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On-line version ISSN 1695-6141
Enferm. glob. vol.11 no.27 Murcia July 2012
Relevance of data collection instruments for quality of care
Relevancia de instrumentos de recolecta de datos en la calidad del cuidado
Guilherme, C.*; Carvalho, E.C. de**; Landeros López, M.***
*Teaching Diploma in Nursing. CNPq Technical Support Grantee, Nursing and Communication Laboratory. Ribeirão Preto College of Nursing. University of São Paulo, Brazil. E-mail: email@example.com
**Ph.D. in Nursing. Full Professor at the Ribeirão Preto College of Nursing. University of São Paulo.
***Ph.D. in Nursing. Faculty Researcher, School of Nursing, Universidad Autónoma de San Luis Potosí. México.
In view of the importance of the nursing process in evidence-based practice, we attempt to identify validated and reliable instruments to collect data from patients. An integrative review was carried out in the databases CINAHL, BVS and PUBMED, using the words "nursing" and "validated clinical assessment tools", as well as"validation studies", "reproducibility of results" and "nursing assessment". Full articles available in English, Spanish or Portuguese were included, excluding reviews that did not follow the methodological steps describedand did not address the theme. In the 40 analyzed studies, instruments were identified that are applicable to different areas, such as geriatrics and gerontology, intensive care, oncology, psychiatry, nutrition, infectology, occupational health, palliative care, cardiology, among others. Instruments were found to evaluate the follow ingareas: risk of falls, patient satisfaction, quality of life, sleep, depression, mental confusion, dementia, pain, behavior, nutritional status, violence, personality, psychosis, breast feeding, nausea and vomit, fatigue, end of life needs, sedation and agitation, abstinence from opioid use, pressure ulcers, capacity of workers with musculoskeletal problems to restart activities, immunological status of patients with HIV/AIDS, and patients' degree of knowledge about their disease. There was an increase in the number of publications from 1990 to 2006. Most of the instruments, 47.5%, were applicable to elderly populations. Nursing, when using validated instruments in its practice, provides more qualified care. Several behaviors and clinical manifestations exist,however, without validated instruments for their assessment.
Key words: Instruments. Validation. Data collection. Nursing.
Considerando la importancia del proceso enfermero en la práctica basada en evidencias, buscamos identificar instrumentos validados y confiables para la recolección de datos en pacientes. Realizamos una revisión integrativa utilizando las bases CINAHL, BVS, PUBMED. Fueron incluidos artículos disponibles a texto completo en inglés, español y portugués, se excluyeron las revisiones que no contenían descritos los pasos metodológicos y los que no abordaban el tema. En los 40 estudios analizados fueron identificados instrumentos aplicables a diferentes áreas como geriatría y gerontología, terapia intensiva, oncología, psiquiatría, nutrición, infectología, salud del trabajador, cuidados paliativos, cardiología, entre otros. La mayoría de los instrumentos 47.5% aplicaba para población anciana. Enfermería al utilizar instrumentos validados en su práctica pasa a ejercer una asistencia con mayor calidad. Sin embargo, es evidente que diversos comportamientos y manifestaciones clínicas todavía no disponen de instrumentos validados para su evaluación.
Palabras clave: Instrumentos. Validación. Recolección de datos. Enfermería.
To strengthen nursing autonomy1-2, in professional practice, intuition has been replaced by the inclusion of research results that support the assessment of patients' health conditions3.In the development of the nursing process, it is relevant to collect data with a view to identifying the phenomena or diagnoses present that will constitute the reference framework for the elaboration of the care plan and the implementation of care actions.
This explains the relevance of validated instruments, which are still limited, considering the range of the profession. Besides, validated instruments are not always known and used. Thus, the aim in this research is to identify validated and reliable instruments that can be applied in the data collection phase of the Nursing process.
An integrative review was accomplished4 in the databases CINAHL, BVS and PUBMED, using the key words "nursing" and "validated clinical assessment", as well as "validation studies", "reproducibility of results" and "nursing assessment". The titles and abstracts were analyzed, and publications without a clear presentation of the instruments' construction or validation were discarded. Out of 132 identified abstracts, 12 were excluded because they reported on a bibliographic review without paper selection criteria; 46 did not adapt to there search objectives, as they evaluated nursing services, medical instruments or diagnosis validations; 17 others were repeated, i.e. they were present in more than one database, andone was not available in English, Spanish or Portuguese. Then, out of 56 remaining papers, 16 were excluded because they were not available online, finally resulting in 40 papers.
Characteristics of investigated papers
First, in the analysis of the 40 papers5-44, general identification, dissemination, study designand subject characteristics were considered.
As for the publication date, the studies were issued between 1990 and 2009, and increasedas from 1999, particularly in 20 0 47,16,29,41,42,44 2 0 0 66,8,11,30,38,39 and 200821,26-28,37,43
When identifying the study population, it was evidenced that an important number of studies (n=19) contained instruments applied to the elderly population5,8,10,13,15,16,18,19,21,23,28-30,32,34,36,39,40,43 followed by studies with instruments focused on adults (n=9)6-7,17,22,24,26,35,38,44, pediatric patients (n=2)11,25, infants (n=2)27,41 and subjects of different ages (n=4)20,33,37,42 , while others did not specify the study population (n=4)9,12,14,31.
Concerning the clinical areas, 18 studies were developed in Geriatrics and Gerontology5,8,10,13,15-16,18-19,21,23,28-30,32,34,39-40,43, five in Intensive Care11,17,25,37,41; four in Oncology26,35,38,42, besides Occupational Health9, Palliative Care31, Cardiology14 and other studies that did not specify the area12,36.
Patient data collection instruments according to clinical area
According to the clinical areas, instruments were identified with different goals. The Geriatrics and Gerontology instruments were focused on the identification and assessment of fall risks5,21,29-30, patient satisfaction assessment8, assessment of patients' perceived quality oflife13, sleep assessment15, depression assessment and identification16,18,28, assessment of mental confusion10, identification of dementia in elderly patients32, pain assessment in elderly patients with dementia40, identification of behavioral changes in elderly patients with dementia39, eating difficulties of elderly patients with dementia19 nutritional assessment of hospitalized elderly34 physical morbidity assessment36 and assessment of discomfort inpatients with Alzheimer's43.
The instruments cited in Psychiatry were aimed at: assessment of personality aspects6, specification of violence in psychiatric patients7,44 and assessment of psychosis patients20.
Specific nutrition instruments were used to discuss the assessment of neonatal breastfeeding27 and appetite33. Oncology instruments were focused on the assessment of chemotherapy-induced nausea and vomiting26, assessment and identification of depression35, and sleep assessment42. In the Palliative Care area, an instrument was used to identify end-of-life needs31.
In Intensive Care, instruments were used to assess sedation and agitation levels in pediatric patients11, confusion17, opioid and benzodiazepine abstinence syndrome at a pediatric ICU25,pressure ulcer risk prevention37 and neonatal pain41. In occupational health, the aim was toassess the capacity of workers with musculoskeletal problems to perform their activities upon their return to work9. In the Infectology area, an instrument was used to assess the immunological status of HIV/AIDS patients22,24 and, in Cardiology, to assess patients'knowledge level on their disease14. Another instrument was aimed at identifying and assessing fall risks in hospitalized patients without age specifications12.
Data collection instruments according to validation
Among the elderly fall risk assessment instruments, the "Morse Falls Scale" and "STRATIFY" demonstrated comparability with nurses' clinical judgment and precision5. The use of the "Hendrich Fall Risk Model" to assess fall risks can predict almost 75% of falls, with a 74.9% sensitivity and 73% specificity level. The instrument has been validated and tested in anacute care context12.
Researchers in Australia evaluated the fall risk through two instruments, one of which specifically assessed the fall risk in elderly patients with conditions to stay alone. The otherwas a specific instrument to assess patients who needed help for self-care. Three times higher fall levels (sensitivity 73%, specificity 55%) were identified among patients able to stay alone and with two or three fall risk factors (e.g. previous falls, being institutionalized, presence of urinary incontinence), while two times higher fall rates (sensitivity 87%,specificity 29%) were found among patients who needed help with self-care, were in no conditions to stay alone and displayed between one and three risk factors21.
In the United States, existing types of post-fall instruments were assessed at private andpublic care institutions. It was found that, at most institutions, fall risk assessment instrumentswere used instead of post-fall assessment instruments (63.7%). The authors highlighted the importance of this distinction, as post-fall assessment instruments specifically serve to identify the etiology of falls, and indicated that no validated and empirically tested post-fall assessment instrument was identified29. In a more recent study30, the feasibility of the "PostFall Index" for care institutions was assessed, showing good inter-rater agreement (70-100%). That instrument has been validated and is reliable and clinically applicable to prevent falls.
To support the assessment of behaviors and injuries in the fields of memory, daily activities, mood, social behavior and behavioral disorder, the "Nurses' Observation Scale for Geriatric Patients" (NOSGER) was another validated instrument for elderly populations. Nurses orcaregivers can apply it, and both relatives and caregivers considered the approval levelgood23. The identification of dementia in elderly patients was another research problem. The "Dementia Screening Scale" (DSS) obtained a precision level of AUC=0.912 (95% CI 0.89-0.94), showing a better validity score than the team's diagnostic assessment. The scale was considered easy to apply, low-cost and associated with low levels of non-response32. Behavioral changes in elderly patients with dementia could also be measured through the "Behavioural and psychological symptoms of dementia" (BPSD) instrument, with goodinternal consistency (a=0.86), agreement (ICC=0.79), and test-retest reliability (ICC=0.98). Behavioral changes were associated with the male gender, cognitive problems, functional disability, neuropsychiatric symptoms and high levels of work overload in caregivers39.
For pain assessment, four instruments were correlated with the "Observational Rating Scale" for validation purposes, including the "Escala Horizontal Visual Analógica" (HVA), "EscalaVertical Visual Analógica" (VVAS), the "Faces Pain Scale" (FPS) and the "6-point verbal rating scale" (VRS), showing high reliability and strong correlation levels (Spearman's=0.81 -0.95; p<0.01). The "Observational Rating Scale", then, was moderately correlated with thepatient's self-assessment, tended to underestimate pain intensity and was only indicated forthose patients who proved they were unable to answer the self-assessment41.
The risk of pressure ulcers was assessed with the help of the "Suriadi and Sanda Scale" (SSScale), applied to patients hospitalized at intensive care units, with a sensitivity level of 81%,specificity 83%, positive predictive value 65% and negative predictive value 91%. Further research on predictive validity was considered necessary after the validation of the scale, as well as the determination of cut-off points in different populations37.
The perceived quality of life in a community of elderly patients was assessed through the 12 items of the "Assessment of Quality of Life" (AqoL) instrument, whose psychometric validity was considered acceptable. The instrument demonstrated sensitivity to predict future health costs, showing that high scores result in lower future costs, as opposed to low scores13.
The patient satisfaction assessment instrument "Satisfaction with the Nursing Home" was applied to elderly people living in care institutions with a view to assessing satisfaction withthe quality of nursing services. Its use is indicated for researchers, leaders, managers and professionals who work to improve care quality for institutionalized elderly patients8.
The knowledge of patients with heart conditions on their own disease was measured with thehelp of the "Patient Knowledge questionnaire" (PKQ). Through this instrument, the assessment of patients' knowledge became fundamental to identify and clarify doubts, besides contributing to behavioral changes14.
The "Observational Sleep Assessment Instrument" (OSAI) was used to measure elderly people's sleep pattern, with an agreement level of 92.7%. Most variables showed consistency and correlation, being very similar with the information obtained from the portable monitor. The study simple was considered small though, demanding further studies in larger populations15. Cancer patients' sleep could be assessed through the "Pittsburg Sleep Quality Index" (PSQI), which is considered relatively easy to apply. The Index showed reliability and construct validity on the psychometric evaluation but, also, additional research was suggested to assess the reliability, sensitivity and construct validity in cancer patients of different ethnic origins, with a view to using the instrument in clinical studies42.
Among instruments to assess the functional capacity of workers with musculoskeletal problems to perform their activities when returning to work, the "Functional Abilities Confidence Scale" (FACS) and the "Occupational Role Performance Questionnaire" (ORQ) showed the highest percentages of psychometric evidences. This type of instrument helps to monitor the rehabilitation of workers' damage progress, offers a comprehensive assessment of the impact of treatment and its global effect, and indicates the workers' aptitude to return to their functions. Other potential uses for these instruments are the assessment of change inworkers' limitations, the identification of workers with lower production levels, besides there organization of aims and work responsibilities, decreasing task demands, besides identifying people at risk of damage9.
The "Sign and Symptom Check-List for Persons with HIV Disease" (SSC-HIV) focused on common signs and symptoms of HIV patients. The evaluated symptoms were: fever, fatigue, confusion, nausea and vomiting, psychological anguish, dyspnea, gastrointestinal discomfortand diarrhea, which can help with the intervention plan. As a limitation, the lack of items that expressed women's experience in living with HIV/AIDS was appointed. Sign and symptom management is considered the main component of HIV/AIDS patient care. Their assessment in this process can improve communication between patients and professionals, besides facilitating early diagnosis and intervention22. Another study also assessed changes in the immunological status of HIV patients through the "HIV-Quality Audit Marker" (HIV-QAM). Its predictive validity for mortality ranged between three and six months after the start of hospital treatment against pneumonia related with Pneumocystis carinii24.
The instruments that assessed the opioid abstinence syndrome focus attention on children in Intensive Care. It was high lighted that this event can affect up to 20% of children exposed to opioid use, and is related with the duration of the total dose infusion25. The syndrome can beassessed using instrument like the "NAS". Its use revealed greater effectiveness than the clinical judgment used at most neonatal centers. The "OBWS" showed a strong correlation with nurses' clinical judgment, with 80% reliability, 87% specificity and 50% sensitivity; the" Seven Signs of Behavioural Distress" revealed a 95% inter-rater reliability coefficient; and the "Sedation Withdrawal Score" provided no validated data to sustain its use25. A pilot study was accomplished to validate the "State Behavioural Scale" (SBS), with a view to measuring sedation and agitation levels in intubated infants and small children, showing moderate tohigh inter-rater correlation11.
Measuring the intensity and duration of chemotherapy-induced nausea and vomiting is beneficial to control antiemetics use. For this purpose, the "MAT" and "INVR" were used, which could be combined with a small scale of daily measures to evaluate the intensity and duration of nausea and vomiting and an additional question about previous use of antiemetics and adverse events26. The cancer patient fatigue assessment instrument provides quantitative information to monitor patients' condition and treatment progress. The information can improve communication between professionals and patients and even be included in proposed treatment decisions. The instrument used was the "Wu Cancer Fatigue Scale" (WCFS), applied to women with breast cancer. Nevertheless, validation is needed inpatients with other types of cancer, treatment and in other populations38.
Eating difficulties in elderly patients with dementia were assessed with the help of the instrument "Edinburgh Feeding Evaluation in Dementia" (EdFED), which obtained a significant correlation between the Nursing interventions (supervision, physical help andnursing care level) and the eating difficulty indicators (spilling or leaving food on the plate after eating)19. The aim of the "Nutrition Screening Tool" (nST) was to identify the nutritional status of hospitalized elderly patients, and the instrument permitted documenting this assessment. The tool is recommended for outpatient or hospital care centers34. Eight items from the "Council on Nutrition appetite questionnaire" (CNAQ) and two items deriving from the "Simplified Nutritional Appetite Questionnaire" (SNAQ) were used to predict weight loss and assess appetite. Both instruments were considered clinically efficient and facilitated the early identification of anorexia risk due to weight loss33. Neonatal breast feeding could beassessed using the "NOMAS", whose psychometric properties are considered consistent and complete to assess both maternal and bottle feeding27.
The assessment of depression in elderly people and the importance of effective screening for depressive symptoms in this population were demonstrated when applying the "GDS Score".The nurses detected corresponding symptoms in 50.1% of the elderly28. When applying the five items of the "Geriatric Depression Scale" (GDS) to identify depression in elderly people, another study18 showed significant agreement with the clinical diagnosis, as 48.1% of this population was depressed. The "ISAR" instrument was validated to identify severe functional losses and depression in elderly people and to assess the results of subsequent interventions16. Assessing depression in palliative care patients is relevant and, on many occasions, is not considered in clinical practice, although it can be done with the help of the visual scale35.
To assess psychosis, the "Positive and Negative Syndrome Scale" (PANSS) and "Routine Assessment of Patients Progress" (RAPP) were used, which identified score differences between groups with the same diagnosis, demonstrating the characteristics of the psychosis manifestation pattern. Focusing on the importance of evidence-based practice, the use of instruments was considered relevant to document clinical results20. Using the "Millon Multiaxial Clinical Inventory" (MMCI-II) and the "Entitlement Scale" (ES) (Cronbach's &alpha:=.9740) to assess personality traits, traits of aggression, sociopathy and paranoia were found, which permitted the accomplishment of therapeutic interventions based on the evidence the study provided6. Another study used an instrument to preview violence in psychiatric patients in a clinical practice context, called the "BVC-VAS". The instrument revealed easy use and precision to predict violent attacks in psychiatric nursing services7.The same instrument can be applied with a 64.3% sensitivity and 93.9% specificity level44.
The "NEECHAM Confusion Scale" was used to identify delirium in elderly hospitalized patients, to monitor the course of the cognitive dysfunction and the severity of the delirium10.In another study, the aim was to construct an instrument called "Confusion assessment method for the intensive care unit" (CAM-ICU), with a view to preventing delirium at intensive care units through the assessment of physical, chemical and environmental stressors patients are exposed to. Forty-eight percent of delirium was found, similar to other studies in the area17.
End-of-life care needs were assessed using the "Needs at the End-of-Life Screening Tool" (NEST), with a view to determining the course of actions and desired patient outcomes, addressing social, existential, symptomatic and therapeutic needs31. Physical exercise among institutionalized elderly patients was assessed with the help of the "Continuing Care Activity Measure" (CCAM). This instrument permitted distinguishing gross motor function levels and changes, stimulating the focus of this population's mobilization, with a view to reducing nursing time-associated costs and contributing to wellbeing36. Discomfort in patient with Alzheimer's was also assessed with the help of the "Discomfort Scale for Dementia ofthe Alzheimer's Type" (DS-DAT), which is considered easy to use, fast and effective to help health and mainly Nursing professionals, as they regularly interact with patients and, therefore, need reliable instruments to assess comfort or wellbeing43.
The number of publications on the theme increased between 1999 and 2006. Most papers(47.5%) were focused on the elderly population, with specific instruments for Geriatrics and Gerontology, which are significant today in the context of global population aging. When using validated instruments in its practice, the quality of Nursing care increases. It is evident, though, that different behaviors and clinical manifestations still lack validated instruments for their assessment, and that, on many occasions, Nursing professionals do not know existing ones.
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