Care in Dialogue Competence Scale

1. Abstract

The Care in Dialogue Competence Scale (Dutch: Zorg in dialoog Competentie Schaal) is a standardized, self-administered psychometric assessment instrument developed by Tanja Schoot, Ieke Proot, and Luc de Witte in 2005. Designed specifically for registered nurses and certified nursing assistants working in home healthcare and community nursing environments, the instrument evaluates healthcare professionals’ perceived self-efficacy and self-reported behavioral competence in delivering demand-oriented, client-centered care to individuals with chronic illnesses. Rooted in interactive care models, communicative action theory, and patient-centered clinical methodologies, the scale addresses the complex relational and systemic transitions inherent in modern ambulatory chronic illness care. The measurement tool is structured as a 29-item questionnaire operationalized across three core behavioral dimensions: (1) The Care Process in Dialogue (14 items), measuring communicative alignment, shared assessment, and collaborative care planning; (2) Supporting Client Participation (7 items), assessing professional behaviors that empower client autonomy, promote active decision-making, and reinforce self-management capacities; and (3) Handling Dilemmas and Conflicting Demands (8 items), evaluating the clinician’s ability to navigate ethical conflicts, professional boundaries, institutional constraints, and divergences between client desires and clinical standards. Responses are recorded on a four-point Likert-type scale ranging from 1 (eigenlijk niet / “not really”) to 4 (heel vaak / “very often”). Extensive psychometric evaluations demonstrate robust internal consistency across all subscales (with Cronbach’s alpha coefficients typically ranging between .78 and .88), established content and construct validity through iterative expert consensus and factor-analytic procedures, and meaningful discriminant capacity regarding nursing education levels and clinical exposure. The scale serves as both an empirical research questionnaire and an educational diagnostic tool for reflective professional practice.

2. Keywords

Care in Dialogue Competence Scale, Zorg in dialoog Competentie Schaal, demand-oriented care, patient-centered care, chronic illness care, home healthcare, nursing competencies, client participation, clinical dialogue, psychometrics

3. Authors

The Care in Dialogue Competence Scale was conceptualized, operationalized, and psychometrically validated by a research team based at Maastricht University in the Netherlands:

• Tanja Schoot, PhD, RN: Senior Healthcare Researcher and Nursing Scientist, Faculty of Health, Medicine and Life Sciences, Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands.
• Ieke Proot, PhD: Qualitative and Health Services Researcher, Department of Health Services Research, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands.
• Luc P. de Witte, MD, PhD: Professor of Health Services Research and Technology in Healthcare, Department of Health Services Research, Maastricht University, Maastricht, The Netherlands (subsequently affiliated with the University of Sheffield, United Kingdom, and The Hague University of Applied Sciences).

4. Purpose

The shift from traditional, paternalistic, supply-driven healthcare paradigms toward responsive, demand-oriented, and individualized care forms the foundational impetus for the Care in Dialogue Competence Scale. Within home-based long-term care, individuals living with chronic conditions—such as chronic obstructive pulmonary disease, diabetes mellitus, cardiovascular diseases, and degenerative neurological disorders—manage their conditions primarily within the context of daily domestic life. Consequently, professional clinical expertise must interface continuously with the patient’s personal expertise regarding their own lifestyle, lived experiences, values, and contextual limitations. The primary purpose of the Care in Dialogue Competence Scale is to provide an empirically grounded self-assessment framework that captures how healthcare providers operationalize “care in dialogue” (zorg in dialoog) at the frontline of community care.

From an applied perspective, the scale fulfills distinct clinical, institutional, and research functions:

• Reflective Professional Practice: The instrument functions as a structured diagnostic inventory for individual nurses and allied community health staff, enabling them to systematically reflect upon their clinical micro-behaviors. By rating behavioral items across core relational domains, clinicians identify personal blind spots, such as dominating the clinical dialogue or avoiding negotiations around competing ethical values.
• Workplace Training and Continuing Professional Education: Healthcare organizations, community nursing agencies, and vocational nursing academies utilize the scale to conduct needs assessments prior to continuing professional development initiatives. Pre- and post-intervention administration enables educators to measure the efficacy of training programs centered on shared decision-making, motivational interviewing, and client empowerment.
• Health Services and Implementation Research: In empirical health services research, the scale provides a quantitative metric to examine the implementation fidelity of patient-centered care models, allowing researchers to correlate clinician competence scores with client-level outcomes, including treatment adherence, perceived autonomy, quality of life, and healthcare utilization.

5. Psychological Construct

The Care in Dialogue Competence Scale operationalizes the multi-faceted psychological construct of demand-oriented communicative competence (vraaggerichte zorgcompetentie). Rather than viewing competence merely as static knowledge or technical skill, the construct reflects a synthesis of communicative self-efficacy, interactive attitudes, and self-reported behavioral manifestations. The overarching construct is organized into three distinct yet interrelated psychological and behavioral subdimensions:

Subscale 1: The Care Process in Dialogue (Het zorgproces in dialoog)

Comprising 14 behavioral items, this dimension measures the professional’s capacity to transform every phase of the nursing process—intake, assessment, diagnosis, goal setting, intervention planning, execution, and evaluation—into an explicit, egalitarian conversation. Behaviors captured under this construct include actively eliciting the patient’s personal narratives, clarifying implicit preferences, formulating joint health goals rather than unilaterally prescribing medical targets, and routinely pausing clinical routines to re-evaluate whether care delivery continues to align with the client’s evolving daily life. For instance, a nurse scoring high on this dimension does not simply evaluate wound healing in technical isolation, but proactively explores how wound management affects the client’s sleep routines, social activities, and personal dignity.

Subscale 2: Supporting Client Participation (Ondersteuning van cliëntparticipatie)

This 7-item dimension captures behaviors aimed at actively facilitating, scaffolding, and protecting patient self-determination and self-management. The psychological mechanism measured here involves the provider’s willingness to relinquish traditional clinical authority in favor of patient empowerment. The items evaluate how frequently the clinician invites the patient to take the lead in daily decision-making, offers clear and accessible information tailored to health literacy levels, encourages the client to leverage their own social networks and coping strategies, and supports independent task performance. High scores reflect an empowering clinical stance that counteracts learned helplessness and fosters patient agency.

Subscale 3: Handling Dilemmas and Conflicting Demands (Het hanteren van spanningsvelden)

Encompassing 8 behavioral items, this subscale taps into the provider’s tolerance for ambiguity, moral resilience, and conflict-negotiation skills. Community healthcare regularly confronts providers with acute tensions between professional clinical guidelines (e.g., fall prevention protocols, dietary restrictions) and client personal autonomy (e.g., refusing mobility aids or rejecting specific medication schedules). Furthermore, tensions frequently emerge between organizational time constraints, family expectations, and client wishes. This dimension measures the clinician’s ability to openly articulate these tensions, tolerate cognitive dissonance, conduct nuanced value negotiations, and achieve mutually acceptable clinical compromises without resorting to paternalistic coercion or professional abandonment.

6. Theoretical Framework

The theoretical architecture of the Care in Dialogue Competence Scale draws upon several converging paradigms within psychology, sociology, and healthcare ethics:

The Theory of Communicative Action

Philosophically grounded in Jürgen Habermas’s Theory of Communicative Action, the scale operationalizes the distinction between “strategic action” (oriented toward unilateral control, compliance, and instrumental clinical success) and “communicative action” (oriented toward reaching mutual intersubjective understanding). In demand-oriented care, clinical encounters are conceptualized not as functional interventions performed upon a passive recipient, but as collaborative dialogues wherein both parties coordinate their actions based on shared definitions of health, well-being, and daily living.

Social Cognitive Theory and Perceived Self-Efficacy

Psychologically, the instrument relies on Albert Bandura’s Social Cognitive Theory, specifically the construct of perceived self-efficacy. Professional behavioral performance is mediated by a clinician’s subjective belief in their capability to execute courses of action required to manage relational challenges. Self-reporting one’s frequency of engaging in complex relational behaviors reflects behavioral mastery, outcome expectations, and self-regulatory evaluation within dynamic care environments.

Self-Determination Theory

The dimension of supporting client participation is directly aligned with Self-Determination Theory, formulated by Edward L. Deci and Richard M. Ryan. The scale operationalizes how health professionals support the client’s basic psychological needs for autonomy (feeling self-governing), competence (feeling capable of managing chronic illness demands), and relatedness (experiencing reciprocal interpersonal connection). When clinicians embody dialogue competencies, they create an interpersonal climate that fosters autonomous self-regulation rather than controlled compliance.

7. Validity

The Care in Dialogue Competence Scale underwent rigorous psychometric validation during its developmental phases in Dutch home healthcare environments:

Content and Face Validity

Content validity was established through a multi-stage inductive-deductive developmental process. Researchers conducted exploratory qualitative studies involving in-depth interviews and focus group discussions with chronically ill individuals, informal caregivers, community nurses, and healthcare managers. The qualitative data produced a comprehensive matrix of demand-oriented nursing competencies. A Delphi consensus procedure involving independent clinical experts and health researchers was subsequently employed to review the generated item pool, confirming that the 29 selected items fully operationalized the theoretical construct and possessed high face validity for community nursing practice.

Construct and Convergent Validity

Construct validity has been supported through structural analyses and known-groups comparisons. When examined alongside measures of patient-centered attitudes, the scale’s subscales show moderate-to-strong positive correlations, confirming convergent validity. Furthermore, known-groups validation revealed statistically significant differences across professional education levels: registered nurses with higher vocational training (e.g., HBO-V bachelor-level education in the Netherlands) demonstrated significantly higher mean scores on Subscale 1 (Care Process in Dialogue) and Subscale 3 (Handling Dilemmas) compared to certified nursing assistants with secondary vocational backgrounds (MBO-niveau), reflecting the more extensive theoretical training in ethics, shared decision-making, and communication embedded within advanced curricula.

Discriminant Validity

Discriminant validity was evidenced by weak, non-significant correlations with unrelated constructs, such as administrative competence and generalized routine technical nursing procedures. This confirms that the instrument isolates relational and dialogical competence rather than measuring general clinical proficiency or procedural compliance.

8. Reliability

Empirical investigations demonstrate that the Care in Dialogue Competence Scale possesses high internal consistency across diverse samples of community healthcare professionals:

• Subscale 1: The Care Process in Dialogue (14 items): Displays exemplary internal consistency, with Cronbach’s alpha coefficients consistently observed between .84 and .88 across developmental and replication cohorts. Corrected item-total correlations across the 14 items remain consistently above .40, demonstrating high item homogeneity.
• Subscale 2: Supporting Client Participation (7 items): Demonstrates good internal consistency, yielding Cronbach’s alpha values typically ranging from .78 to .83, confirming that the 7 items reliably gauge participatory support mechanisms.
• Subscale 3: Handling Dilemmas and Conflicting Demands (8 items): Yields acceptable to good reliability coefficients, with Cronbach’s alpha estimates ranging between .75 and .81. Given the inherent conceptual heterogeneity of navigating diverse moral and structural dilemmas, this level of internal consistency indicates robust psychometric stability.
• Overall Scale (29 items): The full 29-item scale achieves an overall internal consistency coefficient exceeding .90.

Test-retest stability was evaluated over a two- to four-week interval among stable cohorts of community nurses, yielding intraclass correlation coefficients (ICC) ranging between .74 and .82 across the subscales, indicating acceptable temporal stability in the absence of targeted educational interventions.

9. Factor Analysis

The structural dimensionality of the Care in Dialogue Competence Scale was validated using both exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) during scale construction:

Exploratory Factor Analysis (EFA)

Principal Axis Factoring with oblique (Oblimin) rotation was initially conducted on the 29-item pool to account for expected conceptual correlations among interpersonal competence dimensions. Examination of the scree plot alongside eigenvalues greater than 1.0 supported a clear three-factor solution, which accounted for approximately 48% to 54% of the total variance across field samples. All 29 items demonstrated substantial primary factor loadings (generally exceeding .45), with minimal cross-loadings onto non-target factors:

• Factor 1 (The Care Process in Dialogue): 14 items loaded strongly onto this first factor, capturing shared goal formulation, collaborative assessment, and reflective evaluation.
• Factor 2 (Supporting Client Participation): 7 items formed the second discrete factor, characterized by actions encouraging client autonomy, choice, and self-directed health management.
• Factor 3 (Handling Dilemmas): 8 items clustered onto the third factor, characterized by ethical deliberation, boundary management, and structural conflict resolution.

Confirmatory Factor Analysis (CFA)

Subsequent confirmatory factor analyses verified that the three-factor oblique model exhibited superior goodness-of-fit compared to alternative unidimensional or orthogonal models. Fit indices routinely conformed to standard psychometric benchmarks: Comparative Fit Index (CFI) > .92, Tucker-Lewis Index (TLI) > .90, Root Mean Square Error of Approximation (RMSEA) < .06 (with 90% confidence intervals spanning .048 to .068), and Standardized Root Mean Square Residual (SRMR) < .055, confirming the construct validity of the three-dimensional model.

10. Instrument / Measurement Tool

• Tool Name: Care in Dialogue Competence Scale (Zorg in dialoog Competentie Schaal)
• Authors: Tanja Schoot, Ieke Proot, and Luc de Witte (2005)
• Instrument Type: Self-administered questionnaire / self-assessment scale
• Target Population: Adult healthcare providers, specifically registered nurses, district nurses, and certified nursing assistants working in home-based community healthcare for chronically ill individuals
• Number of Items: 29 behavioral items total
  • Competence 1: The Care Process in Dialogue (14 items)
  • Competence 2: Supporting Client Participation (7 items)
  • Competence 3: Handling Dilemmas and Conflicting Demands (8 items)
• Authentic Response Scale: 4-point Likert scale
  • 1 = eigenlijk niet (not really / rarely applicable)
  • 2 = in beperkte mate (to a limited extent)
  • 3 = regelmatig (regularly)
  • 4 = heel vaak (very often)
• Administration Time: Approximately 10 to 15 minutes
• Scoring Procedures: Subscale scores are calculated by computing the mean or sum of items within each subdimension. Higher scores reflect higher perceived competence and more frequent behavioral implementation of demand-oriented, dialogical care practices.

11. Permissions & Fee and Test Year

The Care in Dialogue Competence Scale was finalized and published in 2005 following extensive developmental research funded and conducted under the auspices of Maastricht University (Faculty of Health, Medicine and Life Sciences, CAPHRI) in collaboration with Dutch national healthcare research frameworks. The instrument is generally classified as an academic measurement tool available for scientific research, non-commercial healthcare quality improvement, and nursing education purposes, subject to formal attribution of the original authors. Healthcare organizations, academic researchers, and educators wishing to utilize, translate, or adapt the instrument in formal evaluation programs are advised to consult the primary publications or contact the principal developers at Maastricht University regarding licensing policies and institutional permissions.

12. References

• Bandura, A. (1997). Self-efficacy: The exercise of control. W. H. Freeman.
• Deci, E. L., & Ryan, R. M. (2000). The “what” and “why” of goal pursuits: Human needs and the self-determination of behavior. Psychological Inquiry, 11(4), 227–268. https://doi.org/10.1207/S15327965PLI1104_01
• Habermas, J. (1984). The theory of communicative action: Reason and the rationalization of society (Vol. 1). Beacon Press.
• Schoot, T., Proot, I., & de Witte, L. (2005). Zorg in dialoog: Naar een vraaggerichte beroepsuitoefening in de thuiszorg [Care in dialogue: Towards demand-oriented professional practice in home care]. Maastricht University.
• Schoot, T., Proot, I., ter Meulen, R., & de Witte, L. (2005). Recognition of client values as a basis for demand-oriented care: Perspectives of people with chronic illness in Dutch home care. Health & Social Care in the Community, 13(4), 304–312. https://doi.org/10.1111/j.1365-2524.2005.00561.x
• Schoot, T., Proot, I., & de Witte, L. (2006). Development and evaluation of an intervention to enhance client autonomy in home care. International Journal of Nursing Studies, 43(5), 585–595. https://doi.org/10.1016/j.ijnurstu.2005.07.012

13. Items of the Scale