http://doi.org/10.33698/NRF0146 – Renu Bala, Karobi Das, Avinash Rana, S.K.Matoo

Abstract: Nursing Evaluation Tool (NET) is a combined total measure to check the recovery in patients during disease process. Recovery is a deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills and/or roles when hospitalised for the treatment. Hence, a methodological study was undertaken to develop Nursing Evaluation Tool for assessing the recovery in subjects admitted in drug-deaddiction centre. Delphi technique was used to develop NET along with a scoring key and the guidelines to use the tool with 8 experts. After four Delphi rounds the tool was tried on 30 subjects admitted in Drug-Deaddiction & Treatment Centre. The reliability of NET was assessed by Cronbach alpha coefficient (Unstandardised) which was 0.91 indicated the reliability and internal consistency of tool. For inter-item correlation Spearman Correlation showed 33 items having <0.2 correlation and those items were dropped from the tool prior to factor analysis. In factor analysis 13 components were generated with 57 items which accounts for 89% of variance. Hence a valid and reliable Nursing Evaluation Tool was develop to assess the functional recovery in drug- addicted subjects.The feasibility of present scale can also be checked for other institutes/hospital’s Drug-Deaddiction & Treatment Centre.

Key-words

Nursing Evaluation Tool, Functional Recovery, Substance Dependence.

Correspondence at:

Mrs. Renu Bala

Clinical Instructor,

National Insitute of Nursing Education, PGIMER, Chandigarh.

Email: rain_nsg@yahoo.com

Introduction

Evaluation is the process of examining a system or system component to determine the extent to which specified properties are present1. It is the process of examining and rating a subject based on its important features. We determine how much or how little we value something, arriving at our judgment on the basis of criteria that we can define2.Evaluation can help health professionals to determine the efficacy of a health care program and how well it has been implemented. In addition, it can produce data or results that can help to promote a program and its services3 . Evaluating the effectiveness of nursing care is necessary for developing a sound knowledge base to guide practice4.

According to literature, there are several documents present which helps to determine holistic care given to the patient including recovery phase. Anthony (1993) identifies recovery as a deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills and/or roles. It is a way of living a satisfying, hopeful, and contributing life even with limitations caused by the illness. Recovery involves the development of new meaning and purpose in one’s life as one grows beyond the catastrophic effects of mental illness’5 Recovery in the patients of substance abuse is a complex process requiring intense, continuous personal effort that not only involves abstinence but also requires a series of changes to maintain sobriety6. Successful recovery requires acquisition of knowledge about substance-abuse disorders, renewal of self-esteem and personal responsibility, development of sober living abilities and social interactions, identification with sources of inspiration, and a unified approach to guide these changes7.

During recovery phase in the treatment of drug addiction, health professionals help the patient to achieve all the parameters of positive health. Drug addiction is a complex illness characterised by intense and at times, uncontrollable drug craving, along with compulsive drug seeking and use that persists even in the face of devastating consequences. Because drug abuse and addiction have many dimensions and disrupt many aspects of an individual’s life, treatment is not simple8. Effective treatment programs typically incorporate many components, each directed to a particular aspect of the illness and its consequences9. Most patients require long- term or repeated episodes of care to achieve the ultimate goal of sustained abstinence and recovery of their lives10.

Recovery can be in the form of positive or negative functional outcome as there are multiple elements of functional recovery. These include freedom from troubling psychotic symptoms and relapses, satisfaction with life and daily activities. Many tools have been developed to assess functional outcome and quality of life11. Recommendations for evaluating functional outcomes include: (i) adequately assessing functional impairment; (ii) identifying or developing treatment plans that will target symptoms associated with functional impairments; and (iii) monitoring functional impairments and associated symptoms throughout the course of treatment12. The development of treatments that specifically target improvements in functional impairments is needed and may require the use of novel treatment strategies such as proper evaluation and documentation of significant findings related to the recovery13.

A Nursing Evaluation Tool is needed to measure the functional recovery in subjects with substance dependence admitted in Drug- Deaddiction & Treatment Centre. There are several scales and tools to assess the recovery in patients, but there is no specific tool to assess the functional recovery in drug- addicted patients during their stay in ward. Presently multiple charts are being used by different members of health team working in Drug De-addiction & Treatment Centre. A single chart will lessen the confusion in documentation. Hence the present study was undertaken.

Objective:

To develop a “Nursing Evaluation Tool” to assess the functional recovery from substance dependence in subjects admitted in drug de-addiction & treatment center of PGIMER, Chandigarh

Materials, Methods & Results

Nursing Evaluation Tool was developed in four phases. The first phase was preliminary phase. This phase was completed in 3 steps. In the preliminary phase components of functional recovery were assessed by reviewing the literature. Item pool was generated and organised. Hence, First draft was prepared which comprised of eleven with 93 items. In the second phase, content validity was checked with the help of Delphi technique. Three Delphi rounds were undertaken. Eight experts from the field of psychiatry and psychiatric nursing have been consulted and requested to check the face validity, item validity, item wording and item order. In every stage, expert’s opinion has been consulted and after incorporating their valuable suggestions in Delphi round – I, 3 items added, 3 items deleted and 35 items modified. In Delphi round – II, no new item was added, 6 items deleted, 35 items modified. In Delphi round-III, no new item was added, 1 item deleted and 6 items were modified.Hence after phase-II the tool comprised of eleven domains with 86 items.

In Phase-III pilot study was done and developed Nursing Evaluation tool was administered on 10 subjects admitted in Drug- Deaddiction & Treatment Centre, PGIMER, Chandigarh. The average completion time for the Nursing Evaluation Tool was 15 minutes. After administration of tool, it was found that tool is easily understandable and can be used by nursing professionals. The need was felt to add one more domain. After adding one more domain and few modifications in some of the items again fourth Delphi round was undertaken.At the end of third phase the tool was comprises of 12 domains with 90 items.Each item was rated from 0 to 2. Maximum score of the tool was 180 which was further divided into 6 categories or levels indicating the functional recovery in the client whether it is stable or progressive. The six levels are excellent, very good, good, average, poor and very poor. The functional recovery is indicated as score range of 1-30 very poor recovery, 31-60 poor recovery, 61-90 average recovery, 91-120 good recovery, 121-150 very good recovery and 151-180 excellent recovery.

Reliability of Nursing Evaluation Tool:-

In Phase-IV final draft of Nursing Evaluation Tool was tried out on 30 subjects admitted in Drug-De addiction & Treatment Center (DDTC), PGIMER, Chandigarh. This ward is located near by the Advanced Eye Care Center. It is special unit of 20 beds, for subjects with substance-dependence & drug- abuse. There are total 3 units in ward with 6- 7 beds. There is one common room with recreational facilities &television, another one is Play room with outdoor & indoor games, magazines, articles and novels. There is a lawn for outdoor games & activities.

The Nursing Evaluation Tool was applied on total 30 subjects with substance dependence who were admitted in the unit. Verbal consent was taken from each subject who was willing to participate in the study. Nursing staff working in the unit were also explained about the study and their voluntarily participation for data collection was saught. Nursing staff was trained about the use and administration of the tool. The Nursing Evaluation Tool scored after regular observation and interaction with subjects by the researcher for 3 times a day for 5-10 minutes for 3 consecutive days i.e. in morning after prayer session, after lunch and before evening tea. Apart from it interactions were also done during their visit to nursing station for any complain. After 5 P.M. staff nurses observed the subjects for any complains or any significant observations and noted in the evaluation sheet and signed it. For assessing the domains of nutrition and metabolism, elimination, self-perception and self-concept, roles and relationships; interaction method was adopted. On the other hand domains like health perception and health management, activity and exercise, sleep and rest, cognitive- perceptual, mood and stress tolerance, value- belief, sexuality and behaviour observation method was adopted. Hence every subject was observed or interacted for each item minimum 9 times. Under 12 domains all items scored as: most of the time, sometimes and never. If any characteristic item is observed persistently for 5 to 9 times then the option marked will be as most of the time. If any characteristics item is observed occasionally or 1 to 4 times then the option marked will be sometimes. If any characteristics item is not observed et al or zero time then the option will be marked as never. If any characteristics evaluation is made beside these items, then it was documented in the column of any other specific observation.Each item was rated on the scale of 0, 1 and 2. The items observed most of the times were rated as 2, items observes sometimes were rated as 1 and items never observed were rated as 0. Data was collected in 40 days.

The data was analysed by SPSS (Version-16).To find out internal consistency and reliability of present Nursing Evaluation Tool, the Cronbach’s Alpha (Unstandardised) was used. There were total 90 items in the scale and overall Cronbach’s Alpha coefficient of present tool was 0.91 which indicates reliability and internal consistency of the tool (Ideally Cronbach’s alpha coefficient should be >0.70).

TABLE-1

Reliability analysis of first 6 domains of Nursing Evaluation Tool by Cronbach’s Alpha

 

Items of Tools Scale Mean if Item Deleted Corrected Item Total Correlation
1(a) – Is aware of his illness 131.73 .05*
1(b) – Denies for his drug-addiction 131.97 .16
1(c) – Wants to quit drug-addiction 132.00 .65
1(d) – Seeks treatment for his withdrawal symptoms 131.80 .59
1(e) – Accepts the medicines easily 131.73 .48
1(f) – Looks well kempt and tidy 131.81 .62
1(g) – Is ready to comply with the treatment 132.03 .68
2(a) – Complains of loss of appetite 132.50 -.14*
2(b) – Complains of increased appetite 131.83 .51
2(c) – Complains of heart burn 131.97 -.01*
2(d) – Has dry mouth 131.90 .29
2(e) – Accepts his meals without persuasion 131.90 .03*
2(f) – Has reduced weight  (>2 kg in a month) as needed 133.03 -.62*
2(g) – Has gained weight (>2 kg in a month) as needed 133.07 -.52*
2(h) – Complains of nausea and vomiting 132.07 .33
2(i) – Is on supplementary treatment (Multivitamins) 133.53 .24
3(a) – Complains of abdominal pain 132.43 -.22*
3(b) – Has diarrhea (loose stools>3 times/day) 132.03 .29
3(c) – Needs anti-diarrheal drug (lomotil as a treatment) 132.00 .44
3(d) – Has constipation (stool passed once in 3 days) 131.73 -.00*
3(e) – Needs laxatives/enema 131.73 -.00*
3(f) – Has painful micutration 131.73 -.03*
3(g) – Has urinary retention 131.70 -.05*
4(a) – Is able to do his self care activities 131.77 .36
4(b) – Does his self care activities on persuasion 131.97 .32
4(c) – Does not participate in ward activities 132.10 .21
4(d) – Participates in prayer voluntarily/persuasion 131.77 .59
4(e) – Engages himself in P.T. voluntarily/persuasion 131.77 .59
4(f) – Easily tells about his complaints on asking 131.13 .26
4(g) – Takes meals from meal trolley by self 131.73 .76
4(h) – Washes his utensils by self 131.77 .76
4(i) – Indulges self in group activities 132.07 .18*
4(j) – Participates in indoor games without persuasion 132.67 .58
4(k) – Attends art of living/yoga classes 132.33 .33
5(a) – Complains of sleep disturbance 132.67 -.06*
5(b) – Has early awakening in morning 131.97 .30
5(c) – Prefers daytime sleep 132.07 .23
5(d) – Feels refreshed after a sound sleep 132.03 .43
5(e) – Demands sedatives for sound sleep 132.33 .50
5(f) – Has excessive sleep 131.77 .23
5(g) – Feels drowsy/lethargic throughout the day 132.13 .26
6(a) – Complains of aches and pains 132.47 -.26*
6(b) – Is aware of his withdrawal symptoms 131.80 78
6(c) – Has full orientation to time 131.80 .61
6(d) – Has full orientation to place 132.33 .50
6(e) – Has full orientation to person 131.73 .32
6(f) – Has poor attention & concentration (DB & DF) 132.43 .42
6(g) – Appears confused everytime 132.67 .58
6(h) – Has hallucinations at present 131.73 -.05*
6(i) – Has delusions at present 131.70 .41
6(j) – Understands the facts related to treatment 131.73 .32
6(k) – Is aware of motor incoordination 131.83 .74
6(l) – Is aware of inappropriate behavior & impaired functioning 131.80 .61
  • Overall scale mean was 06
  • *Items in the tool which shows item to total correlation <0.2
  • Cronbach’s Alpha if item deleted for 88 items is 91 and for 2 items i.e. 2(f) & 2(g) was 0.92
  • Overall reliability of tool was 91(UnstandardizedCronbach’s alpha)

TABLE-2

Reliability analysis of 7-12 domains of Nursing Evaluation Tool by Cronbach’s Alpha

 

Items of Tools Scale Mean if Item Deleted Corrected Item Total Correlation
7(a) – Looks anxious/fearful 131.83 .75
7(b) – Looks sad and depressed 132.30 -.00*
7(c) – Has frequent mood changes 131.80 .68
7(d) – Laughs or smiles appropriately 131.77 .38
7(e) – Feels restless 132.47 .62
7(f) – Feels agitated 132.10 .38
7(g) – Has tremors 132.13 -.03*
7(h) – Has destructive and assaultive behavior 131.80 .48
7(i) – Shows anger and annoyance towards himself 131.83 .28
7(j) – Shows anger and annoyance towards others 132.37 .55
8(a) – Participates in prayer voluntarily 131.80 .54
8(b) – Believes to remain in religious activities for whole day 132.10 -.09*
8(c) – Believes in faith-healers 132.43 .12*
8(d) – Refuses to believe in faith-healers 131.73 .39
9(a) – Talks about sex matters with fellow patients 132.13 .26
9(b) – Has tendency to exhibit sex organs 131.47 .62
9(c) – Openly masturbates 131.10 .38
10(a) – Is cooperative with others 131.93 .61
10(b) – Has uncooperative and unfriendly behavior with others 131.90 .65
10(c) – Initiates the conversation 132.47 .12*
10(d) – Avoids talking to staff members 131.80 .36
10(e) – Participates in ward activities without any persuasion 132.07 .51
10(f) – Easily interacts with family members 131.87 .56
10(g) – Understands about his role in family 132.07 .46
10(h) – Is ready to take responsibilities of his family 132.10 .39
11(a) – Blames himself for drug-abuse(if tell verbally by self) 132.40 .45
11(b) — Understands about losses associated with drug-abuse 132.00 .44
11(c) – Has full determination to quit drug- addiction 132.23 .64
11(d) – Has feeling of hopelessness and emptiness 132.50 -.09*
11(e) – Maintains eye contact during conversation 132.00 .36
12(a) – Has manipulative behaviour 131.97 .66
12(b) – Has demanding nature 132.03 .66
12(c) – Doing mischievous activities 131.87 .73
12(d) – Seeking/hiding drugs 131.90 .76
12(e) – Doing quarrels and fights with fellow patients 131.93 .77
12(f) – Participating in groupism activities 132.03 .69
12(g) – Doing unfair sexual indications towards females 131.70 .01*
  • Overall scale mean was 06
  • *Items in the tool which shows item to total correlation<0.2
  • Cronbach’s Alpha if item deleted for 88 items was 91 and for 2 items i.e. 2(f) & 2(g) was 0.92
  • Overall reliability of tool was 91(UnstandardizedCronbach’s alpha)

TABLE-3

Correlation-Coefficient of NET’s items(Domain-1 to Domain-5) by using Spearman’s rho correlation

 

Items of Tools Correlation-Coefficient
1(a) – Is aware of his illness 0.17*
1(b) – Denies for his drug-addiction 0.29
1(c) – Wants to quit drug-addiction 0.49
1(d) – Seeks treatment for his withdrawal symptoms 0.36
1(e) – Accepts the medicines easily 0.29
1(f) – Looks well kempt and tidy 0.00*
1(g) – Is ready to comply with the treatment 0.57
2(a) – Complains of loss of appetite -0.71*
2(b) – Complains of increased appetite 0.56
2(c) – Complains of heart burn 0.13*
2(d) – Has dry mouth 0.41
2(e) – Accepts his meals without persuasion 0.04*
2(f) – Has reduced weight  (>2 kg in a month) as needed -0.51*
2(g) – Has gained weight (>2 kg in a month) as needed -0.43*
2(h) – Complains of nausea and vomiting 0.41
2(i) – Is on supplementary treatment (Multivitamins) 0.27
3(a) – Complains of abdominal pain -0.20*
3(b) – Has diarrhea (loose stools>3 times/day) 0.55
3(c) – Needs anti-diarrheal drug (lomotil as a treatment) 0.63
3(d) – Has constipation (stool passed once in 3 days) 0.04*
3(e) – Needs laxatives/enema 0.04*
3(f) – Has painful micutration 0.00*
3(g) – Has urinary retention -0.04*
4(a) – Is able to do his self care activities 0.42
4(b) – Does his self care activities on persuasion 0.36
4(c) – Does not participate in ward activities 0.14*
4(d) – Participates in prayer voluntarily/persuasion 0.33
4(e) – Engages himself in P.T. voluntarily/persuasion 0.33
4(f) – Easily tells about his complaints on as king 0.00*
4(g) – Takes meals from meal trolley by self 0.43
4(h) – Washes his utensils by self 0.43
4(i) – Indulges self in group activities 0.33
4(j) – Participates in indoor games without persuasion 0.43
4(k) – Attends art of living/yoga classes 0.04*
5(a) – Complains of sleep disturbance -0.04*
5(b) – Has early awakening in morning 0.52
5(c) – Prefers daytime sleep 0.41
5(d) – Feels refreshed after a sound sleep 0.42
5(e) – Demands sedatives for sound sleep 0.43
5(f) – Has excessive sleep 0.52
5(g) – Feels drowsy/lethargic throughout the day. 0.46
* Items with Correlation-Coefficient <0.2 has dropped from the tool.(33 items).

TABLE-4

Correlation-Coefficient of NET’s items (Domain-6 to Domain-12) by using Spearman’s rho correlation

 

Items of Tools Correlation-Coefficient
6(a) – Complains of aches and pains -0.13*
6(b) – Is aware of his withdrawal symptoms 0.52
6(c) – Has full orientation to time 0.00*
6(d) – Has full orientation to place 0.00*
6(e) – Has full orientation to person 0.00*
6(f) – Has poor attention & concentration(DB & DF) 0.39
6(g) – Appears confused everytime 0.52
6(h) – Has hallucinations at present 0.29
6(i) – Has delusions at present 0.27
6(j) – Understands the facts related to treatment 0.50
6(k) – Is aware of motor incoordination 0.41
6(l) – Is aware of inappropriate behaviour & impaired functioning 0.51
7(a) – Looks anxious/fearful 0.17*
7(b) – Looks sad and depressed 0.18*
7(c) – Has frequent mood changes 0.28
7(d) – Laughs or smiles appropriately 0.34
7(e) – Feels restless 0.39
7(f) – Feels agitated 0.54
7(g) – Has tremors 0.29
7(h) – Has destructive and assaultive behaviour 0.48
7(i) – Shows anger and annoyance towards himself 0.19*
7(j) – Shows anger and annoyance towards others 0.16*
8(a) – Participates in prayer voluntarily 0.51
8(b) – Believes to remain in religious activities for whole day 0.33
8(c) – Believes in faith-healers 0.07*
8(d) – Refuses to believe in faith-healers 0.18*
9(a) – Talks about sex matters with fellow patients 0.12*
9(b) – Has tendency to exhibit sex organs 0.35
9(c) – Openly masturbates 0.00*
10(a) – Is cooperative with others 0.00*
10(b) – Has uncooperative and unfriendly behaviour with others 0.00*
10(c) – Initiates the conversation 0.10*
10(d) – Avoids talking to staff members 0.29
10(e) – Participates in ward activities without any persuasion 0.52
10(f) – Easily interacts with family members 0.48
10(g) – Understands about his role in family 0.45
10(h) – Is ready to take responsibilities of his family 0.37
11(a) – Blames himself for drug-abuse(if tell verbally by self) 0.39
11(b) – Understands about losses associated with drug-abuse 0.37
11(c) – Has full determination to quit drug- addiction 0.64
11(d) – Has feeling of hopelessness and emptiness 0.14*
11(e) – Maintains eye contact during conversation 0.44
12(a) – Has manipulative behaviour 0.53
12(b) – Has demanding nature 0.46
12(c) – Doing mischievous activities 0.58
12(d) – Seeking/hiding drugs 0.56
12(e) – Doing quarrels and fights with fellow patients 0.70
12(f) – Participating in groupism activities 0.62
12(g) – Doing unfair sexual indications towards females 0.04*

 

Corrected item to total correlation was applied on 90 items of tool. All the items in the scale had item score to total score correlation between -0.62 to 0.05 (Table 1-2). Total 67 items had item score to total score correlation more than 0.02 whereas 23 items in the tool had item score to total correlation less than 0.2 showing their incompatibility with the overall tool.

The correlation-coefficient was also calculated by Spearman’s correlation (bivariate). Out of total 90 items in the original tool 33 items were deleted as correlation-coefficient was <0.2. Rest 57 items had correlation-coefficient between 0.2 to -0.71*. Those 33 items (Correlation- coefficient<0.2) were dropped from the tool.(Table 3-4 )

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 0.787(The KMO value of data should be 0.50 for proceeding for factor analysis.) where as p value of Bartlett’s test of sphericity was 0.001(Table-5) which was significant (Value of Bartlett’s test of sphericity must be <0.05). It means that the data was suitable for factor analysis.

For calculating factor analysis only 57 items were considered which had Spearman’s correlation-coefficient more than 0.02. Total 13 components was generated through Principal component (Varimax rotation). All 57 items were retained in the 13 components so generated which accounted for the 89% of the variance.
Bartlett’s test of sphericity(p value)**     0.001

To find out the extraction communality value of each item of Nursing Evaluation Tool, Principal Analysis extraction method was applied. Initial communality is assumed as 1(100%) for each item. Table-6 depicts the extraction communality of each item.

Extraction communality of items was in range of 0.64-0.98. Average communality extraction was 0.89 (Average communality extraction should be >0.60). It means data is suitable to carry out factor analysis. The item as 4(g)-Takes meals from meal trolley by self, 12(a)-Has manipulative behaviour, 12(d)- Seeking/hiding drugs , 12(e)- Doing quarrels and fights with fellow patients; had highest value of communality extraction i.e.0.98 in comparison to 11(a)-Blames himself for drug-abuse which got lowest value of communality extraction i.e. 0.64.

Principal component analysis technique with varimax rotation had yielded a total of 13 domains having Eigen Value of above 1.The Eigen values of 13 components was in the range of 1.745-13.125.The 13 domains so generated accounted for 89% variance.(Table-7)

TABLE-6

Extraction communality of items of Nursing Evaluation Tool

 

Items of Tools Extraction communality of items
1(b) – Denies for his drug-addiction .89
1(c) – Wants to quit drug-addiction .97
1(d) – Seeks treatment for his withdrawal symptoms .90
1(e) – Accepts the medicines easily .93
1(g) – Is ready to comply with the treatment .96
2(b) – Complains of increased appetite .93
2(d) – Has dry mouth .80
2(h) – Complains of nausea and vomiting .94
2(i) – Is on supplementary treatment (Multivitamins) .75
3(b) – Has diarrhea (loose stools>3 times/day) .87
3(c) – Needs anti-diarrheal drug (lomotil as a treatment) .94
4(a) – Is able to do his self care activities .87
4(b) – Does his self care activities on persuasion .88
4(d) – Participates in prayer voluntarily/persuasion .89
4(g) – Takes meals from meal trolley by self .98
4(h) – Washes his utensils by self .97
4(i) – Indulges self in group activities .87
4(j) – Participates in indoor games without persuasion .67
5(b) – Has early awakening in morning .88
5(c) – Prefers daytime sleep .89
5(d) – Feels refreshed after a sound sleep .87
5(e) – Demands sedatives for sound sleep .94
5(f) – Has excessive sleep .84
5(g) – Feels drowsy/lethargic throughout the day .88
6(b) – Is aware of his withdrawal symptoms .97
6(f) – Has poor attention & concentration(DB & DF) .86
6(h) – Has hallucinations at present .94
6(i) – Has delusions at present .88
6(j) – Understands the facts related to treatment .91
6(k) – Is aware of motor incoordination .97
6(l) – Is aware of inappropriate behavior & impaired functioning .97
7(b) – Looks sad and depressed .81
7(c) – Has frequent mood changes .97
7(d) – Laughs or smile appropriately .96
7(e) – Feels restless .77
7(f) – Feels agitated .90
7(j) – Shows anger and annoyance towards others .79
8(a) – Participates in prayer voluntarily .84
9(a) – Talks about sex matters with fellow patients .72
10(a) – Is cooperative with others .92
10(b) – Has uncooperative and unfriendly behaviour with others .95
10(d) – Avoids talking to staff members .85
10(e) – Participates in ward activities without any persuasion .89
10(f) – Easily interacts with family members .89
10(g) – Understands about his role in family .94
10(h) – Is ready to take responsibilities of his family .94
11(a) – Blames himself for drug-abuse(if tell verbally by self) .64
11(b) – Understands about losses associated with drug-abuse .87
11(c) – Has full determination to quit drug- addiction .96
11(e) – Maintains eye contact during conversation .91
12(a) – Has manipulative behaviour .98
12(b) – Has demanding nature .79
12(c) – Doing mischievous activities .97
12(d) – Seeking/hiding drugs .98
12(e) – Doing quarrels and fights with fellow patients .98
12(f) – Participating in groupism activities .88
12(g) – Doing unfair sexual indications towards females .93
*Initial communality of each item is assumed 1(100%). **Average communality extraction is 0.89
***Extraction communality of items was in range of 0.64-0.98

 

 

TABLE  – 7

Principal Component Analysis (Varimax Rotation) of NET

Rotation Sums of Squared Loadings

Component           Eigen values of        % of Variance of      Cumulative % of of tool                        components            components            components

1 13.215 23.184 23.184
2 5.912 10.371 33.555
3 4.265 7.483 41.038
4 4.184 7.340 48.378
5 3.920 6.877 55.255
6 3.501 6.142 61.397
7 2.693 4.725 66.122
8 2.658 4.663 70.785
9 2.631 4.615 75.400
10 2.404 4.217 79.618
11 2.126 3.729 83.347
12 1.844 3.236 86.582
13 1.745 3.061 89.644

Scree plot of 57 items of Nursing Evaluation Tool was drawn and it showed the point of inflection at 13thcomponent (Figure-1). And it as clear in the Scree plot that till 13thcomponent the Eigen value is above one. So it is clear that all the 13 components can be retained with 57 items.

Scree Plot

20

15

10

5

0

 

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57

Component Number

Figure-1

Scree Plot of Nursing Evaluation Tool showing amount of variance accounted for each factor Out of 13 components generated 8 components retained more than 3 items so finally eight components were retained with 49 items and the rest of eight items were listed under miscellaneous domain.

Domains generated by Factor Analysis using Principal Component Analysis through Varimax Rotation

Domain-1(Health perception and health management)

1(c)     Wants to quit drug-addiction

1(d)    Seeks treatment for his withdrawal symptoms

1(e)    Accepts the medicines easily

1(g)    Is ready to comply with the treatment

4(d)           Participates in prayer voluntarily/persuasion

4(e)    Engages himself in P.T. voluntarily/ persuasion

4(g)    Takes meals from meal trolley by self 4(h)  Washes his utensils by self

4(j)     Participates in indoor games without persuasion

6(b)    Is aware of his withdrawal symptoms

6(j)   Understands the facts related to treatment

6(k)    Is aware of motor incoordination

6(l)    Is aware of inappropriate behavior & impaired functioning

12(a) Has manipulative behaviour 12(b) Has demanding nature 12(c) Doing mischievous activities 12(d) Seeking/hiding drugs

12(e) Doing quarrels and fights with fellow patients

12(f) Participating in groupism activities

Domain-2 (Role-relationship)

9(a) Talks about sex matters with fellow patients

10(f) Easily interacts with family members 10(g) Understands about his role in family 10(h) Is ready to take responsibilities of his

family

11(a) Blames himself for drug-abuse(if tell verbally by self)

11(b) Understands about losses associated with drug-abuse

11(c) Has full determination to quit drug- addiction

Domain-3 (Nutrition and Metabolism) 2(b)    Complains of increased appetite 2(h)    Complains of nausea and vomiting

11(e) Maintains     eye   contact  during conversation

Domain-4 (Activity and Exercise)

3(c) Needs anti-diarrheal drug (lomotil as a treatment)

4(a) Is able to do his self care activities 6(h) Has hallucinations at present

8(a) Participates in prayer voluntarily

Domain-5 (Sleep and Rest)

5(c)    Prefers day time sleep

5(d) Feels refreshed after a sound sleep 5(e) Demands sedatives for sound sleep 5(f) Has excessive sleep

6(i) Has delusions at present

Domain-6 (Mood and Stress Tolerance)

7(c)    Has frequent mood changes 7(d)          Laughs or smiles appropriately 10(a) Is cooperative with others

10(b) Has uncooperative and unfriendly behavior with others

Domain-7 (Self-Perception and Self-Concept)

5(g)     Feels drowsy/lethargic throughout the day

7(f)     Feels agitated 7(g)       Has tremors

10(e) Participates in ward activities without any persuasion

Domain-8(Behaviour)

4(i)     Indulges self in group activities 7(b)       Looks sad and depressed

7(e) Feels restless

Miscellneous

1(b)     Denies for his drug-addiction

3(b)    Has diarrhoea (loose stools>3 times/ day)

2(d)    Has dry mouth

4(b)    Does his self care activities on persuasion

5(b)    Has early awakening in morning

2(i)     Is on supplementary treatment (Multivitamins)

10(d) Avoids talking to staff members

6(f)      Has poor attention & concentration (DB & DF)

 

Discussion:

Nursing evaluation is the process of examining a system or system component to determine the extent to which specified properties or care components are present. Evaluation is the process of examining and rating a subject based on its important features. In review of literature,it is revealed that nursing evaluation in documentation is very important. The documentation about the patient’s recovery in psychiatric as well as Drug-De addiction and Treatment Centre set- up is very scanty. The nursing evaluation is a part of nursing process. A nurse plans according to the needs of patient and implements the plans and then evaluates her work and documents in the records whether there are positive or negative results of his/ her implementations.14The present study was based on the assumption that the nurses working in addiction treatment centres spend a large amount of time with the patients and have so much to observe; but a very small proportion of their observation is actually communicated to the other treating team members. This happens for a variety of intrinsic and extrinsic factors. One important factor is the lack of standardized performa or tool to document the nurse’s observation regarding the recovery of the patients in the unit.

The present study was undertaken to develop such a tool which would cover all domains of functional recovery and wouldprimarily guide the nurses to perform as well as document the assessment and observation made by them. In this study, initially the in-depth review of literature related to functional recovery and evaluation was done and the preliminary Nursing Evaluation Tool was drafted. The preliminary Nursing Evaluation Tool (NET) was further refined by using the Delphi technique. It is an iterative process designed to combine experts opinion into group consensus.15It is a method for structuring a group communication process.16It’s not only the knowledge, rather the willingness to engage in discussion and the interest and involvement with the question being addressed are also important. While choosing a panel of experts for the current study, by the investigator these factors were kept in mind. For the conventional Delphi, a heterogeneous sample is used to ensure that the entire spectrum of opinion is determined.17 In the present study the heterogeneous panel of exper ts included the psychiatrists, psychologists, nurse educators, clinical instructors and the staff nurses. The Delphi technique employs repeated rounds in which questionnaires are sent out until a consensus is reached. The process raises the question of how many rounds it takes to reach a consensus.18The classical original Delphi used four rounds. 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.19The current study had a total of four rounds to develop a final version of the NET.

Some studies were reviewed for construct validity and reliability. In one of the studies Williams et al also used Cronbach’s Alpha to find out reliability of short form of Chinese version of Anxiety State for Children. The Cronbach’s alpha coefficient of their tool was 0.83 suggesting the reliability of the tool.20Another study was on development and initial psychometric evaluation of patient is perspective of Arrhythmias questionnaire. In this study also Cronbach alpha coefficient was used to find out the reliability of tool. The value of Cronbach alpha coefficient for tool was 0.93 which indicates the internal consistency of the tool.21 Jones et al also used Cronbach’s alpha to find out reliability of Postnatal Health Instruments-one for mother (M-PHI) and one for father (F-PHI)-to measure health during the first year of parenting. The Cronbach’s alpha coefficient of M-PHI was 0.87 and F- PHI was 0.90 respectively suggesting the reliability of the instrument.22Another study was on psychometric evaluation of the Index of Self-regulation for Physical Activity. In present study also Cronbach’s alpha coefficient was used to find out the reliability of tool. The value of Cronbach’s alpha coefficient for their tool was 0.81 which indicates the internal consistency of the tool.23Similarly a study on reliability and validity of a Chinese language version of Palmore’s Facts on Aging Quiz had also applied and established Cronbach’s alpha coefficient at 0.68 which also suggested the reliability of the tool.24 In another study of construct validity and reliability of the Chinese version of the Patient Rated Wrist Evaluation (PRWE) ,Wah et al had used Cronbach’s alpha to find out the internal consistency of their questionnaire and value of Cronbach’s alpha coefficient was 0.78 which also suggested the reliability of the questionnaire.25In the present study internal consistency (reliability) was checked by Cronbach’s alpha The Cronbach’s alpha coefficient of present NET was 0.91, showing the reliability of the tool. It also revealed that all the items were uniformly contributing for the reliability of the tool.

Factor analysis is most often used as a part of instrument development process. It is a method for organizing the items into the factors. It can be used to reduce the number of items in the scale by eliminating factors with low factor loadings or items that load approx. equal on two or more factors.26In one study, Kuoand et al developed a scale to measure peer caring behaviour of nursing students by using factor analysis in Southern Taiwan. There were 27 items in the original tool out of which 17 items were retained after applying the factor analysis. In another study; there was development of the differentiation of self and role inventory for nurses. There were a total of 47 items in the original tool which were reduced to 23 after factor analysis.27 One more study on alcohol and drug confrontation scale had also used factor analysis. There were total 72 items in the original scale and out of which only 64 items were retained.28

Inter-item correlation was checked by Spearman’s correlation (bivariate) in the present study. There were a total of 90 items in the original tool and out of that 33 items were deleted as Correlation-Coefficient was <0.2 and then factor analysis was done on 57 items to check the construct validity. Total 13 components were generated through Principal component (Varimax rotation). And all 57 items were retained in the 13 components so generated which accounted for the 89% of the variance. Only 8 domains could retain three or more items accounting for 49 items. Hence rest of the eight items were listed under the miscellaneous domain. After factor analysis the final tool has 57 items under 8 domains and miscellaneous items.

The overall Cronbach’s alpha coefficient of 90 items was 0.91 which indicates internal consistency of the tool. When the Cronbach’s alpha if item deleted was applied only two items has shown increase in the value of Cronbach’s alpha coefficient. It indicates all the items are retained through Cronbach’s alpha coefficient. Experts felt that other 33 items which were dropped in factor analysis are also important and could be used to assess the functional recovery in the subject and should be retained.Hence with the expert’s consensus all the items of the tool were retained.

From the above discussion it is clear that the developed Nursing Evaluation Tool is reliable, valid and can be used by other nursing professionals to assess the functional recovery in the subjects with substance dependence. The scale has 12 domains. It covers all the domains of functional recovery in the subjects with substance dependence

i.e. Health Perception and Health Management, Nutritionand Metabolism, Elimination, Activity and Exercise, Cognition and Perception, Sleep and Rest, Self-Perception and Self-Concept, Roles and Relationships, Sexuality and Reproduction, Coping and Stress Tolerance, Values and Belief, Behaviour. The average time taken in assessing the functional recovery of a substance dependent subject is 15 minutes.The feasibility of tool in other Drug- De addiction centres can also be checked.

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