare fisicamente del caregiver con mani o oggetti a portata di mano o con altre parti del corto (es. testa , intero corpo),
    Colpire, spingere, graffiare cc…
                                          incluso spingere, spintonare, graffiare, pizzicare (deve esserci il contatto).
    TENTATIVO di colpire,
                                          Agitare le braccia e le mani con forza verso il caregiver (verificare la presenza di segni di uno scherzo).
    spingere, graffiare, ecc.
    Tirare calci                          Colpire energicamente con piedi o gambe (deve esserci il contatto).
    TENTATIVO di tirare calci             Agitare gambe o piedi con forza verso il caregiver.
    Mordere                               Mordere, masticare (SOLO sul caregiver).

    TENTATIVO di mordere                  Muovere la faccia e aprire la bocca verso il caregiver per mordere
                                          Aggrapparsi al caregiver, afferrare il cagiver. Non valutare se il paziente si aggrappa al caregiver per ragioni di sicurezza. Se
    Afferrare il caregiver
                                          il comportamento non è chiaro non valutarlo.
    Lanciare oggetti                      Lanciare oggetti con forza, scagliare oggetti a terra.

    Sputare                               Sputare ma non per motivi di igiene dentale.


    2. Manifestazioni verbali
    COMPORTAMENTO                         DESCRIZIONE
    Chiamare per                          Dire “Mi stai facendo male”, “Ahi”, “Aiuto”ecc.. questo potrebbe includere espressioni di dolore, discomfort o
    aiuto/protestare/obiettare            insoddisfazione o chiamate di aiuto.
                                          Minacciare verbalmente il caregiver e di danneggiarlo fisicamente, per esempio “ti ammazzo”, oppure minacciare il
    Usare un linguaggio                   caregiver non in modo fisico, per esempio “parlerò a mio figlio di te”. Devono essere usate parole.
    ostile/aggressivo
                                          Usare parolacce (un linguaggio osceno o profano).
                                          Chiaramente sopra il livello di conversazione: urlare, gridare, incluse scenate rumorose, per esempio forti esclamazioni
    Urlare/gridare                        come “Oh!”oppure “Aiuto!” dovrebbero essere valutate come urlare/gridare e protestare/obiettare. Valutare “Aiuto” detto
                                          in maniera supplichevole come protestare/obiettare.


         Corresponding author:                                                         78                                     Submission received: 09/11/2022
         Giada Cocciolo: giadacocciolo88@hotmail.com                                                                   End of Peer Review process: 12/12/2022
         Lmu Klinikum Grosshadern Marchioninistrasse 15,                                                                                Accepted: 16/12/2022
         Munich, Germany
                                                                                                    This work is licensed under a Creative Commons
           Dissertation Nursing V.2, N.1 (30/01/2023)                                               Attribution-NonCommercial-NoDerivatives 4.0 nternational
