Nosilia teyxos 53_eng

1ISSUE 53
SCIENTIFIC JOURNAL, 3 ISSUES PER YEAR JANUARY - APRIL 2019
ISSUE
53
Published by the Greek
Nursing Studies Association
(GNSA)
INDEXED IN
SCOPUS, ΕΒSCO, CINAHL, INANE
ISSN 22413960
• HUMAN RIGHTS, OLDER PEOPLE AND AGEISM
• Cross-cultural adaptation and validation of the
Employment Precariousness Scale (EPRES) in
employees in Greece
• Comparison of Patients, Significant Others,
and Nursing Staff Views about Empowering
Education in Greece
• Assessment Neonatal Pain - Assessment Tools
• Evaluation of Anesthesia Depth through
Bispectral index monitor
PUBLICATIONS
οcelotos

3ISSUE 53
Scientific Journal, 3 Issues per Year
Published by the Greek Nursing Studies Association (GNSA)
Nursing
Care AND Research
EDITOR-IN-CHIEF
Chryssoula Lemonidou, RN, MSc, PhD, Professor of Nurs-
ing, University of Athens
CO-EDITOR
Panagiota Sourtzi, RN, MSc, PhD, Professor, Faculty of Nursing,
University of Athens
Thalia Bellali, Representative to the International Academy of
Nursing Editors
MANAGING EDITOR
Olga Siskou, RN, M.Sc. Ph.D.
EDITORIAL BOARD
Lambros Anthopoulos, Emeritus Professor, Faculty of Nursing,
Eleni Apostolopoulou, RN, PhD, Emeritus Professor of Nursing,
George Baltopoulos, PhD, Emeritus Professor, Faculty of Nurs-
Konstantinos Birbas, PhD, Associate Professor, Faculty of Nurs-
Gerasimos Bonatsos, PhD, Professor, Faculty of Nursing, Univer-
sity of Athens
Charalambos Economou, Associate Professor, Department of
Sociology, Panteion University
Ioannis Elefsiniotis, PhD, Associate Professor, Faculty of Nurs-
Petros Galanis, RN, MPH, PhD, Center for Health Services Man-
agement and Evaluation, Department of Nursing, National &
Kapodistrian University of Athens
Margarita Giannakopoulou, MSc, PhD, Associate Professor,
Faculty of Nursing, University of Athens
Michael Igoumenidis, RN, M.Sc. Ph.D.
Dafni Kaitelidou, MSc, PhD, Associate Professor, Faculty of Nurs-
Ioannis Kaklamanos, PhD, Associate Professor, Faculty of Nurs-
Maria Kalafati, RN, MSc, PhD, Faculty of Nursing, University of
Athens
Athina Kalokerinou, RN, PhD, Professor of Nursing, Faculty of
Nursing, University of Athens
Stylianos Katsaragakis, Assist. Professor, Faculty of Nursing,
University of of Athens
Theodoros Katsoulas, Assist. Professor, Faculty of Nursing, Uni-
versity of Athens
Evangelos Konstantinou, RN, MSc, PhD, Professor, Faculty of
Nursing, University of Athens
Vassiliki Matziou, RN, PhD, Professor, Faculty of Nursing, Uni-
versity of Athens
Pavlos Myrianthefs, PhD, Professor, Faculty of Nursing, Univer-
sity of Athens
Elisabeth Patiraki, RN, PhD, Professor, Faculty of Nursing, Uni-
versity of Athens
Sotiris Plakas, RN, MSc, PhD, General Hospital of Attika «Sism-
anoglion»
Antonios Stamatakis, Associate Professor, Faculty of Nursing,
EleniTheodossopoulou, Professor, Faculty of Nursing, Univer-
sity of Athens
StylianiTziaferi, Assistant Professor Faculty of Nursing, Univer-
sity of Peloponnese
Venetia-SofiaVelonaki, Assist. Professor, Faculty of Nursing,
INTERNATIONAL EDITORIAL BOARD
John Albarran, Principal Lecturer in Critical Care Nursing, Uni-
versity of the West of England, Bristol, UK
Maria Katopodi, PhD, Assistant Professor, University of Michi-
gan, USA
Katerina Labrinou, PhD, Assistant Professor in Nursing, Cyprus
University of Technology
Anastasia Mallidou, RN, MSc, PhD, Assistant Professor,
University of Victoria, Canada
Anastasios Merkouris, RN, MSc, PhD, Associate Professor of
Nursing, Faculty of Nursing, Cyprus University of Technology
Evridiki Papastavrou, PhD, Assistant Professor in Nursing,
Cyprus University of Technology
Elisabeth D.E. Papathanassoglou, RN, MSc, PhD, Associate
Professor, Faculty of Nursing, Cyprus University of
Technology
Julie Scholes, Professor of Nursing, University of Brighton,
Brighton, UK
Riita Suhonen, RN, PhD, Profes sor, University of Turku,
Department of Nursing Science, Turku, Finland

5ISSUE 53
Contents
NursingCare AND Research
Published by the Greek Nursing Studies Association (GNSA)
Publisher and Editor-in-Chief: Chryssoula Lemonidou
Address: 123, Papadiamantopoulou st., 115 27 - Athens, GREECE
Tel.: +30 210-7461485
e-mail: info@nursingstudies.gr
Technical publisher: Ocelotos publishing
Annual Subscriptions 2012 for Εlectronic Version
Public Services, Libraries, Companies, Organisations: € 30,00
Individual Subscriptions: € 20,00
© Copyright 2007 - 2014: All rights reserved. The reproduction of articles (or parts of them) is
prohibited without permission of the publisher and the writers.
Instructions to Authors��12
HUMAN RIGHTS, OLDER PEOPLE AND AGEISM�� 18
Elizabeth Mestheneos
ORIGINAL PAPER
Cross-cultural adaptation and validation of the
Employment Precariousness Scale (EPRES) in
employees in Greece�� 23
Tsopoki Vassiliki Maria, Sourtzi Panagiota, Galanis Petros,
Vives Alejandra, Benach Joan, Tziaferi Styliani,
Velonakis Emmanouil
ORIGINAL PAPER
Comparison of Patients, Significant Others,
Education in Greece�� 39
Copanitsanou Panagiota, Sourtzi Panayota, Valkeapaa Kirsi,
Lemonidou Chryssoula
A SYSTEMATIC REVIEW
Assessment Neonatal Pain - Assessment Tools�� 51
Christina Dionysakopoulou, Margarita Giannakopoulou,
Vasiliki Matziou
REVIEW
Evaluation of Anesthesia Depth through Bispectral
index monitor��65
Bastaki Maria, Kapritsou Maria, Katsoulas Theodoros,
Giannakopoulou Margarita
2019 • ISSUE 53

6
GENERAL INFORMATION
1. “Nursing Care and Research” publishes, fol-
lowing peer review, articles in Greek or English,
contributing to the understanding and devel-
opment of all aspects of nursing care. The Ed-
itorial Department receives manuscripts relat-
ing to nursing practice, research, education
and management, with scientific, theoretical
or philosophical basis.
2. Papers published in the journal belong to
one of the following categories: a) research
studies, b) literature reviews and c) articles re-
lating to developments in nursing practice,
education and management. Additionally, let-
ters (no longer than 500 words), including re-
views or comments on previously published
work, are published if submitted within two (2)
months from the publication of the research
concerned.
3. Manuscripts must be submitted exclusive-
ly to the “Nursing Care and Research” journal,
they must not have been published in print or
electronic form, or undergo peer review at an-
other journal or medium at the time of sub-
mission. The Editorial Director decides time of
publication and reserves the right to change
manuscript format; however, large or substan-
tial changes are made only following author
consent.
Authors should avoid submitting two manu-
scripts from the same study without clear jus-
tification. Also, they should not include in new
work material from background literature re-
views that have already been published (eg
avoidance of self-plagiarism). In the event that
two papers emerge from the same research
study, presenting different aspects of the
work at hand, they must be submitted inde-
pendently and not as two parts of the same ar-
ticle. Each article should be autonomous and
must not include the other, although cross -
references can be made. When a complete de-
scription of the research methodology is made
in the first article a brief description is suffi-
cient in the the second provided the first is
adequately referenced. Generally, one should
avoid publishing numerous individual papers
emanating from the same study (“salami slic-
ing”) and instead should focus on the different
aspects and research findings within a single
publication.
If the manuscript is accepted for publication,
the authors must complete and send via fax
at 00302107461485 the Non-Publication in An-
other Medium Form, which forms part of the
supporting files as required in the submission
process.
Instructions for Authors
MISSION AND AIM OF THE JOURNAL
“Nursing Care and Research” is a peer-reviewed journal accepting manuscripts from researchers
from Greece and abroad. Its mission is to contribute to the development of nursing science and
practice in Greece as well as internationally. The aim is to promote and disseminate new knowledge
and research data for eventual application in clinical practice. To this end, nurses and other affiliated
researchers are invited to submit high-calibre manuscripts in Greek or English. The journal welcomes
original research papers, reviews, theoretical or philosophical articles, interesting clinical cases and
methodological articles from experts. Nursing Care and Research is recognized at national level (FEK
issue B 1961/23-9-2008) and is indexed at the CINHAL, EBSCO and SCOPUS International Databases.

7ISSUE 53
4. Author participation in the drafting pro-
cess
All authors cited in a manuscript must have ac-
tively contributed to the conception and de-
sign of the study and/or the analysis and in-
terpretation of data and/or in drafting the
manuscript and all should have analysed and
approved the content of the final version sub-
mitted for publication. Participation only in
the funding-seeking process or data collection
does not justify listing among the authors, and
can be acknowledged in the Acknowledge-
ment section. For this reason, when several au-
thors are cited, a separate letter is required ex-
plaining in detail the contribution of each (eg
methodological design, statistical analysis and
interpretation, drafting of final text, reviewing
and editing, literature review etc). The editori-
al department reserves the right to contact au-
thors to obtain clarifications on specific issues.
5. Submission process
Manuscriptsforpublicationaresubmittedelec-
tronically via e-mail: info@nursingstudies.gr
in Word for Windows format. Figures, tables,
graphics and images (only black white) are
to be submitted in separate files in JPEG, GIF,
TIFF, Microsoft PowerPoint and Excel formats.
Authors are advised to confirm that their work
has been received by contacting the Secre-
tariat on weekdays between 10.00-16.00, tel:
00302106512282. In addition, authors should
always maintain a copy of their work.
6. Periodicity
The journal is published three (3) times per
year (quarterly) and includes research pa-
pers submitted exclusively by its subscribers.
The author or at least one of the authors of
any manuscripts submitted must already be a
registered subscriber of the journal or a paid
member of the Nursing Studies Society for the
current year.
7. Retention of material
Authors are advised that submitted manu-
scripts are kept in record for one month af-
ter publication. If there is a request for the re-
turn of any material it should be clearly stated
when manuscripts are being submitted.
Organisation and format
8. Script: Texts should be double-spaced,
with font size 12 and 2.5 cm white margin on
all sides of each A4 page. All pages must be
numbered in the lower right corner and the
figures, tables, graphics and photos are to be
submitted in separate pages, in continuous
numbering.
9. Identification Page: The first page of each
manuscript includes the title (up to 15 words)
and the names of the authors in Greek and En-
glish. Each author name is accompanied by
qualifications, the last professional title, em-
ployer, mailing and e-mail address and tele-
phone number. In case of several authors, the
name of the author to whom inquiries regard-
ing the paper should be directed must be indi-
cated (corresponding author).
The authors of research studies cannot exceed
six (6), apart from exceptional circumstanc-
es when it comes to multi-disciplinary, large-
scale multicenter studies. The authors of oth-
er types of manuscripts cannot exceed two (2).
All authors listed in the manuscript must have
made an active contribution to the conception
and design of the study and/or the analysis
and interpretation of data and/or in the draft-
ing of the manuscript and everyone should
have studied and approved the final version
submitted for publication. Participation only
in the funding-seeking process or data collec-
tion does not justify listing among the authors,
and can be acknowledged in the Acknowledg-
ment section.
The identification page will be stored at the
journal’s Secretariat office until the comple-
tion of each anonymous peer review, receiv-
ing a code number communicated to the au-
thor via e-mail. With this number the author
can request information on the progress of
their manuscript following submission.
10. Title Page: Immediately after the identi-
fication page, follows the title page, which in-
cludes the title and the running title of the pa-
per. The running title will appear in Greek and

8
English language and cannot exceed five (5)
words. This page does not list names of au-
thors or any other item that violates their ano-
nymity during the peer-review process.
11. AbstractsandKeywords:The title page is
followed by the abstracts (up to 250 words) in
Greek and English, which will accurately sum-
marize the content of the work. The abstract
includes a) introduction, b) aim(s), c) method-
ology, d) results and e) conclusion, and must
not contain bibliographical references and ab-
breviations. Each abstract is followed by up to
six (6) keywords that indicate the content, pur-
pose and focus of the manuscript.
12. Main body of work: The area of the main
body of the manuscript should be 2,000-5,000
words (excluding abstracts, tables and bibliog-
raphy). Short manuscripts (up to 2,500 words
in the main body and up to fifteen (15) refer-
ences) are particularly welcome. This option is
recommended for the dissemination of small-
scale research studies of outstanding val-
ue, without the possibility of extrapolations
or repetition. In addition, smaller-scale man-
uscripts are more likely to reach publication
stage faster.
The manuscript should include headings to
further clarify text sections. Proposed head-
ings include: a) introduction, b) literature re-
view, c) aims, d) research questions and
assumptions, e) sample f) data collection pro-
cess, g) reliability and validity, h) ethical issues,
i) data analysis, j) results, k) discussion, l) lim-
itations of the study,m) conclusions and rel-
evance to nursing practice, n) acknowledg-
ments etc. Headings must be selected and
adapted to content needs and their hierarchi-
cal order should be clearly distinguishable; for
example first level headings should appear in
upper case and bold fonts, second level head-
ings in lower case and bold fonts, third level
headings in italics and so on and so forth.
Study population anonymity and informed
consent
In order to ensure anonymity, the manuscript
should not include the names of specific in-
dividuals, hospitals or other entities, without
their explicit consent. Furthermore, patients
retain a fundamental right in regards to re-
specting their privacy which should not be in-
fringed without their informed consent. How-
ever, in those cases where the authors consider
that certain personal patient data are essen-
tial for scientific purposes (such as patient ini-
tials or photographs or names of hospitals) in-
formed consent is necessary. This means that
authors are required to show the final version
of their work (with the accompanying files: Im-
ages and Annexes) prior to submission to the
journal and receive written consent from the
patients.
In each case, the authors should make an ef-
fort to ensure the greatest possible degree of
patient anonymity. For example, covering the
eye area in photos does not fully ensure the
anonymity of the depicted. Changes in some
patient characteristics is the technique rec-
ommended to authors, provided that these
changes do not distort/misinterpret the re-
search results. Such changes should always be
communicated to the publisher along with as-
surances that these changes will not result in
any “alteration” of a scientific nature. Obtain-
ing of the written informed consent should be
stated in the methodology section, in the final
text of the submitted manuscript.
ADHERING TO THE HUMAN RIGHTS CODE OF
CONDUCT
Should authors publish results of studies con-
ducted on humans, the methodology section
should indicate whether they were conducted
according to the principles of the Declaration
of Human Rights, (Helsinki 1975) as revised in
2004. Should certain processes deviate from
these principles, these must be methodolog-
ically outlined and justified.
Specifically, concerning clinical studies (in-
vasive or not), authors should indicate, in the
methodology section whether they were con-
ducted upon approval of the National Agency

9ISSUE 53
for Medicines (EOF) in accordance with Minis-
terial Decision DYG 3/89292 Gazette V1973/31-
12-2003 (aligned with Directive 2001/20/EC).
It should also be indicated that data is histori-
cal and should be referred to in the past tense.
The time of data collection should be reported
in both the abstract and the main text. For ex-
ample, in the case of empirical studies, this can
be stated thus: “Data collection was carriedout
during 2007” or “Data collection was performed
over 18 months, in the 2006-2007 period.” Note
that the “Nursing Care and Research” journal
does not publish studies citing data older than
five (5) years, unless current relevance is suffi-
ciently justified. In qualitative studies, individu-
als should refer to numbers or aliases (in quotes)
and mentions should be balanced equally across
the full range of responses.
In the case of reviews, the year of the review
should be reported and the range of publica-
tion years of the studies reviewed should be
reported. Such details should be mentioned
in historical studies. The statistical tests used,
ought to be defined and, where necessary,
documented with references.
Abbreviations and symbols should be used
rarely and only in the case of names or expres-
sions of extensive length. The full names or ex-
pressions will be referred to during first use,
followed by the abbreviation in parentheses.
In any case, abbreviations will follow the rules
set out by the Royal Society of Medicine Press.
13. Conficts of interest
Public confidence in the peer-review process
depends partly on the management of any
conflicting interests arising in the writing, eval-
uation and final publication decision as artic-
ulated by the editorial department. Conflicts
of interest arise when an author (or the institu-
tion to which the author belongs to), a review-
er or the Managing Editor maintain financial or
personal relationships that can in a negative
way affect their actions/judgment regarding
the manuscript submitted to the journal. More
specifically, according to the requirements for
manuscripts submitted to biomedical journals
(as issued in February 2006 by the Internation-
al Committee of Medical Journals Publishers)
conflicting interests arise when financial rela-
tionships exist (eg employer – employee, own-
ership of property, financial honorary prizes,
and paid expert opinions) and these are the
most easily identifiable cases and those that
most often undermine the credibility of the
journal, the publishers, the authors and the sci-
entific endeavours in general. However, con-
flicting interests may arise for other reasons as
well such as poor interpersonal relationships,
academic competition etc.
Authors must indicate at the end of the text
and prior to the references section if they con-
sider that the peer review of their work may be
affected or not by the existence of any conflict
of interest as described above.
14. Sources of funding
Authors should indicate details (entity name,
contact information, amount awarded) of all
funding sources from which their research
benefitted. Examples of such sources in-
clude: medical or non-medical interest com-
pany funds, scholarships, national or Europe-
an Community grants, support from scientific
bodies (eg scientific societies, non -profit insti-
tutions etc.). It should also be indicated if the
work was carried out as part of a national or
transnational program, financed by nation-
al or international sources. In this case, full de-
tails of the program (awarding body, duration,
amount of funding, etc.) must be disclosed.
This information should be listed in a separate
section following the conflicts of interest sec-
tion.
15. Acknowledgements
The funding sources section is followed by
the optional Acknowledgements section, stat-
ing the names and affiliations of all those who
contributed (eg through the provision of pri-
mary data, or by reviewing the text or provid-
ing their opinion) to the drafting of the man-
uscript (apart from the authors). This section

10
should acknowledge any sponsors donating
materials and tools required for the research.
16. Bibliographic References: Bibliograph-
ic references in the text should indicate the
names of the authors followed by the date in
chronological order, eg. (Lewis 1975, Barnett
1992, Chalmers 1994). When there are more
than two authors, the name of the first author
followed by et al., eg. (Barder et al. 1994), is ref-
erenced in the text but all authors should be
listed in the bibliography. When quotes are
used in the text, the page should be referred
to eg. (Chalmers 1994, p.7). All references must
be from primary sources.
The literature list follows the Harvard system,
written in alphabetical order based on the sur-
name of the first author. The list should in-
clude authors’ surnames and initials, the date
of publication, article title, full name of journal,
volume number (and issue number if the vol-
ume pages are not consecutive) and the first
and last page of the article. When the refer-
ence applies to a book, the author, the date,
the title, followed by the publisher and the city
must be stated. When the reference applies to
a chapter in a book, details on the author(s) of
the book, the date, place of publication and
publisher must be provided. These references
that are said to be “in press”, shall be accepted
only if accompanied by a letter of acceptance
from the journal in question.
Examples:
Williams N. (2001). Patient resuscitation follow-
ing major thermal trauma. Nursing in Critical
Care: 6: 115-121
Muller D, Harns P, Watley L. (1986). Nursing
Children: Psychology Research and Practice.
London: Harper Row.
Lewis T, Hell J. (1992). Rhabdomyolysis and
Myoglobinuria. In: Hall J, Schmidt G, Wood L.
(eds), Principles of Critical Care, Volume 2. New
York: McGraw Hill.
Websites are refencees as follows:
National Institute for Clinical Excellence (2000)
Final appraisal determination: Drugs for early
thrombolysis in the treatment of acute myo-
cardial infarction, NICE, www.nice.org.uk/ar-
ticle.asp?a =36672. Last access on 7 October
2006.
17. Figures , Tables , Graphics , Photos :
Tables must be referred to herein as Tables,
numbered in the order they are presented, eg
as Table 1, Table 2, etc. and incorporated in the
correct place in the body of the text. All imag-
es, including photos, must be referred to here-
in as Figures and numbered in the order they
are presented, eg Figure 1, Figure 2 etc. They
must also be captioned and may be accom-
panied by a legend not exceeding thirty (30)
words. Figures of all forms will cover a single
column (width 86mm) or two columns when
needed (width 177mm). The journal reserves
the right to adjust the size of figures for tech-
nical reasons.
When material (including figures, tables, etc.)
that has already been published elsewhere ap-
pears in the manuscript, the written permis-
sion of the original authors (or those who own
the copyright of said material) must be ob-
tained. The authors of published papers are
fully liable for any copyright infringement.
Peer-review process
18. All submitted work is reviewed (anony-
mously) by two (2) independent referees/re-
viewers and, if they contain complex statistical
methodologies by a statistician as well. Re-
viewers decide whether an article is a) accept-
ed, b) requires modifications or c) rejected. In
case of disagreement among the reviewers,
the Managing Editor will reach a final decision,
taking into account all reviewer comments.
If the reviewers suggest modifications, the
manuscript is returned by the journal secretar-
iat to the corresponding author for redrafting
and resubmission within six weeks from the
date the comments were made (the review
process spans usually 6-8 weeks and in some
cases can reach up to 10 weeks). During resub-
mission, authors are required to indicate the
modifications they have carried out in accor-
dance to reviewer instructions in a letter to the
Managing Editor. The modified manuscript is
forwarded to the reviewers if deemed neces-

11ISSUE 53
sary, and they confirm whether or not modi-
fications comply with their recommendations.
At that point the Managing Editor reaches the
final decision to publish the article.
19. Electronic Reprint: Following publica-
tion, the corresponding author will receive an
electronic reprint of the article in PDF format.
Electronic reprints will be distributed by him/
her to the other authors. The journal does not
issue printed reprints of published work.
COPYRIGHT
20. In order to publish any article in the “Nurs-
ing Care and Research” journal, the authors are
asked to grant this exclusive right to the Soci-
ety for Nursing Studies. Along with the draft
for modifications the authors receive an Au-
thorization for Exclusive Publication form
which must be filled, signed and returned by
mail (or by email as a pdf file) to the journal,
along with the modified manuscript.
When a paper is derived from an extensive re-
search study and the same or other authors
have prepared additional papers, which have
been published or submitted for publication
in this or other journals, the corresponding
author must notify the Managing Editor so as
to ensure that third party copyright is not in-
fringed. Any impact emanating from copyright
infringement lies exclusively with the authors
of published articles and the journal will pro-
ceed with all necessary actions.
FINAL NOTE
Subscribers preparing manuscripts for publi-
cation in the “Nursing Care and Research” jour-
nal are requested to adhere to these Instruc-
tions for Authors carefully in order to avoid
delays in the publication of their work and the
publication of new volumes of the journal.

12
HUMAN RIGHTS, OLDER PEOPLE AND
AGEISM
Elizabeth Mestheneos., Ph.D., Founder member of 50plus Hellas, Past President Age Platform Europe.
Member of Hellenic Gerontological and Geriatric Association, and FFN Network
The Universal Declaration of Human Rights as
proclaimed by the United Nations General As-
sembly on December the 10th 1948 was a fasci-
nating development in human history, the result
in great part of the Second World War which had
seen millions of people murdered and impris-
oned on the basis of their religion, beliefs, gen-
der, ethnic origins, sexual orientation, and age.
These horrific acts led to the establishment of the
United Nations in 1945 followed by the Univer-
sal Convention which can be considered a mor-
al beacon and ethical code for the world, and a
way in which all signatory states can be held to
account if they infringe the political and citizen-
ship rights of individuals and groups. However
difficult it is to enforce such rights, and every day
we are aware of infringements in the world, they
represent an effort and commitment by Mem-
ber States to work nationally and international-
ly for human rights. Over the years groups that
faced continuing difficulty in enforcing or ob-
taining their human rights and met widespread
discrimination, e.g. women, children and the dis-
abled, after long negotiations and debates, were
supported by additional Universal Charters (UN
1967, UN 1989, UN 2006).
The UN has been made aware of discrimination
against older people over the years and in 2010
started on the long road to considering whether
it would be vital, useful or legally enforceable for
MemberStatestodevelopaCharterorotherlegal
instrument to support the rights of older people.
They established the United Nations’ Open-End-
ed Working Group on Ageing and meet regular-

13ISSUE 53
ly with Member States, national and internation-
al human rights organizations and NGOs of and
for older. Worldwide there is evidence that older
people confront age discrimination in many as-
pects of their lives (Eurostat 2012), are treated as
lesser citizens, while there are many who do not
have the capacity or knowledge to exercise their
existing human rights (Council of Europe 2014).
At the EU level human rights have been extend-
ed to cover fundamental rights (European Fun-
damental Rights Agency) which also include eco-
nomic, social and cultural rights backed by the
European Court of Justice. Thus the EU is con-
cerned with a wider range of rights than the
UN backed by a method of legal enforcement,
though perhaps too few people are aware of
these institutionalized rights. Critically important
is the fact that the EU backs and supports NGOs
concerned with obtaining their rights, from
women’s groups, to gay and lesbian rights et al.
In this framework it enabled older people voic-
es to be heard through its institutional support
of Age Platform Europe - an umbrella organiza-
tion funded in great part by the European Com-
mission - a network of over 130 non-profit organ-
izations of and for people aged 50+. It speaks for
and promotes the interests of the 200 million cit-
izens aged 50+ at European Union and UN lev-
els (Age Platform 2019). Some of its members
organizations are also members of the Global Al-
liance on the Rights of Older People who push
for the human rights of older people even when
their own Member States and governments do
nοt see this as a priority (Karl 2018). Yet what we
know is that age discrimination is often seen as
“natural”, that older people are perceived as hav-
ing lesser rights and as being irrelevant, a cost to
society (Age Platform 2018). How does this oc-
cur? Judgments made inappropriately on the ba-
sis of age, and discriminating age based legisla-
tion have negative effects on well being, health,
employment, and education, access to goods
and services, and civil and political rights. Age-
ism can make people vulnerable, feel socially ex-
cluded and indeed can even reduce their life ex-
pectancy e.g. through depression, isolation and
social exclusion (Robertson 2017).
Age Platform ran a media campaign “Ageing
Equal” from 1st October to 10th December 2018
to mark the 70th UN anniversary and bring to
public notice the widespread ageism that under-
lies age discrimination. Many older people expe-
rience ageism in language, laws, health policies,
in legal decisions and in statistics, e.g. EU data has
generally been collected up to the age of 74 (AGE
Platform 2010, 2018). Ageism does not directly af-
fect everyone and some groups have more neg-
ative experiences e.g. those with chronic health
problems and disabilities, minorities e.g. Roma
life expectancy in some EU countries is ten years
less than the general population, the poorly edu-
cated and older women.
It is not the first time that AGE Platform and its
members have worked against ageism. In 2010
with a number of partner older people’s organ-
izations they developed a European strategy for
combating elder abuse, recognizing abuse as a
common human rights violation. The 2007 Eu-
robarometer special report on health and long-
term care in the European Union had shown
that 55% of the European citizens interviewed
thought that many dependent older people are
victims of abuse from people (informal and for-
mal carers) who are supposed to look after them.
The DAPHNE Eustace a project (2008-10) devel-
oped a Charter on the Rights of older people
setting out nine rights: on dignity, physical and
mental well-being, freedom and security; self-
determination; privacy; care; information and ad-
vice; participation in social activities; freedom of
expression; dignity in dying and; redress. Article
10 concerns the responsibilities of older people
needing care (e.g. to respect the rights and needs
of other people, to take responsibility for the im-
pact of actions, etc.) To enhance the effective-
ness of the Charter, the project team developed a
guide with detailed suggestions and recommen-
dations, addressed to different target groups, to
explain what each right means and how they can
be translated into practice (Age Platform 2010).

14
Writing information materials and charters does
not necessarily translate into improving prac-
tice so a further action was the development,
through two successive EU funded projects, of a
European partnership for the wellbeing and dig-
nity of older people WeDo (2010-12) and WeDo2
(2013-14) concerned with preventing elder abuse
and ensuring the dignity and wellbeing of older
persons in need of care. With the work of all the
NGOs and organizations involved a Toolkit for
policymakers and practitioners and education-
al materials were created. In Greece, WeDo suc-
cessfully brought together many organizations –
public, private, NGOs, who worry about the issue
of abuse and how to improve the lives of older
people who are dependent and really unable to
defend their own human rights.
This work continues since changing mindsets, at-
titudes and behavior is not achieved overnight
in governmental bodies, or amongst employers,
workers or older people themselves. Throughout
the EU member NGOs support Age Platform in
its work to insist that the EU institutions include
age discrimination in their work programmes
e.g. European Parliament, European Commis-
sion, the Fundamental Rights Agency. As a high-
ly varied and ever growing sector of the popu-
lation, we need to be involved as citizens of our
localities, our country and the EU. The communi-
ty of nurses meets such ethical and practical is-
sues every day. How to ensure that older people
are fully included in decisions about their own
care and well being; receive the care and support
they need; are not abused by family members or
by those caring for them professionally. The re-
sources mentioned above may help stimulate
and provide ideas in everyday practice whether
the reader is a researcher, a teacher and trainer,
or a practitioner.
A shift in attitudes about ageing and human
rights is needed throughout society.
REFERENCES
50plus Hellas https://www.50plus.gr/en/. (Accessed
4th Feb. 2019)
Age Platform Europe https://www.age-platform.eu/
about-age (Accessed 4th Feb. 2019)
Age Platform Europe. Dignity and wellbeing of old-
er persons in need of care https://www.age-plat-
form.eu/publications/dignity-and-wellbeing-old-
er-persons-need-care-0 2018
http://publications.age-platform.eu/opcare-toolkit/
(Accessed 4th Feb. 2019)
Age Platform Europe. WeDo 2 https://www.age-plat-
form.eu/project/wedo2 (acccessed 17th Jan. 2019)
Age Platform Europe. EU Charter of rights and respon-
sibilities of older people in need of long-term care
and assistance - DAPHNE Eustacea 2010
https://www.age-platform.eu/publications/eu-char-
ter-rights-and-responsibilities-older-people-need-
long-term-care-and-assistance (Accessed 4th Feb.
2019)
Council of Europe. (2014) Adopted Recommenda-
tion CM/Rec(2014)2 of the Committee of Minis-
ters to Member States on the promotion of human
rights of older persons.
Eurobarometer. Discrimination in the EU in 2012. Spe-
cial Eurobarometer No.393. TNS Opinion Social.
For E.C. http://ec.europa.eu/commfrontoffice/
publicopinion/archives/ebs/ebs_393_en.pdf (Ac-
cessed 17th Jan.2019)
Eurobarometer. Health and long-term care in the E.U.
Special Barometer No. 283. TNS Opinion So-
cial. For E.C. http://ec.europa.eu/commfrontoffice/
publicopinion/archives/ebs/ebs_283_en.pdf (Ac-
cessed 4th Feb. 2019)
European Fundamental Rights Agency https://fra.eu-
ropa.eu/en (Accessed 4th Feb.2019)
Fundamental Rights Forum; https://fundamental-
rightsforum.eu/en/frf/blog/ageism-last-accepta-
ble-form-discrimination. 2018. (Accessed 17th Jan.
2019)
Karl F. (ed.) (2018). Ageing in the Crisis: Experienc-
es from Greece. Reihe: Soziale Gerontologie
Bd. 4, ISBN 978-3-643-90984-8
Robertson G. (2017) Ageing and ageism: the impact
of stereotypical attitudes on personal health and
well-being outcomes and possible personal com-
pensation strategies. Journal Self Society An In-
ternational Journal for Humanistic Psychology Vol-
ume 45
U.N. (1979) Convention on the Elimination of Discrim-
ination against Women. http://www.un.org/wom-
enwatch/daw/cedaw/ (Accessed 18th Jan.2019)
U.N. (1989) Convention on the Rights of the
Child https://treaties.un.org/pages/View-
D e t a i l s . a s p x ? s r c = I N D m t d s g _ n o = I V -
11chapter=4lang=en (Accessed 18th Jan 2019)
U.N. (2006) Charter of the Rights of those with Disa-
bilities http://www.un.org/disabilities/documents/
convention/convoptprot-e.pdf (Accessed 18th Jan
2019)

15ISSUE 53
U.N. (2010) United Nations’ Open-Ended Working
Group on Ageing. Resolution 65/182 , https://so-
cial.un.org/ageing-working-group (Accessed 18th
Jan 2019)
UN Universal Declaration of Human Rights (1948)
http://www.un.org/en/universal-declaration-hu-
man-rights (Accessed 18th Jan. 2019)

16
ABSTRACT
BACKGROUND: Employment precariousness is a social
determinant of health which is characterized by reduced
rights and protection at work. In this framework, job inse-
curity during the Greek financial crisis is a risk that needs to
be assessed.The Employment Precariousness Scale (EPRES)
is a questionnaire developed in Spain to measure employ-
ment precariousness and its dimensions. Scores range from
0 to 4, with high values indicating high levels of employ-
ment precariousness.
OBJECTIVE: To translate, adapt and validate EPRES in em-
ployees in Greece, for the evaluation of employment pre-
cariousness that affects the workforce during the Greek
financial crisis.
MATERIALS METHODS: A standardized forward back-
ward translation was performed. Reliability was tested in a
sample of 604 employees during a 2-years study. Internal
consistency was assessed with Cronbach’s alpha and cor-
relations between the EPRES subscales “temporariness”,
“disempowerment”,“vulnerability”,“wages”,“rights”and“ex-
ercise rights” and the global EPRES score were calculated
to assess construct validity. Exploratory factor analysis and
ceiling and floor effects were also evaluated.
RESULTS: A high response rate to EPRES was observed in
most items, indicating good accept ability of the tool, with
the exception of the subscale“wages”. Cronbach’s alpha co-
efficients for all subscales and the global score of the Greek
version ranged from 0.70 to 0.95, indicating good internal
consistency reliability. Six factors were extracted by factor
analysis and explained 69.125% of the cumulative variance,
supporting the six-subscale structure of the tool. The glob-
al EPRES score was higher among temporary (2.01) than
permanent (1.43) employees.
CONCLUSIONS: Greek version of EPRES is a reliable and
valid instrument and studies are needed to investigate
possible adverse effects of employment precariousness on
health.
KEY WORDS: Employment precariousness, job insecurity,
psychometric properties, Greece, EPRES.
ORIGINAL PAPER
Cross-cultural adaptation and validation
of the Employment Precariousness Scale
(EPRES) in employees in Greece
Tsopoki Vassiliki Maria RN, BSc, MPH, MSc(c), PhD(c) PhD Candidate in National Kapodistrian
University of Athens, Faculty of Nursing, Department of Public Health, Laboratory of Prevention, e-mail:
valiatsopoki@gmail.com.
Sourtzi Panagiota, RN, BSc, MMedSc, PhD., Professor in National Kapodistrian University of Athens,
Faculty of Nursing, Department of Public Health, Laboratory of Prevention. e-mail: psourtzi@nurs.uoa.gr.
Galanis Petros, RN, M.Sc, PhD., Scientific Laboratory and Teaching Staff in National Kapodistrian
University of Athens, Faculty of Nursing, Department of Public Health, Center for Health Services
Management and Evaluation, e-mail: pegalan@nurs.uoa.gr.
Vives Alejandra, MD, MPH, PhD., Assistant Professor in Pontificia Universidad Católica de Chile,
Departamento de Salud Pública., e-mail: alvives@med.puc.cl.
Benach Joan, MD, MPH, PhD., Professor Co- Director in University Pompeu Fabra, Department of
Political and Social Sciences, Barcelona, Spain and Appointed Professor in Johns Hopkins University.
e-mail: joan.benach@upf.edu.
Tziaferi Styliani, RN, BSc, MPH, PhD. Assistant Professor in University of Peloponnese, Faculty of Nursing,
Sparta, Greece. e-mail: stziafer@uop.gr.
Velonakis Emmanouil, MD, PhD. Professor in National Kapodistrian University of Athens, Faculty of
Nursing, Department of Public Health, Laboratory of Prevention. e-mail: evelonak@nurs.uoa.gr.
CorrespondingAuthor:
TsopokiVasiliki-Maria, RN, BSc, MPH, MSc(c), PhD(c)

17ISSUE 53
INTRODUCTION
Working under a contract with low levels of so-
cial security, solidity and working rights, is wide-
ly characterized as precarious for the workforce
(Benach et al. 2014). While flexible, contingent,
untypical, temporary employment contracts are
thought to be an insecure type of employment,
their adverse effect on income and economic
status of employees is not always apparent (In-
oue et al. 2011). A definition given by the Inter-
national Labor Organization (2011) is that “pre-
carious employment generally refers to a lack or
inadequacy of rights and protection at work”. In
this framework, having a job that is considered
as precarious, due to a temporary contract, or re-
duced access to rights and benefits or wages that
are insufficient for basic or unexpected needs, is
an occupational risk at the workplace that needs
to be managed (Benach et al. 2015).
Prevalence of employment precariousness in
Europe is considered as high, since two out of
three employees are affected (Matilla-Santand-
er et al. 2018). As a major social determinant of
health (Marmot et al. 2008),precarious employ-
ment is associated with all-cause mortality, alco-
hol-related mortality and smoking-related can-
cer mortality (Kivimaki et al. 2003), poor health
status (Benach et al. 2004), high risk for occupa-
tional injury(Benavides et al. 2006)and poor men-
tal health (Vives et al. 2013).Relevant studies in
Greece have become essential, due to the finan-
cial crisis, which has started in 2008and is prom-
inent up to now, affecting employment condi-
tions among others (Foundoulakis et al. 2012,
Simou Koutsogeorgou 2014, Parmar et al. 2016).
Over the years, several instruments have been
developed to quantify job insecurity either exclu-
sively or as a subscale, among which are the Job
Diagnostic Survey (Hackman Oldman 1975),
the Job Characteristics Index (Sims et al. 1976),
the Job Insecurity Scale (Ashford et al. 1989), the
Job Content Questionnaire (Karasek et al. 1998),
the Pressure Management Indicator (Williams
Cooper 1998), the Job lnsecurity Questionnaire
(De Witte 2000),the General Nordic Question-
naire (Lindstrom 2002), the HSE Indicator Tool
(Cousins et al. 2004) and the Copenhagen Psy-
chosocial Questionnaire (Kristensen et al. 2005).
All mentioned instruments are considered to ba-
sically reflect Western working conditions, such
as overall working time, wages and work in-
tensity, which - without major adaption orient-
ed modifications- are likely to be quite differ-
ent from employment conditions met in Greece,
where current labor market reforms focus on job
flexibility and at the same time unemployment
rate, particularly affecting the young, is the high-
est among all OECD countries (OECD 2017).
Employment Precariousness Scale (Vives et al.
2010) (EPRES) is a questionnaire developed by
researchers from the Health Inequalities Re-
search Group- Employment Conditions Network
(GREDS-EMCONET). The development of the
tool included an initial qualitative study, a con-
tent analysis and a pilot study, which resulted to
a 26items questionnaire, aiming to quantitatively
assess job insecurity and its dimensions among
employees. The fact that EPRES can assess the
degree to which employees can cover their fi-
nancial needs with their salaries and the extent
to which they can actually exercise some work-
ings rights they theoretically have was strong
ground to attempt to measure job insecurity
during the Greek financial crisis via EPRES. In ad-
dition, the tool can provide information regard-
ing how employees are treated by their employ-
ers (in an authoritarian or event violent manner),
and if their contract elements (salary, working
hours and schedule) are defined by employer or
by collective labor agreements, which are factors
that have changed during the Greek financial cri-
sis (Hellenic Republic 2012 a b). A final reason
why EPRES was chosen for the measurement of
employment precariousness was cultural back-
grounds and general employment conditions
similarity between Spain and Greece (Navarro
2012).
EPRES evaluates employment precariousness
as the combination of six dimensions; “tempo-
rariness”, measured by two items, “disempow-
erment”, measured by three items, “vulnerabili-
ty”, measured by six items, “wages”, measured by
three items, “rights”, measured by seven items,
and “exercise rights”, measured by five items. To
respond to items, 5-point frequency scales are
used for the “vulnerability” and “exercise rights”
subscales, 5-point ordinal scales are used for
the “wages” and “temporariness” subscales and
3-point categorical scales are used for the “dis-
empowerment” and “exercise rights” subscales.
Scores of each subscale can be calculated as the

18
average of the corresponding items responses,
whereas the “global score” is also calculated as
the simple average of the six subscales scores.
Subscale scores and overall “global score” range
from 0, indicative of no precariousness, to 4, in-
dicative of high precariousness.
The objective of the study was to translate, adapt
and validate EPRES in employees in Greece, in or-
der to study the prevalence of job insecurity in
the workforce during the financial crisis.
METHOD
Translation Adaptation
Atranslationteamandanexpertcommitteewere
formed for the purpose of translating into Greek
and adapting EPRES for use in Greece. Cultural
adaptation, along with results of the original test-
ing of the Greek version are documented in this
paper. The series of actions for the translation are
presented in a chronological order, emphasizing
the importance of the fact that translation; eval-
uation (both qualitative and quantitative) and re-
vision were done iteratively.
Developing the Greek version involved seven
phases (Beaton et al. 2000), in order to maximize
equivalence between the Spanish ant the Greek
questionnaire, finally leading to the deployment
of the Greek EPRES version 1.2 (Figure1).
Phase 1: Contact with EPRES developers
Initially, contact was made with EPRES devel-
opers, who originally constructed and validat-
Figure 1: Graphic representation of the stages of the translation process
T1= 1st translator for forward translation, T2= 2nd translator for forward translation,
T3= 3rd translator for backward translation, T4= 4th translator for backward translation.

19ISSUE 53
ed the Spanish version of the questionnaire. Our
proposal was to agree on a collaboration proto-
col for the study of precarious employment in
Greece, using EPRES.
Phase 2: Initial translations (Spanish to Greek)
Two separate forward translations from Spanish
into Greek were produced by translators (T1, and
T2). Both translators were bilingual, with Greek
as their first language and one having a medical
background. Working independently, translators
T1, and T2 produced two initial Greek versions of
EPRES, for which they were asked to keep word-
ing simple and compatible with the initial notion
and concept of the questionnaire items. Transla-
tors provided their comments in a written report,
focusing on providing justification for support-
ing specific translation alternatives, especially in
challenging phrases.
Phase 3: Synthesis
Asynthesisoftheoriginalquestionnaireandboth
initial Greek translations from T1, and T2 was per-
formed, resulting in Version 1.0. The method in-
volved comparing and noting translation uncon-
formities which reflected potentially ambiguous
wordings. Drafting options that were recognized
as unsuitable were communicated between
translators, who finally reached a consensus.
Phase 4: Backward translations
Following synthesis, two translators (T3, and T4),
both blind to the original version of EPRES, trans-
lated Version 1.0 back into Spanish independent-
ly. One translator had Spanish as his first lan-
guage though none had medical background.
Backward translations had the purpose to ensure
that Version 1.0 actually stands for Spanish ver-
sion’s item content.
Phase 5: Expert committee review
Backward translations were compared with each
other and with the original questionnaire by an
expert committee, comprised by seven mem-
bers. This expert committee included three
health professionals, one Spanish language pro-
fessional, all four translators involved in the pro-
cess (forward and back translators) and one
developer of the Spanish EPRES, who communi-
cated via e-mail. Committee members communi-
cated their views regarding any unconformities,
to identify linguistic or cultural origin of differ-
ences in translation and finally provided their
translation options. This phase ended up with
version 1.1, a pre-final version of the question-
naire’s Greek translation.
Phase 6: Test of the pre-final version
Version 1.1 of the questionnaire was tested on
121 employees of five different companies in
Greece. Each respondent self-completed EPRES
and was asked to sincerely express any difficul-
ties faced in completing questionnaire items or
in understanding the purpose or meaning of
each question. After this process, all expert com-
mittee members considered findings in a struc-
tured discussion, which resulted in EPRES final
Greek version.
Phase 7: Final version
Version 1.2, EPRES final Greek version, was estab-
lished.
Validation
Approved by Ethics Committee of Nursing De-
partment of National and Kapodistrian Univer-
sity of Athens, the validation study took place
throughout 2012-2014 and involved a conveni-
ence sample of employees living and working in
Greece. Participants were selected in accordance
with their social and demographic characteris-
tics, such as gender, age and educational status,
to facilitate and strengthen actual representa-
tiveness of the sample included in the study for
the working population in Greece. Question-
naires were distributed at the workplace and to-
tally, 604 out of 815 employees(response rate=
74.11%) completed the questionnaire.
The questionnaire contained EPRES (Greek ver-
sion 1.2) and demographic items, including a
question that refers to the degree to which an
employee believes that has been affected by the
economic crisis. These additional items are pos-
sibly indicative of the socio-economic status of
participants. The anonymous questionnaire was
self-administered by employees, to reassure
confidentiality and maximize sincere respons-

20
es as an outcome. For items of EPRES, responses
were coded, recoded were applicable and finally
transformed into the six subscales scores and the
global EPRES score, ranging from 0 (least precar-
ious employment) to 4 (most precarious employ-
ment). Specifically, according to original cut-off
scores, the lowest category (0 to 1) was defined
as non-precarious, the mid-range category (1 to
2) was considered low to moderate and the high-
range category (2 to 4) was considered highly
and very highly precarious.
Greek EPRES version 1.2 went through inter-con-
sistency reliability testing, for the purpose of
which a convenience sample of 604 employees
of 34 random companies in Greece was utilized.
Characteristics of study participants and compa-
nies they work for are presented in Tables1 and 2.
Table 1: Demographic and occupational characteristics of the study population
N %
Gender
Women 207 34.5
Men 393 65.5
Age (years)
18-30 56 9.7
31-66 523 90.3
Type of contract
Permanent 514 85.8
Temporary 85 14.2
Educational status
Primary education 7 1.2
Secondary education 16 2.7
Lyceum/ Technical school 210 34.9
University/ Technological educational institute 255 42.4
Master/ Doctorate 113 18.8
Marital status
Married 364 61.1
Single 193 32.4
Seperated 36 6
Widowed 3 0.5
Studies related to occupation
Yes 401 68.2
No 187 31.8

21ISSUE 53
N %
Financially affected by crisis
Yes, due to my job 273 58.3
Yes, due to other reasons 163 34.8
My company has, but not me 7 1.5
No 25 5.3
Yeas in the company
1 47 8
1-5 126 21.6
6-10 127 21.7
10 284 48.6
Type of job
White collar worker 437 76.8
Blue collar worker 132 23.2
Employment sector
Private 407 67.5
Public 196 32.5
Weekly working hours
40 55 9.4
40 331 56.4
40 201 34.2
Table 2: Characteristics of the companies of the study population
N
Type of activity
Industry 11
Offices 6
Health Services 3
Technical Services 4
Technology- Informatics 4
Retail 6
Sector
Private 29
Public 5

22
RESULTS
Almost 65% of the sample completed all ques-
tionnaire items. Proportion of subjects with miss-
ing items was below 10% for most subscales,
showing good acceptability, except for “wages”
where 20.8% of permanent workers had missing
items in the scale. All observed score ranges coin-
cided with the theoretical range (0-4). While per-
centages of ceiling effects were low, interestingly
high floor effects were observed in several sub-
scales: “temporariness” (92%), “rights” (45%), “ex-
ercise rights” (18%) in permanent workers, and
“disempowerment” in both permanent and tem-
porary workers (53.3% and 25.3%). Floor and ceil-
ing effects for “global score” were trivial among
permanent and temporary employees (≤ 1.5%).
Internal consistency reliability was good, since
Cronbach’s α coefficients were equal to or above
0.70 for all subscales and the “global score”, sup-
porting the homogeneity of scale items. In terms
of construct validity, differences between tem-
porary and permanent workers were assessed.
“Temporariness”, “disempowerment”, “vulnera-
bility” and “rights” mean scores were significant-
ly (p0.001) higher in temporary than permanent
workers, whereas “wages” and “exercise rights”
means scores were higher in permanent than
temporary workers (Table 3).
Table 3: Distribution and reliability of EPRES in a population sample of permanent (n= 514) and temporary (n= 85)
workers in Greece, 2012- 2014
EPRES= the Employment Precariousness Scale; P= Permanent workers, T= Temporary workers;
*Proportion of participants with any item missing on the scale; †Proportion of participants with lowest
(floor) and highest (ceiling) EPRES scores
Mean SD
Missing
items*
(%)
Observed
range
Floor† Ceiling† Cronbach’s α
P T P T P T P T P T P T
Temporariness 0.13 3.02 0.47 0.75 4.3 0.4 0-3 0.5-4 92 1.2 0.4 11 0.81
Disempowerment 1.00 1.46 1.26 1.15 7.4 0.9 0-4 0-4 53.3 25.3 7.5 7.6 0.95
Vulnerability 1.34 1.68 0.78 0.89 2.3 0.8 0-4
0.17-
3.83
2.6 2.5 0.4 1.3 0.81
Wages 2.10 2.08 0.89 0.79 20.8 0.4 0-4 0.33- 4 1.3 2.4 2.1 2.4 0.76
Rights 0.58 1.41 0.72 0.89 7.4 0.9 0-4 0-4 45 3.8 0.4 2.5 0.70
Exercise rights 2.82 2.35 1.05 1.16 5.1 1.1 0-4 0-4 18 9 1.2 3.8 0.89
EPRES score 1.43 2.01 0.35 0.36 36.5 2.9
0.46-
2.63
1-2.69 0.3 1.5 0.3 1.5 0.80

23ISSUE 53
Loading weights produced by factor analysis are
shown in Table 4. All items presented the high-
est loading within their theoretical subscale and
all items loading were above 0.46. The model ex-
plained 69.125% of cumulative variance, whereas
the scree plot (Figure 2) also yielded six factors to
be retained.
Multitrait- multimethod matrix of comparisons
is presented in Table 5. Inter-scale correlations
were all positive and low (0.3) except for three,
which were moderate;“temporariness” and
“rights” (0.359), “disempowerment” and “rights”
(0.393), “vulnerability” and “wages” (0.320). Cor-
relations between the global score and the six
subscales were substantial (0.354- 0.650), sup-
porting the validity of the tool regarding expect-
ed directions.
Patterns for known groups are presented in Table
6. Mean EPRES “global score” was higher among
workers aged 30 years or less (1.75) than older
workers (1.5) (p0.001), among temporary (2.01)
than permanent (1.43) workers (p0.001), among
those working for their employers for less than
1 year (1.78) than all other subgroups (p0.001),
among blue (1.66) than white (1.49) collar work-
ers (p0.001), among workers of the private (1.56)
than the public (1.4) sector (p0.05) and among
employees working for less than 40 hours per
week (1.81) than all other subgroups (p0.001).
These differences are in line with higher expect-
ed scores in disadvantaged groups of employ-
ees in terms of job insecurity, showing good con-
struct-related validity.
Table 4: Exploratory factor analysis of the Greek version of Employment Precariousness Scale (EPRES) in
Greece, 2012- 2014
Factor 1
ER
Factor 2
VU
Factor 3
DE
Factor 4
TE
Factor 5
WA
Factor 6
RI
Temporariness (TE)
Duration of current contract 0.90
Months under temporary
contracts previous year
0.87
Disempowerment (DE)
How did you settle your
workplace schedule?
0.95
How did you settle your working
hours?
0.94
How did you settle your wages or
salary?
0.89
Vulnerability (VU)
Afraid to demand better working
conditions
0.64
Defenseless towards unfair
treatment
0.85
Afraid for being fired for not
doing…
0.74

24
69.125% of cumulative variance was explained by Greek version of EPRES.
Factor 1
ER
Factor 2
VU
Factor 3
DE
Factor 4
TE
Factor 5
WA
Factor 6
RI
Treated in a discriminatory and
unjust manner 0.82
Treated in an authoritarian and
violent manner
0.65
Made to feel easily replaceable 0.46
Wages (WA)
Cover basic needs? 0.87
Allow for unexpected expenses? 0.82
Monthly take home (net) wage or
salary
0.71
Rights (RI)
Paid holiday 0.46
Pension 0.46
Severance pay 0.77
Maternity/ paternity leave 0.49
Day off for family or personal
reasons
0.80
Weekly holidays 0.78
Unemployment benefit/
compensation
0.68
Exercise rights (ER)
Weekly holidays 0.59
Sick leave 0.87
Go to the doctor 0.86
Holiday 0.70
Day off for family or personal
reasons
0.84

25ISSUE 53
Figure 2: Scree Plot of the exploratory factor analysis of the Greek version of Employment
Precariousness Scale (EPRES) in Greece, 2012- 2014
Table 5: Spearman correlation coefficients: multitrait- multimethod matrix of the Greek version of
EPRES in workers in Greece, 2012-2014
Note. EPRES score was obtained as the mean of the six subscales.
*Cronbach’s alpha; †Correlation is significant at p= 0.01; ‡Correlation is significant at p= 0.05
TE=temporariness, DE= disempowerment, VU= vulnerability, WA= wages, RI= rights, ER=
exercise rights.
TE DE VU WA RI ER EPRES
Temporariness (TE) 0.81*
Disempowerment (DE) 0.139† 0.95*
Vulnerability (VU) 0.160† 0.007 0.81*
Wages (WA) 0.014 0.104‡ 0.320† 0.76*
Rights (RI) 0.359† 0.393† 0.025 0.015 0.70*
Exercise rights (ER) 0.118† 0.028 0.177† 0.018 0.094‡ 0.89*
EPRES 0.595† 0.509† 0.354† 0.423† 0.473† 0.650 0.80*

26
Table 6: Mean EPRES scores according to demographic and occupational factors
Demographic- occupational factor EPRES P value
Age
30 1.75
0.001
31 1.50
Type of contract
Temporary 2.01
0.001
Permanent 1.43
Years in the company
1 1.78
0.001
1 to 5 1.56
6to 10 1.51
10 1.45
Type of job
White collar 1.49
0.001
Blue collar 1.66
Company sector
Private 1.56
0.026
Public 1.40
Weekly working hours
40 1.81
0.00140 1.56
40 1.44
DISCUSSION
In order to have a reliable scale for measuring
employment precariousness among employ-
ees in Greece, Employment Precariousness Scale
(EPRES) (Vives et al. 2010) was translated, adapt-
ed and validated. Study results suggest that
Greek version of EPRES is a reliable and valid in-
strument, given the good internal consistency
reliability and the confirmation of the six-sub-
scale structure of the tool.
The fact that guidelines for translation were care-
fully designed and structured led to high com-
pliance and adequate translation, which also
reflects some social and cultural similarities be-
tween Spain and Greece. Moreover, all four trans-
lators were asked to provide their alternatives
and suggestions prior to group meetings, which
we believe provided expert committee with crit-
ical material for productive discussion and rea-
sonable consensus. Outcomes of these process-
es suggest that EPRES is an epidemiological tool
that can successfully be applied in Greece.
Following translation, we tested psychometric
properties of the Greek version of EPRES, using a
sample of 604 employees from 34 different com-
panies in Greece. Characteristics of the Greek
study population were comparable to the ones
of the Spanish study (Vives et al. 2010), since the
basic difference refers to age, allowing for com-
parison of scores between both samples. In the
Greek study, subjects were 65% men, 90.3%
aged above 31 years old, and 85.8% with a per-
manent type of contract in comparison to the
Spanish population, where subjects were 51.6%
men, 66.2% aged above 31 years old, and 73.9%
with a permanent type of contract. The charac-
teristics of the study population are highly com-
patible with the demographic characteristics and
the mean age of the Greek workforce during the
period of the financial crisis (OECD 2018)and al-
though demographic information in not ade-
quate for comparing samples within Greece and
Spain in terms of their cultural characteristics, we
believe that mean age difference between the

27ISSUE 53
two study populations does not affect the vali-
dation study outcome.
Scale homogeneity was assessed with Cron-
bach’s alpha coefficient and high values of Cron-
bach’s alpha indicate that the six subscales are in-
ternally consistent. Values of Cronbach’s α in the
Greek study were almost the same to those ob-
tained in Spain (Vives et al. 2010) for “temporari-
ness” (0.81 versus 0.82), “disempowerment” (0.95
in both studies), and “exercise rights” (0.89 versus
0.87)subscales. Cronbach’s α was greater in the
Greek than in the Spanish study in the “wages”
(0.76 versus 0.7) subscale, and smaller in the “vul-
nerability” (0.81 versus 0.90) and “rights” (0.70
versus 0.80)subscales. The high value of Cron-
bach’s α in “global score” (0.80 versus 0.86) in-
dicates a high level of reliability of EPRES in the
Greek population.
Expected score differences revealed with re-
spect to type of contract (permanent or tempo-
rary) were similar to those found in Spain (Vives
et al. 2010). Working as a temporary employee is
a factor giving adverse effects on “disempower-
ment”, “vulnerability”, “rights” and employment
precariousness as a general construct, through
the “global score”. Mean scales scores, “glob-
al score”, standard deviations and floor and ceil-
ing effects were appropriate for comparisons
between Greece and Spain. Significantly high-
er mean scores of “exercise rights” subscale (2.82
in permanent and 2.35 in temporary versus 0.8
in permanent and 1.3 in temporary in Spain) and
the “global score” (1.43 in permanent and 2.01
in temporary versus 0.9 in permanent and 0.7 in
temporary in Spain) among the Greek sample of
permanent works reflect the high job insecuri-
ty that even permanent workforce experienced
during the financial crisis, as found in recent stud-
ies, due to structural reforms(Barlow et al 2015,
Nella et al. 2015).
We believe that high percentages of missing
values in the Greek sample, especially when it
comes to wages (20.8 in permanent and 20.4 in
temporary versus 10.5 in permanent and 7.3 in
temporary) and- as a consequence- the “global
score (36.5” in permanent and 2.9 in temporary
versus 12.2 in permanent and 10.5 in temporary
in Spain), reflect the difficulty among workers in
Greece to share data referring to wages and em-
ployment conditions, possibly due to concerns of
job continuity in the context of the economic cri-
sis. Income data is often missing in relevant epi-
demiological studies (Kim et al. 2007, Chen et al.
2008).As mentioned, Cronbach’s α for the “wag-
es” subscale was satisfying (0.76), nevertheless
we believe that in order to approach the matter
without affecting study findings, an inclusion of
a missing wages category could be an option for
further analysis of the data.
“Global score” and subscale scores of EPRES
were spread widely across the theoretical 0-4
score range and ceiling and floor effects are com-
parable to the ones found in the Spanish survey,
as were the reliability and the exploratory factor
analysis of the Greek version. The high floor effect
of “temporariness” that was highlighted in the
Spanish survey too (Vives et al. 2010), along with
the high floor effect of “rights”, “exercise rights”
and “disempowerment” found in our study sug-
gests the inclusion of additional items that can
capture job insecurity among permanent work-
ers, who have employment conditions, under a
collective bargaining legislative framework.
We believe that differences in EPRES subscale
scores and “global score” between the Greek and
the Spanish studies capture the deeper financial
crisis observed in Greece in comparison to Spain
and other countries (Karanikolos et al. 2013). The
impact of the current financial crisis on employ-
ees in Greece that we report in this study, having
93.1% of the study sample feeling affected due
to occupational or other reasons, is a finding that
needs to be noticed by occupational health pro-
fessionals and policy makers.
“Global score” and “temporariness”, “rights”, “vul-
nerability”, and “disempowerment” subscale
scores were higher among temporary employ-
ees, a finding that is consistent with the results of
the Spanish survey (Vives et al. 2010). Neverthe-
less, higher scores among permanent employees
in the “exercise rights” (2.82 vs. 2.35) and “wag-
es” (2.1 vs. 2.08) subscales were observed in our
study. We believe that this finding is compatible
with specific changes in employment conditions
in Greece, as a result of the national legislation
amendments during the financial crisis, includ-
ing the new definition of the national minimum
wages, through the General National Collective
Agreement that took place in 2012 (Hellenic Re-
public 2012a). These modifications probably cre-

28
ated insecurity among permanent employees,
who come to face instability regarding their sala-
ries and negative consequences on the ability to
fully exercise their rights. Moreover, introduced
limitations in all collective agreements (Hellen-
ic Republic 2012b) was a reform that additionally
affected perception of job insecurity among per-
manent employees of the public sector.
An important finding of this study was the sta-
tistically significantly higher levels of employ-
ment precariousness among temporary workers
(p0.001), young employees under the age of 30
(p0.001), working for their employer less than
1 year (p0.001) and for less than 40 hours per
week (p0.001), blue collar workers (p0.001) and
occupied in the private sector (p=0.026). These
factors could be used by health professionals and
policy makers to determine high risk groups for
employment precariousness, since our findings
are comparable with results of other studies that
took place in Greece (Zarvas et al. 2013, Mechili et
al. 2015) during approximately the same period.
Future modifications in employment conditions,
and initiatives for the management of psychoso-
cial risks at the workplace based on these find-
ings could be more effective towards reducing
the impact of job insecurity.
Regarding the limitations of the study, question-
naires were self-administered and for that, em-
ployment precariousness may have been under-
estimated. In addition, the high percentage of
missing values in the “wages” subscale and con-
sequently in the global EPRES score may also be
related to the self-administration of the ques-
tionnaire and modifications in the responses op-
tions and scoring may be useful.
Concluding this article, our results suggest that
EPRES is suitable to perform studies within
Greece than include assessing the levels of em-
ployment precariousness. An interesting chal-
lenge for further surveys would be the admin-
istration of EPRES to a representative sample of
immigrant workers, as well as an adaptation for
application to self-employed workers in Greece.
Conflict of Interest
The authors declare no conflict of interest.
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30
ABSTRACT
INTRODUCTION: Empowering education is used by nurses
for patients and significant others to promote nursing care
outcomes and includes biophysiological, functional, experi-
ential, ethical, social, and financial issues.
AIM: To compare the empowering knowledge that patients
undergoing total arthroplasty receive with that of their sig-
nificant others and the education provided by the nursing
staff.
METHODS: A descriptive cross-sectional study was imple-
mented, with a convenience sample of 180 patients, 72 sig-
nificant others, and 77 nursing staff members from three
hospitals in Athens, Greece (2010-2011). The method of
triangulation was chosen to compare data from multiple
sources. The instruments for assessing empowering educa-
tion were the Received Knowledge of Hospital Patient/ Sig-
nificant Others Scale and the EPNURSE Questionnaire.
RESULTS: There was agreement among all parties that
education was not sufficient. For all dimensions, patients
reported being less educated than their significant others.
Nursing staff members assessed the provided education
less favorably compared to both patients and significant
others and seem to recognize their inadequacies. Conclu-
sion: Nursing care practices should be redesigned to include
both patients’and significant others’education. Educational
projects for improving nursing staff’s knowledge could be
useful, as well as addressing the problems of understaffing
and lack of educational materials.
KEY WORDS: “empowerment/ empowering education”,
“family education”, “nurses/ nursing staff”, “patient educa-
tion”,“significant others education”,“quantitative research”
Comparison of Patients, Significant Others,
Education in Greece
Copanitsanou Panagiota, RN, BSc, MSc, PhD, General Hospital of Piraeus “Tzaneio”, Email: giwta_c@hotmail.com
Sourtzi Panayota, Professor, Faculty of Nursing, National and Kapodistrian University of Athens, Email: psourtzi@
nurs.uoa.gr
Valkeapaa Kirsi, Adjunct professor, University of Turku, Department of Nursing Science, Turku, Finland, Email:
kimajo@utu.fi
Lemonidou Chryssoula, Professor, Faculty of Nursing, National and Kapodistrian University of Athens, Email:
clemonid@nurs.uoa.gr
CorrespondingAuthor:
Copanitsanou Panagiota, Email: giwta_c@hotmail.com
Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-
profit sectors.
Acknowledgments
The authors would like to thank all patients, significant others, and nursing staff members who
participated in the study, as well as Professors Helena Leino-Kilpi and Jouko Katajisto from the
University of Turku for their valuable support and advice.
Author contributions:
Study design: KV, in cooperation with the research group
Data collection: PC
Data analysis: PC, PS, CL
Study supervision: CL
Manuscript writing: PC, PS, KV, CL
Critical revisions for important intellectual content: PS, CL
All authors approve the final version of the manuscript.
ORIGINAL PAPER

31ISSUE 53
INTRODUCTION
The term “empowerment” is often referred to in
the scientific literature and it is used in nursing
care (Leino-Kilpi et al. 1998, 1999, Johansson et
al. 2007). There is not one single definition of em-
powerment; it can be viewed as the capacity of
individuals to take control of their circumstances,
to exercise power and achieve their goals, as well
as the process by which they are able to maximise
the quality of their lives (Adams 2008), while ac-
cording to an earlier definition it was viewed as a
process by which people gain mastery over their
lives (Rappaport 1984). Empowerment is a multi-
dimensional concept, as it includes the different
perspectives of patients, their significant others
(SO) and healthcare professionals. The theory of
empowering education is based on sociopsycho-
logical theories and constructivism (Gibson 1991,
Kuokkanen Leino-Kilpi 2000, Freire 2007).
Empowering education involves an individual-
ised and holistic approach; empowered patients
are the ones who have the knowledge and the
abilities of how to best manage their condition
and improve their quality of life (Loft et al. 2003).
Empowerment is not about increasing compli-
ance with therapy, but increasing patients’ au-
tonomy (Johansson et al. 2007, Anderson
Funnell 2010). The purpose of empowerment
through education is to increase patients’ and SO
knowledge in all three domains of learning, e.g.,
theoretical knowledge (cognitive domain), self-
confidence (affective domain), and skills (psych-
omotor domain) to enable them to make deci-
sions about their health and situation (Debono
Cachia 2007, Johansson et al. 2007, Ryhanen et al.
2010).
An important prerequisite in the empowerment
via education is that patients and their SO are at
the centre of the process, so they are able to ask
questions (Poskiparta et al. 2001, Kettunen et al.
2002), to choose the knowledge that interests
them the most (Leino-Kilpi et al. 1998, Debono
Cachia 2007, Johansson et al. 2007), and to set
personal goals (Arnold et al. 1995). The basic as-
sumptions of empowerment theory regarding
education are: a) the learner is able to know and
act for her/his health, b) the person’s knowledge,
actions, and self-management can be improved
through education, c) education represents a
very important nursing intervention in everyday
clinical practice, and d) the main outcome of ed-
ucation is the person’s empowerment.
With empowering education, learners can be
supported to control and manage their condi-
tion in six dimensions: biophysiological (e.g.,
signs/ symptoms, illness, diagnostic tests, differ-
ent treatment options), functional (e.g., involve-
ment in care and mobilisation), experiential (e.g.,
emotions and experiences), ethical (e.g., patients’
rights, confidentiality of information), social (e.g.,
communication with family/ friends), and finan-
cial (e.g., costs of treatment and medications,
sickness benefits, insurance issues) (Leino-Kilpi
et al. 1998, Johansson et al. 2007, Heikkinen et al.
2008).
This study is part of a larger study, conducted in
seven European countries (Greece, Cyprus, Fin-
land, Iceland, Lithuania, Spain, Sweden), that
aimed to explore the empowering knowledge
patients undergoing total arthroplasty and their
SO receive (Valkeapää et al. 2014, Κοπανιτσάνου
και συν. 2015, Copanitsanou et al. 2018). The pur-
pose of the present study was to compare the pa-
tients’ empowering knowledge with that of their
significant others and the education provided by
the nursing staff in Greece. The main research
question was “Is there a difference between the
knowledge patients and their SO receive and the
education provided by nursing staff?”.
METHODS
Design, Sample, and Settings
This is a descriptive observational study, with da-
ta collection for exploratory analysis from pa-
tients undergoing total knee or hip arthroplasty,
their SO, and members of nursing staff who were
working in the orthopaedic departments where
the patients were hospitalised. The sample was
of convenience, drawn from three general hos-
pitals in Athens, Greece. Data collection started
in 2010 and was completed in 2011.The inclusion
criteria for the patients and SO included the flu-
ent communication in the Greek language; the
ability to fill in the questionnaires (patients could
complete the questionnaires themselves or with
the help of their SO); age older than 18 years, ab-
sence of obvious cognitive disorders. In addi-

32
tion, patients should have undergone total hip or
knee arthroplasty to treat arthritis, should have
given their voluntary informed consent for their
participation, as well as their consent for one of
their SO to participate. The inclusion criteria for
the nursing staff (nurses and nursing assistants)
included working at an orthopaedic ward and
the voluntary participation in the study.
Data Collection
Data collection from patients and their SO took
place postoperatively, at discharge from the hos-
pital. The collection of data from nursing staff
took place after the data were collected from pa-
tients and SO, so as not to affect the education
normally provided.
A pilot study was completed by gathering ques-
tionnaires from 30 patients, 30 SO, and 30 mem-
bers of nursing staff. All participants were able to
complete the questionnaires easily and did not
report problems in their understanding of ques-
tions, therefore no modifications of the instru-
ments were required for them to be used in the
main phase of the study.
Instruments
In order to adapt the instruments to the Greek
language, the international practice was applied
(Jones 1987, Huey-Shys et al. 2003), i.e., the in-
struments were translated from English to Greek
and then from Greek to English (back- transla-
tion). The two versions were compared and dis-
cussed by a panel of experts. Finally, the original
authors’ permissions were asked for the instru-
ments to be used in the study.
The instruments for assessing the empowering
knowledge received by patients and their SO
were the Received Knowledge of Hospital Pa-
tient Scale (RKhp) and the Received Knowledge
of the Patient’s Significant Other Scale (RKhpso)
(Leino-Kilpietal.1998,Leino-Kilpietal.2005).The
RKhp and RKhpso Scales are parallel instruments
consisting of 40 items related to empowering ed-
ucation (8 items about the biophysiological di-
mension, 8 items about the functional dimen-
sion, 3 items about the experiential dimension, 9
items about the ethical dimension, 6 items about
the social dimension, 6 items about the financial
dimension). The answers are given in a 4-level
Likert scale, from “1” (= totally agree) to “4” (= to-
tally disagree), while “0” corresponds to the op-
tion “Not applicable in my case”. This means that
the lower the mean, the more the patients and
their SO report that they have been educated
about the issues included in the instruments.
The EPNURSE Questionnaire (Johansson et al.
2002) was used to evaluate the empowering
education provided by nursing staff. The ques-
tionnaire includes, among others, a set of ques-
tions in relation to the dimensions of empower-
ing knowledge, with the same 40 items for which
patients and their SO were questioned. The dif-
ference in the EPNURSE Questionnaire is that the
answers are given in a 4- level Likert scale, from
“1” (= for all patients) to “4” (= no patients).
The background characteristics of the patients
and their SO included age, gender, level of basic
and vocational education, and occupational sta-
tus. The background characteristics of the nurs-
ing staff included only the age and the highest
level of vocational education.
Reliability
The internal consistency estimate of reliability
of the instruments was evaluated with the Cron-
bach’s alpha coefficient. Cronbach’s alpha was
0.993 for the RKhp Scale and 0.996 for the RKhp-
so Scale, indicating an excellent reliability. The re-
liability of the EPNURSE Questionnaire was good,
equal to 0.867.
Ethical considerations
The principles of the Helsinki Declaration on Hu-
man Research (World Medical Association 2008)
were followed throughout the study. Permis-
sions for data collection were obtained from
the Institutional Review Boards of the partici-
pating hospitals. All participants were proper-
ly informed, both in writing and verbally, about
the purpose of the study and the way the data
would be collected, analysed, and kept confiden-
tial, and gave their voluntary consent. The con-
fidentiality of personal data was ensured and
maintained throughout the study, and only the
research team had access to them.

33ISSUE 53
Data analysis
Data analysis was performed by using descrip-
tive statistics. Categorical variables are expressed
as numbers (percentages) and continuous var-
iables as means (standard deviations). Paramet-
ric tests (due to normal distribution of data) were
used to determine whether the differences be-
tween patients’ and SO received knowledge and
nursing staff’s provided knowledge were signif-
icant (Pearson correlation coefficient). Only the
questionnaires in which at least 50% of the ques-
tions were filled in were included in the statistical
analyses. The statistical package SPSS 21.0 was
used for the analyses and p-values 0.05 were
considered significant.
RESULTS
Sample’s Background Characteristics
A total of 180 patients (response rate= 86.1%,
mean age 72.3 years, standard deviation- SD 7.85,
range 46-91 years), 72 SO (response rate= 67.9%,
mean age 51.3 years, SD 14.5 years, range 20-90
years) and 77 members of nursing staff (response
rate= 100.0%, mean age 39 years, SD 7.51, range
25-55 years) participated in the study. The major-
ity of patients and SO were females; most of the
patients had elementary education, while most
SO had high school education. The majority of
the nursing staff was nurses with four-year tech-
nological education (Table 1).
Results on Empowering Education
Patients, SO, and nursing staff agreed that edu-
cation was not fully provided in any of the em-
powering knowledge dimensions and that the
functional dimension was the one in which more
education was provided (mean= 1.65 for pa-
tients, 1.57 for SO, 2.17 for nursing staff). Patients
reported that they were less educated in the ex-
periential dimension (mean= 2.38), while SO re-
ported that the least education was provided in
the experiential (mean= 1.81) and in the financial
Table 1. Sample’s background characteristics.
Characteristic
Patients
N= 180 (%)
Significant
others
N= 72 (%)
Nursing staff
N= 77 (%)
Mean age 72.3 years 51.3 years 39 years
Gender
Female
Male
Missing
131 (72.8)
49 (27.2)
0 (0.0)
58 (80.6)
13 (18.1)
1 (1.3)
Basic
education
Primary school
Comprehensive school
Matriculation examination
139 (77.2)
12 (6.7)
29 (16.1)
19 (26.4)
10 (13.9)
43 (59.7)
Vocational
education
None
Secondary vocational education
College level vocational education
Academic degree
Missing
146 (81.2)
17 (9.4)
8 (4.4)
5 (2.8)
4 (2.2)
33 (45.8)
13 (18.1)
10 (13.9)
11 (15.3)
5 (6.9)
0 (0.0)
34 (44.2)
42 (54.5)
1 (1.3)
0 (0.0)
Employment
status
Employed
Retired
Working at home
Unemployed/job applicant
Other
Missing
7 (3.9)
108 (60.0)
53 (29.5)
3 (1.6)
1 (0.5)
8 (4.5)
39 (54.2)
10 (13.9)
18 (25.0)
2 (2.8)
1 (1.4)
2 (2.7)
77 (100)

34
Table 2. Mean scores for empowering knowledge dimensions for patients, significant others, and
nursing staff (highest and lowest means in bold).
dimension (mean= 1.81). The nursing staff mem-
bers reported they provided less education in
the financial dimension (mean= 3.21) (Table 2).
For all dimensions of empowering knowledge,
patients reported they were less educated than
their SO (statistically significant difference in the
experiential, ethical, social, and financial dimen-
sions) (Table 3). The smallest difference was in the
functional and in the biophysiological dimension
(without statistical significance) and the highest
in the financial dimension (p= 0.003).
For all dimensions, the nursing staff reported that
they provided less education than that reported
by the patients (statistically significant difference
for all dimensions except the ethical and the so-
cial) and SO (statistically significant difference
for all dimensions). The difference between the
views of SO and nursing staff was greater in com-
parison to the difference between patients’ and
nursing staff’s views in all dimensions.
The highest difference in views was observed in
the financial dimension, both between patients
and nursing staff (-0.86), as well as between SO
and nursing staff (-1.40). Similarly, the smallest dif-
ference was observed in the ethical dimension,
both between patients and nursing staff (-0.13),
and between SO and nursing staff (-0.58). The
lowest difference between patients and SO was
in the functional dimension (+0.08) and the high-
est in the experiential dimension (+0.57) (Table 3).
DISCUSSION
The purpose of this study was to explore wheth-
er there are differences among the views of pa-
tients who undergo total arthroplasty, their SO,
and nursing staff about the empowering educa-
tion provided during perioperative hospitalisa-
tion. Triangulation is a method of cross-checking
data from multiple sources to search for regular-
ities (O’Donoghue Punch 2003) and data tri-
angulation involves the parameters of space (in
this case, three different hospitals) and individu-
als (i.e., patients, SO, and nursing staff) (Denzin
2006).
What is known from the international literature
is that patients with chronic illnesses may feel
that education is less than they would wish, and
may have difficulties in asking for clarifications
(Debono Cachia 2007, Lewis Newell 2009).
These patients probably experience inadequate
support, while patients who believe they receive
Dimension of empowering knowledge
Patients
Mean
(standard
deviation)
Significant
others
Mean (standard
deviation)
Nursing staff
Mean
(standard
deviation)
Biophysiological 1.89 (1.07) 1.60 (1.04) 2.20 (0.93)
Functional 1.65 (0.82) 1.57 (1.03) 2.17 (0.89)
Experiential 2.38 (1.33) 1.81 (1.22) 2.70 (0.88)
Ethical 2.23 (1.24) 1.78 (1.20) 2.36 (0.99)
Social 2.15 (1.17) 1.72 (1.17) 2.35 (0.95)
Financial 2.35 (1.33) 1.81 (1.21) 3.21 (0.97)
Total 2.05 (1.06) 1.71 (1.14) 2.50 (0.94)

35ISSUE 53
sufficient knowledge may feel confident to par-
ticipate actively in the treatment (Lewis New-
ell 2009). In another study, patients with cardiac
conditions rated the education they received as
inadequate (Bajorek et al. 2007).
In a review study it was found that surgical pa-
tients are not often given the information they
need (Suhonen Leino-Kilpi 2006). It has also
been reported that patients believe that they are
not adequately supported perioperatively and
would like more encouragement to ask ques-
tions and more possibilities to decide about the
care (Leinonen et al. 2001). In a Greek study, most
patients from medical and surgical wards stated
that most of the information they received from
the nursing staff was trustworthy and that they
were given willingly, but this was done on the in-
itiative of the patients themselves (Kolovos et al.
2013).
On the other hand, as SO participation in care is
connected with the quality of care (Leino-Kilpi et
al. 2016), they should be prepared and educated
on how to take care of the patients. However, de-
spite their important role in patients’ recovery,
SO may think they do not have sufficient knowl-
edge, although they consider it necessary (Ast-
edt-Kurki et al. 1997, Lewis Newell 2009). Often,
they cannot help patients effectively because
they do not understand how they can contrib-
ute to treatment (Lewis Newell 2009). Howev-
er, the literature regarding the education of both
patients with orthopaedic conditions and, in par-
ticular those undergoing total joint arthroplasty,
as well as their SO, is limited.
According to the findings of this study, there are
both similarities as well as differences among the
views of patients, SO, and nursing staff. All par-
ticipating groups agreed that education was not
adequately provided in any dimension of em-
powering knowledge and that the functional di-
mension was the one for which more education
was provided, although not sufficiently. The find-
Table 3. Differences for empowering knowledge dimensions among patients, significant others, and
nursing staff (highest and lowest differences in bold).
Dimension of empowering
knowledge
Patients- Significant
others
Mean difference,
p-value
Patients - Nursing
staff
Mean difference,
p-value
Significant others–
Nursing staff
Mean difference,
p-value
Biophysiological +0.29, p=0.067
-0.31,
p=0.045*
-0.60, p=0.0003*
Functional
+0.08,
p=0.512
-0.52,
p0.0001*
-0.60,
p=0.0002*
Experiential +0.57, p=0.005*
-0.32,
p=0.027*
-0.89,
p0.0001*
Ethical
+0.45,
p=0.012*
-0.13,
p=0.444
-0.58,
p=0.001*
Social +0.43, p=0.014*
-0.20,
p=0.227
-0.63,
p=0.0004*
Financial +0.54, p=0.003*
-0.86,
p0.0001*
-1.40,
p0.0001*
Total +0.34, p=0.036*
-0.45,
p=0.014*
-0.79, p0.0001*
*Statistically significant difference.

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