90 items - .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.
Development of Nursing Evaluation Tool: A methodological study for evaluating the functional recovery in subjects with substance dependence Renu Bala, Karobi Das, Avinash Rana, S.K.Mattoo 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 0.70).
Nursing and Midwifery Research Journal, Vol-8, No.4, October 2012
250
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
131.73 131.97 132.00 131.80 131.73 131.81 132.03 132.50 131.83 131.97 131.90 131.90 133.03 133.07 132.07 133.53 132.43 132.03 132.00 131.73 131.73 131.73 131.70 131.77 131.97 132.10 131.77 131.77 131.13 131.73 131.77 132.07 132.67 132.33 132.67 131.97 132.07 132.03 132.33 131.77 132.13 132.47 131.80 131.80 132.33 131.73 132.43 132.67 131.73 131.70 131.73 131.83 131.80
.05* .16 .65 .59 .48 .62 .68 -.14* .51 -.01* .29 .03* -.62* -.52* .33 .24 -.22* .29 .44 -.00* -.00* -.03* -.05* .36 .32 .21 .59 .59 .26 .76 .76 .18* .58 .33 -.06* .30 .23 .43 .50 .23 .26 -.26* 78 .61 .50 .32 .42 .58 -.05* .41 .32 .74 .61
1(a) 1(b) 1(c) 1(d) 1(e) 1(f) 1(g) 2(a) 2(b) 2(c) 2(d) 2(e) 2(f) 2(g) 2(h) 2(i) 3(a) 3(b) 3(c) 3(d) 3(e) 3(f) 3(g) 4(a) 4(b) 4(c) 4(d) 4(e) 4(f) 4(g) 4(h) 4(i) 4(j) 4(k) 5(a) 5(b) 5(c) 5(d) 5(e) 5(f) 5(g) 6(a) 6(b) 6(c) 6(d) 6(e) 6(f) 6(g) 6(h) 6(i) 6(j) 6(k) 6(l)
-
Is aware of his illness Denies for his drug-addiction Wants to quit drug-addiction Seeks treatment for his withdrawal symptoms Accepts the medicines easily Looks well kempt and tidy Is ready to comply with the treatment Complains of loss of appetite Complains of increased appetite Complains of heart burn Has dry mouth Accepts his meals without persuasion Has reduced weight (>2 kg in a month) as needed Has gained weight (>2 kg in a month) as needed Complains of nausea and vomiting Is on supplementary treatment (Multivitamins) Complains of abdominal pain Has diarrhea (loose stools>3 times/day) Needs anti-diarrheal drug (lomotil as a treatment) Has constipation (stool passed once in 3 days) Needs laxatives/enema Has painful micutration Has urinary retention Is able to do his self care activities Does his self care activities on persuasion Does not participate in ward activities Participates in prayer voluntarily/persuasion Engages himself in P.T. voluntarily/persuasion Easily tells about his complaints on asking Takes meals from meal trolley by self Washes his utensils by self Indulges self in group activities Participates in indoor games without persuasion Attends art of living/yoga classes Complains of sleep disturbance Has early awakening in morning Prefers daytime sleep Feels refreshed after a sound sleep Demands sedatives for sound sleep Has excessive sleep Feels drowsy/lethargic throughout the day Complains of aches and pains Is aware of his withdrawal symptoms Has full orientation to time Has full orientation to place Has full orientation to person Has poor attention & concentration (DB & DF) Appears confused everytime Has hallucinations at present Has delusions at present Understands the facts related to treatment Is aware of motor incoordination Is aware of inappropriate behavior & impaired functioning
-
Overall scale mean was 132.06 *Items in the tool which shows item to total correlation 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) Nursing and Midwifery Research Journal, Vol-8, No.4, October 2012
255
TABLE-6 Extraction communality of items of Nursing Evaluation Tool Items of Tools 1(b) 1(c) 1(d) 1(e) 1(g) 2(b) 2(d) 2(h) 2(i) 3(b) 3(c) 4(a) 4(b) 4(d) 4(g) 4(h) 4(i) 4(j) 5(b) 5(c) 5(d) 5(e) 5(f) 5(g) 6(b) 6(f) 6(h) 6(i) 6(j) 6(k) 6(l) 7(b) 7(c) 7(d) 7(e) 7(f) 7(j) 8(a) 9(a) 10(a) 10(b) 10(d) 10(e) 10(f) 10(g) 10(h) 11(a) 11(b) 11(c) 11(e) 12(a) 12(b) 12(c) 12(d) 12(e) 12(f) 12(g)
-
Extraction communality of items
Denies for his drug-addiction Wants to quit drug-addiction Seeks treatment for his withdrawal symptoms Accepts the medicines easily Is ready to comply with the treatment Complains of increased appetite Has dry mouth Complains of nausea and vomiting Is on supplementary treatment (Multivitamins) Has diarrhea (loose stools>3 times/day) Needs anti-diarrheal drug (lomotil as a treatment) Is able to do his self care activities Does his self care activities on persuasion Participates in prayer voluntarily/persuasion Takes meals from meal trolley by self Washes his utensils by self Indulges self in group activities Participates in indoor games without persuasion Has early awakening in morning Prefers daytime sleep Feels refreshed after a sound sleep Demands sedatives for sound sleep Has excessive sleep Feels drowsy/lethargic throughout the day Is aware of his withdrawal symptoms Has poor attention & concentration(DB & DF) Has hallucinations at present Has delusions at present Understands the facts related to treatment Is aware of motor incoordination Is aware of inappropriate behavior & impaired functioning Looks sad and depressed Has frequent mood changes Laughs or smile appropriately Feels restless Feels agitated Shows anger and annoyance towards others Participates in prayer voluntarily Talks about sex matters with fellow patients Is cooperative with others Has uncooperative and unfriendly behaviour with others Avoids talking to staff members Participates in ward activities without any persuasion Easily interacts with family members Understands about his role in family Is ready to take responsibilities of his family Blames himself for drug-abuse(if tell verbally by self) Understands about losses associated with drug-abuse Has full determination to quit drug- addiction Maintains eye contact during conversation Has manipulative behaviour Has demanding nature Doing mischievous activities Seeking/hiding drugs Doing quarrels and fights with fellow patients Participating in groupism activities Doing unfair sexual indications towards females
*Initial communality of each item is assumed 1(100%). ***Extraction communality of items was in range of 0.64-0.98
.89 .97 .90 .93 .96 .93 .80 .94 .75 .87 .94 .87 .88 .89 .98 .97 .87 .67 .88 .89 .87 .94 .84 .88 .97 .86 .94 .88 .91 .97 .97 .81 .97 .96 .77 .90 .79 .84 .72 .92 .95 .85 .89 .89 .94 .94 .64 .87 .96 .91 .98 .79 .97 .98 .98 .88 .93 **Average communality extraction is 0.89
Nursing and Midwifery Research Journal, Vol-8, No.4, October 2012
256
TABLE - 7 Principal Component Analysis (Varimax Rotation) of NET Rotation Sums of Squared Loadings Component of tool
Eigen values of components
% of Variance of components
Cumulative % of components
1 2 3 4 5 6 7 8 9 10 11 12
13.215 5.912 4.265 4.184 3.920 3.501 2.693 2.658 2.631 2.404 2.126 1.844
23.184 10.371 7.483 7.340 6.877 6.142 4.725 4.663 4.615 4.217 3.729 3.236
23.184 33.555 41.038 48.378 55.255 61.397 66.122 70.785 75.400 79.618 83.347 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
Eigenvalue
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 Nursing and Midwifery Research Journal, Vol-8, No.4, October 2012
257
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) Par ticipates 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 drugaddiction 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
Nursing and Midwifery Research Journal, Vol-8, No.4, October 2012
258
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 supplementar y 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 impor tant 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 setup is very scanty. The nursing evaluation is a par t 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.
Nursing and Midwifery Research Journal, Vol-8, No.4, October 2012
259
The present study was undertaken to develop such a tool which would cover all domains of functional recover y 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 str ucturing 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 FPHI 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
Nursing and Midwifery Research Journal, Vol-8, No.4, October 2012
260
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
