Design and validation of the INICIARE instrument, for the assessment of dependency level in acutely ill hospitalised patients

The impact of humanising hospital care on health outcomes: an observational study protocol

BACKGROUND

The humanisation of care has emerged as a crucial element in contemporary healthcare, with several countries adopting the concept of patient and family-centred care. This change signifies an ongoing evolution within contemporary healthcare, emphasising person-centred approaches, patient autonomy and preferences. The humanisation of care extends beyond patients to include their families and healthcare professionals, to enhance health outcomes, clinical safety, accessibility and therapeutic relationships holistically. This project aims to evaluate the humanisation of care in hospital settings in southern Spain, examining its impact on health outcomes and identifying areas for improvement.

METHODS

The research employs a three-year multiphase approach, combining cross-sectional designs, qualitative-quantitative analyses and psychometric assessments. The study involves a diverse sample population, including patients admitted to several hospitals in southern Spain along with nursing professionals. Data collection incorporates a range of validated tools, items developed ad hoc and sociodemographic variables.

DISCUSSION

The study findings are expected to offer insight into healthcare management, clinical practice and education. Humanising care has the potential to positively impact health outcomes, and the study methodology may serve as a model for future research and educational programmes in healthcare. Whilst acknowledging its limitations, the study represents a critical step in evaluating the humanisation of care in Spanish hospitals and informing strategies for improvement. In conclusion, this comprehensive study addresses the humanisation of care in hospital settings, examining its dimensions and potential impact on health outcomes. The findings may influence policy decisions, emphasising the need to enhance the humanisation of care as a fundamental aspect of healthcare management.

TRIAL REGISTRATION

NCT06174844 (18/12/2023).

Enhancing nursing care through technology and standardized nursing language: The TEC-MED multilingual platform

PURPOSE

This study describes the design, integration, and semantic interoperability process of a minimum data set using standardized nursing language in the caring module of the TEC-MED care platform.

METHODS

The caring module was developed in three phases (2020-2022): platform concept, functional design and construction, and testing and evaluation. Phases involved collaboration among academics, information technology developers, and social/healthcare professionals. Nursing taxonomies (NANDA-I, NOC, NIC) were integrated to support the nursing process. The platform was piloted in six Mediterranean countries.

FINDINGS

The final platform features an assessment module with eight dimensions for data collection on older adults and their caregivers. A clinical decision support system links assessment data with nursing diagnoses, outcomes, and interventions. The platform is available in six languages (English, Spanish, French, Italian, Greek, and Arabic). Usability testing identified the need for improved Arabic language support.

CONCLUSIONS

The TEC-MED platform is a pioneering tool using standardized nursing language to improve care for older adults in the Mediterranean. The platform's multilingualism promotes accessibility. Limitations include offline use and mobile app functionality. Pilot testing is underway to evaluate effectiveness and facilitate cross-cultural validation of nursing taxonomies.

IMPLICATIONS FOR NURSING PRACTICE

The TEC-MED platform offers standardized nursing care for older adults across the Mediterranean, promoting consistent communication and evidence-based practice. This approach has the potential to improve care quality and accessibility for a vulnerable population.

The Association of Cognitive Impairment and Depression with Malnutrition among Vulnerable, Community-Dwelling Older Adults: A Large Cross-Sectional Study

(1) Background: Mental health issues in older adults, particularly cognitive impairment and depression, can affect nutritional status. This study investigates the prevalence of malnutrition among community-dwelling older adults at risk of social exclusion and dependency in Lebanon and its association with cognitive impairment and depression. (2) Methods: This cross-sectional study used secondary data from the TEC-MED project, involving 1410 older adults aged 60 and above in Beirut. Nutritional status was assessed with the Mini Nutritional Assessment _Short Form (MNA_SF), cognitive impairment with the AD8 Dementia Screening Interview, and depression with the Geriatric Depression Scale (GDS-15). (3) Results: 87.2% of participants were at risk of malnutrition, and 2.5% were malnourished. Cognitive impairment was present in 82.2% of the sample and 45% experienced moderate to severe depression. Malnourished individuals had significantly higher rates of cognitive impairment (96.7% vs. 57.8%) and depression (85.7% vs. 23.2%). Significant associations were found between the risk of malnutrition, decreased food intake, cognitive impairment, and depression; however, no significant association was found with BMI. Logistic regression analysis indicated that older age, cognitive impairment, and depression were significant predictors of malnutrition, while having a caregiver was protective. (4) Conclusions: The high prevalence of risk of malnutrition among vulnerable older adults with cognitive impairment and depression underscores the need for policies integrating nutritional screening into routine health check-ups for older adults.

Optimized Continuity of Care Report on Nursing Compliance and Review: A Retrospective Study

The Continuity of Care Report (CCR) is a fundamental document for ensuring high-quality healthcare and a smooth transition between different levels of care. The aim of this study was to evaluate the impact of optimizing the CCR to improve its completion rate by hospital nurses and its review by primary care nurses. To achieve this, a retrospective observational study was conducted on patients discharged from the University Hospital of La Plana de Vila-real during two three-month periods, one prior to the CCR improvement (2022) and one after (2023). No increase in the completion rate for the CCR was observed following its optimization (p = 0.226). However, a statistically significant improvement was noted in the percentage of reports reviewed (p > 0.001), increasing from 4.4% (n = 49) in 2022 to 30.5% (n = 327) in 2023. These results indicate that the optimization of the Continuity of Care Report enhances the communication between specialized care and primary care professionals.

Development and Validation of a Meta-Instrument for Nursing Assessment in Adult Hospitalization Units (VALENF Instrument) (Part I)

Nursing assessment is the basis for performing interventions that match patient needs, but nurses perceive it as an administrative load. This research aims to develop and validate a meta-instrument that integrates the assessment of functional capacity, risk of pressure ulcers and risk of falling with a more parsimonious approach to nursing assessment in adult hospitalization units. Specifically, this manuscript presents the results of the development of this meta-instrument (VALENF instrument). A cross-sectional study based on recorded data was carried out in a sample of 1352 nursing assessments. Socio-demographic variables and assessments of Barthel, Braden and Downton indices at the time of admission were included. The meta-instrument's development process includes: (i) nominal group; (ii) correlation analysis; (iii) multiple linear regressions models; (iv) reliability analysis. A seven-item solution showed a high predictive capacity with Barthel (R2adj = 0.938), Braden (R2adj = 0.926) and Downton (R2adj = 0.921) indices. Likewise, reliability was significant (p < 0.001) for Barthel (ICC = 0.969; τ-b = 0.850), Braden (ICC = 0.943; τ-b = 0.842) and Downton (ICC = 0.905; κ = 7.17) indices. VALENF instrument has an adequate predictive capacity and reliability to assess the level of functional capacity, risk of pressure injuries and risk of falls.

Predictive validity of the INTEGRARE scale in identifying the risk of hospital-acquired pressure ulcers in acute care hospital settings

BACKGROUND

Hospital-acquired pressure ulcers (HAPUs) are prevalent around the world and are an indicator of care quality. Numerous instruments are available to predict their appearance, but few evaluate predictive validity. No instruments based on Nursing Outcomes Classification indicators have been found, despite these indicators reflecting the patient's condition. The aim of the study was to analyse the predictive validity of the INTEGRARE scale in preventing the risk of HAPUs.

METHODS

A multicentre prospective observational cohort study design was used. 1,004 patients from 11 public hospitals in Andalusia (Spain) were recruited between February 2015 and October 2017. Participants were aged over 18 and had been admitted to medical and surgical units, with a predicted stay exceeding 48 h. Predictive validity was checked using a multivariate logistic regression model and a receiver operating characteristic curve, with development of pressure ulcers during the hospital stay as the dependent variable.

RESULTS

The INTEGRARE scale obtained an area under the curve of 0.886 (95% CI = 0.85-0.923). Within the 30-point range, the optimal cut-off value is 23 points with a sensitivity of 80.8% and a specificity of 80%. The odds ratio was 16.86 (95% CI = 8.54-33.28). Among the patient variables, age was significant, while among the hospital variables, the type of unit and the Nurse Staffing Level (NSL) were significant.

CONCLUSIONS

The INTEGRARE scale has robust predictive validity when patients are admitted to medical and surgical inpatient units. Patients with a higher risk of developing HAPUs are in surgical units, are elderly, and have an NSL exceeding 10.4.

Factors That Influence Nurse Staffing Levels in Acute Care Hospital Settings

PURPOSE

To identify which patient and hospital characteristics are related to nurse staffing levels in acute care hospital settings.

DESIGN

A cross-sectional design was used for this study.

METHODS

The sample comprised 1,004 patients across 10 hospitals in the Andalucian Health Care System (southern Spain) in 2015. The sampling was carried out in a stratified, consecutive manner on the basis of (a) hospital size by geographical location, (b) type of hospital unit, and (c) patients' sex and age group. Random criteria were used to select patients based on their user identification in the electronic health record system. The variables were grouped into two categories, patient and hospital characteristics. Multilevel linear regression models (MLMs) with random intercepts were used. Two models were fitted: the first was the null model, which contained no explanatory variables except the intercepts (fixed and random), and the second (explanatory) model included selected independent variables. Independent variables were allowed to enter the explanatory model if their univariate association with the nurse staffing level in the MLM was significant at p < .05.

RESULTS

Two hierarchical levels were established to control variance (patients and hospital). The model variables explained 63.4% of the variance at level 1 (patients) and 71.8% at level 2 (hospital). Statistically significant factors were the type of hospital unit (p = .002), shift (p < .001), and season (p < .001). None of the variables associated with patient characteristics obtained statistical significance in the model.

CONCLUSIONS

Nurse staffing levels were associated with hospital characteristics rather than patient characteristics.

CLINICAL RELEVANCE

This study provides evidence about factors that impact on nurse staffing levels in the settings studied. Further studies should determine the influence of patient characteristics in determining optimal nurse staffing levels.

Development and External Validity of a Short-Form Version of the INICIARE Scale to Classify Nursing Care Dependency Level in Acute Hospitals

Background: The increasing dependence care in patients hospitalized in acute hospitals around the world entails classification systems heeding the wide range of care dependency levels generated by the many different types of dependent patients. This article is a report of a study assessing the validity and reliability of a short-from version of the instrument (Inventario del NIvel de Cuidados mediante Indicadores de Resultados de Enfermería (INICIARE)) used to classify inpatients according to their care dependency level. Methods: The validation, carried out in a multicenter longitudinal study, included three different samples: the first sample of 1800 patients to evaluate the reliability and validity, a second of 762 patients for confirmatory factor analysis, and a third of 762 to test the short-form version. Patients over 16 years of age, admitted to medical or surgical units at 11 public hospitals, were included. Results: The final sample included 3605 patients. Patients had a mean age of 64.5 years, 60% were admitted to medical units, with severe dependency. The validation process yielded two versions of the instrument: a 40-item version, with eight factors with 83.6% of total variance explained and Cronbach's alpha values between 0.98 and 0.92, and a short-form with 26 items, with five factors and Cronbach's alpha values between 0.96 and 0.90. The Confirmatory Factor Analysis yielded a good fit model to the 40-item version (Chi Square on Degrees of Freedom CMIN/DF) = 1.335; Normed Fit Index (NFI); Tucker-Lewis Index (TLI); Comparative Fit Index (CFI) > 0.90; Standardized Residual Root Mean Square (RMSEA) = 0.02; and Standardized Residual Root Mean Square (SRMR) = 0.027) and 26-item version (Chi Square on Degrees of Freedom CMIN/DF = 1.385; NFI = 0.998; CFI = 0.999; RMSEA = 0.02; and SRMR 0.02). Both INICIARE versions obtained a high correlation between them (r = 0.96; p < 0.001). Conclusion: INICIARE has proved to be a valid and reliable instrument for the assessment of the level of care dependency of acutely hospitalized patients.

Factors Associated with In-Hospital Mortality in Acute Care Hospital Settings: A Prospective Observational Study

Background: In-hospital mortality is a key indicator of the quality of care. Studies so far have demonstrated the influence of patient and hospital-related factors on in-hospital mortality. Currently, new variables, such as nursing workload or the level of dependency, are being incorporated. We aimed to identify which individual, clinical and hospital characteristics are related to hospital mortality. Methods: A multicentre prospective observational study design was used. Sampling was conducted between February 2015 and October 2017. Patients over 16 years, admitted to medical or surgical units at 11 public hospitals in Andalusia (Spain), with a foreseeable stay of at least 48 h were included. Multivariate regression analyses were performed to analyse the data. Results: The sample consisted of 3821 assessments conducted in 1004 patients. The mean profile was that of a male (52%), mean age of 64.5 years old, admitted to a medical unit (56.5%), with an informal caregiver (60%). In-hospital mortality was 4%. The INICIARE (Inventario del Nivel de Cuidados Mediante Indicadores de Clasificación de Resultados de Enfermería) scale yielded an adjusted odds ratio [AOR] of 0.987 (95% confidence interval [CI]: 0.97-0.99) and the nurse staffing level (NSL) yielded an AOR of 1.197 (95% CI: 1.02-1.4). Conclusion: Nursing care dependency measured by INICIARE and nurse staffing level was associated with in-hospital mortality.

Nursing workload, nurse staffing methodologies and tools: A systematic scoping review and discussion

BACKGROUND

The importance of nurse staffing levels in acute hospital wards is widely recognised but evidence for tools to determine staffing requirements although extensive, has been reported to be weak. Building on a review of reviews undertaken in 2014, we set out to give an overview of the major approaches to assessing nurse staffing requirements and identify recent evidence in order to address unanswered questions including the accuracy and effectiveness of tools.

METHODS

We undertook a systematic scoping review. Searches of Medline, the Cochrane Library and CINAHL were used to identify recent primary research, which was reviewed in the context of conclusions from existing reviews.

RESULTS

The published literature is extensive and describes a variety of uses for tools including establishment setting, daily deployment and retrospective review. There are a variety of approaches including professional judgement, simple volume-based methods (such as patient-to-nurse ratios), patient prototype/classification and timed-task approaches. Tools generally attempt to match staffing to a mean average demand or time requirement despite evidence of skewed demand distributions. The largest group of recent studies reported the evaluation of (mainly new) tools and systems, but provides little evidence of impacts on patient care and none on costs. Benefits of staffing levels set using the tools appear to be linked to increased staffing with no evidence of tools providing a more efficient or effective use of a given staff resource. Although there is evidence that staffing assessments made using tools may correlate with other assessments, different systems lead to dramatically different estimates of staffing requirements. While it is evident that there are many sources of variation in demand, the extent to which systems can deliver staffing levels to meet such demand is unclear. The assumption that staffing to meet average need is the optimal response to varying demand is untested and may be incorrect.

CONCLUSIONS

Despite the importance of the question and the large volume of publication evidence about nurse staffing methods remains highly limited. There is no evidence to support the choice of any particular tool. Future research should focus on learning more about the use of existing tools rather than simply developing new ones. Priority research questions include how best to use tools to identify the required staffing level to meet varying patient need and the costs and consequences of using tools.

TWEETABLE ABSTRACT

Decades of research on tools to determine nurse staffing requirements is largely uninformative. Little is known about the costs or consequences of widely used tools.

The Safer Nursing Care Tool as a guide to nurse staffing requirements on hospital wards: observational and modelling study

Background

The Safer Nursing Care Tool is a system designed to guide decisions about nurse staffing requirements on hospital wards, in particular the number of nurses to employ (establishment). The Safer Nursing Care Tool is widely used in English hospitals but there is a lack of evidence about how effective and cost-effective nurse staffing tools are at providing the staffing levels needed for safe and quality patient care.

Objectives

To determine whether or not the Safer Nursing Care Tool corresponds to professional judgement, to assess a range of options for using the Safer Nursing Care Tool and to model the costs and consequences of various ward staffing policies based on Safer Nursing Care Tool acuity/dependency measure.

Design

This was an observational study on medical/surgical wards in four NHS hospital trusts using regression, computer simulations and economic modelling. We compared the effects and costs of a ‘high’ establishment (set to meet demand on 90% of days), the ‘standard’ (mean-based) establishment and a ‘flexible (low)’ establishment (80% of the mean) providing a core staff group that would be sufficient on days of low demand, with flexible staff re-deployed/hired to meet fluctuations in demand.

Setting

Medical/surgical wards in four NHS hospital trusts.

Main outcome measures

The main outcome measures were professional judgement of staffing adequacy and reports of omissions in care, shifts staffed more than 15% below the measured requirement, cost per patient-day and cost per life saved.

Data sources

The data sources were hospital administrative systems, staff reports and national reference costs.

Results

In total, 81 wards participated (85% response rate), with data linking Safer Nursing Care Tool ratings and staffing levels for 26,362 wards × days (96% response rate). According to Safer Nursing Care Tool measures, 26% of all ward-days were understaffed by ≥ 15%. Nurses reported that they had enough staff to provide quality care on 78% of shifts. When using the Safer Nursing Care Tool to set establishments, on average 60 days of observation would be needed for a 95% confidence interval spanning 1 whole-time equivalent either side of the mean. Staffing levels below the daily requirement estimated using the Safer Nursing Care Tool were associated with lower odds of nurses reporting ‘enough staff for quality’ and more reports of missed nursing care. However, the relationship was effectively linear, with staffing above the recommended level associated with further improvements. In simulation experiments, ‘flexible (low)’ establishments led to high rates of understaffing and adverse outcomes, even when temporary staff were readily available. Cost savings were small when high temporary staff availability was assumed. ‘High’ establishments were associated with substantial reductions in understaffing and improved outcomes but higher costs, although, under most assumptions, the cost per life saved was considerably less than £30,000.

Limitations

This was an observational study. Outcomes of staffing establishments are simulated.

Conclusions

Understanding the effect on wards of variability of workload is important when planning staffing levels. The Safer Nursing Care Tool correlates with professional judgement but does not identify optimal staffing levels. Employing more permanent staff than recommended by the Safer Nursing Care Tool guidelines, meeting demand most days, could be cost-effective. Apparent cost savings from ‘flexible (low)’ establishments are achieved largely by below-adequate staffing. Cost savings are eroded under the conditions of high temporary staff availability that are required to make such policies function.

Future work

Research is needed to identify cut-off points for required staffing. Prospective studies measuring patient outcomes and comparing the results of different systems are feasible.

Trial registration

Current Controlled Trials ISRCTN12307968.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full inHealth Services and Delivery Research; Vol. 8, No. 16. See the NIHR Journals Library website for further project information.

Comparing Interrater reliability between eye examination and eye self-examination 1

Objective:

to compare Interrater reliability concerning two eye assessment methods.

Method:

quasi-experimental study conducted with 324 college students including eye self-examination and eye assessment performed by the researchers in a public university. Kappa coefficient was used to verify agreement.

Results:

reliability coefficients between Interraters ranged from 0.85 to 0.95, with statistical significance at 0.05. The exams to check for near acuity and peripheral vision presented a reasonable kappa >0.2. The remaining coefficients were higher, ranging from very to totally reliable.

Conclusion:

comparatively, the results of both methods were similar. The virtual manual on eye self-examination can be used to screen for eye conditions.

Psychometric Testing of INTEGRARE, an Instrument for the Assesment of Pressure Ulcer Risk in Inpatients

PURPOSE

The aim of this study is to evaluate the psychometric properties of INTEGRARE, an instrument based on Nursing Outcome Classification.

METHOD

A multicenter, cross-sectional, methodological design was used.

FINDINGS

The study included 3,835 patients. Internal consistency α = 0.86. Confirmatory factor analysis demonstrated the unidimensionality of the scale, indicating a good model fit (CMIN/DF = 4; GFI, CFI, NFI, IFI = 0.999; RMSEA = 0.028).

CONCLUSIONS

INTEGRARE is a valid and reliable instrument with high sensitivity, specificity, and diagnostic accuracy in measuring pressure ulcer (PU) risk in inpatients.

IMPLICATIONS FOR NURSING PRACTICE

This instrument allows us to know the effectiveness of nursing interventions, providing evidence for the validation of the diagnosis Risk for pressure ulcer (00249) as well as on health outcomes, due to the fact that PUs are nursing-sensitive outcomes.

OBJETIVO

Evaluar las propiedades psicométricas de INTEGRARE, un instrumento basado en la Clasificación de Resultados de Enfermería. MÉTODO: Se optó por un diseño transversal multicéntrico.

RESULTADOS

El estudio incluyó a 3,835 pacientes. Consistencia interna α = 0.86. El análisis factorial confirmatorio demostró la unidimensionalidad de la escala, indicando un buen ajuste del modelo (CMIN/DF = 4; GFI, CFI, NFI, IFI = 0.999; RMSEA = 0.028).

CONCLUSIONES

INTEGRARE es un instrumento válido y fiable con alta sensibilidad, especificidad y precisión diagnóstica en la medición de riesgo de úlcera por presión (UPP) en pacientes hospitalizados. IMPLICACIONES PARA LA PRÁCTICA ENFERMERA: Este instrumento nos permite conocer la efectividad de las intervenciones enfermeras, aportando evidencia para la validación del diagnóstico Riesgo de úlcera por presión (00249), así como sobre los resultados de salud, debido a que las UPP son resultados sensibles a la práctica enfermera.

[Opinions and nurse' satisfaction with INICIARE 2.0 scale: A qualitative study in a hospital setting]

OBJECTIVE

To know the opinions and satisfaction of nurses with the use of INICIARE, an instrument developed for assessment of nursing care needs in hospitalized patients. INICIARE is based on Virginia Henderson's conceptual model, and built up with indicators of Nursing Outcomes Classification (NOC) taxonomy.

METHOD

Exploratory qualitative study, using focus group technique for data collection. The sessions were recorded until saturation of information. A content analysis of syntactic, semantic and pragmatic levels of transcripts was performed. Participants' informed consent was obtained.

RESULTS

Three focus groups were developed; 24 nurses from two Public Hospitals in Andalusia (Southern Spain) participated; and four thematic categories were created to measure satisfaction with the instrument. INICIARE helped the nursing process. Its closed format, and items in NOC taxonomy streamline evaluation, facilitates its inclusion in Electronic Information Systems, and strengthens effective communication at all levels.

CONCLUSIONS

Nurses are satisfied with the use of INICIARE scale as a tool to enhance quality of care. It also has potential to be used as a tool for decision making in management of nursing care.

Psychometric properties of an instrument to measure family disease management

An instrumental study of 392 households with sick or disabled members was conducted to analyze the psychometric properties of the Family Disease Management Scale. Three different models were analyzed using the Confirmatory Factor Analysis (CFA). One was a single-dimensional factor (family disease management) with 30 items; and two hierarchical models with three factors, which represent the dimensions, family support, family normalization and family participation, that placed the workload into another of higher order called family disease management, the first with 30 items and the second with 29. The CFA results showed that the latter 29-item model provided a better fit. The internal consistency analysis using the Cronbach alpha test showed a value of .93 for the complete scale and above .80 in the three subscales. This instrument may be useful to assess how families manage the illness or disability of its members, especially in clinical practice given the importance of the family as the primary caregiver. As well as in performing epidemiological studies, and in the field of management, planning and assistance.