Validation of Nursing Outcome Indicators in Patients with Postsurgical Delirium

TL;DR

This study validates nursing outcome indicators for managing delirium in older adults after surgery, showing they are highly relevant and applicable.

Contribution

The paper provides empirical validation of nursing outcome indicators specifically for delirium management in older surgical patients.

Findings

14 experts validated the indicators, showing a global average content index of 0.93.

97.05% of the indicators had a Content Validity Coefficient greater than 0.75.

The indicators are highly relevant and can be used to measure care changes in delirium patients.

Abstract

To validate the content of the indicators proposed from the Nursing Outcome Classification in a care plan for delirium management in older adults.

Content validity study, conducted under the expert judgment technique. The procedure was developed in five moments: organization of indicators that respond to the nursing outcome classification for delirium management, support with literature of the indicators that responds to the result, selection of experts, establishment of agreements, and discussion. Quality criteria evaluated: pertinence and relevance, the Content Validity Coefficient and average scores assigned by the experts were calculated.

The study had the participation of 14 experts. The indicators, according to criteria of pertinence and relevance evaluated by experts showed a global average content index value of 0.93; 97.05% (66) of the indicators had Content Validity Coefficient > 0.75.

The quantitative findings of the indicator validation process showed high relevance and pertinence index, which favors their being applied to measure care changes in patients with delirium.

Full text

Introduction

The nursing care process (NCP) is a tool that allows professional nurses to apply the scientific method to provide care in continuous and individualized manner, rationally, logically, and systematically.1 Application of the NCP has been enriched with the use of the nursing taxonomies about results2 and interventions3 that summarize the diagnoses of the North American Nursing Diagnosis Association (NANDA).4 The use of nursing outcomes from the Nursing Outcome Classification (NOC) began in the 1960s; its objective was to assess the quality of nursing care. From there, processes of adjustments and measures have been developed. Currently, the NOC classification, in the sixth-edition text, contains 540 results, 7 domains, and 32 classes. The NOC results, in care plans, quantify the state, behavior or perception of the patient expected to occur in specific moments of a care episode. Each NOC has a battery of indicators evaluated by the professional. The scores issued from the NOC, using a Likert scale from one to five, measure the initial and final state of the diagnosis intervened and, consequently, the change in the patient's health, if any.2 However, for the NOC to be replicated, it is necessary to validate its indicators, which analyze the adequate psychometric characteristics to measure that for which it was designed.5 This content validity consists in the evaluation by experts on the study theme of the relevance (importance of the item measured in the context) and pertinence (quality of the item of corresponding entirely to the context) of the items included in a scale.6^,^7

The evaluation of care by nursing professionals to patients with delirium is part of interdisciplinary work, given that management of the diagnosis is multicausal, commonly goes unnoticed by over 67% of non-psychiatric physicians8^,^9 and only 22% of the nursing staff identifies delirium and its criteria.10 A study conducted in Cartagena (Colombia) affirmed that 54.23% of medical professionals and nurses evaluate delirium occasionally, 68.31% evaluate delirium through general clinical evaluation; moreover, 52.11% of the professionals consider that delirium is a pathology that requires intervention.11

The foregoing identifies a void in the continuity of caring for delirium and in unifying the results and interventions to implement. In addition, it has led to the need to use evaluation scales for the early detection and management of delirium. However, few of these scales or tools have been validated and are typical of nursing professionals.12 Based on the aforementioned, the aim of this study was to validate the indicators contained in the NOC of a nursing care plan developed previously by the research team to manage elderly patients with postsurgical delirium. This care plan included 11 NOC: cognition, nutrition, cardiac pump effectiveness, circulatory state, hydric balance, respiratory state, pain control, mobility, electrolyte and acid-base balance, sleep and vital signs.8 The vital sign NOC was identified as an activity inherent to the care provided by professionals in addition to being in the protocols of hospital institutions, hence, it was excluded from the validation. The context to which the care plan is applied corresponds to the intensive care units (ICU) and hospitalization units where postsurgical delirium is treated.

Methods

Design. A content validity process was carried out by expert judgment using the Delphi method.13 The population was comprised by nurses with graduate studies, experience in ICU and hospitalization of at least two years, including management of patients with delirium and the nursing care process. The participants were recruited according to their compliance with the inclusion criteria through contact with the academic units linked to the hospital institutions participating in the research. The sample was taken according with the criteria by Hyrkäs et al.,14 who manifest that 10 experts provide a reliable estimation of the content validity of an instrument; in turn, Voutilainen & Liukkonen15 indicate that if 80% of the experts have agreed with the validity of an item, it can be incorporated onto the instrument.

Data collection. The study was conducted during two moments: the first from January to May of 2021, with the literature search by the researchers to select the indicators of the results that have been used to evaluate the evolution of patients with delirium, according to NANDA diagnoses established in a prior study carried out in the city of Cartagena (Colombia).8 The second moment was the evaluation by nurses from August to October of 2021, with the participation of 14 experts from four hospital institutions who assessed the pertinence and relevance of the NOC indicators with the aid of a form delivered via e-mail. The nurses took between five and twenty days to respond.

Instruments. The form used contained two questionnaires: one for sociodemographic variables (age, academic training, work experience, knowledge about the NCP, experience in managing patients with delirium) and another that contained the results to be evaluated with their indicators according to relevance and relevance. Each indicator corresponded to an item from the form, so that nurses made their judgment based on the relevance and pertinence measured with a Likert scale, where they assigned a score from one to five, considering one as not relevant or not pertinent and five as very relevant or pertinent.16

Data analysis. To analyze the information, relative and absolute frequencies were calculated for categorical or qualitative variables and measures of central tendency and dispersion for numerical variables. The Content Validity Coefficient (CVC) was calculated for each of the items. When the experts assigned scores of 4 or 5 (relevant and pertinent), these were assumed as a favorable concept and the fraction was calculated with the total responses for each item, following what was proposed by Polit et al.,16 in addition, the mean of the scores of the indicators is presented. Calculations were performed on the STATAv statistical software.

Ethical considerations. The study was based on Resolution 8430 of 1993 by the Colombian Ministry of Health17 and the Declaration of Helsinki promulgated by the World Medical Association in 2000.18 The research was considered a study without risk. Among the ethical principles of the research, autonomy was taken into account. The informed consent was requested to be signed and forwarded by e-mail; the objective of the research was explained to the participants in the document, highlighting that their participation and withdrawal was voluntary. The study was endorsed by the ethics committee at Universidad de Cartagena (Colombia) with minute 02 of May 11, 2021.

Results

Fourteen expert judges participated by reviewing the indicators from 10 NOC. The experts were characterized, thus: eight with Masters educational level and 7 with specialization; with an average of 15.28 ± 8.87 years of work experience and an average of 9.21 ± 4.26 years managing patients with delirium (Table 1).

Table 1. Description of participating expert judgesParticipantSexEducational levelWork experienceYears managing patients with deliriumP1Woman Specialist86P2Woman Masters2010P3Woman Masters2510P4Woman Specialist55P5Woman Masters1510P6Woman Masters165P7Woman Specialist87P8Woman Specialist22P9ManMasters2216P10ManMasters2110P11Woman Masters2615P12Woman Masters3016P13ManSpecialist77P14Woman Specialist1010

Table 2 shows the CVC according to the pertinence and relevance criteria of each of the NOC indicators; 68 indicators were linked, among which 9 from cognition NOC, 7 from sleep, 10 from nutrition, 7 from cardiac pump effectiveness, 7 from circulatory state, 5 from hydric balance, 10 from electrolyte and acid-base balance, 6 from respiratory state, 5 from pain control, and 7 from mobility. It is noted that 85.52% (58) had CVC > 0.80, 97.70% (66) with CVC > 0.75, and only two items had low scores, which are “040004 Ejection fraction” with CVC = 0.64 and “040105 Central venous pressure” with CVC = 0.57.

Table 2. Content Validity Coefficient and average score of the NOC indicatorsIndicatorsPertinence 181. Relevance 183. Total 185. 186. CVCAverageCVCAverageCVCAverageCognition

90003 Aware1.004.500.854.500.934.5090004 Concentrates1.004.571.004.501.004.5490005 Is oriented1.004.780.784.850.894.8290006 Immediate memory0.784.141.004.350.894.2590007 Recent memory0.784.071.004.500.894.2990009 Processes information0.924.501.004.570.964.5490013 Understands meaning of situations0.854.420.854.420.854.4290014 Clear communication according to age0.854.280.784.140.824.2190015 Adequate communication according to age1.004.710.924.570.964.64Sleep 277. 278. 279. 280. 000401 Hours of sleep1.004.871.004.921.004.90000404 Quality of sleep1.004.781.004.921.004.85000418 Sleeps entire night0.924.500.784.350.854.43000420 Comfortable room temperature1.004.640.924.640.964.64000421 Difficulty falling asleep0.924.710.924.570.924.64000406 Interrupted sleep0.924.570.854.570.894.57060014 Blood urea nitrogen0.784.140.784.070.784.11Nutrition

100901 Calorie intake0.854.280.854.350.854.32100902 Protein intake0.924.500.854.640.894.57100903 Fat intake0.924.500.854.570.894.54100904 Carbohydrate intake0.924.500.854.570.894.54100910 Fiber intake0.924.500.854.570.894.54100905 Vitamin intake0.854.280.784.350.824.32100906 Mineral intake0.784.000.784.070.784.04100907 Iron intake0.784.210.714.210.754.21100908 Calcium intake0.854.420.784.500.824.46100911 Sodium intake0.924.500.854.500.894.50Cardiac pump effectiveness

040001 Systolic blood pressure1.004.921.004.921.004.92040019 Diastolic blood pressure1.004.921.004.921.004.92040002 Heart rate1.0051.004.921.004.96040003 Cardiac index1.004.781.004.571.004.68040004 Ejection fraction0.6440.643.920.643.96040020 Urinary output0.924.710.854.50.894.61040025 Central venous pressure0.714.070.784.350.754.21Circulatory state

040101 Systolic blood pressure0.924.640.924.570.924.61040102 Diastolic blood pressure0.924.640.924.570.924.61040104 Mean arterial pressure1.004.921.004.851.004.89040105 Central venous pressure0.574.640.5740.574.32040135 Partial pressure of oxygen in blood0.854.640.854.570.854.61040137 Oxygen saturation0.924.640.854.570.894.61040140 Urinary output0.924.500.854.420.894.46Hydric balance

60107 Balanced daily inputs and outputs1.004.781.004.711.004.7560116 Cutaneous hydration0.854.50.924.500.894.5060118 Serum electrolytes1.004.921.004.851.004.8960119 Hematocrit1.004.851.004.781.004.8260127 Amount of urine0.924.710.924.570.924.64Electrolyte and acid-base balance

060003 Breathing frequency0.924.640.924.710.924.68060005 Serum sodium0.924.640.924.570.924.61060006 Serum potassium0.924.570.924.570.924.57060007 Serum chloride0.854.500.924.570.894.54060008 Serum calcium0.784.280.714.280.754.28060009 Serum magnesium0.784.920.714.280.754.60060010 Serum pH1.004.921.004.921.004.92060013 Serum bicarbonate1.004.781.004.921.004.85060026 Serum glucose1.004.780.854.710.934.75060014 Blood urea nitrogen1.004.780.924.640.964.71Respiratory state

41004 Respiratory frequency1.004.921.0051.004.9641005 Respiratory rate1.004.921.0051.004.9641007 Pathological respiratory sounds1.004.921.0051.004.9641012 Ability to eliminate secretions1.004.711.004.781.004.7541017 Depth of inspiration1.004.781.0051.004.8941018 Use of accessory muscles1.004.921.004.921.004.92Pain control

160502 Recognizes beginning of pain0.924.781.004.710.964.75160509 Recognizes symptoms associated with pain1.004.851.004.711.004.78160511 Reports controlled pain1.004.710.924.570.964.64160513 Reports changes of symptoms to health staff1.004.641.004.571.004.61160516 Describes pain1.004.851.004.781.004.82Mobility

020801 Maintaining balance0.854.350.924.570.894.46020809 Coordination1.004.570.924.570.964.57020815 Bone integrity of the lower extremity0.853.920.7140.783.96020803 Muscular motion1.004.711.004.711.004.71020804 Articular motion0.854.280.854.280.854.280200802 Maintaining body position0.924.641.004.780.964.71020806 Ambulation0.924.350.924.420.924.39

Table 2 shows that the health physiology domain contains the most nursing outcomes (NOC) 7/10; in these seven results, each indicator was scored by the experts with agreement among them > 4.20, corresponding to being pertinent and relevant. Likewise, it is possible to identify the relationship between results, like Cardiac pump effectiveness and Circulatory state, where indicators to be evaluated are shared, and between Hydric balance and Electrolyte and acid-base balance, which share indicators to measure. It is shown how the nutritional state NOC is a necessary element to be incorporated in monitoring of patients with eight indicators.

Discussion

The findings reveal that the indicators selected for each of the 10 NOC contemplated in this study are pertinent and relevant, which is why they can be considered by nursing professionals to evaluate the evolution of care for adult and elderly patients with postsurgical delirium. Most of the indicators had a CVC mean > 0.80. The evolution is complemented with monitoring of vital signs.

This work is among the first to use NOC indicators to measure the evolution of patients with postsurgical delirium, a fact that also hinders discussion with other previous studies. The expert participants showed graduate academic level, which leads to believe that they managed adequately the concept of patients with delirium. It is noteworthy that the use of these indicators may complement the use of other evaluation instruments, highlighting the CAM-ICU scale, considered the valid and reliable psychometric instrument to issue the delirium diagnosis,19^,^20 as well as to determine the prevalence of the problem.21

In relation with the indicators, the NOC result: Cognition showed nine indicators to measure, with “is oriented” being relevant. Thus, is how Inouye et al.,22 showed in their study that specific interventions of information on orientation, for example, date, time, names of hospital staff, cognitive stimulation activities, among others, reduce significantly the number and duration of delirium episodes in relation with patients not monitored with the information described. Due to being quite close to patients, nurses are perhaps the individuals who can better stimulate patient orientation in the ICU and contribute to earlier reversal of delirium.

Moreover, from the nutrition NOC, it was evidenced that protein, fat, carbohydrate, fiber, and calcium intake is considered important by the experts. The literature shows that managing elements, like electrolytes and proteins is key. It has been demonstrated that biochemical alterations (low sodium and potassium levels) and a low body mass index (BMI) are indicators that lead to deteriorated cognitive function that predispose the severity of delirium.23 Thereby, the need is evidenced for biochemical monitoring in coordination with other disciplines.

The NOC indicators related with cardiac pump effectiveness and circulatory state relate to monitoring of diastolic and systolic blood pressure in patients, as mechanism to control adequate and sufficient perfusion at the cerebral level in these patients. This is coherent with the findings by Wang et al.,24 who reported greater prevalence of postsurgical delirium in patients undergoing surgical procedures that occurred with low saturations due to their decreased mean arterial pressure.

It was evidenced in the results that maintaining electrolytes, pH, bicarbonate, and hematocrits are necessary variables to measure during the patient’s clinical signs and symptoms. This agrees with that explained by Artola et al., ^(^25 who reported that early detection of dehydration signs, states of oliguria added to maintaining a hydric balance lead to early identification of hydro-electrolyte alterations and, with this, permit unifying correct treatment actions by the interdisciplinary team.

With regards to the respiratory state NOC, the experts classified the six indicators with maximum pertinence and relevance, which could infer that oxygenation is an essential process for optimal brain functioning, thought processes and the state of cognition that, in situations like surgical procedures can be compromised, causing delirium in patients. Therefore, if each of the indicators is evaluated in time, the condition could be controlled early. In this respect, Recasens et al.,26 through a program, via prior training and formation of nursing professionals on the management of the NANDA, NOC, NIC taxonomy, managed to incorporate the evaluation of the respiratory state NOC and, with this, evaluation of care was standardized, in addition to supporting nursing professionals to pay attention to changes specific to the respiratory state.

Finally, upon analyzing the mobility, pain control and sleep NOC indicators, it may be documented that their articulation is important in the evolution of the delirium condition; patients can recognize the moment when their pain begins and mention these changes to the health professional, they could correlate whether it is during mobility, exercise, or postural change, in addition to the fact that it could cause changes in the hours and quality of sleep of patients with delirium. The foregoing is corroborated with the study by Rodríguez et al.,27 where the range of pain prevailing in postsurgical patients was slight, attributed, among other factors, to its early detection and to correcting activities, like early mobilization to ensure that the patient intervened reconciles sleep.

Among the strengths of this study, it is considered that the indicators evaluated guide in care process for patients with delirium in ICU and hospitalization contexts in which this condition can develop. It is convenient to continue exploring other interventions that involve, for example, the family,28 or that take place in other services, like emergency,29 besides analyzing the effect on the workload30 of the nursing staff given the occurrence of delirium in patients. Further, it would be worth investigating possible interventions or guidelines at the home level,31 as well as performing post-discharge research to determine the quality of life and functionality ^(^32 in patients who have endured this event.

Among the limitations of this study, it should be noted that the validation was applied by experts who manage the taxonomies, which is why its implementation requires extensive knowledge by all nursing professionals to manage a clinical diagnosis, like delirium. Furthermore, it is necessary to continue advancing in validation studies involving more countries and which explore more advanced procedures.

Regarding the practical implications of this research, it is worth highlighting that application of the NANDA, NOC, NIC taxonomy allows obtaining precise information that should be assumed by health professionals, in their care practice, because it has been proven that it allows them to make their practice fluid, define interventions patients require, and evaluate the evolution of the diagnosis labeled. In line with the aforementioned, this requires training on managing taxonomies, something that should be evaluated in undergraduate and graduate training.

Conclusion. The findings, herein, show a high relevance and pertinence index of the indicators evaluated, which favors their being applied to measure care changes in patients with delirium. Among these changes, indicators of aspects related to sleep quality, biochemical measures, pain control or cognition are included.