The need for valid and reliable measuring instruments is important in any research field. The nursing discipline especially nursing science has not been able to establish accurate instruments for measuring research results. Therefore a systematic approach is required to validate the validity of the proposed research instruments. Steps to develop evidence-based research require the researcher to acquire knowledge of the instrument being used before use for validation purposes. Currently, informatics have become key contributors to nursing research and the promotion of quality patient care. The methodology and research instruments provided in this research are not standard; the research, therefore, provides an opportunity to impact quality care through the use of up-to-date evidence.
A study population is needed in any given research and for this case; the research project recruited 117 participants. Test-retest reliability should be used to discover the consistency of results obtained on more than one item of the instrument which is obtained the by using reliability coefficient. The usual time upon which results are validated is 2 to 3 weeks.
Survey research usually begins with assessing the validity and reliability of selected research instruments and an established systematic approach in determining the validity and reliability of the chosen research instrument. This research did not meet the requirement as it failed to assess the validity of the measuring instrument before use. Research requirements also require the researcher to seek permission before using a given instrument, review the literature evidence of content validation and check the reliability of statistics from published studies that have already used the instrument. The researcher should select experts for different fields to review the data for relevance and clarity. The number of experts could range from 2 to 20. The tool should be developed to evaluate the content validity of the research instrument used and then send the reworded instrument to content experts with the evaluation tool (Polit & Beck, 2004, p.78).
The researcher is required to evaluate the returned review tools and calculate Content Validity Index (CVI) before using the instrument and removing items that are not necessary. Research instruments should also be modifies according to CVI feedback.
The content of validity rarely changes. Polit & Beck (2004, p.421) in their research argues that reliability of an instrument is a property of the instrument when applied to certain samples under certain conditions. Population surveyed statistics are based on estimates and credible research calls for re-estimate to check for reliability on each population surveyed and should be done each time research instrument is used.
Polit and Beck (20004, p. 417) describes reliability of coefficient as the “correlation coefficient between two sets of scores”. Attitudes tend to remain stable but knowledge changes affecting the second administration attributed from the direct results of the first administration. Scales and test that require summing items up should be evaluated for internal consistency (Polit & Beck, 2004). Internal consistency is used where items being measured are attributes of attitudes desired for validation. This method is mostly applied in knowledge-based survey where a researcher validates results against an evidence- based referent.
Purpose of the research
The purpose of research is to determine frequency and cause of delirium on older adults admitted to surgical intensive care unit (SICU). According to the research results, the research only determined the frequency of delirium development on older patients upon hospitalization but failed to study the root of cause of the ailment. The weekly phone calls the research made should have been aimed at 1). Studying causes of delirium development 2). Determining the frequency of delirium development on hospitalization and 3).avail the information to nursing research to provide a solution to the problem. It’s pointless to research on delirium development frequency without assessing what really causes the ailment.
Designs and Methods
The researcher used observable cohort study where he selected 114 English-speaking participants for the study. The age group was 65 years and older and admitted at the SICU. The researcher contacted chart reviews and interviews within 24 hours upon the patient’s admission in the SICU. The interviews were aimed at collecting information on evidence of dementia on admitted patients using an informative Questionnaire on Cognitive Decline in the elderly. Patients in the SICU were also screened for delirium daily in the course of their hospitalization. The screening used Confusion Assessment Methods-ICU (CAM-ICU) for patients in SICU and CAM for surgical unit patients. A study contacted by McNoll to on reliability of measuring instruments, he compared CAM and CAM-ICU for delirium detection in the ICU patients. The tools showed varied results, CAM recorded 68% while CAM-ICU recorded 50%. These instruments showed varying results therefore making results obtained here unreliable (Balas et al, 2008, p. 9).
Before development of Confusion Assessment Method-ICU (CAM-ICU), nurses, clinicians and researchers were limited to only assessment and studying delirium in seriously ill patients. The invention of this method helped early detection of delirium symptoms enabling clinical practitioners provides early treatment to the patient. With the advent of CAM-ICU, studies have shown delirium is problematic in a critical care setting. One study reported that 87% of adult patients in ICU were delirious during their stay at the hospital, while another reported 81% of patients undergoing mechanical ventilation experienced delirium. Current studies have shown that adults admitted at the SICU are at greater risk at developing delirium symptoms. With all these arguments, only one study has been able to evaluate the occurrence and clinical course of delirium in older patients admitted to ICU. Current research reveals that 70% of older adults admitted at the hospital develop delirium while 40% of dementia patients are more likely to become delirious despite controlling confounding variables (Balas et al, 2008, p.5).
However reliable the evidence seems to appear, the literature misses studies that carefully examine etiology, demiology and consequences that delirium may have to the patent admitted at ICUs. Lack of this critical examination of delirium generates gap on the credibility of research results. The gap is so evident in the manner it calculates its statistics. For instance, considering the frequency with which older patients are admitted to the hospital in the ICU section and other conditions such as unexpected mobility, direct and indirect financial and human related conditions are not reflected in the final research results thereby affecting the validity and reliability of results obtained (Balas et al, 2008, p. 5).
The study of occurrence and clinical course of delirium adds to the researcher’s knowledge of delirium development. Therefore the researcher should not transfer the findings already established by the books to study the frequency of delirium occurrence to the patients admitted to ICUs. In relation to frequency use of anesthesia in SICU, critically admitted older adults in medical and surgical ICUs may differ in severity of illness thereby affecting validity of the results. Anesthesia will also affect mechanical ventilation rates, amounts and nature of invasive procedure and the results of preadmission physical and cognitive ability. Use of anesthesia affects delirium rates and patient outcomes subsequently affecting research aims and therefore results. The research objectives were aimed at a). Determining the frequency with which older patients with pre-existing delirium and dementia were admitted to SICU b). use the findings to determine the frequency with which older patients develop delirium during SICU admission and c). critically examine the course, duration and characteristics of delirium throughout patients hospitalization (Balas et al, 2008, p. 5).
Study Design and settings
This research used observation cohort design with 117 participants admitted in three SICU in a 672-bed university teaching hospital with the permission of University of Pennsylvania Institutional Review Board. Critically ill patients were admitted to the surgical critical care service SCCS. The patients were 65 years and over and were all screened for delirium before being admitted to operation room. The researcher obtained verbal and written consent from each patient before the study was carried out. In surrogate selection, the researcher selected participants of 65 years or older, admitted at the SICU, English-speaking surrogates who could provide consent, intubated, recovering from anesthesia and were mechanically ventilated. The research was consistent with methodology approach and screened surrogates for any contact with the participant. Researchers were not allowed to have phone contact exceeding 4 hours a week for a given participant. Patients undergoing cardiothoracic surgery were not included in the research because their frequencies would be affected as they were in cognitive dysfunction, hypothermia and cardiopulmonary bypass condition (Balas et al, 2008, p.6).
From August 22 to December 31 20,04, a total of 259 patients of 65 years old age were admitted to the hospital SCCS. The researcher, therefore, did not include 55 patients in this study. These patients’ results were not reflected on the screening test and did not appear on the researcher’s SCCS admission list. On the remaining 204 screened patients, 16 of them failed to qualify for participation as they had either a recent CNS injury, had deafness, were blind, or were in radiotherapy. This leaves 188 eligible patients. Then out of 188 eligible patients, 71 were left out as they could not speak English, lacked required surrogate despondent, surrogate refusal, physician refusal, were discharged within 24 hours of SICU or the researcher was unable to contact the patient or surrogate within 24 hours of admission. This leaves us to the final sample of 117 participants. From the collected samples, the enrolled group did not differ significantly from the un-enrolled group in age. The enrolled group represented (P=40), surgical service (p=28), gender (p=27) and severity of the illness (p=40). When the study was completed two participants remain in the hospital and one was withdrawn from the study before the research was completed. This study did not include the three participants in the analysis as the sample should have reflected 114 and not 117. These conflicting results affect the validity of the results collected (Balas et al, 2008, p. 6).
The principle investigator (researcher) contacted all participant and surrogate interviews before the research kicked off. Team members in the research team were trained to use the Confusion Assessment Method (CAM) and the CAM-ICU). All team members performed delirium assessment together until overall diagnosis of delirium reached 100%. After training all interviewers reported comfort with the use of tools. The researcher assessed participants each morning and recorded baseline demographic data, past medical history, surgical, admission diagnosis, psyachric history, SICU room location, planned or unplanned admission and cases of Acute Physiology and Chronic Health Evaluation (APACHE). APACHE scores obtained were used to measure severity the of the illness and were calculated upon SICU admission by a critical care resident and the results verified by a SCCS’s nurse practitioner. Involvement of critical care resident and a nurse practitioner in calculation of results improved the validity and reliability of information obtained in this research (Balas et al, 2008, p. 6).
Participants were asked questions regarding study eligibility, surrogate- participant relationship, history of drug and alcohol abuse, sensory impairment, use of assistive device, psychiatric history, marital status and any cases of prior hospitalization. Dementia score was set at 3.31 and was assessed by obtaining information from participants (surrogates) using Informant Questionnaire in Cognitive Dementia in the elderly (IQCODE). The IQCODE used was specifically designed for personal communication which the proxy administration used 5 years ago to record relative memory and compare it to the present ability. The scale rated 16 questions on a five point scale where 1represented much improved patient and 5 for much worse patient. Then, scores for each question were summed up then divided by the total number of questions asked. The average score of 3.31 shows a balance of sensitivity of 79% and specificity indicated 82 % for dementia detection (Balas et al, 2008, p.6). In designing questionnaire, they researcher should have formulated his own questionnaire rather than relying on the preexisting IQCODE, this way he would have obtain reliable information on what other new causes might have been promoting the development of delirium and use the information for designing new methods for dealing with delirium (Polit & Beck, 2004).
Baseline was determined by Activities of Daily Living scale (ADL). This scale was selected by health care providers. Use of ADL scale will not accurately record functional ability since the researchers were in most contact with the patient before admission. This measuring instrument will therefore not provide formal reliability, surrogate accuracy or validity of the results obtained. Actually, ADL tool has been used for over 35 years in older adult population and there is need for researchers to device new measuring tools that will provide reliable results (Balas et al, 2008, p.6).
During the research, nurses did not participate in research activities. Nurses would have participated by helping the researcher observe patients responses to treatments and techniques. Their presence would have helped the researcher answer unanswered questions and assist in data collection. For instance, where a patient was likely to go into coma upon hospitalization, the researcher would have been informed in time not to include the participant in the study. According to research results, 87% developed delirium while on admission and the researcher had to conduct a survey to discover the mischief. Nurses should have been involved in clinically relevant research to enable them acquire knowledge on delirium development or work as consultants to novice researchers (Craven & Hirnle, 2008. p. 121).
Before hospitalization, delirium assessment was performed daily on patients’ homes between 1000 to 1900 hours. Researcher used Richmond Agitation Sedation Scale (RASS) to assess the level of arousal in determining the capacity for daily screening delirium. RASS scale was based on 10 point scale representing four levels of anxiety. Patients’ various levels of anxiety were recorded on different ranges of the scale. At some point, the researcher encountered difficulties in evaluating delirium status during the day on one of the patients and the final results did not reflect the missing data thereby affecting the validity and reliability of results obtained in this research (Balas et al, 2008, p. 7).
The literature did not differentiate between delirium from residual anesthetic affects. The researcher did not tell us what symptoms they were looking for in a patient before declaring him/her delirium. Therefore the results of the research are not valid and reliable as residual anesthesia might have been confused for delirium symptoms. On results examination, out of the 114 old patients admitted, 81 of them received anesthesia within 24 hours of SICU hospitalization. During that period, 14 of 81 participants were reported to have generated delirium symptoms and the remaining 67 did not have the symptoms. Its therefore evident that the results obtained did not reflect true results of development of dementia among old people.
Management, assessment, diagnosis and prevention of delirium are nursing care responsibilities and it lies upon them to invest in good measuring instruments in carrying out research activities. Decisions nurses make can positive or negatively enhance the likelihood of patients acquiring delirium. Out of all the hospitalized patients SICU, 18.4% of them had preexisting dementia and the rest developed dementia while on admission. According these results, the researcher should have investigated the causes of dementia on patients while on SICU admission rather than the frequency within which the disease occurs as it would have helped devise a solution to improve patients’ health care (Balas et al, 2008, p. 7).
Medical ICUs records showed some patents did not wake up from coma and 88.9 % of patients who were in coma developed delirium. How then did the research obtain a verbal or written consent for the patient who wouldn’t speak? This makes us question the reliability and validity of researcher’s results. The researcher should have therefore assessed the ability of hospitalized patients to give information about delirium development. The researcher relied on surrogates for information on patents preadmission health status and cognitive ability which made the results reflect reliable. Also, the IQCODE measurement of personal communication and CAM-SV had not undergone pre-testing which raises the question of reliable and validity of the data obtained. This literature does not provide sufficient evidence to explain the reason for low rates of delirium in 24 hours before admission and the sudden increase several days after hospitalization. Therefore the screening tools may have underestimated the occurrence of SICU delirium (Balas et al, 2008, p. 9).
According to dementia research, 18.4% of older patients revealed evidence of dementia on admission to SICU, 2.6% evidence of pre-existing delirium, 28.3% developed delirium while on admission at SICU and 22.7% acquired it during the post-SICU period. Out of 144 participants, a total of 52 participants (45.6%) were delirious during their hospital stay or 24 hours before they were admitted to the hospital. Also reported were episodes of deep sedation and nonarousal incidents occurring in only 9.7% of the sample. The research findings should have been used by nurses to define and seek solution to the development of delirium but hospital never seemed to be concerned about the results. Nurses would have otherwise been involved in the researcher to enable them acquire observation skills and use their clinical experience to organize priorities that could offer patients effective and timely treatment subsequently reducing the rates of delirium development on hospitalization (Crave & Hirnle, 2008, p. 121).
Polit and Beck (2004) identifies nursing organizational barriers in using research evidence by practicing nurses. This research does not indicate where nurses used the research information in practice. He argues that keeping nurses out the research practice makes them lack motivation to make changes that will impact on efficient practice. He calls for organization to provide a climate that stimulates innovation, the hospital for instance. Hospitals should support research by providing instruments that support innovation as well as moral and emotional support and provide a reward package for nurses who are innovative and those who use evidence based practice. To make available use of research information, Polit and Beck (20004) recommends the following strategies be used in current research; a). He calls upon researchers to work with staff nurses to identify current clinical problems. If nurses at the hospital were involved in the research, they would be able to find a solution to the development of delirium on patients on hospitalization and prevent the problem from re-occurring b). the research will also enable nurses use vigorous designs, able to replicate findings, report findings that incorporate meta-analysis, able to present clinical implications research, write clear reports and share information, disseminate findings and prepare integrative and critical research reviews and pass them to practicing nurses.
In conclusion, research was aimed at formulating problem statement, performing a study and disseminating the findings. The results should be disseminated so that the hospital can evaluate and apply the findings. The researchers results were clear and readable therefore easy for application. Nursing research should therefore use the result to devise a solution that will minimize development of dementia on hospitalized patients. Nursing practice encounter many answered questions and should use research studies to answer unanswered questions. Essentially, research instruments must be assessed before use to check for reliability and validity.
- Balas. M. C., Deutschman, C.S., Sullicvan-Marx, E.M., Nellive, E. S., Alston, R.P., & Richmond, T. S. (2008). Delirium In Older Patients in Surgical Intensive Care Units. Journal of Nursing Scholarship, 254-939-0827, 1-11.
- Crave, R. F., & Hirnle, C.J. (2008). Fundamentals of nursing:human health and function. Philadelphia: Lippincott, William & Wilkins.
- Polit, D.F. & Beck, c. T. (2004). Nursing research: Principles and methods (eds.7). Philadelphia: Lippincott, William & Wilkins.