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UBC Theses and Dissertations

A study to develop an instrument to assist nurses to assess the abilities of patients with chronic conditions… Phillips, Frances Patricia 1971

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A STUDY TO DEVELOP AN: INSTRUMENT TO ASSIST NURSES TO ASSESS THE ABILITIES OP PATIENTS WITH CHRONIC CONDITIONS TO FEED THEMSELVES by FRANCES PATRICIA PHILLIPS B.A.Sc, University of B r i t i s h Columbia, 1949 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF Master of Science i n Nursing i n the Department of Nursing We accept t h i s thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA A p r i l , 1971 In present ing th i s thes i s in p a r t i a l f u l f i lmen t of the requirements for an advanced degree at the Un iver s i t y of B r i t i s h Columbia, I agree that the L ib ra ry sha l l make i t f r ee l y ava i l ab le for reference and study. I f u r ther agree that permission for extens ive copying of th i s thes i s f o r s cho la r l y purposes may be granted by the Head of my Department or by his representat ives . It is understood that copying or pub l i c a t i on o f th i s thes i s fo r f i nanc i a l gain sha l l not be allowed without my wr i t ten permiss ion. Department of The Un ivers i ty of B r i t i s h Columbia Vancouver 8, Canada C o n s t r u c t i o n o f a t o o l t o a s s i s t n u r s e s t o a s s e s s t h e a b i l i t i e s o f p a t i e n t s , w i t h c h r o n i c c o n d i t i o n s , t o f e e d t h e m s e l v e s w a s b a s e d u p o n t w e n t y - o n e i d e n t i f i e d f e e d i n g b e h a v i o r s d e r i v e d f r o m o b s e r v a t i o n s o f a r a n d o m s a m p l e o f f i f t y s u c h p a t i e n t s f r o m t w o u r b a n h o s p i t a l s . O b s e r v a t i o n s w e r e a l s o m a d e o f t h e n u r s e s w h o c a r e d f o r t h e s e p a t i e n t s . I d e n t i f y i n g s p e c i f i c b e h a v i o r i t e m s w a s c o n c u r r e n t w i t h d e f i n i n g f i v e c a t e g o r i e s a l o n g t h e d e p e n d e n c e - i n d e p e n d e n c e c o n t i n u u m d u r i n g a n a l y s i s o f t h e d a t a . A 3*1*1 r a t i o f o r w e i g h t i n g b e h a v i o r a l c o m p o n e n t s w a s e s t a b l i s h e d a r b i t r a r i l y . T h e K e n n y S e l f - c a r e f i v e p o i n t n u m e r i c a l r a t i n g s c a l e w a s a d a p t e d t o p r o v i d e a m e t h o d o f d e t e r m i n i n g t h e a m o u n t o f h e l p a p a t i e n t w o u l d r e q u i r e t o f e e d h i m s e l f . E x p e r t s i n t h e f i e l d a g r e e d , w i t h m i n o r m o d -i f i c a t i o n s , t h a t t h e t o o l c o u l d d e t e r m i n e a m e a s u r e o f I n d e p e n d e n t f e e d i n g . A r e l i a b i l i t y t e s t , u s i n g e i g h t p a i r s o f r e g i s t e r e d n u r s e s t o a s s e s s t h i r t y - t w o p a t i e n t s p r o d u c e d a r e l i a b i l i t y c o e f f i c i e n t o f .81+9; e v i d e n c e t h a t t h i s t o o l i s d e p e n d a b l e a n d c o n s i s t e n t i n m e a s u r i n g t h e r e l a t i v e s t a t e o f f e e d i n g d e p e n d e n c e - i n d e p e n d e n c e o f p a t i e n t s w i t h c h r o n i c c o n d i t i o n s . R a t i n g b e h a v i o r s p r o v i d e s w r i t t e n e v i d e n c e o f t h e d e g r e e t o w h i c h t h e p a t i e n t i s a b l e t o f e e d h i m s e l f . T h e d i f f e r e n c e b e t w e e n w h a t a p a t i e n t c a n d o a n d t h e c r i t e r i a f o r i n d e p e n d e n t f e e d i n g p r o v i d e s a m e a s u r e of t h e h e l p a p a t i e n t w i l l r e q u i r e t o f e e d h i m s e l f . F u r t h e r r e s e a r c h i s I n d i c a t e d i n t h e a r e a s of u s e f u l n e s s of t h e t o o l f o r r e g i s t e r e d n u r s e s , i d e n t i f y i n g p s y c h o s o c i a l b e h a v i o r s m o r e p r e c i s e l y , t e s t i n g t h e t o o l i n d i f f e r e n t f e e d i n g s i t u a t i o n s a n d e x p a n s i o n o f t h e t o o l to i n c l u d e t h e o t h e r a c t i v i t i e s of d a l l y l i v i n g . 83 p a g e s CHAPTER PAGE I. INTRODUCTION TO THE STUDY 1 Introduction 1 Purpose of the Study 5 The Problem 5 Statement of the Problem 5 Specific Objectives 6 Significance 6 Assumptions 8 Definitions 8 Limitations 9 II. REVIEW OF THE LITERATURE . 11 Institutionalization and Chronic Conditions.. 11 Nursing Assessment Tools » 15 Feeding Studies 22 III. METHOD 24 Overview 24 Sample 24 Feeding Behavior Data Collection..... 25 Analysis of Feeding Behavior Data 26 Construction of Preliminary Tool 27 Validation 27 CHAPTER PAGE R e l i a b i l i t y Testing.. . 28 IV. ANALYSIS OF THE DATA 29 Analysis of Feeding Behaviors 29 Construction of the Tool 41 Analysis of Patient Sample Data 45 V. VALIDATION AND RELIABILITY TESTING 53 V a l i d a t i o n 53 R e l i a b i l i t y Testing 55 Assessment of Nurses Responses to Questions on Use of the Tool 59 VI. SUMMARY, CONCLUSIONS AND RESEARCH IMPLICATIONS.. 62 Summary 62 Conclusions 64 Research Implications 66 BIBLIOGRAPHY 68 APPENDIX 73 TABLE : • PAGE' I. Tabulation of Feeding Behaviors of a Random Sample of Patients with Chronic Conditions, Number and Percentage of Positive Behaviors by Category "34 I I . Preliminary Tool for Assessing A b i l i t i e s Related to Independent Feeding 46 I I I . Description of Random Sample of Patients with Chronic Conditions. Age Range and Mean by Category ' 48 IV. Description of Random Sample of Patients with Two or more Chronic Conditions. Number and Percentage by Category 49 V. Description of Random Sample of Patients with Chrdnic Conditions. Minutes Spent Eating Range and Mean by Category 50 VI. Item Analysis of Agreement of Pairs of Nurses, Using the Feeding Assessment Tool, to Rate Self-feeding A b i l i t y of Selected Patients.... 57 VII. Perceived Usefulness of Tool to the F i r s t Three Pairs of Nurses P a r t i c i p a t i n g i n R e l i a b i l i t y Test, Group 1 59 TABLE PAGE VIII. Perceived Usefulness of Tool to the Second Group, Five Pairs of Nurses, P a r t i c i p a t i n g i n R e l i a b i l i t y Test 60 FIGURE PAGE 1. Analysis of Feeding Behaviors of a Random Sample of Patients with Chronic Conditions, P r o f i l e s of Behaviors, Percentage of P o s i t i v e Behaviors f o r the twenty-one Items by Category 39 2. Analysis of Feeding Behaviors of a Random Sample of Patients with Chronic Conditions, Patterns of Decreasing Percentage of Independent Behaviors by Category 40 3. Outline of Procedure f o r Rating Feeding Behaviors, C l a s s i f i c a t i o n and Symbolization..... 43 4. Five-point and Seven-point Rating Scales, Rationale f o r Defining Ratings 44 ACKNOWLEDGEMENTS The guidance and assistance which I received from my committee members as well as the support and encouragement of my husband and family made t h i s thesis possible. I appreciated t h e i r help very much. I would p a r t i c u l a r l y l i k e to thank Mrs. Helen Elfe.rt, my committee chairman, and Miss Rose Murakami f o r t h e i r many hours of time and e f f o r t on my behalf. I would also l i k e to thank the di r e c t o r s of nursing, head nurses, s t a f f nurses and the patients who so w i l l i n g l y gave of t h e i r time to forward t h i s study. INTRODUCTION TO THE STUDY I. INTRODUCTION Many factors are involved in'determining the amount of basic nursing care a patient w i l l receive. One of the primary factors w i l l be the degree to which the patient i s capable of s a t i s f y i n g h i s own needs. The i n d i v i d u a l who occupies a sick r o l e f o r any length of time i s gradually cut out of his established place i n society, thus diminishing h i s capacity to meet h i s own needs. C l e a r l y t h i s i s a problem of the 1 c h r o n i c a l l y i l l . A ttitudes of the patients themselves w i l l influence the kind of care they w i l l expect. Patients who see the care s i t u a t i o n as one of r e h a b i l i t a t i o n and progress w i l l have d i f f -erent expectations from those who see t h e i r care as custodial i n nature. The eld e r l y constitute a large part of the population who have chronic conditions. For those of t h i s population who are h o s p i t a l i z e d the problems of aging may complicate t h e i r view or the care they expect to receive. XA.N. Exton-Smith, Doreen Norton and Rhoda McLaren, An Investigation or G e r i a t r i c Nursing Problems i n Hospital ^London: The National Corporation f o r the care of Old People, 196*) , p. ^R.E. Irvine, M.K. Bagnall and B.J. Smith, The Older Managerial problems of handling large numbers of peopl on a twenty-four-hour-a-aay basis have been solved, by r o u t l n i z ing procedures, fragmenting practice and depersonalizing the patient. This bureaucratization determines the amount the 3 . 4 patient w i l l be allowed to do f o r himself. Attitudes of those caring f o r the ch r o n i c a l l y i l l w i l l also a f f e c t the amount of care the patients w i l l receive. The nurse's own fe e l i n g s about patient p a r t i c i p a t i o n and decision making w i l l determine both the extent to which her patient w i l l be allowed Independent action as well as the degree to which he w i l l be encouraged to meet his own needs. Doing e i t h e r too much or too l i t t l e f o r the patient deprives him of independence. In the ups and downs of chronic i l l n e s s the patient gains and loses h i s independence as h i s condition changes. I t becomes a matter of management—a balanced a t t i t u d e between demanding t o t a l function and accepting a degree of l o s s . For the c h r o n i c a l l y i l l t h i s management function i s la r g e l y Patient (London: The English U n i v e r s i t i e s Press Ltd., 1968), p. x. 3 Fred E. Katz, "Nurses," The Semi-professlonals and  Their Organizations, A. E t z i o n i , editor (New York: The Free Press, 19o9). p. 169 "^Luther Christman, "What the Future Holds f o r Nursing, Nursing Forum, V o l . 9, No. 1 (January, 1970), p. 18. a problem f o r the nurse. Hendersons d e f i n i t i o n of nursing would imply that the nurse, on the basis of the patient's lack of "strength, w i l l or knowledge" to meet his basic needs, must intervene to a s s i s t the patient. She states: The unique function of the nurse i s to a s s i s t the in d i v i d u a l , sick or well, i n the performance of those a c t i v i t i e s contributing to health, or i t s recovery (or to peaceful death) that he would perform unaided i f he had the necessary strength, w i l l or knowledge. And to do t h i s i n such a way as to help him to gain independence as ra p i d l y as possible.5 In the past, and i n much of today's practice, nursing 6 uses the i n t u i t i v e process i n assessing patient needs. Dumas represents the increasing recognition of nursing leaders of the need f o r systematic i n v e s t i g a t i o n of patient problems when she said, " I t i s . . . o f utmost Importance...that the nurse i d e n t i f y with accuracy those patients who are i n need of 7 her help." 5 v i r g i n i a Henderson, The Nature of Nursing (New York: The MacMillan Company, 1 9 6 6 ) , p. 1 5 . 6R. Paye McCain, "Nursing Assessment Not I n t u i t i o n , " American Journal of Nursing, V o l . 6 5 , No. 4 ( A p r i l , 1 9 6 5 ) , p. 82. 7phetaugh Dumas, "Psychological Preparation for Surgery," American Journal of Nursing, Vol. 63, No. 8 (August, 1963), p. 5 4 ; Faye G. Abdellah et a l . , Patient-centered  Approaches i n Nursing, (New York: The Macmillan Company, I960), pp. 1-69; Doris Schwartz et a l . , E l d e r l y Ambulatory Patient (New York: The MacMillan Company, 1964), pp. 3-10; Dorothy M. Smith, "A C l i n i c a l Nursing Tool," American Journal of Nursing, Vol. 68, No. 11 (November 1968), pp. 2384-2388": A preliminary study, observing nursing care i n a sixty bed extended care h o s p i t a l indicated that problems for nursing existed i n the areas of t o i l e t t r a i n i n g , hygiene, feeding, transportation, s o c i a l i z a t i o n and r e h a b i l i t a t i o n . Feeding was chosen f o r the area of th i s study because some nurses expressed a concern about the increasing number of patients who depended upon nurses for feeding and the amount of time th i s required. Other nurses suggested that management considerations dictated the p r i o r i t i e s of patient care. This resulted i n decisions to feed patients who could feed them-selves, given time and some degree of assistance and supervision. There was a general f e e l i n g that patients who were fed, whether they required i t or not, would regress i n other a c t i v i t i e s of d a i l y l i v i n g . Nurses could not e a s i l y and c l e a r l y explain how they arrived at decisions to a s s i s t or feed patients nor was there any agreement among the nurses as to the degree of help any given patient required. Nurses and patients appeared le s s disturbed by observation by a stranger i n the feeding a c t i v i t y than i n the more personal a c t i v i t i e s of d a i l y l i v i n g where nursing problems existed. The author's conclusion was that the feeding a c t i v i t y presented an opportunity to study an important aspect of patient care as well as obtain measurable data about the feeding a b i l i t i e s of patients with chronic conditions. I t was also f e l t that such data would lend i t s e l f to organization into an instrument that would a s s i s t nurses with the assess-ment of patient problems i n the feeding a c t i v i t y . I I . PURPOSE OF THE STUDY The purpose of t h i s study was to construct an i n s t r u -ment to a s s i s t nurses to assess feeding behaviors of ch r o n i c a l l y i l l patients. Functional aspects of feeding behaviors were explored as well as the motivation and i n t e r e s t that a f f e c t feeding. I t i s intended.that the study w i l l contribute to the knowledge of nursing assessment by providing an i n s t r u -ment that w i l l a s s i s t nurses to observe and rate the feeding behaviors of c h r o n i c a l l y i l l patients and one that w i l l constitute a record of these behaviors. I I I . THE PROBLEM Statement of the Problem. . Can an instrument be developed that w i l l a s s i s t nurses to assess the a b i l i t i e s that patients with chronic conditions w i l l require i n order to feed themselves? W i l l the instrument indicate i f the patient requires help f o r feeding? W i l l the instrument a s s i s t the nurse to decide the degree of help the patient w i l l require? S p e c l f l c Objectives. To answer the above questions i t w i l l be necessary to (1) determine the feeding behaviors a patient must demonstrate to feed himself independently; (2) rate the behaviors so as to determine the degree to which a patient i s able to feed himself; and (3) construct an instrument that w i l l provide a registered nurse with written evidence of an assessment of the feeding a b i l i t i e s of a patient with chronic conditions. Significance of the Problem. In t h e i r survey of g e r i a t r i c nursing problems Exton-Smith et a l . concluded that "physical d i s a b i l i t i e s arid mental states are shown to be factors governing the amount and kind of help patients receive." They stated .that the factor, "The extent of know-ledge of the patient's capabilities,"' pointed to a need fo r research i n assessment so that the degree of help a patient 8 might require could be determined. . This survey provided evidence that the feeding a c t i v i t y was the second most time-consuming, fo r nurses, of a l l the a c t i v i t i e s of d a i l y l i v i n g . Timing did not include bringing and removing the food but counted only the d i r e c t feeding assistance the patients received* Exton-Smith, Norton and McLaren OJD. c i t . , p. 5 2 . The preliminary study at the extended care unit would appear to support these findings. Twenty-two of the sixty patients,,thirty-seven percenti were given total or partial help with feeding. Abdellah suggests that the limited research done i n the c l i n i c a l area i s , in part, due to "lack of adequate measuring instruments" and "lack of criterion measures of 9 quality nursing practice." Schoening points out the need for "global measures that refleot the a b i l i t y of the patient to function independently...also needed are global measures of the patient*s emotional capacity to function within his environment or the manner i n which he interacts on a social 10 level...." The need for c r i t e r i a that w i l l assist the nurse to determine the amount of help she must provide for feeding, i n terms of assistance and supervision, would indicate this to be an area for study. Information obtained from such a study could provide a basis for nursing decision regarding intervention i n the feeding process. It could also Indicate 9paye G. Abdellah."Overview of Nursing Research 1955-1968, Part I," Nursing Research. Vol. 19. No. 2 (February, 1970), p. 8. 1 0Herbert A. Schoening, "Numerical Scoring of Self-Care Status: A Study of the Kenny Self-Care Evaluation," Archives of Physical Medicine and Rehabilitation. Vol. 49, No. 4 (April, 1968), p. 222. Implications f o r nursing care feeding plans that go beyond the physiologic and safety needs of the patient to consider-atio n of a degree of independence. I f the method of designing the tool i s e f f e c t i v e i t could be applied to other a c t i v i t i e s of d a i l y l i v i n g or other problem feeding areas. IV. ASSUMPTIONS This study i s based on the assumption that (1) the independent state i s a desirable goal for patients with chronic conditions; (2) determining nursing needs of a patient requires assessment of both independent and dependent behaviors; (3) written communication of nursing assessment i s a function of the nurse. V. DEFINITIONS : Chronic condition, "...no precise d e f i n i t i o n e x i s t s , and at what point i n time acuteness becomes chron i c i t y i s 11 open to varying interpretations." For the purposes of t h i s study a chronic condition i s considered to be a "Prolonged, 12 l i n g e r i n g state or mode i n which a person exists" which includes some measure of d i s a b i l i t y In the a c t i v i t i e s of ^ U n i t e d Community Services of Greater Vancouver, A Total Concept of Care (Vancouver:. United Community Services of Greater Vancouver, 1968) f p. 1 2 . ^ 2Funk and Wagnalls, Standard Dictionary, V ol. 1 (New York: Funk and Wagnalls Company, 1958), p. 237, p. 272. d a l l y l i v i n g . Feeding behaviors. Observable actions representing the physiological, psychological and social factors involved i n consuming food. Nurse. For the purpose of this study the terra w i l l refer to a registered nurse. Nursing assessment. "An orderly and precise method of collecting information about the physiological, psychological 1 3 and social behaviors of a patient" to determine nursing help needed. Feeding; task. The steps required to transfer food from dish to mouth, chew and swallow. Independent feeder. Completes the feeding task without help. Assists self while eating and performs personal hygiene relat i v e to eating. Responsible for own motivation and adjust-ment i n order to eat. VI. LIMITATIONS OF THE STUDY The study i s subject to the following limitations; ( 1 ) who should give feeding assistance, what resources are 13McCain, loc. c i t . . available and how i n s t i t u t i o n a l variables a f f e c t implementation of nursing care plans In thi s area are beyond the scope of t h i s study; (2) the random sample and r e l i a b i l i t y study populations were drawn from hospitals i n an urban center; (3) the mean age of the random sample population was 77-77 years. REVIEW OF THE LITERATURE I. INSTITUTIONALIZATION AND CHRONIC CONDITIONS There Is Increased emphasis In the l i t e r a t u r e of the need to help patients to deal with the extended sick r o l e . Irvine, Bagnal and Smith point out that a feature of prolonged d i s a b i l i t y i s the rapid d e t e r i o r a t i o n of patients' a b i l i t i e s . They suggest that important contributing roles can be made ava i l a b l e to those people who are c h r o n i c a l l y i l l by maintain-ing or encouraging t h e i r independence and including them i n a 1 plan f o r t h e i r care. L i t t l e and Carnevall support t h i s view and indicate that the concept of self-worth and i n d i v i d u a l i z e d care have increased consideration of the "dimensions of 2 prevention, restoration, r e h a b i l i t a t i o n and conservation." Rudd states that nurses may unwittingly reinforce the deperson-a l i z i n g of care. He suggests that "harnessing the power of the human mind can put sensitive, responsive energy to work ^R.E. Irvine, M.K. Bagnall and Smith, The Older  Patient (London: The English U n i v e r s i t i e s Press Ltd., I 9 6 8 ) , 2. 2Dolores E. L i t t l e and Doris L. Carnevall, Nursing  Care Planning (Philadelphia: J.B. Lippincott Company, 1969), p. 3. i n favor of better patient care." There i s a concern expressed by these authors about the independence and self-worth of persons who receive care for a prolonged period of time. Few studies have been done which shed much l i g h t on the problems of such I n s t i t u t i o n a l care. Townsend concludes that i n s t i t u t i o n a l i z a t i o n i s related to physical and/or mental d i s a b i l i t y . His study c l e a r l y shows that the absence of p r a c t i c a l a l t e r n a t i v e s , supporting r e l a t i v e s , friends or s o c i a l services, increases the p r o b a b i l i t y of i n s t i t u t i o n a l i z a t i o n . Townsend questions the use of i n s t i t -u t i onal f a c i l i t i e s f o r the aged, c h r o n i c a l l y i l l . He feels that such care i s incomoatible with human needs for independence, freedom, dignity and productive l i v i n g . Jaeger and Simmons, on the other hand, say "such organized care...may prove, i n time and on the whole, to be among the more s a t i s f a c t o r y 5 solutions to many of the problems involved." .N. Rudd, "The Mosaic of Interpersonal Relationships i n G e r i a t r i c s , " G e r i a t r i c s , V o l . 25, No. 2 (February, 1970) p- 166. Peter Townsend, "The E f f e c t s of Family Structure on the Likelihood of Admission-to an I n s t i t u t i o n i n Old Age," So c i a l Structure and the Family,Ethel Shanas and Gordon Streib, editors (Englewood C l i f f s : Prentice-Hall, Inc., 1965). pp. 163-137. ^Dorothea Jaeger and Leo W. Simmons, The Aged 111 (New York: Appleton-Century-Crofts, 1970), p. v i . Townsend's alarm about the e f f e c t of i n s t i t u t i o n a l -i z a t i o n upon long-term patients and Jaeger and Simmons contention that the c h r o n i c a l l y i l l w i l l , nevertheless, be cared f o r i n i n s t i t u t i o n s leads to the conclusion that i t w i l l become increasingly necessary to add psychosocial assessment to the physical assessment of needs of patients i n such i n s t i t u t i o n s . McClusky argues that adult performance i n unexpected situations i s determined by having a b i l i t i e s l e f t over to deal with such situations a f t e r meeting l i f e ' s obligations. A b i l i t i e s are described as physical, psychological, s o c i a l and economic assets. Obligations are defined as l i f e tasks i n d i v i d u a l i z e d by expectations and c a p a c i t i e s . There are implications f o r nursing assessment f o r the c h r o n i c a l l y i l l i n his argument, i n that the margin of a b i l i t i e s i s reduced i n people with such conditions. This leaves them fewer 6 assets to deal with chronic i l l n e s s and d i s a b i l i t y . Jaeger and Simmons' study reveals some i n t e r e s t i n g s t a t i s t i c s on how various l e v e l s of nurses; aides, Licensed P r a c t i c a l Nurses (LPN's), Registered Nurses (RN's) and degree Registered Nurses; cope with behavioral problems of t h e i r chronically i l l patients. Nursing personnel seemed l e a s t "Howard Y. McClusky, "The course of the Adult Lifespan," The Adult Learner, I r v i n g Lorge, editor (Washington D.C.: Adult Education Association of the U.S., 1965)., pp. 1 0 - 1 5 . accepting of those patients who do not conform to convent-ional patterns of behavior. The l e a s t accepting among t h i s 7 group were the aides and LPN's. The important point here i s the f a c t that i t i s t h i s group to whom the nurse delegates much of the actual nursing care. In order to i n s t r u c t nursing assistants, nurses must improve t h e i r own a b i l i t y to assess patients which w i l l enable them to see a l t e r n a t i v e s t o ! t h e way they now delegate t h e i r r e s p o n s i b i l i t i e s . The World Health Organization view i s that health i n 8 the e l d e r l y i s best measured i n terms of function. Bayne supports t h i s notion and extends i t further into the need to define the functional positives and negatives of patients with 9 chronic conditions. Weiss's experimental study of the nurse-patient i n t e r a c t i o n concluded that, i n order to develop nursing care plans which w i l l consider patients' autonomy, in d i v i d u a l needs and self-worth, nurses must f i r s t . p e r c e i v e patient resources. "Both p o s i t i v e resources f o r development and negative resources f o r atrophy"'are part of the ^Dorothea Jaeger and Leo W. ,Simmons, The Aged 111 (New York: Appleton-Century-Grofts, 1970), p. 10. ^VJorld Health Organization, The Public Health Aspects  of the Aging Population, Report of an Advisory Group Convened by the Regional O f f i c e r f o r Europe, Copenhagen World Health Organization, 1959. p. 8. 9 ^Ronald J . Bayne, " I l l n e s s and Age," Canadian Welfare, V o l . 4^. .No. 2. (March-April, 1967) .';p. 16. "...nursing diagnosis of the patients'nursing needs." II. NURSING ASSESSMENT TOOLS Some e f f o r t s have been made to evaluate the e f f e c t -iveness of nursing practice by developing c r i t e r i o n measures of patient welfare. The independent variables used have been such things as increasing t o t a l s t a f f , i nservice education 11 or observation of patient a c t i v i t i e s . The hypothesis that the nurse's a b i l i t y to assess patient needs i s basic to prediction 12 and diagnosis has been proposed by a number of nursing leaders. Both Abdellah's twenty-one nursing problems and Henderson's fourteen basic patient needs have served as guides to nursing assessment but f a i l e d to provide a concise and i UJames M.A. Weiss (ed.), Nurses, Patients and Soc i a l  Systems (Columbia: University of Missouri Press, 19657, p. 103. 1 ]-Myrtle K i t c h e l l . Aydelotte, "The Use of Patient Welfare as a C r i t e r i o n Measure," Nursing Research, V o l . 2, No. 1 (Winter, 1962), pp. 10-14; J.R. Simon and S a l l y S. Chastin, "Take a Systematic Look at Your Patients," Nursing ' Outlook, Vol. 8, No. 9 (September, i 9 6 0 ), p. 511. 12Dorothy M. Smith, "A C l i n i c a l Nursing Tool," American Journal of Nursing, Vol. 68, No. 2•(November•1968), p. zy6^; Louis McManus, "Assumptions of Functions of Nursing," Regional Planning f o r Nursing and Nursing Education Report, Work Conference at Plymouth, N.H., June 12-13. 1950 (New York: Bureau of Publications, Teachers' College, Columbia University, I95I). p. 5 4 ; Faye G. Abdellah et. a l . , Patlent-.centered  Approaches to Nursing (New York: The Macmillan Company, I960), pp. 1-69. easy-to-use method. The need f o r nurses to assess patients i n a systematic,precise way was not recognized u n t i l recent years, "To practice e f f e c t i v e l y , a nurse must assess...but no precise 15 method of such assessment has, as yet, been widely accepted." Bonney and Rothberg's method of i d e n t i f y i n g the needs of the ch r o n i c a l l y disabled was geared to s t a f f i n g patterns 16 and proved to be a lengthy, time-consuming device. McCain argued that the functional a b i l i t i e s approach to assessment can be rela t e d to patient behaviors. Her guide, however, i s l a r g e l y unstructured, leaving the assessor free to determine what Information w i l l be c o l l e c t e d under the t h i r t e e n functional areas I d e n t i f i e d . In additi o n i t i s very lengthy and rather 17 medical i n or i e n t a t i o n . Manthey shares McCain's concern about random c o l l e c t i o n of patient data by nurses. She designed a guide f o r the nurse who was team leader to do an i n i t i a l 1 3 i b l d . . 14 , V i r g i n i a Henderson, The Nature of Nursing (New York: The Macmillan Company, 1966), p. 16. ^R. Faye McCain, "Nursing Assessment—Not I n t u i t i o n . " American Journal of Nursing, V o l . 65» No. 4 ( A p r i l , 1 9 6 5 ) , p. 82... - ^ V i r g i n i a Bonney and June Rothberg, Nursing Diagnosis  and Therapy: An Instrument f o r Evaluation and Assessment (New York: National League f o r Nursing, 1963). P« 6 . ^McCain, ojo. c i t . , p. 8 3 . admissions interview. "Often information about a patient i s gathered i n b i t s and pieces by many members of the nursing s t a f f . . . u s i n g [a} form has helped us reduce the lag between 19 patient admission and a working nursing care plan." The tool developed by Smith had as i t s purpose "--systematically, consistently, concisely and economically 20 ( i n t i m e ) — t o c o l l e c t information relevant to nurse problems." The usefulness of t h i s t o o l to baccalaureate prepared nurses has been demonstrated. V a l i d i t y and r e l i a b i l i t y tests have not been reported. McPhetrldge supports Smith's view and adds that knowing what the patient perceives about his i l l n e s s and h o s p i t a l i z a t i o n and what he prefers about h i s care enables the 21 nurse to personalize nursing care. Development of an Instrument to measure a patient's a b i l i t y to meet hi s own needs was 22 reported by Williams. Testing of r e l i a b i l i t y of t h i s t o o l , l^Marie E. Manthey, "Guide f o r Interviewing," American Journal of Nursing. Vol. 67, No. 10 (October, 1967). pp. 2088-2090. 1 Q I b i d . . p. 2090. ^Osmith, op. c i t . , p. 2385. Mae McPhetrldge, "Nursing History: One means to Personalize Care," American Journal of Nursing, V o l . 68, No. 1 (January, 1968), p. 68. ' ZZft&ry Edna Williams, "Patient P r o f i l e , " Nursing  Research, V o l . 9. No. 3 (Summer, i960), p. 122. using'eight pairs of nurses, r a t i n g two hundred and forty-one 23 patients, showed a p o s i t i v e c o r r e l a t i o n of . 8 5 . Hamdi and Hutelmeyer separate nursing diagnosis into assessment of patients and recognition of problems. They relate the two facets to the planning, implementation and v a l i d a t i o n of nursing care plans. They further r e l a t e t h i s process to " i d e n t i f i c a t i o n of nursing function and the development of 2 4 nursing science." These authors argue that i f a tool i s to be used i n nursing, i t must.be so designed that i t can be used by . 25 registered nurses who are responsible for most nursing care. They also contend, along.with other a u t h o r i t i e s on testing, that before a tool can be put into general use, i t must be 2 6 tested f o r v a l i d i t y and r e l i a b i l i t y . ^Suzanne Dziak, " R e l i a b i l i t y of the Patient P r o f i l e " (Unpublished Master's theses, University of Pittsburgh, 1958). p. 44. 2^Mary Evans Hamdi and Carol M. Hutelmeyer. "A Study of the Effectiveness of an Assessment Tool i n the I d e n t i f i c a t i o n of Nursing Care Problems." Nursing Research, V o l . 19, No. 4 (July-August, 1970), p. 3 5 4 . 2 5 l b i d . 2 o i b i d . ; Georgia Sachs Adams, Measurement and Education (New York: Holt, Rinehart and Winston, 1965), PP- 60-147; Lee J . Cronbach, Ess e n t i a l s of Psychological Testing (New York: Harper and Row, PublisHers, I960), PP. 96- 1 5 3 -Abdellah i d e n t i f i e d a need to develop instruments that measure patient care d i r e c t l y as a p r i o r i t y area f o r further research. "Measurement of qu a l i t y care w i l l have to be both d i r e c t and i n d i r e c t before a complete assessment of the e f f e c t of nursing practice upon patient welfare can be 27 made." One of the techniques f o r measurement discussed was the development of r a t i n g scales. Abdellah warns that, when using r a t i n g scales, problems e x i s t with weighting the d i f f e r e n t components of the scales. "A problem i n s c a l i n g that must be solved i s the way i n which d i f f e r e n t components of the measurement scale are to be weighted i n the process of 28 * a r r i v i n g at a t o t a l . " A review of various tools, which measure a c t i v i t i e s of d a i l y l i v i n g , currently used i n several hospitals leaves some doubt as to the basis on which reported behaviors were selected. In one Instance patients were c l a s s i f i e d as requir-ing heavier care because they are over seventy years of age. I t was noted that i n many of the tools reviewed there were no c r i t e r i o n behaviors of independence. Most such tools are eit h e r f a r too long or assessment of feeding behaviors i s confined to a catalog of past events. None of these too l s 2?Faye G. Abdellah, "Overview of Nursing Research 1955-1968, Part I," Nursing Research. V o l . 19. No. 1 (January-February, 1970), p. 14 - 1 5 . 2 8 I b l d . p. 16. provide a q u a n t i f i c a t i o n of the r e l a t i v e value of the indiv-29 idual's behaviors. An examination of tools described i n the l i t e r a t u r e indicated useful approaches to the design of a feeding assessment t o o l . Rick and Dent f e l t that behavioral state-ments would be objective and free from emotional evaluation and therefore not acceptable f o r t h e i r study designed to 30 measure at t i t u d e s . An extensive series of patient behavior statements was developed by Brodt and Anderson i n order to overcome the lack of p r e c i s i o n i n a preliminary t o o l that appeared to be based on a review of the l i t e r a t u r e and 3 1 i n s u f f i c i e n t d i r e c t observation. The purpose of the PETO system of assigning i n t e n s i t y of care ratings was to manage-the balancing of work-load and was l i m i t e d to physical assessment. The authors themselves say they 2 9 p a t i ent C l a s s i f i c a t i o n system, Vancouver General Hospital, 1 p.; New York Hospital, "A Study of Nursing Needs of the Chronically 1 1 1 " , 1 2 p p . ; Highland View Hospital, Clevland Ohio, "Patient's Dally A c t i v i t i e s " , 2 pp.; B r i t i s h Columbia Health Insurance Service, "Assessment Guide", 2 pp.; Oakherst Private Hospital History, 2 p p . . 3 0 f t o s e n i a ry Rick and James K. Dent, "Patient Rating Scale," Nursing Research, V o l . 1 1 , No. 3 (Summer, 1 9 6 2 ) , p. 1 6 3 . 3lDagmar E. Brodt and E l l e n H. Anderson, " V a l i d a t i o n of a Patient Welfare Evaluation Instrument," Nursing Research V o l . 1 6 , No. 2 (Spring, 1 9 6 7 ), PP. 1 6 7 - 1 6 8 . hoped the system was f l e x i b l e enough to "provide for some 32 of the intangibles." T i l l ' s report on the assessment of patient's needs emphasizes the usefulness of areas of a b i l i t y as motivation f o r the learning needed to improve a condition or adapt to a d i s a b i l i t y . Rating i s achieved by l e t t e r grading,.A through E, to indicate the degree of assistance that w i l l be required. This method of r a t i n g l i m i t s the use of the t o o l to one of 33 assessment. The Kenny se l f - c a r e evaluation used numerical scoring to e s t a b l i s h the s e l f - c a r e status of the patient. A b i l i t y to handle functional needs i s the basis f o r s e l e c t i n g behaviors i n each of the a c t i v i t i e s of d a i l y l i v i n g categories. The numerical scoring system i s used b a s i c a l l y to measure improvement. In the process, however, an assessment of the patient's physical needs i s achieved. The authors demonstrate the usefulness of the t o o l as an assessment device, i n d i v i d u a l nursing case-load score and as a work-load score f o r a unit of 34 a h o s p i t a l . Kerlinger supports the use of numerical r a t i n g . 3 2 j y j a r i ^ y n Poland et a l . "PETO a System fo r Assessing and Meeting Patient Care Needs," American Journal of Nursing, V o l . 70, No. 7 (July, 1970), p. iWF. rothy T i l l , "Some Aspects of Self-care," Physio-therapy, V o l . 53. No. 1 (January, 1957)., PP. 18 - 2 2 . erbert Schoening et a l . , "Numerical Scoring of Self-care Status of Patients," Archives of Physical Medicine and R e h a b i l i t a t i o n , Vol. 46, No. 10 (October 1965), p. 689. scales i n behavioral research as concise and easy to use with a wide range of applications and applicable where a large 35 number of characteristics are involved. III. FEEDING STUDIES Anthropological literature attests to the fact that the Individual i s deeply involved with food in relation to 36 communication, religion, culture and diversion. Wilson discusses food habits, not so much in terms of cooking and eating practices but i n terms of "their emotional value for 37 the persons holding them." L i t t l e research relative to feeding has been done i n the area of patients with chronic conditions. Studies that have been done are confined, largely, to the development of feeding devices or to assist i n the development of motor 38 control for the severely handicapped. Exton-Smith, Norton and 35Fred N. Kerlinger, Foundations of Behavioral  Research (New York: Holt Rinehart and Winston, 1964), pp. 514-518. 36RUth Benedict, Patterns of Culture (New York: The American Library, 1934), p. 33; Elenore Sraith-Bowen, Return to Laughter (New York: Doubleday and Company, Inc., 1964), p. 24-25. 37christine S. Wilson, "Food Beliefs Affect Nutritional Status of Malay Fisherfolk", Journal of Nutrition. Vol. 2, No. 3 (Winter, 1971), p. 98. 3®C.R. Wegenast, "The self-adjusting Lap Tray," American Journal of Occupational Therapy, Vol. 22, No. 1 (1968). pp. 36-377" McLaren's survey of basic nursing care on g e r i a t r i c wards includes a section on the provision of nourishment. I t was found that t h i s aspect of nursing care was the second most time-consuming area of nursing service. Physical and mental states are shown to be the factors governing the amount and kind of help patients receive. But there are other factors, some of which are shown to increase a patient's handicap and thereby create greater feeding d i f f i c u l t i e s . 3 9 These authors stress the need f o r a written record of feeding c a p a b i l i t i e s of each p a t i e n t . ^ 3 9 A .N. Exton-Smith, Doreen Norton and Rhoda McLaren, G e r i a t r i c Nursing Problems i n Hospital (London: The National Corporation f o r the Care of Old People, 1 9 6 2 ) , p. 130. 4 Q I b l d . . p. 1 3 1 . METHOD I. OVERVIEW A methodological approach was indicated f o r the develop-ment of an instrument that w i l l measure a b i l i t i e s of a patient f o r s e l f - f e e d i n g . Data about feeding and rela t e d a b i l i t i e s were c o l l e c t e d during meal times by observing, examining and. questioning a population of (1) patients h o s p i t a l i z e d with chronic conditions and (2) the nurses who care f o r them, as well as aides, etc.. A preliminary instrument was con-structed and submitted to a panel of experts f o r v a l i d a t i o n . The f i n a l instrument was tested f o r r e l i a b i l i t y using eight pairs of nurses r a t i n g two patients each. I I . SAMPLE The random sample on which observations of feeding behaviors were made, was drawn from a population of patients from two hospitals caring f o r people with chronic conditions. One h o s p i t a l had s i x t y - f i v e patients admitted to i t s extended care f l o o r . The second h o s p i t a l was a private h o s p i t a l with s i x t y - s i x patients. Both hospitals were situated i n a large urban area and operated under government regulations set down by the B r i t i s h Columbia Hospital Insurance Service 1 (BCHIS). The patient sample consisted of thirty-two females and eighteen males. More than one h a l f of these patients had two or more chronic conditions. The patients 9 consent to p a r t i c i p a t e i n the study was obtained wherever possible. In the few instances where patient consent was impossible, owing to the patient's condition, h o s p i t a l consent was obtained. For the r e l i a b i l i t y t e s t , patients were selected randomly from a l i s t of patients who were designated by the head nurse as requ i r i n g varying degrees of help with feeding. The nurses who normally cared f o r these patients were asked to use the t o o l to assess feeding behaviors. Consent was obtained i n the case of each nurse. Three hos-p i t a l s i n a large urban area were used f o r the r e l i a b i l i t y t e st, two of which had not been used f o r gathering the o r i g i n a l feeding behavior data. i. I I I . FEEDING BEHAVIOR DATA COLLECTION' F i f t y patients were observed from the time the tray •^•British Columbia Hospital Insurance Service, BCHIS Manual, Department of Health Services and Hospital Insurance ( V i c t o r i a : The Government of the Province of B r i t i s h Columbia, 1948), chapter VIII. was brought to the patient u n t i l the patient f i n i s h e d eating. A tape recorder was used by the author to record conversat-ions, observed behaviors and physical condition, as well as answers to questions regarding the feeding function. This information was gathered from the patients and the nurses, aides and others, who cared f o r them. Data were c o l l e c t e d concerning the physical c a p a b i l i t i e s f o r feeding as well as psychological and s o c i a l factors r e l a t e d to the feeding area. Information concerning age, diagnosis and written orders concerning feeding was recorded from the patients 1 charts. IV. ANALYSIS OP'FEEDING BEHAVIOR DATA Iden t i f y i n g s p e c i f i c items of feeding behavior was concurrent with defining categories during analysis of the data. Patients* a b i l i t i e s and d i s a b i l i t i e s of a physical, psychological and s o c i a l nature were l i s t e d to i d e n t i f y items related to feeding. The amount and kind of help received by patients was the basis f o r defining f i v e dependence-independence categories. Behavioral items were ordered using a framework of performance s k i l l development. The ordered items were used to reanalyze the data included under each category to develop a l i s t of cl e a r , d i s c r e e t feeding behaviors. This l i s t was the foundation f o r estab-l i s h i n g the assessment t o o l , the c r i t e r i a f o r independent feeders. A detailed discussion of the analysis of feeding behavior data appears i n chapter IV. V. CONSTRUCTION OP PRELIMINARY TOOL The feeding behaviors, evident i n the data, were ordered into neuromuscular, motivation and adjustment areas. Twenty-one behaviors were i d e n t i f i e d which measure not only the physical capacity but also provide some measure of the patient's emotional capacity to function and in t e r a c t i n h i s hosp i t a l environment i n r e l a t i o n to feeding. A r a t i n g scale, adapted from the Kenny numerical scoring of s e l f - c a r e , was used to provide a method of scoring behaviors. The advantage of numerical scoring i s that i t gives the assessor a simple method of r a t i n g . I t w i l l define degrees of a b i l i t y from which the nurse may receive clues to the amount and kind of help the patient w i l l need to feed independently. A series of observations provides a concise, written reference to a patient's change of state i n the area of s e l f - f e e d i n g . VI. VALIDATION A preliminary t o o l was designed and submitted to a panel of f i v e experts. Two of the experts were d i r e c t o r s of nursing i n hospitals caring f o r patients with chronic conditions. Three of the experts were head nurses on wards of such hos-p i t a l s . Pace v a l i d i t y was established. Two nurses offered suggestions to improve the preciseness of three behavior descriptions. VII. RELIABILITY TESTING Three pairs of nurses used the validated t o o l to separately assess two patients each, gi v i n g s i x pairs of observations. Observations of patients were to be made within twenty-four hours or l e s s . The purpose of the t o o l , the code f o r Judging behaviors, and the code f o r r a t i n g was explained v e r b a l l y and i n writin g . A series of questions concerning use of the t o o l was also put to each nurse. Some te s t i n g was incomplete due to i l l n e s s among the s t a f f and patients. A second t e s t was done. Five pairs of nurses used the t o o l to assess two patients each. Prepared i n s t r u c t i o n s were read to each nurse and the questions a l t e r e d i n l i g h t of the previous r e s u l t s . Seventy percent agreement was considered acceptable f o r t h i s t e s t . ANALYSIS OF THE DATA I. ANALYSIS OF FEEDING BEHAVIOR DATA In each of the f i f t y cases drawn i n the random sample, feeding behaviors were divided into a b i l i t i e s and d i s a b i l i t i e s i n the physical, psychological and s o c i a l areas. Clues from nurses, aides, etc. were determined from the amount and kind of help given to the patient during the meal and answers to questions asked f o r c l a r i f i c a t i o n of observed actions. Patients were roughly divided into categories according to the varying amounts and kinds of help they received from those who cared f o r them. The d i v i s i o n was accomplished by f i r s t separating patients into those who ate t h e i r meal with no assistance or supervision and those who required help to eat t h e i r food. Those who received no help were designated independent. Category I. Of those who received help, the patients who were fed a l l of t h e i r meal and were reported by s t a f f not to feed themselves were designated dependent. Category V. Of the remaining patients, those who received no d i r e c t help during the meal observed and were reported by s t a f f to receive help i n c i d e n t a l to feeding, f o r instance, medication f o r pain, were designated as minimally a s s i s t e d independent. Category II". The remaining patients were separated by whether or not they received help with the feeding task, which i s defined as the steps required to transfer food from dish to mouth, chew and swallow I t . Those who were fed e i t h e r part of the meal or were reported by s t a f f to receive such help were designated as p a r t i a l l y dependent. Category IV. The remaining patients were those who were observed to feed themselves independently and were reported by s t a f f to do so but received varying amounts of assistance for a c t i v i t i e s associated with feeding. They were designated as a s s i s t e d independent, Category I I I . This category i s defined by the fac t that the patient does not f i t into any of the other categories. No attempt was made to define the varying amounts of assistance f o r a c t i v i t i e s assoc-i a t e d with feeding. Observations i n each category were translated into p o s i t i v e behavioral terms which were ordered into a framework based on the development of performance s k i l l s . This framework i s the basis f o r l a t e r construction of the preliminary t o o l . Examples of t r a n s l a t i o n from raw data follow. Observations t y p i c a l of patients who behaved independ-ently; some teeth missing, no problem chewing or swallowing--was translated to, able to chew well enough to swallow. Used napkin, salted food, wiped hands and mouth—were behavioral i n nature and were used without t r a n s l a t i o n . Talked to observer about past—was translated to (1) responds to verbal stimuli (2) responds r e a l i s t i c a l l y to others, and (3) a l e r t to surroundings. Observations t y p i c a l of patients who behaved depend-ently; orderly fed patient e n t i r e meal, says patient unable to use hands—was translated to, able to use fingers or u t e n s i l s to put food i n mouth (negative) and eats entire meal independently (negative).. Patient fed by levlne tube--was translated to, able to swallow food without choking (negative). Did not respond or look at observer, blank expression during meal—was translated to, shows emotion (negative). Patient was repositioned several times during the meal as he f e l l over—was translated to', controls trunk to s i t erect (negative). Observations t y p i c a l of patients who received a s s i s t -ance and/or supervision of a minimal nature and aside from the feeding process; patient given morphine h a l f an hour before meal f o r pain—was translated to, assistance (medication) to be physically comfortable i n order to eat. Patient not eating, said she was angry at another patient, nurse talked to her and moved her to the sunroom—was translated to, a s s i s t -ance with mental stress i n order to eat. Patient given more time to eat as she was very slow eating because she f e l t t ired—was translated to, supervision to be ph y s i c a l l y comfortable i n order to eat. Observations t y p i c a l of patients who receive assistance and/or supervision of an extensive nature Including p a r t i a l feeding; patient rubbed fork on plate instead of eating, aide gave her a few mouthfuls and encouraged her to continue eating—was translated to, assistance and supervision to be able to focus attention on eating. Nurse said patient was aphasic, patient made sounds to get attention, nurse made several attempts to understand aphasic patient's sounds— was translated to, assistance to make needs known. Nurse helped patient with slurred speech to practice words—was translated to, assistance to be able to speak coherently. Observations t y p i c a l of patients who do not f i t i n other categories; aide gave patient a straw to make i t easier to drink—was translated to, assistance to use u t e n s i l s i n order to eat. Orderly changed patient's bib because of spillage--was translated to, assistance to manage s p i l l a g e . Aide supervised a b l i n d patient who could not locate her food—was translated to, supervision to cope with i n a b i l i t y to see s u f f i c i e n t l y to d i s t i n g u i s h objects. A l i s t of twenty-one s p e c i f i c feeding behaviors which describe the independent feeder was i d e n t i f i e d concurrent with the defining of f i v e categories along the dependence-independence* continuum. The data from the f i f t y cases observed were tabulated i n Table I, and shows the number and percent of po s i t i v e behaviors i n each category. A key to Table I follows the table. One hundred percent of the patients i n the Independent Category were able to perform a l l twenty-one feeding behaviors. This i s the basis f o r the d e f i n i t i o n of Category I. One hundred percent of the patients i n the Minimal Assistance Category could perform the feeding task, a s s i s t themselves with feeding and be responsible for t h e i r own motivation with one exception. "Eats at a normal rate of speed" was performed by only 50 percent of t h i s category. Patients i n t h i s category were not a l l capable of feeding adjustment behaviors. 57.14 percent of these patients did not receive medication, reassurance or nursing care f o r mental or physical comfort i n order to eat. 91 . 3 0 percent were independent i n focussing attention on the eating process and showing emotion. 92 . 8 5 percent responded r e a l i s t i c a l l y to others and were a l e r t to surroundings. On the basis of these percentages Category II was defined as receiving minimal assistance and/or supervision. Category III determines that the patient i s e n t i r e l y independent f o r the feeding task, however, there i s some reduction of independence i n those behaviors re l a t e d to a s s i s t -ing s e l f with the feeding task and feeding adjustment. Less TABLE I TABULATION OP FEEDING BEHAVIORS OF RANDOM SAMPLE OF PATIENTS WITH CHRONIC CONDITIONS. NUMBER AND PERCENTAGE OF POSITIVE BEHAVIORS BY CATEGORY FKKDTNG BRHAgIQB&>. NEUROMUSCULAR . A. PERFORM THE PJimNG-JCASK, pie to use fingers . toput.. food In mouth. e j ^ _ j i s e , j u j t e n s l l s _ ^ ble to chew food well enough to swallow i t , B. ASSIST SELF WITH FEEDING TASKS. jContr.QIs..trunk,.to.. slt._erect, Swallow.s__wlthout choking. J5a£s_.a;t,„a_ normal ...Tate^o£js Pours tea, butters bread etc £J-P-ERFQRM .EERSQMK, HYGIENE. Cat.._l._ Indept. a|-jLoo.. 0 0 . 1 0 0 . 0 0 . 1QP...0.Q.. . 9 1 1 0 0 . 0 0 a l i o o . o o . 1 0 0 . 0 0 1 0 0 . 0 0 .Cat . _ J I . _.Min» -Assisted. Indept. . JL % 14 14. 1.4 14 7. 14 1 0 0 . 0 0 1 0 0 . 0 0 1 0 0 , 0 0 1Q0..00 5 0 . 0 0 Cat,. J X I Assisted.. Indept. 14 14 14 10 11 5 6 14 .100.00 100.00 7,1^3. 78,37 35.71 Cat. IV. P a r t i a l l y Dept. i 1 0 0 , 0 0 . 1 0 0 . 0 0 . XOO.CQ,. 5 Q , o o . Ms 50. . 1 . 3 * 5 0 . . Cat. V. Dept. CL.JQ..QQ. . o^p.o. 0 . 0 0 60..QQ,. 0 . 0 0 4 0 . 0 0 0 . 0 0 8. Able to use napkin;p.r JJUt_on.Jblb.... A^e_tp.jaana^e.jp.wn_splllage.t  L 0 . Able to wipe, hands..and, .mouth.. . 1 0 0 . 0 0 . 1 0 0 . 0 0 -1 0 0 . 0 0 14 14 14 1 0 0 . 0 0 100.. 00 1 0 0 . 0 0 42.86 8_]_57-l4.3|-37-J-2,50 *50-4 ^Q0_J3 0_. 0 0 . - 0 . 0 0 -: i . FEEDING BEHAVIORS. MOTIVATION-. LI*. 12. Ea^^ntlr.e_j^al^ncl.ependently.™ Speaks coherently. -3^ Hakes.-jaeeds .known. l i t -L i -Eesponds to verbal s t i m u l i . . ...... Sees S u f f i c i e n t l y to distinguish objects. . 1 0 0 . 0 0 . XOCi.OO. 1 0 0 . 0 0 1 0 0 . 0 0 lif, Ik. 14 14 14 1 0 0 . 0 0 1 0 0 . 0 0 1 0 Q . 0 0 1 0 0 . 0 0 10,0 t 0Q .14 11 13 13 12. X0SLAQ. 78.57 92.85 92.85 35*11 . 0 . 0 0 2 5 . - 0 0 5 0 . 0 0 5 0 . 0 0 5LJ6^JL5.Q-o.oo 2 0 . 0 0 4 0 . 0 0 _ 6 0 . 0 0 i n w r a n T N t t R F . H A V I O R S . ADJUSTMENT. 16. L7. Responds r e a l i s t i c a l l y to others. Alert.jto_surro.und,lngs, _._ 18*. 19. 20^ C.an_f ocus. a t t e n t i o n .pn...eating. process.,._ Shows emotion. -Mentally...comf or table... .Physically,comfortable,  1 0 0 . 0 0 1 0 0 , 0 0 . 1 0 0 . 0 0 1 0 0 , 0 0 1 0 0 . . 0Q 1 0 0 . 0 0 13 13 12 12 8 8 92 . 8 5 9 2 . 8 5 91.30 51,.3Q .57.14. .57.1^ 10 9 ..8 13 11 71.43 64 . 2 9 57.14 64 . 2 9 92.85 2 5 . 0 0 1 2 . 5 0 1 2 . 5 0 1 2 . 5 0 7 5 . 0 0 ,3?., 59, 2 0 * 0 0 . . 0 . 0 0 . 2 0 . 0 0 - 1 2 0 . 0 0 8 0 . 0 0 . . 6 0 * 0 P _ Total number i n category 1 4 14 8 # of persons i n the Independent category observed to have t h i s s p e c i f i c a b i l i t y . 1 VO - " - — . , ... % of persons i n the Independent category observed to have t h i s s p e c i f i c a b i l i t y . 100.00 # of persons i n the Minimally Assisted Independent category observed to have t h i s s p e c i f i c a b i l i t y . co • % of persons In the Minimally Assisted Independent category observed to have t h i s s p e c i f i c a b i l i t y . « M -P" # of persons i n the Assisted Independent category observed to have t h i s s p e c i f i c a b i l i t y h-> h-» % of persons i n the Assisted Independent category observed to have t h i s s p e c i f i c a b i l i t y . co • . # of persons i n the P a r t i a l l y Dependent category observed to have t h i s s p e c i f i c a b i l i t y . u> % of persons i n the P a r t i a l l y Dependent category observed to have t h i s s p e c i f i c a b i l i t y . • O # of persons i n the Dependent category observed to have t h i s s p e c i f i c a b i l i t y . % of persons In the Dependent category observed to have t h i s s p e c i f i c a b i l i t y . ' ' " " " ' „,. •• .1 • , . „.,. , . . --. .—— • |, ON o • o o V g f W o o 6 8 o w M CO o > M M •3 M w w c •3 •3 O 25 a erosion i s seen i n the motivation area as i t averages 90 percent achievement of these behaviors. This category does not c l e a r l y d i f f e r e n t i a t e mild, moderate, or severe handicaps but includes them a l l . Category IV i s defined as covering patients who can successfully perform the feeding task but receive extensive assistance with associated a c t i v i t i e s of feeding. There i s considerable erosion of independence i n the l a t t e r a c t i v i t i e s . An average of only 3 2 . 5 percent of patients i n t h i s category can a s s i s t themselves with feeding or perform personal hygiene, 3 7 . 5 percent had a b i l i t i e s to promote i n t e r e s t i n independent feeding and only 2 9 . 1 6 percent showed a b i l i t i e s which might overcome d i s t r a c t i o n s i n order to eat. Patients i n Category V were unable to place any food i n t h e i r mouths. 60 percent of them could chew well enough to swallow the food. The others were fed by levine or at the time of the observation were considered unsafe to feed due to a sudden worsening of t h e i r physical condition. None of these patients could a s s i s t themselves with the feeding a c t i v i t y with the exception that 40 percent could swallow Without.choking. Only 33 percent of the patients i n t h i s category had a b i l i t i e s to promote i n t e r e s t i n eating or a b i l i t i e s to overcome d i s -tractions i n order to eat. Figure 1 shows the p r o f i l e of the decreasing percentage of achieved behaviors by category. I t i l l u s t r a t e s the erosion of independence as patient's d i s a b i l i t i e s overtake his a b i l i t i e s i n the a c t i v i t i e s r e l a t e d to feeding. Figure 2 provides a percentage pattern of dependent and independent behaviors. This demonstrates the progressively reducing area of Independence and i l l u s t r a t e s the f i v e cat-egories along the feeding dependence-independence continuum. Defining categories provides a measurement of the degree of help a patient w i l l require to feed himself. The following categories were derived 'from the data. Category I, Independent feeder: completes, without help, the steps required to transfer food from dish to mouth, chew and swallow. A s s i s t s s e l f while eating and performs personal hygiene r e l a t i v e to eating. Responsible f o r own motivation and adjustment i n order to eat. Category I I . Minimally assisted Independent feeder: completes the feeding tasks, a s s i s t i n g s e l f with feeding, and personal hygiene and i s responsible f o r own motivation. Requires minimal assistance and supervision to overcome d i s t -ractions i n order to eat. Category I I I , Assisted Independent feeder: completes the feeding tasks but receives varying amounts of assistance Behaviors  Feeding Tasks 1 2 3 A s s i s t s S e l f With Feeding Tasks 4 5 6 7 _ 8 9 10 Promote Interest i n Independent Feeding 11 12 13 14 Overcome Dis t r a c t i o n s 16 17 18 19 20 21 # of patients i n each category t ! 1 If- it *\5 -ice'/oS" Figure 1. Analysis of feeding behaviors of the random^sample of patients V i t h chronic conditions. P r o f i l e of behaviors. Percentage of p o s i t i v e behaviors f o r the twenty-one items by category. V*) NO Categories I II III IV V 0-100 % 0-100 % 0-100# 0-100# 0-100 % Figure 2. Analysis o f feeding behaviors o f patients with chronic conditions. Patterns of behaviors. or supervision with other associated a c t i v i t i e s as defined f o r the independent feeder. Category IV, P a r t i a l l y dependent feeder; receives some assistance with the feeding tasks as well as extensive assistance with other associated a c t i v i t i e s as defined f o r the Independent feeder. Category V, Dependent feeder: t o t a l l y dependent on others f o r the feeding task Including extensive assistance with other associated a c t i v i t i e s as defined for the independent feeder. I I . CONSTRUCTION OF THE TOOL Twenty-one behaviors were I d e n t i f i e d from the raw data which would describe the a b i l i t i e s of an independent feeder. These behaviors were divided into neuromuscular, motivation and adjustment fa c t o r s . The neuromuscular a b i l i t i e s were further divided into the feeding task, assistance of s e l f with the feeding task and personal hygiene. This allows for the weighting of the neuromuscular fac t o r without which Independent feeding i s not possible. The feeding task con-s i s t s of those steps needed to get food from the plate into the mouth, chewing and swallowing i t . Those steps which are needed to a s s i s t oneself with the feeding task are the contributing a c t i v i t i e s to the feeding task. R e s p o n s i b i l i t y f o r personal hygiene completes the neuromuscular a b i l i t i e s needed f o r sel f - f e e d i n g . The a b i l i t i e s most l i k e l y to promote i n t e r e s t i n independent feeding were included to provide some measure of the patient's motivation toward independent feeding. Those a b i l i t i e s which contributed s i g n i f i c a n t l y to overcoming d i s t r a c t i o n s i n order to eat were included to provide some measure of the patient's a b i l i t y to adapt to situationswhich might Interfere with h i s a b i l i t y to feed himself. To provide a method of determining the amount of help a patient would require to feed independently, a numerical r a t i n g scale, adapted from the Kenny numerical scoring of sel f - c a r e status, was used. The r a t i o n a l e f o r the use of t h i s scoring method i s that i t provides, "Quan t i f i c a t i o n of the r e l a t i v e value... of the t o t a l functional capacity of the patient... i t becomes a numerical d e s c r i p t i o n of the patient's 2 functional nursing needs." A b i l i t i e s were graded i n terms of whether the behavior was performed independently, with a s s i s t -ance or supervision, or not at a l l . The independent ( f u l l a b i l i t y ) and dependent, (no a b i l i t i e s ) categories are defined ^Herbert A. Schoening, et a l . , "Numerical Scoring of Self-care Status of patients," Archives of Physlcal Medicine  and R e h a b i l i t a t i o n . V o l . 46, No. 10 (October, 1965), p. 690. as the two extremes of the self-oare continuum and rated as (0) and (4) respectively. A (1) r a t i n g i s based upon the c r i t e r i a that a patient requires assistance and/or super-v i s i o n with one or two steps of an a c t i v i t y and can perform a l l other steps independently. A (3) r a t i n g i s based upon the c r i t e r i a that a patient requires assistance with one or two steps, or i s independent i n one step but cannot perform any other steps independently. These four ratings describe independence (0), minimal assistance and/or supervision (1), extensive assistance (3) and dependence (4). The (2) r a t i n g i s used f o r a l l other combinations which w i l l include mild, moderate and severe l i m i t a t i o n s of a b i l i t i e s . Figure 3 shows an o u t l i n e of the procedure f o r r a t i n g feeding behaviors, I. Rating Code. I I . Codes f o r judging Items. 0 = independent + = independent 1 = minimal assistance and/or - = requires assistance and/or supervision. supervision. 2 = moderate assistance. - = dependent 3 = extensive assistance. 4 = completely dependent. I I I . C r i t e r i a f o r assignment of r a t i n g . 0 = a l l +• s 1 = 1 or 2 -'s; a l l others +•s 2 = a l l other combinations. 3 = 1 or 2 ±'s (or 1 +); a l l others -'s. 4 = a l l -*s. Figure 3. Outline of procedure f o r r a t i n g feeding behaviors; c l a s s i f i c a t i o n and symboHzatlon. 1 the r a t i n g code, codes f o r Judging items and c r i t e r i a f o r the assignment of ratings. This has been adapted from the Kenny 3 s e l f - c a r e r a t i n g scale. Schoening explains that the r a t i n g scale i s a c t u a l l y a seven-point scale with the middle three points compressed into one. The problem of defining each point on the scale i s thus s i m p l i f i e d . The rat i o n a l e f o r defining ratings may be seen i n Figure 4. 3 " Usual five-point scales. A very mild none T mild t moderate T severe very severe total- 1 Kenny five-point scale. Corresponding seven-point scale, Figure 4. Five-point and seven-point r a t i n g scales. Rationale f o r defining ratings. 3)Herbert A. Schoening and Iver A. Iversen, "Numerical Scoring of Self-care status: A study of the Kenny Self-Care Evaluation," Archives of Physical Medicine and Reh a b i l i t a t i o n . V o l . 49. No. 4 ( A p r i l , 196b), pp. 224-225. 4T"M A n 99« the c r i t e r i a f o r assignment of r a t i n g i n Figure 3. Points three, four and f i v e become the number two r a t i n g . Rationale for t h i s approach i s based upon the fact that the patient i s not l i k e l y to progress through each category at an even rate 5 but i s more l i k e l y to follow the sigmoid learning curve. Acceleration occurs toward the center of the curve allowing f o r the central three points to approximately equal the other points. The l i s t of behaviors and adapted r a t i n g scale were combined to form the preliminary t o o l . The format for t h i s t o o l may be seen i n Table I I . II . ANALYSIS OF PATIENT SAMPLE DATA Categories were derived from analysis of the feeding behavior data previously described. Of the f i f t y patients i n the study sample, nine could be defined as independent, four-teen as minimally assisted, fourteen as being a s s i s t e d but remaining independent i n the feeding task, eight as being p a r t i a l l y dependent and f i v e as being dependent. Table III outlines the age range and mean age of patients i n these categories. I t i s i n t e r e s t i n g to note that the independent category has the highest mean age and the dependent category 5Ibid. THE PRELIMINARY TOOL FOR ASSESSMENT OF ABILITIES RELATED TO INDEPENDENT FEEDING RATING SCALE OF ABILITIES RELATED TO INDEPENDENT FEEDING. NEUROMUSCULAR ABILITIES NEEDED TO: A. PERFORM THE FEEDING TASKS. C i r c l e appropriate code. 1 . Able to use fingers to put food In mouth. 2. Able to use u t e n s i l s to put food In mouth. + ± -+ t -3 . Able to chew food well enough to swallow I t . + - -B. ASSIST SELF WITH FEEDING TASKS. Rating. 4. Controls trunk to s i t erect. • + -5 . Swallows without choking. + ± -6. Eats at a normal rate of speed. + ± -7 . Pours tea, butters bread etc.. + ± -C. PERFORM PERSONAL HYGIENE. Rating. 8 . Able to use napkin or put on bib. + ± -9 . Able to manage own s p i l l a g e . • ± -+ ± -1 0 . Able to wipe hands and mouth. ABILITIES WHICH PROMOTE INTEREST IN INDEPENDENT FEEDTM; ~ ~~ 1 1 . Eats entire' meal independently. + - -1 2 . Speaks coherently. 1 3 . Makes needs known. 14. Responds to verbal s t i m u l i . 1 5 . Sees s u f f i c i e n t l y to d i s t i n g u i s h objects. Rating. + t _ + ± -+ ± -+ ± - . Rating. TABLE II (continued) ABILITIES TO OVERCOME DISTRACTION IN ORDER TO EAT. 16. Responds r e a l i s t i c a l l y to others. + ± _ 17. A l e r t to surroundings. + ± -1 8 . Can focus attention, on eating process. + - -1 9 . Shows emotion. + ± -2 0 . Mentally comfortable. (medication or reassurance not needed) + ± -2 1 . Physically comfortable. (medication or nursing care not needed) + ± -Rating, Rating t o t a l . , has the lowest. The s i g n i f i c a n c e of t h i s can only be disclosed by further i n v e s t i g a t i o n . There are only two people i n t h i s sample under the age of s i x t y - f i v e . The mean age of patients with chronic conditions was 7 7 . 7 7 . These aver-ages cannot be seen to represent the t o t a l population with chronic conditions. TABLE III DESCRIPTION OF RANDOM SAMPLE OF PATIENTS WITH CHRONIC CONDITIONS: AGE RANGE AND MEAN AGE BY CATEGORY Category # i n Category Mean Age. Age range. I Independent 9 82 . 4 4 68-91 II Minimally Assisted Independent 14 74.14 5 6 - 8 9 I I I Assisted Independent 14 7 8 . 8 6 6 7 - 9 6 IV P a r t i a l l y Dependent 8 80 . 0 0 6 7 - 8 9 V Dependent 73.40 6 6 - 8 7 Total 50 77.77 5 6 - 9 6 . The number and percentage of patients i n the random sample who had two or more chronic conditions i s shown i n Table IV. The lowest incidence or two or more chronic conditions occurs i n the independent and dependent categories. This suggests that the severity of the chronic condition may be a f a c t o r i n the dependency of patients. Further study i s needed to c l a r i f y t h i s point as well as to explore the possible s i g n i f i c a n c e of the high occurence of two or more chronic conditions i n categories II and IV. TABLE IV DESCRIPTION OF RANDOM SAMPLE OF PATIENTS WITH TWO OR MORE CHRONIC CONDITIONS. NUMBER AND PERCENTAGE BY CATEGORY Category I Independent II Minimally Assisted Independent III Assisted Independent IV P a r t i a l l y Dependent V Dependent Tp.tal # i n Category 2 or more chronic conditions 14 14 8 50 # 2 8 11 7 1 29 mean-22.22 57.14 78.57 87.50 20.00 *58.00 A l l patients who were involved, even p a r t i a l l y , i n the feeding task had a wide range of time spent eating. The dependent patients had no range of time. They were fed, i n a l l cases, i n f i f t e e n minutes. This suggests that i t i s quicker to feed patients than to allow time f o r involvement In s e l f - f e e d i n g . The range and mean of minutes spent eating i s presented i n Table V. TABLE V DESCRIPTION OF RANDOM SAMPLE OF PATIENTS WITH CHRONIC CONDITIONS MINUTES SPENT EATING BY CATEGORY, RANGE AND MEAN Category # i n Category Minutes Range spent eating Mean I Independent 9 10-45 18 . 3 3 II Minimally A s s i s t e d Independent 14 • 10-45 26.79 III Assisted Independent 14 10-45 26.07 IV P a r t i a l l y Dependent 8 10-45 33.75 V Dependent 1 5 - 0 15 . 0 0 Total 48 Mean 23.99 *Two unconscious patients not included i n timing f o r category V. I t may further indicate that, i f time i s the major c r i t e r i o n f o r patient care, patients w i l l be more l i k e l y to be required to surrender some degree of t h e i r independence i n the feeding area. The F r a t i o , the s t a t i s t i c a l treatment f o r which i s de t a i l e d i n Appendix C, was not s i g n i f i c a n t at the . 0 5 l e v e l . The n u l l hypothesis that the f i v e means of minutes spent eating do not d i f f e r s i g n i f i c a n t l y Is accepted. Relatives fed patients on a regular basis f o r one meal each day i n one out of f i v e cases i n Category V and i n four out of eight cases i n Category IV. In four cases r e l -atives were encouraged to a s s i s t patients with feeding, p a r t i c u l a r l y i f there was a danger of a low, o v e r a l l c a l o r i c Intake or a need f o r stimulation to eat. A b i l i t i e s of the patient were not considered by r e l a t i v e s when givi n g feeding help. In two cases patients had become used to being fed by family members and no longer assumed any r e s p o n s i b i l i t y f o r feeding themselves. In two other cases r e l a t i v e s i n s i s t e d on patients being fed even though the patients were able to handle f i n g e r food and u t e n s i l s . The whole question of the kinds and amount of help given by r e l a t i v e s and the ra t i o n a l e f o r such help needs further i n v e s t i g a t i o n . Contrary to some nurses opinions, as expressed i n the recorded notes, i t was found that missing teeth or dentures did not necessarily a f f e c t the independent status of the patient. Patients stated that mincing or cu t t i n g of food was necessary to t h e i r coping with eating. Others f e l t that t h i s indicated a d e t e r i o r a t i n g condition and preferred to struggle on with the chewing d i f f i c u l t i e s of a regular d i e t . Mobility and s o c i a l i z i n g of the patient did not appear to be a f a c t o r i n determining the amount of help a patient needed with feeding but there was evidence that a b i l i t y to develop interpersonal communications was important. CHAPTER V VALIDATION AND RELIABILITY TESTS I. VALIDATION The preliminary t o o l was submitted to a panel of f i v e experts along with a sample of t y p i c a l observations from which feeding behaviors were derived. The l i s t of t y p i c a l observations from raw data as well as the questions asked of the experts i s reproduced i n Appendix A. The panel consisted of two d i r e c t o r s of nursing and three head nurses, a l l of whom worked c l o s e l y with patients with chronic conditions. This panel agreed that, i n general, the preliminary t o o l had face v a l i d i t y . There was agreement by a l l f i v e experts that behaviors l i s t e d on the scale could be derived from the sample observations submitted f o r t h e i r consideration. Three of the experts, one d i r e c t o r of nursing and two head nurses, agreed that each behavior represented a fa c t o r of independent feeding f o r a person with a chronic condition and that a l l twenty-one behaviors described an independent feeder. The t h i r d head nurse f e l t that item twelve, speaks coherently, and item th i r t e e n , makes needs known, would be more meaningful i f combined to read, able to communicate needs. This nurse f e l t the remaining behaviors described an independent feeder " i n a much more meaningful manner than the o f t used, s t r i c t l y functional assessment." With the suggested modifications above she agreed that each behavior represented a fa c t o r of independent feeding. The second d i r e c t o r of nursing suggested s u b s t i t u t i n g communication f o r speaks, i n item twelve. She questioned adding the explanation f o r item twenty, mentally comfortable (medication or reassurance not needed) and item twenty-one, ph y s i c a l l y comfortable (medication or nursing care not needed), as tending to bias opinion. In addition, she questioned whether an independent feeder would use a bib. The remaining seventeen behaviors along with the four modified ones, were considered by her to describe the independent feeder. She agreed that each of the items i n the revised l i s t represented a fa c t o r of independent feeding f o r a person with a chronic condition. One d i r e c t o r of nursing stated the t o o l would be of considerable value i n the t r a i n i n g of personnel. There was general agreement among the experts that t h i s t o o l would assist' nurses to assess the feeding a b i l i t i e s of patients with chronic conditions. Eight pairs of nurses were asked to assess two patients each, using the Rating Scale of A b i l i t i e s Related to Indep-endent Feeding. This scale was not a l t e r e d from the preliminary t o o l form which i s reproduced i n Table i r . The nurses were asked to use the r a t i n g scale to record t h e i r assessments, without discussing eit h e r the recording or the patients involved with any other nurse. The t e s t was then c a r r i e d out using the procedure described on page twenty-eight. Scores f o r each patient were t o t a l l e d and the r e s u l t s obtained by each p a i r of'nurses were compared. The scores obtained are shown i n Appendix B. The number of pairs of scores which come within the range of scores assigned to a defined category were considered to be i n agreement. Pairs of scores which did not f i t into a sin g l e category were con-sidered to be i n disagreement. Twelve of the sixteen pairs of scores were i n agreement. Four were not. This produces a percentage agreement of 75 percent. A Pearson product-moment c o r r e l a t i o n of the scores of eight pairs of nurses, r a t i n g two patients each, and using the feeding assessment t o o l i s d e t a i l e d i n Appendix C. The c o r r e l a t i o n was .849. This c o r r e l a t i o n indicates that the t o o l w i l l provide consistent measurement of feeding a b i l i t i e s . The time Interval between measurements was twenty-four hours or l e s s . This time i n t e r v a l would tend to produce a lower c o r r e l a t i o n due to the l i k e l i h o o d of change i n patients with chronic conditions. Since major decisions about i n d i v i d -uals on the basis of a sing l e test i s not the purpose of t h i s t o o l , a r e l i a b l e measuring instrument has been produced. Because there was only 6 1 . 9 5 percent agreement be-tween pairs of nurses on s p e c i f i c items i n the t o o l an item 1 analysis was done. The s t a t i s t i c a l treatment i s d e t a i l e d i n Appendix C. The item analysis of agreement of pairs of nurses using the feeding assessment t o o l to rate the s e l f - f e e d i n g a b i l i t y of selected patients i s described i n Table VI. One t h i r d of those ratings with the highest percentage agreement were compared with the one t h i r d with the lowest percentage agreement. There were no negative correlations i n the twenty-one items. The feeding task, items one to three, and the a s s i s t -ing s e l f with feeding task, items four to seven, received acceptable percentage agreement with the exception of item seven, pours tea, butters bread etc.. With only f i f t y percent agreement and a . 2 discrimination index, t h i s item requires ^-Norman E. Gronlund, Measurement and Evaluation i n Teaching (New York: The Macmillan Company, 1 9 6 5 ) , pp. 2 0 7 - 2 1 5 ITEM ANALYSIS OP AGREEMENT OP PAIRS OP NURSES, USING THE FEEDING^ ASSESSMENT TOOL, TO RATE THE DEGREE OP SELF-FEEDING" ABILITY OP SELECTED PATIENTS Number of items=21 Number of Nurses = 16 Response agreed % Level of Agreement Discrimination Index Item Upper (5) Lower ( 5 ) 1 5 5 100 . 0 2 4 4 80 • 0 3 4 3 70 . 2 4 4 2 6 0 .4 5 4 2 60 .4 6 5 4 90 . 2 7 3 2 50 . 2 8 3 1 40 .4 9 2 1 30 . 2 10 5 0 50 1 . 0 11 5 2 70 . 6 1 2 4^ 4 80 . 0 13 4 2 6 0 .4 14 • 5 1 6 0 .8 15 - 5 3 80 .4 16 3 1 40 .4 17 5 2 70 . 6 18 5 2 70 . 6 19 5 1 60 .8 20 3 1 40 .4 21 4 2 6 0 .4 rephrasing. The section, performs personal hygiene, received unacceptable percentage agreement. Since the meaning of these items appears to be quite c l e a r the problem may l i e i n the a b i l i t y of the nurse to discriminate between the assistance and supervision given and that needed. More c a r e f u l i n s t r u c t i o n of nurse raters might help here, f o r instance, defining + as needs no help to perform the task, * as can perform the task i f helped and - needs t o t a l help; unable to perform the task. The group motivation behaviors received acceptable percentage agreement with the possible questioning of items thirteen, makes needs known and fourteen, responds to verbal s t i m u l i . There was not s u f f i c i e n t evidence i n the discrimin-ation index to indicate a need f o r change. Further t e s t i n g of these items w i l l be required. Rating a b i l i t i e s to overcome d i s t r a c t i o n i n order to eat, produced two unacceptable items? sixteen, responds r e a l i s t i c a l l y to others, and twenty, mentally comfortable. Item sixteen might be considered to be represented i n items seventeen, eighteen and nineteen? a l e r t to surroundings, can focus attention on eating process and shows emotion, and therefore i t could be eliminated. There was comment from some nurse raters that mental and physical comfort should not be separated. As there was a discrimination of .4 i n both cases, items twenty and twenty-one, mentally comfortable and physically comfortable, they might be combined and reworded. I I I . ASSESSMENT OP NURSES' RESPONSES TO QUESTIONS ON USE OP THE TOOL Nurses who par t i c i p a t e d i n the r e l i a b i l i t y t e sts were asked to comment on the usefulness of the t o o l f o r assessing feeding behaviors. Responses of the f i r s t three pairs of nurses are seen i n Table VII. The four questions used f o r t h i s group are l i s t e d i n Appendix B. TABLE VII. PERCEIVED USEFULNESS OF THE TOOL TO THE FIRST THREE PAIRS OP NURSES PARTICIPATING IN RELIABILITY TEST, GROUP I Did t h i s r a t i n g scale Total # of a s s i s t you to: Yes No No answer nurses 1 . Assess feeding a b i l i t y , 3 2 1 6 2 . Decide i f patient needed feeding help. 3 2 1 6 3 . Decide degree of feeding help needed. 3 2 1 6 k. Discover new information. 3 2 1 6 Total percentage. 50 3 3 . 3 3 1 6 . 6 6 100 A second group of f i v e pairs of nurses responded to a revised set of three questions l i s t e d i n Appendix B. The responses from t h i s group are seen i n Table VIII. In group I, the nurse who did not answer the questions stated that she had been assessing patients f o r years and d i d not need to mark a chart to decide the amount of assistance a patient would need. She commented that such a t o o l would have been usefu l i n her early work with such patients. TABLE VIII PERCEIVED USEFULNESS OF TOOL TO THE SECOND GROUP. FIVE PAIRS OF NURSES, PARTICIPATING IN RELIABILITY TEST Does t h i s scale a s s i s t you to: Yes Yes with No T o t a l # of reservations nurses 1 . Decide degree of feeding help. 9 1 0 10 2 . Provide evidence of feeding a b i l i t y f o r new s t a f f . 9 1. 0 10 3 . Assess feeding a b i l i t y of a new patient. 8 0 2 10 T o t a l percentage. 8 6 . 6 6 6 . 6 6 6 . 6 6 1 0 0 Two nurses stated the t o o l would not be useful to them. However, one of them commented that i t might be useful i n assessing new patients. Three nurses stated the tool would a s s i s t them to assess patients. Two of these nurses stated that the tool would be p a r t i c u l a r l y h e l p f u l i n assessing new patients. Further favorable comments included such remarks as, "became more aware of patients a b i l i t i e s and d i s a b i l i t i e s , " "great help i n i d e n t i f y i n g what help the patient might need," and "helps i n passing on information, e s p e c i a l l y with so much s t a f f changeover." The nurse who had reservations concerning questions one and two i n Table VII q u a l i f i e d her. answer. She f e l t that, i n both these cases, the information obtained would only s i g n i f y the extent to which the patient can feed himself, not the extent to which he w i l l do so. A second nurse disagreed with the above view by remarking that both a b i l i t y and willingness were revealed by the use of the t o o l . The two nurses i n t h i s group who f e l t the t o o l was not useful f o r assessing the feeding a b i l i t i e s of new patients sa i d they would need a medical history, diagnosis, medications used and observation of the patient f o r some time before attempting assessment. Four nurses emphasized the changeability of behavior i n patients with chronic conditions. They suggested the value of t h i s Instrument would be i n i t s use over a longer period of time. One nurse questioned d i v i d i n g physical and mental comfort, saying, "almost a l l g e r i a t r i c patients need reassurance, a t t e n t i o n and/or the help of drugs at times." SUMMARY, CONCLUSIONS AND RESEARCH IMPLICATIONS I. SUMMARY The purpose of t h i s study was to construct a nursing assessment t o o l based upon feeding behaviors of patients with chronic conditions. The intent was to include behaviors representative of the psychosocial as well as physical a b i l i t i e s . The function of such a t o o l would be to a s s i s t nurses to assess the a b i l i t i e s of patients with chronic conditions to feed themselves. To determine the a b i l i t i e s patients would require to be independent feeders and i d e n t i f y the dependence-independence continuum, a random sample of f i f t y patients was drawn from two urban hospitals admitting patients with chronic conditions. The feeding behavior data were co l l e o t e d by observing, examining and questioning patients and the nurses, aides etc. who cared f o r them. The data were analyzed to define f i v e categories, I Independent, II Min-imally assisted independent.III Assisted independent, IV P a r t i a l l y dependent, and V Dependent. Observations were translated into p o s i t i v e behavioral terms and were c l a s s i f i e d according to the amount and kind of help the patient received. These c l a s s i f i c a t i o n s were symbolized as + meaning no help, i meaning assistance and/or supervision, and - meaning t o t a l help. A preliminary t o o l was designed using a framework of performance s k i l l development. Twenty-one behaviors were i d e n t i f i e d which measure physical a b i l i t i e s and provide some measure of motivation and adjustment a b i l i t i e s of the patient. Weighting of tasks was a r b i t r a r i l y set by r a t i n g the physical a b i l i t i e s as three separate tasks and by r a t i n g motivation and i n t e r e s t as two separate tasks. This produces a 3 : 1 : 1 r a t i o . The Kenny R e h a b i l i t a t i o n Center f i v e point numerical r a t i n g scale was adapted to provide a method of determining the amount of help a patient would require to feed himself. Five experts currently working i n i n s t i t u t i o n s admitt-ingpatients with chronic conditions reviewed the twenty-one behaviors and sample raw data from which the behaviors were derived. Face v a l i d i t y was established f o r determining a measure of independent feeding. A r e l i a b i l i t y test with eight pairs of nurses using the t o o l to assess thirty-two patients, chosen to represent patients within the f i v e categories, produced a r e l i a b i l i t y c o e f f i c i e n t of .849. This gives supporting evidence that use of t h i s tool by registered nurses w i l l produce dependable and consistent measurement of the r e l a t i v e state of feeding dependence-Independence. An item analysis Indicated that eighteen of the twenty-one feeding behaviors were understand-able and applicable. Three behaviors require rephrasing or modification to improve t h e i r c l a r i t y . The nurses who participated i n the r e l i a b i l i t y t e s t were asked to comment on the usefulness of the t o o l . Two sets of questions were used. II CONCLUSIONS V a l i d and r e l i a b l e behaviors have been i d e n t i f i e d which describe independent feeding a b i l i t i e s of patients with chronic conditions. The r a t i n g of these behaviors allows f o r dependable and consistent measurement at f i v e points along the dependence-independence continuum. The a r b i t r a r y s e t t i n g of the 3 : 1 : 1 r a t i o of neuromuscular: motivation: adjustment a b i l i t i e s i s probably sound i n that the neuromuscular a b i l i t i e s are basic to independent feeding. However, the concern of some nurses over the d i f f i c u l t y of v • assessing i n the psychosocial area indicates that t h i s section of the t o o l could be improved. Rating of behaviors provides written evidence concerning the degree to which the patient i s able to feed himself. The difference between what a patient i s able to do and the c r i t e r i a f o r independent feeding gives the nurse a measure of the help a patient w i l l require to feed himself. The question of the usefulness of t h i s t o o l to nurses has not been answered s a t i s f a c t o r i l y . The d e c i s i o n regarding the usefulness of t h i s t o o l must be deferred u n t i l a more co n t r o l l e d test i s done. Having the nurses assess patients, f i r s t without and then with the instrument, and comparing the r e s u l t s would provide evidence of a concrete nature. Sampling opinion cannot provide such evidence. There appeared to be some reluctance on the part of these nurses to commit the more d i f f i c u l t parts of t h e i r assessments to wr i t i n g . Indicating l i t t l e recognition of the value of communicating a l l of the patients' needs. There i s a p o s s i b i l i t y that nurses are not too sure of the accuracy of t h e i r assess-ments. This whole question could be an area f o r further research, since making accurate assessments and communicating them i s e s s e n t i a l to the effectiveness of t h i s t o o l . Making major decisions about i n d i v i d u a l s on the basis of a s i n g l e measurement i s not the purpose of t h i s t o o l . Assessment should be a continuing process. I f used on a regular basis t h i s assessment t o o l produces a concise record of a patient's change of condition. R e l i a b l e information would then be a v a i l a b l e from which a feeding work-load could be derived and s t a f f i n g patterns J u s t i f i e d . This information about change of condition would also be of use to nurses i n evaluating t h e i r nursing care plans i n regard to feeding. I t i s e n t i r e l y possible to use the method developed i n t h i s study to produce s i m i l a r tools which w i l l assess the other a c t i v i t i e s of d a i l y l i v i n g , such as dressing, personal hygiene etc.. Combined, the l a r g e r t o o l would allow nurses to assess the patient as a whole, using more systematic and precise methods of measurement than have yet been a v a i l a b l e . Such methods should produce nursing care plans which w i l l give a s c i e n t i f i c r a t i o n a l e f o r practice and provide measure-able data f o r research into the evaluation of the Impact of nursing practice, i n the a c t i v i t i e s of d a l l y l i v i n g , upon the patient. I l l INDICATIONS FOR FURTHER RESEARCH Since the question of the usefulness of t h i s t o o l f o r feeding assessment by nurses has not been answered s a t i s -f a c t o r i l y i t i s a subject f o r further research. I t i s also recommended that t e s t i n g t h i s t o o l i n feeding s i t u a t i o n s i n other than chronic conditions would determine i t s usefulness i n other areas. The concern of nurses over the d i f f i c u l t y of assess-ing i n the psychosocial area indicates a need f o r research to i d e n t i f y a more precise measurement of psychosocial behaviors than was accomplished i n t h i s study. This study does not intend to imply that feeding i s the only important a c t i v i t y of d a i l y l i v i n g f o r patients with chronic conditions. Extending t h i s study to include behaviors f o r a l l a c t i v i t i e s of d a i l y l i v i n g i s a further area f o r research. This extension would provide a better s o l u t i o n to the problem of weighting components of the r a t i n g scale. However, i f t h i s t o o l i s to be used as designed, the problem of the adequacy of the 3:1*1 r a t i o of weighting 1the components w i l l require, further study. BIBLIOGRAPHY A. BOOKS Abdellah, Faye G., et a l . Patlent-centered Approaches In Nursing. New York: The Macmlllan Company, I960. Adams, Georgia Sachs. Measurement and Evaluation. New York: Holt, Rlnehart and Winston, 1965. Benedict, Ruth. Patterns of Culture. New York: The American Library, 1934. Bonney, V i r g i n i a and June Rothberg. Nursing Diagnosis and  Therapy: An Instrument for Evaluation and Measurement. New York; The National League f o r Nursing, 1963. Bowen, Elenore Smith. Return to Laughter. New York; Doubleday and Company Inc., 1964. Cronback, Lee J . Essentials of Psychological Testing. New York; Harper and Row, Publishers, I960. Exton-Smith, A.N., Doreen Norton and Rhoda McLaren. G e r i a t r i c  Nursing Problems In Hospital. London: The National Corporation f o r the Care of Old People, 1962. Funk and Wagnalls. Standard Dictionary. V o l . 1. New York: Funk and Wagnalls Company, 1958. Gronlund, Norman E. Measurement and Evaluation In Teaching. New York: The Macmlllan Company, 1965. Henderson, V i r g i n i a . The Nature of Nursing. New York: The' Macmlllan Company, i960. Irvine, R.E., M.K. Bagnall and B.J. Smith. The Older Patient. London: The English U n i v e r s i t i e s Press Ltd., 1968. Jaeger, Dorothea and Leo W. Simmons. The Aged 111. New . York: Appleton-Century-Crofts, 1970. •Kerlinger, Fred N. Foundations of Behavioral Research. New York: Holt, Rlnehart and Winston, 1964. L i t t l e , Dolores E. and Doris L. Carnevall. Nursing Care Planning. Philadelphis: J.B. Llppincott Company, 1969. Schwartz, Doris, et a l . . E l d e r l y Ambulatory Patient. New York: The Macmillan Company, 1964. Weiss, James M.A. (ed.). Nurses, Patients and Social Systems. Columbia: University of Missouri Press, 196o\ B. PUBLICATIONS OF GOVERNMENT, LEARNED SOCIETIES, AND OTHER ORGANIZATIONS McManus, Louise. "Assumptions of Functions of Nursing," Regional Planning for Nursing and Nursing Education  Report, Work Conference at Plymouth, N.H., June 1 2 - 1 3 , 1 9 5 0 . New York: Bureau of Publications, Teachers' College, Columbia University, 1951• United Community Services of Greater Vancouver, A Total Concept of Care. Vancouver: United Community Services of Greater Vancouver, 1968. World Health Organization, The Public Health Aspects of the  Aging of the Population, Report of an advisory group convened by the regional o f f i c e r f o r Europe. Copenhagen: World Health Organization, 1959. C. PERIODICALS Abdellah, Faye G. "Overview of Nursing Research 1955-1968, Part I," Nursing Research, V o l . 19. No. 1 (January-February, 1970), pp. 6-17. Aydelotte, Myrtle K i t c h e l l . "The use of patient Welfare as a C r i t e r i o n Measure," Nursing Research, V o l . 2 , No.l (Winter, 1962), pp. 10-14, " Bayne, Ronald J . " I l l n e s s and Age," Canadian Welfare, V o l . 43, No. 2 (March-April, 196?). pp. 14-18. Brodt, Dagmar E. and E l l e n H. Anderson. " V a l i d a t i o n of a Patient Welfare Evaluation Instrument," Nursing Research, V o l . 16, No. 2 (Spring, 1967), pp. l67-16~9l Christman, Luther. "What the Future Holds for Nursing," Nursing Forum. Vo l . 9 . No. 1 (January, 1 9 7 0 ) , pp. 1 2 - 1 8 . Dumas, Rhetaugh. "Psychological Preparation f o r Surgery," American Journal of Nursing, Vol. 6 3 , No. 8 (August, 1 9 6 3 ) , PP. 5^K55. McCain, R. Faye. "Nursing Assessment - Not I n t u i t i o n , " American Journal of Nursing, V o l . 6 5 , No. 4 ( A p r i l , 1965) . PP. 82-81+. McPhetridge, Mae. "Nursing History: One Means to personalize Care," American Journal of Nursing, Vol. 6 8 , No. 1 (January, 1 9 6 8 ) , .pp. 6 8 - 7 5 . Manthey, Marie E. "Guide for Interviewing," American Journal of Nursing, V o l . 6 7 , No. 10 (October, 1 9 6 7 ) , p p . 2 0 8 8 - 2 0 9 0 . Poland, Marilyn, et al.."PETO A System for Assessing and Meeting Patient Care Needs," American Journal of Nursing, Vol. 7 0 , No. 7 (July,,- 1 9 7 0 ). pp. 1 4 7 9 - 1 4 8 2 . Rich, Rosemary and James K. Dent. "Patient Rating Scale," Nursing Research. V o l . 1 1 , No. 3 (Summer, 1 9 6 2 ) , pp. 1 6 3 - 1 7 1 . Rudd, T.N. "The Mosaic of Interpersonal Relationships i n G e r i a t r i c s , " G e r i a t r i c s , V o l . 2 5 , No. 2 (February, 1 9 7 0 ) , p. 1 5 8 , p. 1 6 3 , P. 1 6 6 , p. 1 6 8 . Schoening, Herbert A., et a l . . "Numerical Scoring of Self-care Status of Patients," Archives of Physical Medicine and  Re h a b i l i t a t i o n , V o l . 4 6 , No. 10 (October, 1 9 6 5 ) , ppT"6"89-697. ,and Iver A. Iversen, "Numerical Scoring of Self-Care Status: A Study of the Kenny Self-Care Evaluation," Archives of Physical Medicine and Rehabl1 1tat1on,Vol. 4 9 , No. 4 ( A p r i l , 1 9 6 8 ), pp. 2 2 1 - 2 2 9 -Simon, J.R. and S a l l y S. Chastin, "Take a Systematic Look at Your Patients," Nursing Outlook, V o l . 8 , No. 9 (September, I 9 6 0 ) , pp. 5 0 9 - 5 1 2 . Smith, Dorothy M. "A C l i n i c a l Nursing Tool," American Journal of Nursing, V o l . 6 8 , No. 11 (November, I 9 6 B ), pp. 2 3 8 4 - 2 3 8 8 . T i l l , Dorothy. "Some Aspects of Self-care," Physiotherapy. Vol. 5 3 . No. 1 (January, 1 9 5 7 ) , p p . 1 8 - 2 2 . Wegenast, C.R. "The Self-adjusting Lap Tray," American Journal of Occupational Therapy, Vo l . 2 2 , No. 1 ( 1 9 6 8 ) , PP. 3 6 - 3 7 . Williams, Mary Edna. "Patient P r o f i l e , " Nursing Research, V o l . 9 , No. 3 (Summer, i 9 6 0 ), pp. 122-124. Wilson, Christine S. "Food B e l i e f s A f f e c t N u t r i t i o n a l Status of Malay Fi s h e r f o l k , " Journal of N u t r i t i o n , Vol. 2 , No. 3 (Winter, 1971) . PP. 96-98*. D. ARTICLES IN COLLECTIONS Katz, Fred E. "Nurses," The Semi-professionals and Their  Organizations, A. E t z i o n l , editor. New York: The Free Press, 1969. PP. 54-81. McClusky, Howard Y. "The Course of the Adult Lifespan," The Adult Learner, I r v i n g Lorge, editor. Washington D.C.: Adult Education Association of the U.S.A., I 9 6 5 . pp. 1 0 - 1 5 . Townsend, Peter. "The E f f e c t s of Family Structure on the Likelihood of Admission to an I n s t i t u t i o n i n Old Age," S o c i a l Structure and the Family, Ethel Shanas and Gordon Streib, editors. Englewood C l i f f s : Prentice-H a l l , Inc., 1 9 6 5 . PP. 163-187. E. UNPUBLISHED MATERIALS Dzlak, Suzanne. " R e l i a b i l i t y of the Patient P r o f i l e . " Unpublished Master's the s i s . The University of Pittsburgh, 1958. Nursing Assessment Tools. B r i t i s h Columbia Hospital Insurance Service "Assessment Guide." 2 pp.; Highland View Hospital, Cleveland Ohio. "Patients' Daily A c t i v i t i e s . " 2 p p . ; New York Hospital. "A Study of Nursing Needs of the Chronically 111." 1 2 p p . ; Oakherst Private Hospital. "Patient Informat-ion Guide." 2 p p . ; Vancouver General Hospital. "Patient C l a s s i f i c a t i o n System." 1 p.. APPENDIX' APPENDIX A THE QUESTION SHEETS PRESENTED TO THE EXPERTS FOR VALIDATION' OF THE PRELIMINARY TOOL QUESTION SHEETS PRESENTED TO THE EXPERTS FOR VALIDATION OF THE TOOL The purpose of checking the accompanying l i s t of behaviors i s to estab l i s h , (1) i.f each represents a factor of independent feeding f o r a person with a chronic condition, (2) i f the t o t a l twenty-one behaviors describes an independent feeder. 1. 2. 3 . 4. 5 . 6 . 7. 8-9. 10. 11. 12. 1 3 . 14. 15- • 1 6 . ; 17. 18. 19. 20. 21. Do the t o t a l 21 behaviors describe an independent feeder? TYPICAL OBSERVATION FROM WHICH BEHAVIORS WERE DERIVED 1. Patient was observed putting food i n mouth using f i n g e r s . 2. Used spoon to drink soup. 3. Picked p a r t i a l l y chewed pieces of meat out of her mouth and put back on plate. Said " t h i s meat i s tough as a cow." 4 . Patient slipped over to the l e f t side several times during the meal. 5. (a) Patient coughed when drinking f l u i d s but did not choke on f l u i d s , (b) Levine feeding was required. 6. Left hand shook when using spoon to eat. Patient ate very slowly. 13 and 17. Patient made agitated noises u n t i l nurse buttered her bread. 8 . (a) Patient took out h i s napkin and placed i t on his knee, (b) Patient's bib f e l l o f f (untied) and she was unsuccess-f u l i n putting i t back on. 9. Patient s p i l l e d a great deal. The orderly changed his bib partway through the meal. .10. Patient used napkin to wipe hands and mouth a f t e r meal, (b) The aide wiped the patient's fingers and mouth. 11. The nurses report t h i s patient eats breakfast and lunch by herself but her husband feeds her the e n t i r e evening meal. 12. The patient responded to observer's questions with sounds-" • j i - j i - j i , " (b) The patient responded to a question about how well she could chew with the comment, "Where i s t h i s mountain we are on?" 13« Patient rang for nurse to feed him his j e l l i e d soup. 14. The patient opened her eyes, turned toward observer and looked at the observer when spoken to. (b) The patient responded to questions. 15. The patient tapped with spoon around dishes u n t i l he found his dessert. Was unsuccessful In getting J e l l y onto spoon. 1 6 . (see 12 b) "I have my food minced because I haven't enough teeth to chew anymore. I don't l i k e those plates." 17. (a) The patient introduced the observer to others i n room, (b) The patient d i d not look up or take any notice of the aide when she asked why she wasn't eating. 18. The patient played with the patterns on her plate, was reminded frequently to eat. 19. (a) The patient smiled at observer. (b) The patient showed no expression when reprimanded f o r s p i l l i n g . 20. The nurse gave the patient a t r a n q u i l i z e r because she. becomes very depressed about her physical condition. 21. The patient required medication f o r pain. QUESTION Could the behaviors l i s t e d on the r a t i n g scale be derived from these sample observations? APPENDIX B THE INSTRUCTIONS GIVEN TO REGISTERED NURSES BEFORE USING THE ASSESSMENT TOOL,, THE QUESTIONS TO BE ANSWERED AFTER ITS USE AND THE SCORES OF THE EIGHT PAIRS OF NURSES RATING SIXTEEN" PATIENTS ON THEIR FEEDING ABILITIES THE INSTRUCTIONS GIVEN TO REGISTERED NURSES BEFORE USING THE ASSESSMENT TOOL. The purpose of thi s r a t i n g scale i s to a s s i s t registered nurses to assess the a b i l i t i e s of patients with chronic con-d i t i o n s to feed themselves independently. In order to tes t the r e l i a b i l i t y of t h i s r a t i n g scale you have been asked to use the scale to rate two patients who w i l l be assigned to you. You are asked not to discuss eit h e r the way you have rated your assigned patients, or who they might be, with any of your co-workers. KEY TO THE RATING SCALE A. Code f o r Judging the tasks. + = Performs the task independently. - = Requires assistance and/or supervision to perform the task. - = Is unable to perform the task. Instruction: For each of the twenty-one independent feeding behaviors (tasks) c i r c l e the code which applies to the patient being assessed. B. How to assign the r a t i n g . 0 = a l l +»s 1 = 1 or 2 i ' s ; a l l others +•s. 2 = a l l other combinations not described by 0, 1, 3. 4. 3 = 1 or 2 s (or 1 +); a l l others -»s. QUESTIONS TO BE ANSWERED AFTER THE USE OF THE TOOL Questions asked of f i r s t three pairs of nurses. 1. Did t h i s r a t i n g scale a s s i s t you to assess the patient's a b i l i t y to feed himself? Yes....No....Comment 2 . Did t h i s r a t i n g scale a s s i s t you to decide i f the patient requires your help with feeding? Yes....No.... Comment 3. Did t h i s r a t i n g scale a s s i s t you to decide the degree of help t h i s patient w i l l need to feed himself? Yess.... No....Comment 4. Did t h i s r a t i n g scale help you discover some factors about your patient's feeding a b i l i t i e s which you had not noticed before? Yes....No....If yes, what were the factors? (write overpage). The information you provide w i l l remain e n t i r e l y c o n f i d e n t i a l . Thank you f o r a s s i s t i n g with t h i s study of feeding. Questions asked of the next f i v e pairs of nurses. 1. Does t h i s scale t e l l you the degree of t h i s patient's a b i l i t y to feed himself? Yes....No....Comment 2 . Does t h i s scale provide written evidence of t h i s patient's a b i l i t y to feed himself which would a s s i s t another nurse who d i d not know the patient? Yes....No....Comment.... 3. Would th i s r a t i n g scale help you assess the feeding a b i l i t y of a new patient? Yes....No....Comment General comments would be appreciated: THE SCORES OF THE EIGHT PAIRS OF NURSES RATING SIXTEEN PATIENTS ON THEIR FEEDING ABILITIES USING THE FEEDING ASSESSMENT TOOL it lent Score of Nurse X Score of Nurse Y 1 14 15 2 8 7 3 8 7 4 . 0 0 5 1 0 6 6 8 7 13 10 8 9 8 9 7 13 10 10 13 11 12 7 12 3 8 13 2 5 14 13 10 15 ;. 15 16 16 • 7 5 APPENDIX C STATISTICAL TREATMENT: 1 . The F r a t i o of minutes spent eating of the 5 cat-egories of the random sample of patient population with chronic conditions used the formula: variance among the means p = variance within the group 2 . The r e l i a b i l i t y c o e f f i c i e n t of 16 pairs of nurses r a t i n g 2 patients each, using the feeding assessment t o o l , was obtained using the Pearson product moment co r r e l a t i o n : where. X = score of nurse X Y = score of nurse Y N = number of patients 3." An item analysis of agreement of pairs of nurses i n r a t i n g the degree of self-feeding: number i n the upper 1/3 of ratings (a) % l e v e l of agreement = t o t a l number being analyzed no. i n upper 1/3 - no. i n lower 1/3 (b) Discrimination index = \ t o t a l number being analyzed Where the upper 1/3 = Those pairs with the highest t o t a l number of agreements. The lower 1/3 = Those pairs with the lowest t o t a l number of agreements. Number being analyzed= 10 

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