http://doi.org/10.33698/NRF0307-Bandana, Indarjit Walia, Sushma Kumari Saini
Abstract :The Audit is the major Tool used to evaluate quality of care. The Audit Tool is developed to audit the family health records. The Audit Tool is developed in six phases. In first phase, the preliminary draft of Audit Tool is prepared .In second phase, content validity was checked with the help of Delphi technique. In third phase, necessary modifications were done in the Tool. In fourth phase, feasibility of the Tool is assessed by doing a pilot study. In fifth phase, final draft of the Tool was prepared. In sixth phase, auditing of 500 family folders was done to check the content
validity and construct validity of the Tool by applying Cronbach’s alpha and principal component factor analysis method. Cronbach’s alpha was 0.73, which shows that Tool was reliable. The Kmo value was 0.575 and p-value was 0.000, which makes the data eligible for factor analysis. There were 22 items in the original Tool, but after factor analysis 21 items are retained. This study has made contribution to evaluate the family health record maintained by the nursing students of NINE, PGIMER, Chandigarh with minimum time. Besides this, it will also help in improving the quality of documentation. This Tool enables the supervisors /faculty not to cross check the record by visiting the families personally as this Tool is self explanatory.
Correspondence at :
Mrs. Bandana
Lecturer
Shri Guru Harkrishan College of Nursing,
Sohana
Key words :Audit tool, Family health records, Nursing students
Introduction:Quality is the process of meeting the needs and expectations of customers, both internal and external.1 Quality can also be referred to as a continuous process of incremental improvement. Quality is never an accident;2 it is always the result of high intention, sincere effort, intelligent direction and skillful execution.3 It represents the wise choice of many alternatives. Nursing and Midwifery Research Journal, Vol-5, No. 4,October 2009 167 Audit is a kind of review & is a major tool used to evaluate quality of care4. An audit is “the systematic review of records for the purpose of evaluating the documentation.5 traditionally, audits were mainly associated with gaining information about financial systems and the financial records of a company or a business. An audit involves examination and comparison of results against set criteria; assessment of quality of care with a view to improve; and monitoring the effect of audit-induced changes.6 Nursing audit is the assessment of the quality of nursing care &uses a record as an aid in evaluating the quality of patient care. “Nursing audit refers to assessment of the quality of
clinical nursing.” The audit is a means by which nurses can define standards from their point of view and describe the actual practice
of nursing7. The first report of a nursing audit of a hospital was published in 1955.
The purposes of a nursing audit are to evaluate the given nursing care, to check the quality of nursing care; to stimulate the better
recording, to focus on care provided and not on care provider; and to contribute to research8. A nursing audit is of two types.
First, a retrospective audit which refers to an in-depth assessment of the quality after the patient has been discharged — patient’s char t
is the source of data. A retrospective audit is a method for evaluating the quality of nursing care as it is reflected in the patient care records
for a discharged patient. In this type of audit, specific behaviors are described and then conver ted into questions, and the examiner
looks for answers in the record 9. The secondis a concurrent audit which refers to evaluation when a patient is still undergoing care. It includes assessing the patient at the bedside in relation to predetermined criteria; interviewing the staff responsible for this care; and reviewing the patient’s record and careplan.
10 Today, one of the most challenging issues in nursing practice is “how to document quality client care within the constraints imposed by regulation, resources and finances”. Till now, no single documentation system has been pointed out as effective; each one has its own limitations.
Family is the basic unit of health services. Family folders are the documents inwhich the health records are maintained by BSc Nursing (4years), BSc Nursing (Post-Basic) and MSc Nursing students of National Institute of Nursing Education, Post Graduate Institute of Medical Education and Research Chandigarh, have been visiting rural areas and semi-urban areas of the Union Territory of Chandigarh for many years. They have been
providing preventive, promotive and curative services to the above mentioned communities. They have been visiting families regularly and
these visits are recorded in a family folder. There is a single folder for one family, which can also be called family health record. There
is no Tool to measure the completeness of the components of a family health record without going in the family itself. So, there is need for an instrument to audit such records. Hence a study was conducted to develop a tool for auditing these records. Nursing and Midwifery Research Journal, Vol-5, No. 4,October 2009 168 This will contribute to evaluate the family health record maintained by the nursing students with minimum time. Besides this, it will also help in improving the quality of documentation.
Objective Main objective of the study was to develop a Tool for auditing the family health records maintained by nursing students of NINE, PGIMER, Chandigarh.
Materials, Methods and Results:The study was conducted on the health records of people of Dadu Majra Colony. This colony is situated on the nor th-west corner of Chandigarh and is at a distance of 5 km from NINE, PGIMER Chandigarh and 10 km from Inter-State Bus Terminus sector-43
Chandigarh. Dadu Majra Colony a resettled colony of UT Chandigarh. It has 2,670 houses with a population 18,000 approximately. The
residents of colony are migrants from different states of India, including Punjab, Haryana, Himachal Pradesh, Rajasthan, Utter Pradesh,
Bihar and Uttrakhand. The socio-economic status of residents ranges from lower to upper middle class with different cultural and social
practices. Dadu Majra Colony is chosen purposely for the study because students of the NINE, PGIMER, Chandigarh are providing
their preventive, promotive and curative services to the above mentioned communities.They visit the families regularly and these visits are recorded in a family folder. There is a singlefamily folder for an individual family, which is also called the family health record. On the
front page of family folder name of the head of the family, Address, Caste, Occupation & Sources of family income are entered. On the
back page of family folder date, family characteristics and environment are entered. Inside the family folder the postnatal observation, neonatal card, child under-six, women’s record including obstetric history & antenatal record are attached Audit Tool was developed in six phases. The first phase was preliminary phase. This phase was completed in four steps. In the preliminary phase, components of health record tool were determined and item pool was generated and organized. The preliminary draf t of the audit Tool was prepared. In the second phase, content validity was checked with the help of Delphi technique.Nine Delphi rounds were done. Eleven experts from the field of nursing education & eight
experts from the department of school of public health have been consulted and requested to check the face validity, item validity, item wording, and item order. Nine drafts were prepared in stages. In every stage,experts’ opinion has been consulted and after incorporating their valuable suggestions modifications were done in the tool. The first draft was the preliminary draft. In the second draft, there were five columns (i.e. serial
number (SN), comparison of health record with family, complete, incomplete and wrong.) There was scoring for every item and grading
as poor, average, good, ver y good and excellent. The third draft was prepared in two par ts. In the first par t, items whose number
varies from family to family (women’s record,Nursing and Midwifery Research Journal, Vol-5, No. 4,October 2009 169 antenatal record, obstetrics record and child under six records) were included. In the second par t of this draft, a total 19 items were included. In the four th draft, par t 1 was
named as par t A and par t 2 was named aspar t-B. In the fif th draf t, the sociodemographic profile term was replaced by the terms identification and social status. In this draft, the items (women’s record, antenatal record, obstetrics record and child under six records) were arranged as T/O (total score/obtained score). The sixth draft was prepared in two par ts. In par t A, main items related to maintenance of quality were included, and in par t-B numbers 1, 2, 3, were replaced by A,B, C. In the seventh draft, in part A, there werethree columns and for par t B the items related
to quality of maintenance of family health record were included. In the eighth draft, all the items were categorized under three headings: writing style (total items 12), visit details (total items 5) and record keeping (total items 2). In the ninth draft, a total 10 components were constructed. These components were family background, maintenance of quality, use of nursing process, family characteristics, women record, antenatal record, obstetrics record, postnatal record, neonatal record and child under six records. In the third phase, the necessary modifications were done in the tool under the guidance of guide and co- guide. In the four th phase, the feasibility of the tool is assessed by doing a pilot study on
family health records of village Dhanas,Chandigarh. Village Dhanas was chosen for the pilot study because the sociodemographic profile of the people of Dhanas is similar to the people of Dadu Majra Colony and same students are maintaining the records in both areas. In the pilot study the
Tool was found feasible. In the fifth phase,the final draft of Audit Tool was prepared by incorporating the minor changes after the pilot study. In the sixth phase, auditing of 500 family folders is done to check content validity and construct validity of audit tool. Cronbach’s alpha and principal
component factor analysis method was applied to check the content validity and construct validity of the tool. Cronbach’s alpha was calculated separately for :- (1) overall audit tool (2) sub groups of audit tool (3) individual items of the audit tool. Cronbach’s alpha for (1) overall audit tool was 0.73, which shows that Tool was reliable and All the items of the tool were consistent and show unidimentionality, (As Cronbach’s alpha 0.60
is reliable for any newly developed tool.) All the items of the tool were consistent and show unidimentionality, which means that they were
measuring the specific domain for which they were constructed. When Cronbach’s alpha was calculated for (2) sub groups of audit tool
average value was 0.49 which shows that two groups, family background and maintenance of quality, have little contribution, while use
of nursing process and child record have average contribution. The other two groups, family characteristics and maternal record, have maximum contribution for the overall construction of Audit Tool. When Cronbach’s alpha was calculated for (3) the average value Nursing and Midwifery Research Journal, Vol-5, No. 4,October 2009 170 of Cronbach’s alpha if item deleted was 0.31.The value of Cronbach’s alpha for individual items of two groups, family background and Maintenance of quality was less than 0.31, so they were not retained. For the items of rest of the groups the value is equal to or more than 0.31, so they were retained.
Table-1 : Cronbach’s Alpha for Individual item in each Group of audit tool:-
Subgroup No. of item Cronbach’s Cronbach’s alpha
alpha if item deleted
Family Background 5 0.21 —
Maintenance of Quality 5 0.13 —
Use of Nursing Process 5 0.43 0.49
Family Characteristics 18 0.63 0.37
Maternal record 13 0.61 0. 31
Child record 11 0.41 0.43
To assess the adequacy as well as
eligibility of tool items for undergoing factor
analysis the Kmo value and p-value are
calculated The Kmo value of data in this study
was 0.575. (The Kmo value of data should
be 0.50.for proceeding for factor analysis.)
The p-value of the data was 0.000; (the
p-value should be less than 0.05 for
proceeding for factor analysis.) So the data
was eligible for factor analysis.
Table-2 : Assessment of suitability of Audit
Tool to carry out factor analysis
Test Value
KMO .575
Bar tlett’s test of sphericity 2064 .117
chi-square
p-value .000
Factor analysis of Audit Tool by Principal
Component analysis after varimax rotation
method indicate that total five factors should
be retained in the Audit Tool on the basis of
their factor loading effect. Factor 1 retains four
items which have maximum factor loading
effect in the construction of audit Tool. Factor
2 retains five items with factor loading effect
less than factor 1. Factor 3 retains three items,
for other two items signed by student and
checked by teacher their variance was shared
by the other factors (negative value). Factor 4
retains three items. Item identification has
negative value Factor 5 retains three items.
Factor analysis proves that on the basis of
factor loading effect total eighteen items were
retained in the tool .Item such as identification,
signed by student and checked by teacher
should not be retained in the Tool because
they were not measuring their construct
exactly.
Nursing and Midwifery Research Journal, Vol-5, No. 4,October 2009 171
Table-3 : Factor analysis of Audit Tool by Principal Component Analysis after Varimax
Rotation
Components Factors
1 2 3 4 5
1. Neonatal record .91
2. Postnatal record .90
3. Antenatal record .55
4. Child under six record .45
5. Intervention .71
6. Diagnosis .64
7. Assessment .60
8. Dated .48
9. Implementation .44
10. Signed by student -.31
11. Record is Legible .64 .33
12. Date of star ting the family health record .54
13. Checked by teacher/supervisor .53 .39
14. Obstetrics record -.53
15. Women’s record .62
16. Identification .62
17. Economic status -.45 .38
18. Individual record tally with information .44 .41
19. Environment .39 .65
20. Social status .50
21. Evaluation .40
Nursing and Midwifery Research Journal, Vol-5, No. 4,October 2009 172
Scree Plot
The Scree plot is a graph of the
eigenvalues against all the factors. The graph
is useful for determining how many factors to
be retained in the tool. The point of interest is
where the curve star ts to flatten. In this study
from Scree plot, it is clear that first 2 factors
had major contribution to the total variance
(point of first inflection) and around five factors
appear relevant in explaining data variance
overall (point of second inflection).The first
factor has eigen value 2.39, second factor
mirror the almost same value 2.29, factor 3
has eigen value 1.60,factor four has eigen
value 1.52,and factor five has eigen value
1.35.Subsequent to first five factors, the
Scree plot curve is almost smoother without
anymore inflection .So five factors and all
the 22 items were retained on the basis of
Scree plot test.
Component Number
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22
Eigenvalues
2.5
2.0
1.5
1.0
0.5
0.0
Figure – 1 : Scree plot of eigenvalues against all factors
Nursing and Midwifery Research Journal, Vol-5, No. 4,October 2009 173
Discussion
The Audit Tool is developed to audit the
family health records. The Audit Tool is
developed in six phases. This is compared
with another study which was completed in
six phases.11 In first phase, the preliminary
draft of Audit Tool was prepared .In second
phase, content validity was checked with the
help of Delphi technique. The Delphi is an
iterative process designed to combine
exper t’s opinion into group consesus12 for the
conventional Delphi a heterogeneous sample
is used to ensure that the entire spectrum of
opinion is determined13 .In present study
heterogeneous panel of expert included the
Nursing educators ,Senior residents and
associate professors from School of Public
health department .Delphi technique employs
a number of rounds in which questionnaire
is sent out and are used until a consensus is
reached.14-15 Classical original Delphi used four
rounds however this has been shortened to
two or three rounds.16-17 Current study has nine
rounds, because the exper ts opinion was not
reached into group consensus earlier as all
the items of the questionnaire are finalized in
ninth round. In third phase, necessary
modifications were done in the Tool. In four th
phase, feasibility of the Tool is assessed by
doing a pilot study on family health records
of village Dhanas. Pilot study help to identify
wording difficulty as well as feasibility.16 in fifth
phase, final draft of the Tool was prepared. In
sixth phase, auditing of 500 family health
records of people of Dadu Majra Colony was
done to check the content validity and
construct validity of the Tool. Cronbach’s
alpha and principal component factor analysis
method was applied to check the content
validity and construct validity of the Tool.
The Cronbach’s alpha of newly
developed tool should be 0.60 as per
literature. The Cronbach’s alpha of this study
was 0.73.It means Audit tool is reliable. This
was compared with Cronbach’s alpha of other
studies. In one study The Alcohol and Drug
Confrontation Scale (ADCS) was developed.
This scale had a 72-items.Cronbach’s alpha
of this scale was = 0.6318. In another study
15 items questionnaire was developed and
tested on 69 subjects. The Cronbach’s alpha
was calculated directly on all items and on
individual items of the tool . It was 0.89 &
0.82 respectively.19.
To check the eligibility of data for factor
analysis minimum sample size should be total
no of items multiplied by 10. In this study
there are total 22 items. The sample size
should be 220 .As the sample size was 500
family health records .So the data was eligible
for factor analysis. The data should have Kmo
value 0.50 and p-value less than 0.05.for
making the data eligible for factor analysis.The
Kmo value of data in this study was 0.575
and p-value was 0.000, which makes the data
again eligible for factor analysis.
This is compared with another study
in which Kmo value was 0.52 and p-value was
0.00017
Principal component factor analysis
method was used to select the items on the
basis of factor loading effect. Total five factors
with 18 items were retained Factor 1 retains
Nursing and Midwifery Research Journal, Vol-5, No. 4,October 2009 174
four items which have maximum value of first
item (.90) Factor 2 retains five items. Factor 3
retains three items. For other two items signed
by student and checked by teacher their
variance is shared by the other factors
(negative value). Factor 4 retains three items.
Item identification has negative value Factor
5 retains three items. Factor analysis proves
that on the basis of factor loading effect total
eighteen items should be retained in the tool.
Item such as identification, signed by student
and checked by teacher should not be
included in the Tool because they were not
measuring their construct exactly. In one
study where a shor t form of Chinese version
of the State Anxiety Scale for children was
developed, total five out of ten items were
retained on the basis of factor loading effect17.
In another study 36 items out of 64 items
were retained.20.
On the basis of Scree plot test five
factors and 22 items were retained which was
compared Scree plot test of other studies In
the Alcohol and Drug Confrontation Scale
(ADCS) 60 items were retained out of 72
original items.18 In another study all 15 items
were retained.19
On the basis of exper t’s opinion, three
items i.e. identification, signed by student and
checked by teacher/supervisor should not be
dropped as these are impor tant. Because to
measure the identification of a person, it is
needed to gather information such as
permanent residential proof, ration card/voter
card/identity card. However, it is not feasible
in this study as these details are not included
in the family health record. The other items
i.e. signed by the student and checked by
teacher are there in the visit repor t of family
health record, every record should be signed
by the student who prepares it and every
record should be checked by the teacher/
supervisor. The exper ts felt that these items
were impor tant and should be retained .So
all the original items of the Audit Tool were
retained. Contribution of all these items had
already been proved & suppor ted with
Cronbach’s alpha and Scree plot test.
This study has made contribution to
evaluate the family health record maintained
by the nursing students of NINE, PGIMER,
Chandigarh with minimum time. Besides this,
it will also help in improving the quality of
documentation. This Tool enables the supervisors
/ faculty not to cross check the record
by visiting the families personally as this Tool
is self explanator y. Same study can be
replicated with same audit Tool in a different
setting i.e. in another college of nursing for
auditing the health records maintained by their
students. Audit Tool can be used by the
faculty members to evaluate the student’s
records.
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Acknowledgement
Dr. Suksham Chopra is acknowledged for contributing in the
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