Development of nursing assessment document for patients with mental health problems

http://doi.org/10.33698/NRF0100-  Nitasha Sharma, Avinash Kaur Rana, Ajit Avasthi

Abstract : Documentation is any written information about a client that describes the care or service provided to that client. Documentation is an integral part of nursing, midwifery and health visiting practice. Through documentation, nurses communicate their observations, decisions, actions and outcomes of these actions for clients. There is no structured format to perform and document the assessment done by the psychiatric nurses. In the present study a ‘Nursing Assessment Document’ was developed which can be used by the psychiatric nurses for thorough assessment as well as documentation of the assessment done. The nursing assessment document consists of total eleven domains which have been originally taken from the Jordon’s functional health pattern. The process of tool development was divided in various phases making use of Delphi technique. The criterion related validity was done taking NOSIE (Nurses observation scale for inpatient evaluation) as gold standard. On applying correlation there were significant correlations in the scores on each scale with ‘r’=0.72. The regression analysis was also done which showed the value of coefficient of determination to be 0.53. It explained that 53% of the variability in the nursing assessment document could be explained by the variability in the ‘Nursing observation scale for inpatient evaluation’. The inter-rater reliability was explained by computing the Cohen’s kappa which was found to be >0.9 in all the three sets of observations which makes the newly devised tool is highly reliable. It is recommended to conduct an operationalization study to quantitatively assess the overall utility of nursing assessment document. The interrater reliability was assessed by computing Cohen’s kappa coefficient. (k= 0.9)

Key words :

Nursing Assessment, Document

Correspondence at :

Nitasha Sharma

Kullar College of Nursing

GT Road, Bija, Near Khanna Distt. Ludhiana

Introduction

Documentation is any written information about a client that describes the care or service provided to that client1. It is not merely a set of certain forms, framed and designed but a document of acts and figures, containing segments of observations by trained and experienced observers.2 Docum- entation of care is synonymous with care itself3. It is a perfect proof of the expertise and experience of the team work of all those contributing towards the patient’s health2. Without knowledge of care given in the past, and of circumstances which made that care necessary, continuity of care can’t be achie- ved.4 The two main forms of communication in nursing are verbal handover reports and written nursing documents. It is seen that comprehensive nursing documentation impr- oves patient care5. Documentation can be a valuable source of data for making decisions about funding and resource management as well as facilitating nursing research, all of which have the potential to improve the quality of nursing practice and client care. Individual nurses can use outcome information or infor- mation from a critical incident to reflect on their practice and make needed changes based on evidence. It is a valuable method for demonst- rating that, within the nurse-client relationship, the nurse has applied nursing knowledge, skills and judgment according to professional standards.

Nurses have not been renowned for a high standard of documentation, and failure to pass on information, together with breakdown in communication, rank high in formal complaints about health care4. A study was done to check the validity of data entered into the system during two to three weeks period.12% were found to contain one or more errors6.Another study was done to determine the underlying causes of persistent antipathy towards documentation in patient’s chart. The results supported a common belief that resistance to charting is influenced by extrinsic or environmental factors, such as inflexibility of charting systems and insufficient allocation of time. In addition, intrinsic factors of cognitive and psychosocial domain, such as lack of confidence about written expression, a tendency to succumb to group norms governing charting and difficulty in articulating the nature of nursing practice, surface as impediments to documentation7 Nurses feel that they must develop a documentation system that allows them to communicate the care they give while ensuring that the patient remains the central focus. Still a lot of work needs to be done to try to improve nursing records. There is a need for more experimen-tation with different approaches but as such there is no standard system for documenting nursing.

Nurses are considered to be enhancers of healing and health. They use the humanis- tically oriented nursing practices to achieve their goal. In the care of mentally ill, the main work requires nurses to understand the dysf- unctional internal processes. The nurses are responsible for performing the psychiatric assessment of their clients. The purpose of an assessment is to gather data pertaining to client’s problem, not to collect a lot of data. The actual assessment consists of gathering the data and verifying the data. The use of a standardized tool facilitates the assessment process. The assessment covers social, physical, emotional, cultural, cognitive, and spiritual aspects of the individual. It elicits the information about the system in which the person operates. Specially trained psychiatric nurses take a nursing history and make assessments of client’s pattern of difficulty and progress towards their resolution. There is no structured format to per form and document the assessment by the psychiatric nurses which can be used in our settings. Thus an attempt is being made to develop a ‘Nursing Assessment Document’ for patients with mental health problems and to strengthen the documentation system.

Materials and Methods

The study was conducted in the psychiatry ward of the Nehru Hospital, PGIMER, Chandigarh in the months of July- August 2008. The Nehru hospital is a 1400 bedded tertiary hospital. The hospital is the leading ter tiary hospital of the area with excellent multi speciality facilities. The Psychiatry department has both the inpatient as well as outpatient services. The Psychiatry ward of the Nehru hospital, PGIMER is situated on the 3rd floor, Cobalt block of the Nehru hospital. It is a 24 bedded unit with separate male and female section. In each room there are 6 beds and additional three isolation rooms and two private rooms. There is one common prayer room, T.V. room and recreational therapy room along with a gymnasium for the patients. There is an open terrace for conducting the outdoor activities.

The study consisted of four phases

PHASE 1- Preliminary instrument development

  1. Step 1: During this step the nurse researcher did review of the literature on mental health assessment by nurses and its
  1. Step 2 : the second step involved the development of preliminary instrument. It comprised of total eleven domains which were originally taken from Jordon’s functional health 8

PHASE 2 – VALIDATION PHASE

  1. a) During this phase the content validity and face validity of the preliminary version was done through the Delphi A panel comprising of nurse educators, clinical instructors, psychia- trist and psychologist was sele-cted. The panel determined each item appro- priateness, accuracy and represe- ntativeness. The three subs-equent rounds of Delphi were cond-ucted. As per the expert opinion certain items were deleted, some new items were added and some of the items were reworded. The draft 1 of the nursing assessment document was obtained at the end of this phase. The draft 1comprised of total of eleven domains and a total of 82 items. It was ensured that the items listed in document are relevant to the subject, meaningful and easily understandable.

PHASE 3 – PILOT STUDY

The pilot study was conducted for fur- ther refining of the tool and to establish med- ian completion time. The draft 1 was administ- ered on 10 patients and assessment was done by the staff nurses’ posted in psychiatry ward who were trained for the same. The feedback was taken from each rater to fur ther refine the tool. As per their feedback one item was deleted and one item was reworded. The average completion time for the nursing assessment document was 12.5 minutes. It was found feasible to use the ‘nursing assessment document’ .The outcome of this phase was draft 2 of the document. The draft 2 comprised a total of eleven domains and 78 items. The item stating that client visits faith healers was deleted. Certain items in the domain of Mood and Stress Tolerance were reworded. The item stating that the client giggles and mutter to self was also deleted.

PHASE 4 – ADMINISTRATION OF NURSING ASSESSMENT DOCUMENT

The purpose of this phase was to establish the criterion related validity and interrater reliability for the draft 2 of the document. The ‘nurse’s observation scale for inpatient evaluation’9 (NOSIE) was taken as a gold standard. The Nurses’ Observation Scale for Inpatient Evaluation is a 30-item scale designed in 1965 for behavioral and observational rating of psychiatric inpatients. The scale was originally designed by Honigfeld and Klett (1965) and is reproduced in Lyttle (1986).The draft 2 of the document as well as the gold standard was administered on total of 21 patients. In order to compute the interrater reliability, each patient was rated simultaneously by the nurse researcher as well as the staff nurse working in the wards who were trained by the nurse researcher to use the newly devised document.

THE CRITERIAN RELATED VALIDITY / VALIDATION AGAINST GOLD STANDARD

NOSIE (Nurses Observation Scale for Inpatient Evaluation)23

In order to establish the criterion related validity, the nurse researcher used the gold standard NOSIE (Nurses Observation Scale for Inpatient Evaluation). So each patient, who was rated on the nursing assessment document, (NAD) was also rated on the NOSIE by the nurse researcher.

The given table 2 shows the correlation between the Nursing assessment document (NAD) and NOSIE scores. The Pearson ‘r’ was 0.73 while analyzing correlation between NAD and NOSIE total scores. This indicates that with increase in NOSIE score, NAD score also showed the statistically significant increase and vice versa.

Table 2 : The total correlation on ‘Nursing Assessment Document’ and ‘nurses observation scale for inpatient evaluation’ Correlation

  NAD TOTAL NOSIE
NAD TOTAL Pearson correlation 1 0.728***
  Sig (2 tailed)   00000
  N 21 21
NOSIE Pearson correlation Sig (2 tailed) 0.728**

0.000

 1
  N 21 21

**Correlation is significant at the 0.01 level (2 -tailed)

The given table 3 shows the correlation between the NAD and NOSIE scores on the ‘personal neatness” domain. The Pearson ‘r’ was 0.69 and 0.54 for the personal neatness raw scores and t-scores respectively. This indicates that with increase in the personal neatness scores in NOSIE, the NAD score on same domain also showed statistically significant increase and vice versa.

Table 3 : Correlation on personal neatness domain

Personal neatness Pearson correlation                1Personal Neatness

Sig. (2-tailed)

N                                                                                21

Neatness raw score Pearson correlation                   0.688**

Sig. (2-tailed)                                                                 0.001

N                                                                                     21

Neatness t -score Pearson correlation                           0.545*

Sig. (2-tailed)                                                                  0.011

** Correlation is significant at the0.01 level (2-tailed)
N                                                                                         21

*correlation is significant at the 0.05 level (2 -tailed)

The similar significant correlations were seen on ‘social interest’ and ‘social competence’ domain.

THE REGRESSION ANALYSIS

A linear regression analysis was carried out to quantify the magnitude of change in NOSIE score when calibrated against NAD total score.

The table 9 shows the descriptive estimates of overall total scores on NOSIE & NAD scales

Table 9 : NOSIE and NAD mean scores with standard deviation

  Mean Std. Deviation N
NOSIE 160.3 20.52 21
NAD TOTAL 141.5 9.96 21

This table 10 shows the value of R- square (coefficient of determination).The adjusted R- square was 0.50 indicating that approximately 50% of variability in NOSIE scores could be explained by NAD scores and vice versa.

Table 10 : Coefficient of determinism

Model    R R

Square

 Adjusted R Square R square Change F

Change

 Df 1 Df 2 Sig. F Change
1 .728a .531 .504 .531 20.345 1 18 .0000

The table 11 shows the values of Beta coefficients (Unstandardized as well as standardized) quantifying the strength of relationship between the two scale scores.

Unstandardized beta- coefficient (1.50): This indicates that for every one point increase in NAD score, NOSIE score total increased by

1.5 points.

Standardized bêta- coefficient (0.73): this indicates that for every 1S.D increase in NAD SCORE (i.e. 9.96 or approximately 10 points), the NOSIE score increased by 0.73*20.52=approximately 15 points in total scores.

This change was statistically highly significant. (P-value <0.001)

Table 11 : The Beta coefficient

Model Unstandardized   Standardized Coefficients    
B Std. Error Beta t Sig.
1 Constant NADTOTAL  

-52.06

1.50

  

47.19

.33

  

.73

  

-1.10

4.51

  

.284

.000

From the above data the following linear regression equation can also be calculated.

Y=BO + B1*X

Where ‘Y’ is NOSIE total score, BO is the regression constant and B1 is Unstandardized coefficient of NAD total score.

Therefore equation becomes:

NOSIE Total score = – 52.06 + 1.50 * NAD TOTAL SCORE

Table 12 : R-SQUARE

The similar linear regression analysis was carried out to quantify the magnitude of change in NAD score total when calibrated against NOSIE score

The table 12 shows the value of R- square(coefficient of determinism) . The adjusted R-square was 0.50 indicating that approximately 50% of the variability on the NOSIE score could be explained by the NAD SCORE.

Model             Mean            R-square        Adjusted R-square   Std. error of

1                         0.728               0.531                0.504                7.01138
the estimate

  1. Predictors :(constant), NOSIE

The table 13 indicates that for every 1 point increase in NOSIE score, NAD score increased by 0.35 point. (Unstandardized Beta).

Table 13 : THE BETA COEFFICIENT

Model                 Unstandardized Coefficient      Standardized Coefficients

  B Std. Error Beta T Sig.
1 Constant 84.83 12.66 0.73 6.70 .284
NADTOTAL 0.38 0.08   4.51 .000

For 1 S.D, increase in NOSIE score, the NAD score total increased by approximately 0.73 (standardized beta)*9.96 (S.D of NAD total) = approximately 7 points. This change in scores was statistically highly  significant. (p- Value < 0.001)

We can also derive a linear regression equation from the above analysis.

NAD total score = 84.83 (constant or B0) + 0.35*NOSIE score.

R-square (coefficient of determination)

> 0.25 is highly significant.

This is scatter plot showing linear correlation between two variables.

R- Square of 0.53 indicates that 53% of variability in NAD total score could be explained by NOSIE score.

Establishment of Reliability of the Nursing Assessment Document:

The reliability was calculated by using Cohen’s Kappa coefficient’k’10. This coeffici- ent indicates the degree of agreement bet- ween the pair of raters. Each patient was rated by the nurse researcher and the staff nurse working in the ward at same time independently.

Table 14 shows that the agreement level between rater1 and rater 2 in assessing the patient’s status was good (k=0.95)

Table 14 : Inter-rater agreement for all items at time point A

Rater 1 Never Sometimes Always Total for rater Kappa
        1 at A (P-value)
Never 108 6 0 114 0.95 (<0.0001)
Sometimes 0 216 0 216  
Always 0 24 1325 1349  
Total for rater 2 at A  

108

  

246

  

1325

    

Table 15 shows that the agreement level between rater 1 and rater 2 in assessing the patient’s status was very good (k=0.96).

The kappa coeffient showed the very good agreement on the second and third set of observation with k= 0.96 and 0.95 respectively.

Results

The final draft of the tool had a total of eleven domains and seventy seven items. The final draft of NAD is a three point scale in which the rater has to rate as per observed patient’s behavior of last two days. Most of the items include the objective data about the client whereas few items may require the subjective evaluation. Three items of the document also require the rater to mention the evidence for the observed behavior. The tool fulfills all domains of documentation.

Discussion

The literature review revealed the importance of documentation in effective nursing practice. The documentation is a perfect proof of the expertise and experience of the team of all those contributing towards the patient’s health. The present study was based on assertion that the nurses working in psychiatric units spend maximum time with the patients and have so much to observe but very less proportion of their observation is actually communicated to the members of health team. There are various intrinsic and extrinsic factors for this. The one of the important factor is the lack of standardized Performa /tool to perform and document the patient’s assess- ment. This study was undertaken to develop such document which would be able to fulfill all domains of documentation and primly would guide the nurses to perform as well as document the assessment and observa- tion made by them. The study was conduc- ted in the Psychiatry Ward of Nehru hospital, PGIMER which is an acute psychiatric unit. Initially the in-depth review of literature was done and the Preliminary Nursing Assess- ment Document was prepared. The Prelimi- nary Nursing Assessment Document was further refined by using the Delphi techniq- ue.11-13. The Delphi is an iterative process desi- gned to combine expert opinion into group consensus. The identification of experts has been a major point of debate in use of ‘Delphi’ as there is clearly a potential for bias in the selection as the exact composition of the panel can affect the results obtained.14 Its not only the knowledge, rather the willingness to engage in discussion and the interest and involvement with the question being addressed are also impor tant.15 while choosing a panel of experts for the current study, these factors were kept in mind by the investigator. For the conventional Delphi, a heterogeneous sample is used to ensure that the entire spectrum of opinion is determined .16 In the present study the heter- ogeneous panel of exper ts included the psychiatrists, the psychologists, the nurse educators, the clinical instructors and the staff nurses. The Delphi technique employs a number of rounds in which questionnaires are sent out and are used until a consensus is reached.17,18 The process raises the question of how many rounds it takes to reach a cons- ensus. The classical original Delphi used four rounds.19 However, this has been modified by many to suit individual research aims and in some cases it has been shortened to two or three rounds.17-19 The current study had 3 rounds of Delphi to generate the draft-of nursing assessment document. A study reiterated the importance of pilot testing to identify the wording difficulty as well as to improve the feasibility of administration.20 The pilot study was conducted on a sample of 10 patients and fur ther refinement of tool was done to get the final draft of nursing assess- ment document. The final draft was admini- stered on 20 patients admitted in psychiatry ward. The validation of tool hold great signifi- cance as it ensures the congruence between the research target and the data collection tool21 The psychometric theory offers a number of techniques to examine the reliability and validity of research instruments. A study conducted to establish the validity and reliability of perineal assessment scale in which the researcher calculated the level of agreement between Perineal Assessment Tool and opinion of expert nurses, the inter-rater reliability was calculated by using Pearson’s product moment corre- lation, r= 0.97,showing a strong agreement.22 In the present study the reliability was calculated by using Cohen’s Kappa coefficient’ k’10.This coefficient indicates the degree of agreement between the pair of raters .another study conducted to calculate the validity of Pain.

Assessment tool(PAT) for clinical assessment of neonatal ICU, the validity was tested against the CRIES score and maternal perception of pain using a visual analog scale. The results suggested a strong correlation (r= 0.76) between PAT and CRIES but weak correlation (r=0.38) between the PAT and mother’s perception of pain.23 In the present study criterion related validity was established and NOSIE was used as a gold standard. The results of criterion related validity indicated ‘r’=0.73, p-0.00. This correlation was expected because both are multi-dimensional measures and address the common generic ‘patient’s ward observation by duty nurse’.

Conclusion

The Nursing assessment document which is developed through Delphi technique has a total of eighty items. There are total 12 domains based on the Gordon’s functional health pattern. In order to compute the criteria validity, the ‘Nursing observation scale for inpatient evaluation’ was used as the gold standard. On applying correlation there were significant correlations in the scores on each scale with ‘r’=0.72. The regression analysis was also done which showed the value of coefficient f determination to be 0.53. It explained that 53% of the variability in the nursing assessment document could be explained by the variability in the ‘Nursing observation scale for inpatient evaluation’. The inter-rater reliability was explained by computing the Cohen’s kappa which was found to be >0.9 in all the three sets of observations which makes the newly devised tool is highly reliable. The ‘nursing assessment document’ should be utilized to promote the quality of care being given by better assessment and effective documentation and communication.

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