Validation of β- Patient Self-Sufficiency Assessment Scale - the Results of a Pilot Study
Beáta Frčová¹*, Tatiana Rapčíková¹, Zuzana Frčová ¹, Miriam Mjartanová², Anna Melichová¹ , Martin Hrubala¹
¹Faculty of Health Care in Banská Bystrica, Slovak Medical University in Bratislava, Slovak Republic
²National Rehabilitation Center, Kováčová, Slovak Republic
* Corresponding author: Beáta Frčová, Faculty of Health Care in Banská Bystrica, Slovak Medical University in Bratislava, Slovak Republic
Received Date: 13 February, 2023
Accepted Date: 21 February, 2023
Published Date: 23 February, 2023
Citation: Frčová B, Rapčíková T, Frčová Z, Mjartanová M, Melichová A, et al. (2023) Validation of β- Patient Self-Sufficiency Assessment Scale - the Results of a Pilot Study. Int J Nurs Health Care Res 6: 1407. DOI: https://doi.org/10.29011/2688-9501.101407
Abstract
The aim of the pilot study was to validate the newly created β scale for assessing the self-sufficiency of patients with a focus on selected neurological diseases. A group of 39 patients from the National Rehabilitation Center in Kováčová was included in the pilot testing. Each patient was tested for self-sufficiency three times during hospitalization. The reliability of β scale was evaluated by content construct (convergent) validity, while we chose Barthel's self-sufficiency test as a comparative scale. The reliability of the β scale was verified by Cronbach's α coefficient. In all three assessments, the value of the Cronbach coefficient α was ≤ 0.9. The reliability of the assessment tool was also measured by Person's correlation of the results of repeated measurements. p values were >0.0001. The results encourage further testing of the β scale to assess the level of self-sufficiency, which would lead to the improvement of nursing care.
Keywords : Validation; β scale; Self-sufficiency; Patient; Pilot study.
Introduction
Self-sufficiency and self-care are nursing phenomena and are the central metaparadigm of many nursing theories and models [1]. The nurse has the opportunity to directly identify the areas of nursing care deficit using assessment tools and specialize directly in them, in order to achieve the highest possible level of self-sufficiency [2]. The assessment of the level of self-sufficiency is carried out by a nurse in various areas of nursing care, in all age categories. Self-care means the ability to perform daily activities and is an indicator of health and quality of life [3-5].
In the broadest sense, an assessment tool is a collection of scales, questions and other information that provide a picture of an individual's needs and related factors. In the narrower sense, it is a mean of identifying and aiming for a specific health condition, which also includes self-care [6,7].
Neurological diseases prevent patients from normal activities and therefore adequate self-care, because many patients suffer from a wide range of symptoms, among which motor symptoms predominate. Impairment of gross and fine motor skills gradually leads to partial or complete loss of self-care ability and invalidation of the patient. For the above reason, we decided to create a new scale, which we called the β scale. We believe that it can become a relevant tool for assessing the self-sufficiency of patients with selected neurological diseases [8]. We first presented the β scale in 2006 and since then it has been tested several times at selected workplaces in Slovakia and the Czech Republic.
The starting point for the construction of our proposed scale was the Kurtz scale - EDSS, the Clifton self-sufficiency scale and diagnostic criteria for multiple sclerosis.
Also, many studies of patients with chronic neurological diseases confirm that the patient's belief that he himself is able to manage certain difficulties resulting from the disease is associated with a higher probability of effective adherence, i.e.compliance with the recommended procedures for the treatment of the disease on the patient´s side [9].
Material and Methods
The goal of our pilot study was to validate and assess the reliability of the β scale for assessing the level of self-sufficiency of patients with selected neurological diseases. The β scale (Table 1) contains 20 items - activities, which are evaluated on a scale of 0-3 points, while the evaluation of 0 points represents complete independence, 1 point partial dependence, 2 points significant dependence and 3 points complete dependence of the patient.
Need |
0 points |
1 point |
2 points |
3 points |
Gross motility - - movement |
Trouble
free autonomous
movement |
Autonomous
movement, problems
in overcoming
barriers and obstacles |
Movement
using compensatory
aids |
Immobile
patient (wheelchair,
patient
on bed) |
|
||||
Receiving food and fluids |
Independently
without any help |
Independently,
difficulty grabbing
objects |
Help
required (cutting,
table manners) |
Fed
by another person |
|
||||
Emptying the bladder |
Independently,
without problems |
Occasional
need for
help, occasional spontaneous
urinary or
stool leakage |
Frequent,
spontaneous urinary
leakage using the compensatory aids |
Incontinence |
|
||||
Emptying the colon |
Independently,
without problems |
Occasional
problems with
constipation |
Frequent
problems with constipation |
Incontinence |
|
||||
Dressing, undressing |
Independently
without any help |
Independently,
the tasks take
longer time |
Other
person´s help required |
Full
help from another person required |
|
||||
Fine motility |
Without
problems, without
reduced sensitivity |
Reduced
sensitivity of
the fingers and upper
extremities |
Significant
paresthesis, great
effort in grabbing
objects |
Intentional
tremor |
|
||||
Appearance care, aesthetics |
Independently,
with interest in
own appearance |
Independently,
without a
stronger interest in own appearance |
Requires
occasional
other person´s help |
Other
person´s help required |
|
||||
Body hygiene |
Independently |
Independently,
using the
safety utilities |
Partial
independence, other person´s assistance required |
Other
person´s help required |
|
||||
Active exercises, rehabilitation |
Independently,
several times
a day |
Independently,
once
a day |
Regularly,
other person´s help required |
Immobile |
|
||||
Orientation in time and space |
Fully
oriented |
Occasional
disorientation (especially in
the afternoon), help
required |
Frequent
confusion and
disorientation during
a day |
Total
confusion and
disorientation |
|
||||
Visual perception |
Unlimited |
Loss
of visual acuity,
double vision |
Reduction
of field of view,
oculomotor nerve
paresis |
Blind |
|
||||
Hearing perception |
Unlimited |
Objectively
assessed reduced
audibility without
the need for
compensatory aids |
Loss
of hearing, the
need for compensatory
aids |
Deaf |
|
||||
|
|
|
|
|
Rest and sleep |
Quality
sleep with no
interruption |
Night
waking, 1- to 3-times |
Night
waking, over
3-times |
Insomnia |
|
||||
Communication |
Active,
adequate, fully-preserved
non-verbal
expressions |
Poor
articulation, slightly
limited non-verbal expressions |
Significantly
impeded, poor,
nonverbal expressions,
mourning prevails |
Both
verbal and non-verbal communication inability |
|
||||
Occupation, employment: |
No
limitations |
Full-time
employee, burden causes problems |
Part-time
employee |
Full
disability |
................................... |
|
|||
Learning, receiving new information |
Active, No-limitations |
Adequate
interest, limited
activity |
Reduced
interest in
activities depending on moods and ther person´s help required |
Inactivity |
|
||||
Leisure activities |
Spending
leisure time actively, hobbies: .................... .................... .................... |
Spending
leisure time actively, occasional help required |
Spending
leisure time actively, continuous assistance required |
Inactivity |
|
||||
Cultural events attendance |
Regularly,
independently |
Sometimes
assistance
required |
Very
rarely and
limited |
Inactivity
due to associated
symptoms |
|
||||
Club
visiting ROSKA |
Frequent,
active help
in organizing events |
Occasional,
sporadic help
in organizing events
|
Rare
visit assistance necessary |
Not
attending any club activities |
|
||||
Total number of points |
|
|
|
|
Table 1 : The β scale for patient's self-sufficiency level assessment (Frčová, Rapčíková); Assessment of self sufficiency based on the number of gained points; 0 - 15 point-independent patient; 16 - 30 points patient partially dependent on the help from another person; 31 - 30 points patient considerably dependent on the help from another person; 46 - 60 points patient fully dependent on the help from another person.
Individual items include common daily activities, fine and gross motor skills, aesthetics of appearance, exercise, orientation in space and time, sensory perception, communication, work, learning, free-time activities and self-help groups.
The pilot study involved 39 patients from the National Rehabilitation Center in Kováčová, which is a specialized hospital with a nationwide scope for the treatment of patients after spinal cord injuries with spinal cord damage, selected neurological diagnoses, polytraumatism, amputations, and after demanding operations of the locomotor system. The average length of stay of the patients in this facility was three weeks, so it was possible to assess the level of self-sufficiency in three phases. Of the 39 patients, 17 were women (43.59%) and 22 were men (56.41%). The average age of the men was 58.27 years (SD 11.05, median 58.5 and mode 69 years). The average age of the women was 57.94, (SD 16.36, median and mode were the same 65 years). For 26 patients (66.67%) it was the first hospitalization and 13 patients (33.33%) were hospitalized repeatedly.
Each patient's self-sufficiency was assessed by the β scale to verify its reliability repeatedly at the beginning, in the middle and at end of hospitalization. The average length of hospitalization was three weeks. Between the first and the second measurements, the patients had already completed rehabilitation treatment, which is top-notch in this medical facility and could have affected the level of self-sufficiency of the patients. Kobsah's validity was also expressed by renowned experts from the Center for the Treatment of Demyelinating Diseases at the Thomayer Hospital in Prague in the Czech Republic and at the Neurological Department in Žiar nad Hronom in Slocvakia.
Results
To verify the construct (convergent) validity of the β scale, we used a comparison of its results with the results of the simultaneously performed Barthel self-sufficiency test at each assessment. A statistically significant correlation of the given assessment tools was found, the correlation coefficients of the corresponding items are statistically significant and indicate their high agreement (p < 0.0001 in all items). Due to the fact that the assessment in the items of the b scale and the Barthel test is reversed, the correlation coefficients are negative.
The reliability of the β scale was verified in three ways: Cronbach's a coefficient, repeating of the measurement with a step of time (test-retest method) and determining the agreement of the evaluators despite the fact that there is a time gap between the evaluations.
Cronbach’s coefficienta
In all three measurements, the value of the Cronbach's a coefficient is telling about the significant internal reliability of the assessment scale . Its values are greater than 0.9 in all three evaluations, thus indicating a good internal consistency of the assessment tool.
Cronbach´s a coefficient: I. measurement: II. Measurement III. Measurement
- b scale: 0.9131 0.9121 0.9221
- Barthel´s test 0.9210 0.9156 0.9240
Correlations of individual items to the total score (item-total correlation) were also calculated in each measurement, with proven statistical significance.
Only the correlation of item 12 (visual perception) was problematic, because most of the respondents functioned without limitation of visual perception, only three respondents had a narrowing of the visual field. Item 16, related to employment, was also problematic because most of the respondents in our group are retired (old-age or disabled). Question 20, visiting the ROSKA club, was also problematic because the respondents do not visit the club. However, we would not rule out problematic questions, because we plan to use our assessment tool in various medical facilities, and we must take into account the fact that the patients at the National Rehabilitation Center are mostly patients with more serious health problems.
We also verified the reliability of our assessment tool by Pearson's correlation of the results of repeated measurements. The correlation coefficients indicate the significant relationship of the measured total score of patients' self-sufficiency within all three assessments (Table 2), the corresponding p values confirmed their statistical significance. In all three intercomparisons, p values were less than 0.0001.
TS I. measurement |
1 |
0.9118 |
0.7773 |
TS II. measurement |
0.9118 |
1 |
0.9389 |
TS III. measurement |
0.7773 |
0.9389 |
1 |
Table 2: Pearson correlation matrix of the total score of individual assessments (measurements); TS - Total Score.
We expected that, due to the effect of rehabilitation, the correlation coefficient I. and III. of the measurement could have smaller value. Although the value is smaller compared to the remaining coefficients (0.7773), it still speaks of the statistically significant connection of the first and third measurement. The statistical significance of all correlation coefficients speaks in favor of significant reliability of the assessment tool.
The validity of the use of the Pearson correlation coefficient was verified by the normality of the data of the total score of all three measurements at the significance level a = 0.01. The Shapiro-Wilk test was used to verify the normality of the data (I. measurement: W=0.9308; p=0.0190; II. measurement: W=0.9406; p=0.0398; III. measurement: W=0.9333; p=0.0229; W(39 ;0.01) = 0.917).
The assessment scale was administered by experts, the assessors were professionally qualified nurses from particular departments of the health care facilities.
The total score of the respondents in the β scale identified individual measurements of the frequency of patients independency of the help of another person, partially dependent, significantly dependent and completely dependent on the help of another person (Table 3).
Assessment of selfsufficiency of the patient |
I. measurement |
II. measurement |
III. measurement |
|||
n |
% |
n |
% |
n |
% |
|
Independent |
7 |
17.95 |
10 |
25.64 |
14 |
35.90 |
Partially dependent |
15 |
38.46 |
17 |
43.59 |
15 |
38.46 |
Heavily dependant |
14 |
35.90 |
11 |
28.21 |
9 |
23.08 |
Totally dependant |
3 |
7.69 |
1 |
2.56 |
1 |
2.56 |
together |
39 |
100.00 |
39 |
100.00 |
39 |
100.00 |
Table 3: Assessment of the level of self-sufficiency of the respondents by the β scale.
At the initial measurement, only 7 (17.95%) respondents were completely independent of the help of another person, 15 (38.46%) respondents were partially dependent on the help of another person, almost the same number of respondents 14 (35.90%) were heavily dependent and 3 (7.69%) respondents were completely dependent on the help of another person. We assume that due to the rehabilitation treatment and also due to the patients' diagnosis, their dependence on the help of others could change to a certain extent, as can be seen in the number of respondents of the given categories in Table 3.
We also verified the reliability of our assessment tool by measuring the mutual agreement of the assessors. We expressed the statistical significance of the degree of agreement of given measurements in pairs with each other using Cohen's kappa.
In the classification according to Landis and Koch [10] a statistically significant good agreement between the evaluators was confirmed in all cases. In the case of the 2nd and 3rd measurements, it was the most significant, the value of Cohen's kappa was the largest, and the agreement of the assessors in this case was up to 84.62% (33/39). In the case of the 1st and the 2nd measurements, the percentage of agreement was 71.79% (28/39) and the smallest percentage of agreement was in the case of the 1st and 3rd measurements 58.97% (23/39), which could have already been influenced by the change in respondents' self-sufficiency due to rehabilitation treatment.
The above analysis demonstrated a significant degree of reliability of the β scale as an assessment tool of patients' self-sufficiency and the suitability of testing it by patients of other facilities too.
Discussion
The results of testing the β scale, as a new proposed tool for assessing the level of self-sufficiency of patients with selected neurological diagnoses, show its high validity and reliability and greater suitability of its use in comparison with Barthel's self-sufficiency test. The limiting factor was the size of the tested sample of patients, but the testing will continue with other groups of patients. The low number of tested patients was also caused by the COVID-19 pandemic, when the hospital facility had a significantly lower proportion of hospitalized patients.
In the scientific resources, we encounter similar studies in which the authors monitor the validity and reliability of various assessment tools. In studies of Turkish authors Oguz et al. [11] in 2021, the effectiveness of the Palliative Performance Scale version 2 of geriatric oncology patients was tested and compared with the Katz ADL. The tested scale was evaluated as highly reliable and effective. Studies by Pires et al. In the year 2020 [12], the use of the accelerometer in mobile phones was tested to identify activities of daily life. Although the use of new technologies is certainly revolutionary in this direction, the study also demonstrated certain limits that these technologies still have. In the Finnish studies of the authors Pohjola et al. in 2021 [13] tested the modified Rankin Scale in patients with cerebral vascular malformations and assessed the quality of life and health of these patients and compared the results with the general population. The modified Rankin Scale showed significantly better results of the followed patients than the general population, which was measured by the original Rankin Scale. In 2018, the authors Lee and McCambridge [14] published in the Journal of Physiotherapy the results of testing the Rating Scale (ALSFRS-R) of patients with amyotrophic lateral sclerosis, and it was possible to fill out the questionnaire with the scale not only in print form, but also in online mobile application. The results were very encouraging and the authors confirmed the Rating scale as the most advantageous for assessing the self-sufficiency and quality of life of these patients. An important aspect of the comparison of several scales was the study by the Japanese authors Goto et al. [15], who investigated the effectiveness of the Kurtzke Expanded Disability Scale (EDSS), which is used in multiple sclerosis, and compared it with the Rankin scale in patients with brainstem surgery to assess the performance of patients. The EDSS allowed a better assessment and a more precise assessment of the patient's condition than Kurtzke's extended scale.
We also come across other authors with similar researches where they test different evaluation scales. Above all, there is a study Ghosna et al. in 2016 [16], the results of Australian authors Aggarwal, Kean in 2010 [17] Czech women authors led by Taliánová in 2013 [18].
Conclusion
The use of assessment scales in nursing aims primarily to increase the objectivity of the assessment of the patient's condition and consequently to help the nurse in planning the implementation of interventions in the nursing process. Creating and testing new instruments is such an important research activity, because introducing a new assessment scale into life is a long and demanding process. The results that we have published in this article are very important for informing the professional public, as well as for cooperation on further testing of the β scale for assessing the level of self-sufficiency of patients with selected neurological diseases.
Acknowledgment
We thank the management and staff of the specialized medical facility National Rehabilitation Center in Kováčová and Prof. MUDr. Myrón Malý, CSc. for his support and expert opinions.
Financing
The presented research article is the result of the implementation of an internal grant, which the authors obtained from the Slovak Medical University in Bratislava under no. 04/2021-SVG 1. The authors declare that there is no conflict of interest. The project also includes a written approval opinion of the Ethics Committee of the Faculty of Health of the Slovak Health University on the implementation of the project under no. 1/2022 of March 14, 2022.
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