A STUDY of COMPREHENSIVE NURSING ASSESSMENT of PATIENTS in HOSPITAL by LO Po Hung, Gordon Supervisor

A STUDY OF COMPREHENSIVE NURSING ASSESSMENT OF PATIENTS IN HOSPITAL By LO Po Hung, Gordon Supervisor: Professor Anne Chang A Thesis Submitted to The Department of Nursing, Faculty of Medicine Of the Chinese University of Hong Kong In Partial Fulfillment of the Requirements For the Degree of Master of Philosophy in Nursing December, 1998 U- � X^^^^iik^K l 气 1 ^ j|||^j^i| ‘'X UNIVERSITY""""^1_j %.L!BRARY SY3TE^y \%S^ ACKNOWLEDGMENTS I would like to express my sincere thanks and gratitude to my supervisor, Prof. A. Chang for her expert advice and constant support and guidance throughout the study. I would also like to express my thanks to the participating hospitals, to the department of managers and the ward managers that allow me to conduct the study. Last but not the least, I would also like to express my thanks to the registered nurses who have participated in this study. Without their support, I think I cannot finish the study. i ABSTRACT Assessment provides a basis for diagnostic reasoning and comprehensive nursing assessment is necessary for the provision of a holistic care. The purpose of this study was to understand the implementation of a comprehensive approach to nursing assessment in the acute hospitals of Hong Kong. A descriptive study design was employed. Data were collected by questionnaires, interviews and a review of nursing records. Convenience sampling method was used to select hospitals, wards, nurses and nursing records. In total, two hospitals were selected from the 11 general acute hospitals in Hong Kong. Eight medical wards and six surgical wards in both hospitals were selected. Ninety-one copies of questionnaires from nurses were returned giving a response rate of 65%. For the interviews, 12 nurses with at least two years' experience in the same field participated in the interviews. Fifty-eight nursing records were reviewed. The questionnaire included information about the main areas of assessment and the requested demographic data. The main areas of assessment were devised in accordance to the framework from the General Eclective Data Collection Model and included 5 sections which were the basic information, biophysical, psychological, sociocultural and spiritual. Respondents were required to use a Likert scale to indicate the extent to which their usual assessment included each ofthe items. Content validity was established by three nursing experts. The documentation of assessment was determined from nursing records using a checklist with the same items as in the questionnaire. But yes/no choice was used instead of Likert scale. The correlation ii coefficients for test-retest of the questionnaire and the checklist of nursing records were 0.83, p=0.006 and 0.94, p<0.001 respectively. The alpha coefficients for the questionnaire and the checklist of nursing records for the main study were 0.96 and 0.88 respectively. For the interview, structured guidelines were used for the interview to elicit information about the factors that affected the implementation of comprehensive nursing assessment. The results showed that the level of performance of comprehensive nursing assessment as reported by nurses was at a moderate level. But a greater emphasis was found for the physiological assessment in comparison to psychosocial and spiritual assessment. Nurses in hospital A used a more comprehensive approach to assessment than those from hospital B. Furthermore, no statistically significant differences were found in the nurses' reports or the records of assessment according to age, education level, year of graduation and type of wards. The lack of comprehensive patient assessment may affect the degree of patient satisfaction, quality of care and the cost-effectiveness of the health care system. Barriers to the implementation of comprehensive nursing assessment were identified as heavy workload, lack of knowledge and skills, lack of clarity about the extent to which nurses are expected to perform the assessment and the acute nature of the disease. Improvement in the quality of care to patients is likely to be achieved if education and skill development in assessment, more comprehensive nursing assessment forms are adopted and if the patient-centered delivery system is employed. ii"i 摘要評估是診斷論證的基礎，整全護理評估是提供整全性護理所必需的。本研究的目的是欲了解香港急性醫院應用整全性護理評怙實施的情况。研究採用描述性研究設計，透過問卷、面談及參閱護理記錄查核，應用方便取樣法(03[^^6[1丨6006 sampling旧61:^^1)選取醫院、病室及護理記錄。從香港十一間急性醫院選取兩間醫院，並在兩所 •院選取八間內科及六間外科病室。護士交回問卷共91份，回收率達65% ；面談方面，12名具備最少兩年該科經驗的護士參予面談；並查核了 58份護理記錄。問卷内容包括護理評估的主要範圍及對象的背景資料。評怙的主要範圍是根據一般綜合資料收集模式（General Eclectic Data Collection Model)而設計，有五個部份，包括基本資料、生理、心理、社會文化及靈性。對象需要在Likert量表上顯示日常評估包括各項的程度；內容效度方面，由三位護理專家確定。評估的記錄方面應用與問卷相同項目的評核表作測定，但以是/否選擇代替Likert量表°問卷及^理記錄查核表的再測相關系數分別為0.83 ’ B-0. 006 及0.94，p<0.001 ；而在本研究中，問卷及護理記錄查核表的“系數分別為0. 96及0. 88�在會談方面，透過結構性指引用以了解影響整 iv 全護理評估實踐的因素。結果顯示護士的整全護理評估實踐為中等程度，但比較心理社交及靈性的評估，則生理評怙較為著重。甲醫院的護士比乙醫院的護士較多使用整全評估的方向°就年齡、教育程度、畢業年份及病房類別，無論在護士自述或護理記錄方面均無統計上顯著的差異° 缺乏整全性病人評估會影響病人的滿足感、護理質素及醫療系統的成本效益°阻礙整全護理評估的實施包括工作量大、缺乏知識及技能、期望護士實施評估的範圍欠清晰’以及疾病屬急性的性質。若能發展評估方面的教育及技能、採用較整全的護理評估表格及應用以病人為中心的護理制度，改善病人的護理質素是指日可待的。 V TABLE OF CONTENTS Page ACKNOWLEDGMENTS ABSTRACT (ENGLISH & CHEVESE VERSION) ii LIST OF TABLES vi CHAPTER 1. EVTRODUCTION 1 2. LITERATURE REVIEW 3 Nursing Assessment 3 Purpose ofNursing Assessment 4 The Importance ofNursing Assessment 5 The Influence of the Concepts ofHealth and Holism on Comprehensive Nursing Assessment 7 Philosophical Perspectives on Nursing Assessment 8 The Incorporation ofNursing Theories or Models into Nursing Assessment 10 Implementation of Comprehensive Nursing Assessment 12 Areas Included in the Comprehensive Nursing Assessment 13 Biophysical Assessment 14 Psychological Assessment 16 Sociocultural Assessment 19 Spiritual Assessment 21 Summary 24 3. METHOD 25 Design 26 Sampling _ 28 Data Collection Methods 32 Data Collection Procedure 37 Pilot study 39 Reliability 41 Ethical Considerations 43 Data Analysis 44 vi 4. RESULTS 47 Sample Characteristics 47 Mean Scores for Comprehensive Assessment 50 Items with Higher and Lower Scores in the Questionnaires and the Checklists ofNursing Records 53 Items with Higher and Lower Means in Each Category in Comprehensive Assessment Questionnaire 57 Differences in the Total and Category Assessment Mean Scores 59 Factors Affecting the Implementation Comprehensive Nursing Assessment 64 Suggested Interventions to Enable Nurses to Perform Comprehensive Nursing Assessment 67 5. DISCUSSION AND CONCLUSION 71 The Performance of Comprehensive Nursing Assessment 71 The Focus of the Assessment within Each Component of Nursing Assessment 74 Factors Affecting the Implementation of Comprehensive Nursing Assessment 81 Limitations 87 Implications for Practice 89 Recommendations for Future Research 91 Conclusion 92 REFERENCES 94 vii LIST OF APPENDICES Appendix Page I Application Letters for Approval 108 II Comprehensive Assessment Questionnaire with Cover Letter 110 (Preliminary) III Interview Guidelines 116 IV Comprehensive Assessment Questionnaire (Finalized) English version 117 Chinese version 121 V Checklist ofNursing Records 126 VI Letter from the Ethical Committee of the Faculty ofMedicine, The Chinese University ofHong Kong 129 VII Letters from the Ethical Committees of the Two Sample Hospitals 130 VIII The Mean Scores ofEach Item in the Comprehensive Assessment Questionnaire in Accordance with the Different Categories in Descending Order 132 IX Differences in the Total Score and the Mean Scores ofthe 5 Categories among Different Groups such as Age, Education, Experience and Year of Graduation by Kaiskal-Wallis Test 134 X Differences in the Total Score and the Mean Scores ofthe 5 Categories among Different Groups such as Type of Wards and Hospitals by Mann-Whitney U Test 136 viii LIST OF TABLES Table Page 1 The Number of Questionnaire Items Measuring the 5 Categories and the Subcategories with Its Corresponding Question Numbers 40 2 Frequency Distribution of Sample Characteristics for the Comprehensive Assessment Questionnaires 48 3 Frequency Distribution of Sample Characteristics for Interview 50 4 The Mean of the Total Score and Categories in the Questionnaires 51 5 The Mean Percentage of the Items Included in the Nursing Records 52 6 The Mean and Standard Deviation of the 10 Highest and 10 Lowest Items Included in the Comprehensive Assessment Questionnaires 54 7 The Items with the Highest Mean Percentage Scores and Items Not Included in the Checklists ofNursing Records 56 8 Items with Higher and Lower Scores in Each Category in the Comprehensive Assessment Questionnaire (in descending order) 58 9 Difference in the Total Score and the Mean Score ofthe 5 Categories in the Comprehensive Assessment Questionnaire among Groups with Different Years ofExperience by Kruskal-Wallis Test 60 10 Difference in the Total Score and the Mean Score ofthe 5 Categories in the Comprehensive Assessment Questionnaire between Two Different Hospitals by Mann-Whitney U Test 62 11 Difference m the Means in the Checklist ofNursing Records between the Two Different Hospitals by Mann-Whitney U Test 63 12 Frequency Distribution of the Listed Reasons by the Interviewee 64 13 Frequency Distribution of the Listed Interventions by the Interviewee 68 ix Chapter 1 INTRODUCTION Continuous assessment and interpretations about patient's needs are the nurses' responsibilities which differentiates nurses from doctors and other health care professionals (Latimer, 1998). Nursing assessment is the first step of the nursing process, during which data are collected systematically (Doenges & Moorhouse,

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