VALIDATION OF A PATIENT CLASSIFICATION INSTRUMENT FOR PSYCHIATRIC PATIENTS

BASED ON THE JOHNSON MODEL FOR NURSING

by

Vivien Dee

DISSERTATION

Submitted in partial satisfaction of the requirements for the degree of

DOCTOR OF NURSING SCIENCE

in the

GRADUATE DIVISION

of the

UNIVERSITY OF CALIFORNIA

San Francisco

Approved:

&al º (ZºpCommittee in Charge

Deposited in the Library, University of California, San Francisco

Date- - - - - - - - - - - - - - - -

University Librarian-

SEP 07 1986Degree Conferred:

- - - - - - - -

Copyright G) 1986

by

Vivien Dee

ii

VALIDATION OF A PATIENT CLASSIFICATION INSTRUMENT

FOR PSYCHIATRIC PATIENTS BASED ON THE

JOHNSON MODEL FOR NURSING

Vivien Dee, R.N., D.N.Sc.

University of California, San Francisco, 1986

The purpose of this research was to assess the reliability and validity of a

patient classification instrument for psychiatric patients (NPH-PCI) based on the

Johnson Model for Nursing. Equivalence reliability and criterion-related validity

were the two specific psychometric properties investigated.

Data were collected by direct observation of patient behaviors at the UCLA

Neuropsychiatric Hospital from August, 1982, through November, 1984. A

purposive sample was selected from four child inpatient units for four-hour

observations by three independent raters (staff, shift coordinator and observer). At

the completion of each observational period, the Behavior Criteria Checklist--

comprised of a patient behavior checklist, subsystem category rating scale and

system category rating scale--was completed.

Mean inter-rater agreements, computed on tº 51 patient observations with

respect to patient behaviors for three comparison paired groups (staff, shift

coordinator and observer) exceeded the 60% criterion for inter-rater reliability.

Mean inter-rater agreements ranged from 67% to 84%. Mean inter-rater

agreements of staff and shift coordinator pairs were above the 60% criterion for

iii

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the system category ratings (67%) and most subsystems' category ratings (60% for

dependency to 68% for eliminative), with the exception of sexual (57%) and

aggressive-protective (57%) subsystems.

Findings showed that all R2 values for subsystems categories (ranging from

.08 for sexual to .36 for achievement) had low to moderate explanatory power; but

that the R2 value for the system category (.52) had good explanatory power. The

moderate R2 values for the subsystem categories suggest that further work is

needed to identify additional relevant patient behaviors for inclusion within each

subsystem.

Findings also indicated that the system category was generalizable across

inpatient units, age and sex groups. Affiliative and dependency subsystems

categories were also generalizable across these same groups and units.

In conclusion, the NPH-PCI appears promising for further development. It is

anticipated that additional studies will provide further support for the reliability

x/2” a.a. S-4×4,424 /24. 2).and validity of the NPH-PCI.

iv

--

Dedication

To my mother, Ivy Marie W. Dee, whose courage, integrity and optimism have

guided me throughout my life.

Acknowledgement

This dissertation represents not only the culmination of a course of academic

study at the University of California, San Francisco (UCSF), but also the

continuation of research begun in 1978 with the development of a patient

classification system for the UCLA Neuropsychiatric Hospital (NPH-PCS) at

Los Angeles.

It is impossible to acknowledge in these few paragraphs the direct and

indirect contributions of all my colleagues to the NPH-PCS project and their

support during my doctoral studies. However, certain individuals stand out and

therefore deserve special recognition.

I am most thankful to Mrs. Bertha Unger, Associate Administrator and

Director of Nursing Services at the UCLA Neuropsychiatric Hospital, for my initial

introduction to the concept of patient classification systems and their value to

nursing administration. For her continuing and unfailing support during the many

phases of the patient classification project and throughout the course of my

doctoral studies, I am grateful.

I also wish to thank Dr. Jeanine Auger, my longtime colleague at the UCLA

Neuropsychiatric Hospital. Her ideas were instrumental in shaping the evolution of

the Johnson Model and in translating its theoretical framework into clinical

application. She also provided me with constructive criticism of the manuscript.

I also wish to thank Dean Margretta Styles and Dr. Jane Norbeck, my

graduate advisors at USCF, for their guidance, inspiration and support throughout

my years of academic coursework. I wish to express my sincere appreciation to the

members of my doctoral committee: Dr. Sandra Ferketich, Chair; Dr. Nancy

vi

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Lovejoy and Dr. Charlene Harrington. They provided me with constructive

criticism, sharpened my ideas and challenged me to further develop my thoughts

and to refine the focus of this manuscript.

I also wish to acknowledge the following individuals for their assistance:

Dr. Peter Christensen of UCLA Hospital Computing Services for statistical

analyses of the data and Mr. Bruce Schwagerl of UCLA Neuropsychiatric Hospital,

Nursing Services, for typing the manuscript in its final form.

Finally, I wish to express my appreciation to my husband and friend, John

Robert Smith. He gave me the space and time in which to create and participated

actively in the writing process by asking numerous questions, challenging my ideas

and reviewing the manuscript extensively. I am deeply grateful for his love,

patience, support and understanding.

vii

Table of Contents

ABSTRACT

LIST OF TABLES

LIST OF ILLUSTRATIONS

CHAPTER I: THE STUDY PROBLEM

Introduction

Statement of the problemPurpose of the studySignificance of the study

CHAPTER II: CONCEPTUAL FRAMEWORK AND LITERATURE REVIEW

Conceptual frameworkJohnson Behavioral System Model

Conceptualization of the modelAmplifications of the modelApplications of the modelImplications of the model

Literature review

Patient classification systemsDefinition

Types of patient classification systemsLevels of categoriesIndicators of care

Early developments (1940s-1960s)Current developments (1970s-1980s)Reliability of patient classification systemsValidity of patient classification systemsGeneralizability of patient classification systems

UCLA Neuropsychiatric Hospital Patient Classification SystemDevelopment of instrumentWalidity and reliability of instrument

CHAPTER III: METHODOLOGY

Research designResearch strategies

Equivalence reliabilityCriterion-related validity

Page

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Table of Contents – continued

Research questionsStudy definitionsDescription of research settingSampleData collectors

ObserversStaff and shift coordinators

Instrument

Research proceduresObservational proceduresScheduling of patient observationsData collection proceduresPretesting

Data analyses

CHAPTER IV: RESEARCH RESULTS

Introduction

Sample description of patient observationsProfile of data collectors

Results related to equivalence reliabilityPatient behaviors

Subsystems categoriesSystem categories

Results related to criterion-related validityImpact of patient behaviors on subsystem categoriesImpact of subsystem categories on system category

Examination of residualsZero mean

HomoscedasticityNormal distribution

IndependenceResults related to generalization

Across inpatient unitsAcross sex groupsAcross age groups

Summary of Results

CHAPTER V: DISCUSSION

Interpretation of resultsInterpretation of results related to equivalence reliabilityInterpretation of results related to criterion-related reliabilityInterpretation of results related to generalizability

64646576768085858699

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1 121 12116120

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Table of Contents - continued

Research issues limiting study findingsSample selectionPatient observation schedules

Study periodObservational procedures

Directions for future research

Instrument developmentResearch design

Implications of findings for nursing

REFERENCES

APPENDIX A: NPH Patient Classification System

APPENDIX B; Subsystems Behaviors

APPENDIX C: Behavioral Criteria Checklist

APPENDIX D: Summary Statistics on Independent Variables

Page

12212312312!125126126129130

1.33

1 l;2

152

161

168

Table 1

Table 2

Table 3

Table l;

Table 5

Table 6

Table 7

Table 8

Table 9

Table 10

Table 11

Table 12

Table 13

Table 1 l;

Table 15

Table 16

Table 17

Table 18

List of Tables

A Comparison of Behavioral Subsystems' Functions

Definition and Behavioral Characteristics of Subsystems

General Framework for Categorization of Patient Behaviors

Timetable for Observer Recruitment, Training and DataCollection

Number of Patient Observations Completed and Included inFinal Data Base

Number of Patient Observations Included in Final Data Baseon Each Unit

Number of Patient Observations Included in Final Data Base

by Categories and Time Periods (A-West)

Number of Patient Observations Included in Final Data Base

by Categories and Time Periods (A-South)

Number of Patient Observations Included in Final Data Base

by Categories and Time Periods (5–West)

Number of Patient Observations Included in Final Data Base

by Categories and Time Periods (6-West)

Number and Sex of Patients for All Categories on Each Unit

Number of Patients by Age Groups

Number of Patients by Psychiatric Categories Per Unit

Number and Classification on Staff on Each Unit

Number and Classification of Shift Coordinators on EachUnit

Educational Preparation of Staff and Shift Coordinators

Mean Inter-rater Agreements for Three Paired Groups OnPatient Behaviors for Each Subsystem

Percentage of Patient Behaviors Observed

l;0

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Table 21

Table 22

Table 23

Table 24

Table 25

Table 26

Table 27

Table 28

Table 29

Table 30

Table 31

Table 32

Table 33

List of Tables - continued

Inter-rater Agreement on Subsystems for Three PairedGroups

Inter-rater Agreement Between Staff and Observer GroupsOn Subsystems by Categories

Inter-rater Agreement Between Shift Coordinators andObserver Groups on Subsystems by Categories

Patient Behaviors as Predictors of Subsystem Category

Patient Behaviors as Predictors of Ingestive SubsystemCategory

Patient Behaviors as Predictors of Eliminative SubsystemCategory

Patient Behaviors as Predictors of Affiliative SubsystemCategory

Patient Behaviors as Predictors of Dependency SubsystemCategory

Patient Behaviors as Predictors of Sexual SubsystemCategory

Patient Behaviors as Predictors of Aggressive-ProtectiveSubsystem Category

Patient Behaviors as Predictors of Achievement SubsystemCategory

Patient Behaviors as Predictors of Restorative SubsystemCategory

Comparison of Full and Reduced Equations of PatientBehaviors as Predictors of Subsystem Category

Significance Tests on Full and Reduced Equations ofPatient Behaviors as Predictors of Subsystem Category

Subsystem Categories as Predictors of System Category

Page

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Page

Table 34 Results of Chi-Square Goodness of Fit Tests for Distribution 105of Residuals from Patient Behaviors and Subsystems Regressions

Table 35 Tests on Model Consistency Across Units, Sex and Age Groups 109

xiii

Figure 1

Figure 2

Figure 3

Figure 4

Figure 5

Figure 6

List of Illustrations

Johnson Behavioral System Model

Patient Behaviors as Predictors of Subsystem Category(Reduced Equation)

Subsystems Categories as Predictors of System Category(Reduced Equation)

Plot of Standardized Residuals Against Self-Care Activities

Histogram of Standardized Residuals for Sexual Subsystem

Histogram of Standardized Residuals for AggressiveProtective Subsystem

102

10 l;

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107

xiv

CHAPTER I

The Study Problem

Introduction

Health care expenditures in the United States increased 344% between 1973

and 1983, from $103 billion to $355 billion, and are continuing to outpace inflation

with an annual growth rate exceeding 9%. Current projections indicate that by

1990, health care expenditures will surge to $660 billion and represent over 11% of

the gross national product (Arnett, Cowell, Davidoff & Freeland, 1985).

The primary factors that have contributed directly or indirectly to rising

health care costs are increases in: (1) price of basic materials and services

required (i.e., food, equipment, energy, minimum wage increase), responsible for

approximately 58% of the rise; (2) specialization and greater use of technological

resources, responsible for almost 35% of the rise; and (3) life expectancy, resulting

in an increase of resource utilization and intensity of services, accounting for

approximately 10% of the rise (Davis, 1983). The third party payors' cost-based

retrospective reimbursement schemes have inhibited competition among providers

of care resulting in higher health care costs and ultimately higher insurance

premiums for the consumer of health care (Davis, 1983). All of these factors have

played a significant part in sustaining a continued high level of growth for health

care expenditures.

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Acute care hospitals have been under increasing scrutiny and attack from

both state and federal governments for the past decade with regard to their part in

the ever-increasing costs of health care. For example, the Social Security

Amendment of 1983 (PL 98-21) mandated that hospitals reimbursed by Medicare be

paid a fixed amount for each case based on Diagnostic Related Group (DRG)

categories. This legislation culminates a series of reimbursement reforms and cost

containment measures that were initiated decades ago as part of efforts to alter

health care delivery (Shafer, 1983).

Nursing, as the hospital's largest department, has been particularly vulnerable

to cost containment policies (Walker, 1982). Staffing costs have been estimated to

be approximately 70% of the nursing department's budget (Simms, 1982) and

represent approximately 30% of all hospital costs (Smits, Fetter & McMahan,

1984).

As a result of the federal government's decision to pay hospitals

prospectively by DRGs, nursing costs must be measured in a reliable and valid way

to demonstrate the intensity of nursing care that patients require and the relation

between nursing costs and DRG classification (Piper, 1983; Joel, 1983; Riley &

Schaefers, 1984; Mitchell, Miller, Welcher & Walker, 1984; Lagona & Stritzel,

1984). The need to provide maximum nursing care in the most cost-effective

manner has given impetus to the resurgence of patient classification systems (PCS)

within nursing service settings not only for staff allocation purposes but also as a

foundation for fiscal management in the identification of nursing care costs per

patient (Nyberg & Wolff, 1984). Approximately 5,000 of the 7,000 short-term,

acute care facilities accredited by the Joint Commission on Accreditation of

Hospitals (JCAH) now utilize some form of patient classification system to classify

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patients according to patient care requirements for staffing purposes (Alward,

1983). These systems provide ways of identifying patients' needs for nursing

service and corresponding ways in which these needs may be met (Giovanetti,

1979).

The purpose of classification systems is to categorize patients according to

the magnitude of their need for nursing care. However, problems of defining and

quantifying psychiatric patient needs and required nursing actions have presented

major difficulties in the development of patient classification systems which can

be applied to the psychiatric setting. One possible approach to resolving this

problem is to utilize a model of nursing (Dee & Auger, 1981; Auger & Dee, 1982a;

Dee & Auger, 1983b).

The value of models of nursing as a theoretical basis for educational

programs has been widely accepted within academic nursing circles; most, if not

all, theoreticians have been predominantly identified with education rather than

service. Several advantages for using nursing models in clinical practice have been

proposed, including: (1) allowing nurses to describe, explain, predict and control

clinical phenomena for the purpose of achieving desired patient outcomes; and (2)

changing the way nurses comprehend and process information so that nursing

actions can be more purposeful at all levels (Chinn & Jacobs, 1983).

Preliminary to exploring the problem of defining and quantifying patient

needs, a patient classification instrument based on the Johnson Behavioral System

Model of Nursing was developed at the UCLA Neuropsychiatric Hospital to define

and describe patient behaviors. It was assumed that utilization of a single model

would: (1) provide a frame of reference for systematic assessment of patient

behaviors, (2) enhance communication and agreement among staff regarding

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identified problems, and (3) integrate knowledge concerning significant bio-psycho

socio-cultural factors related to complex patient behaviors (Auger & Dee, 1983).

Statement of the Problem

As stated previously, the purpose of classification systems is to categorize

patients according to the magnitude of their need for nursing care, but the

problems of defining and quantifying patient needs have continued to present major

difficulties in the development of systems which can predict nursing care needs.

The primary use for most patient classification systems has been for staffing

purposes. The majority of patient classification systems found in the literature

have been designed for use in medical surgical settings. To date, there have been

two published articles describing the use of PCS in the clinical setting of

psychiatry. In addition to the PCS developed for UCLA Neuropsychiatric Hospital

in Los Angeles, California (Auger & Dee, 1983), one was developed for C. F.

Menninger Memorial Hospital in Topeka, Kansas (Schroeder & Washington, 1983).

The major difference between the PCS designed for medical and surgical

settings and those designed for psychiatric settings are the critical indicators

chosen for patient care. PCS designed for medical and surgical settings emphasize

physical and physiological indicators of care, while those designed for psychiatric

settings emphasize psychosocial patient care indicators (Auger & Dee, 1983).

Generally, the psychiatric patient is able to provide his or her daily physical care

requirements in contrast to the medical-surgical patient. The focus of psychiatric

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care falls in the areas of behavioral management, for example, establishing limits,

environmental safety, verbal interactions and behavior modification.

Since patient census has not been shown to be a sensitive predictor of nursing

resource utilization (Pardee, 1968; Poland, English, Thornton & Owens, 1970;

Meyer, 1978; Thompson, 1984), the majority of PCS now categorize patients

according to predetermined descriptors of care such as daily living activities,

treatment, nursing procedures and so forth, based on an analysis of current

practice within an institution. A limitation of these systems is that nursing care

may be based on available staffing and budgetary constraints rather than on

clinical decisions based on patient characteristics/behaviors. Another limitation is

that the classification systems based on current institutional practices are

restricted in their application to other institutions where the standards of practice

may differ.

In contrast, the PCS developed for the UCLA Neuropsychiatric Hospital

(NPH) at Los Angeles, California, was designed to address the relationship between

patient characteristics/behaviors and the corresponding nursing care

action/interventions (Auger & Dee, 1983). It was an assumption of this PCS that

patient behaviors provide a more accurate indicator of patient's need for service

than the provision of nursing care based on available staffing.

A major limitation of PCS is the lack of reliability and validity of most

systems. Although Fray (1984), Auger and Dee (1983) and Grant, Bellinger and

Sweda (1982) have begun to address the issue of content validity and the

significance of establishing inter-rater reliability of patient classification systems,

these two areas remain frequently ignored. Many developers and users of PCS have

indicated that the lack of staff sophistication in the use of statistical methods, the

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institution's budgetary constraints and the lack of specific guidelines in which to

conduct validity and reliability studies have been contributing factors for the

continuing failure to address the issue of validity and reliability of PCS (Finlayson,

1976; Georgette, 1970; Fray, 1984; Schroeder, Rhodes & Shields, 1984; Alward,

1983).

The lack of published literature on the application of nursing models in

clinical settings is an indication that the practical usefulness of nursing models has

not been fully explored. To date, only three articles have been published that

discuss the application of the following nursing models within nursing service

settings: (1) Roy Adaptation Model on an 18-bed orthopedic unit at the National

Hospital in Arlington, Virginia (Mastal, Hammond & Roberts, 1982); (2) Johnson

Model on the Child Inpatient Service at the Neuropsychiatric Hospital in Los

Angeles, California (Dee & Auger, 1983a); and (3) Neuman Systems Model on a 27

bed surgical unit at Mercy Catholic Medical Center in Darby, Pennsylvania

(Capers, O'Brien, Kelly & Fenerty, 1985).

In summary, the following conclusions can be drawn:

1. The majority of PCS have been designed for use in medical surgical

settings. Consequently, lists of patient care activities are specific to

the physical and physiological care needs rather than the psychological

and psychosocial patient care needs specific for psychiatric settings.

2. The descriptors of care for most PCS have been developed based on

institutional practices and may therefore be restricted in their

application to other institutions where standards of practice differ.

3. The lack of validity and reliability of most PCS have limited the

generalization of these systems to other patient care settings.

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4. The practical usefulness of nursing models in clinical settings has not

been fully explored and demonstrated.

Purpose of the Study

The primary objective of this study was to assess the reliability and validity

of the patient classification instrument developed for UCLA Neuropsychiatric

Hospital (NPH-PCI). Validation was conducted through empirical investigation and

the use of statistical analyses.

For this study, the following research questions were posed:

1. What is the reliability estimate of the NPH-PCI when patient

behaviors in each of the eight subsystems are observed and

categorized independently by different observers?

2. Which of the patient behaviors in each subsystem are the best

predictors of the subsystem rating?

3. Which subsystems are the best predictors of the system rating?

Significance of the Study

Because of the dearth of literature in the following areas: (1) reliability and

validity of patient classification systems in general, (2) reliability and validity of

PCS designed for use in psychiatric settings in particular, (3) generalization of

patient classification systems, and (4) application of nursing models in patient care

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settings as basis for clinical practice, this research marks the beginning effort to

establish a reliable and valid classification instrument based on the Johnson Model.

The potential advantages of utilizing a reliable and valid patient

classification instrument based on a model of nursing as a theoretical framework

are:

1.

3.

4.

5.

Provides a frame of reference for systematic assessment of patient

behaviors,

Enhances communication and agreement among staff regarding

identified problems,

Provides a basis for the evolution of new knowledge,

Allows for the provision of nursing care based on assessed patient

behaviors, and

Allows for the development of patient outcome criteria.

Furthermore, it is anticipated that a reliable and valid patient classification

instrument has the capability for generalization to other patient care settings. A

patient classification instrument which identifies patient characteristics or

behaviors can more adequately explain the variable intensity of nursing care

required by each patient than patient census as a criteria. Such an instrument can

then serve to:

1.

3.

Estimate nursing workload based on patient care needs as opposed to

patient census, medical diagnoses or DRG classification as a single

criteria for staffing,

Identify nursing care costs for fiscal management and the development

of management and budgetary models for nursing services,

Provide a mechanism for quality care audits, and

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4. Develop nursing practice domains and nursing intervention strategies.

In summary, this chapter has presented the rationale for the development of

the study and objective for the study. Numerous implications for a reliable and

valid patient classification instrument based on a model of nursing were also

presented.

CHAPTER II

Conceptual Framework

Johnson Behavioral System Model

Conceptualization of the Model

The concept of behavior is basic to the Johnson Behavioral System Model

(Johnson Model) for nursing. Behavior, like any other discrete phenomenon, can be

isolated for study apart from all other human qualities as an operational system.

The assumption is that "what a human does is more important than what he is and

that behavior is one of the central problems of existence" (Johnson, 1977, p. 3).

The focus then is on how a person interacts with other people and, more

specifically, the particular forms of behavior that have been shown to have major

adaptive significance (Johnson, 1977; Johnson, 1980).

The Johnson Model is constructed on the following assumptions about man as

a behavioral system (Johnson, 1968; Johnson, 1977; Johnson, 1980):

1. Man strives continually to maintain behavioral system balance which

reflects behavioral adjustments or adaptations that have been

successful. These observed behaviors, however, may or may not

always coincide with the cultural norms for acceptable or healthy

behaviors.

- 10 -

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2. Behavioral systems balance or some degree of regularity and

constancy in behavior is essential to man.

3. Man actively seeks new experiences which may disturb his behavioral

system balance temporarily. Behavioral modifications may be

required to re-establish balance.

Johnson (1968) defines a behavioral system as constituting a complex of

observable features or actions that determines and limits the interaction of an

individual and his environment. The behavioral system establishes the relation of

the person to the objective events and situations in his environment. Behavior

functions as a response modality and serves as a mechanism for communication

between the person and the surrounding environment. These actions and/or

response modes are basic groupings of behavior that can be distinguished in terms

of the purpose or function of the behavior. These groupings of behavior, referred

to as subsystems of behavior, are conceived as forming an organized and integrated

whole, the behavioral system (Johnson, 1968).

The subsystems identified by Johnson (1968 & 1980) are affiliation,

aggression, dependence, achievement, ingestion, elimination and sex. An eighth

subsystem of restoration was subsequently added (Grubbs, 1980; Auger, 1976).

Each subsystem is "'comprised of a set of behavioral responses or responsive

tendencies which seem to share a common drive or goal'." (Johnson, 1968, p.3).

Figure 1 depicts the Johnson Behavioral System Model as illustrated by Auger

(1976).

These behavioral responses are made up of a number of related behavioral

acts which are functional in achieving the goal of the subsystem. Although these

responses are developed and modified through maturation and experience, they are

- 11 -

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Figure 1

Johnson Behavioral System Model

From Behavioral System and Nursing, J. R. Auger, 1976, p.37. Reprinted with

permission.

BEHAVIORAL SYSTEM

|NGESTIVE

RESTORATIVE ELIMINATIVE

ACHIEVEMENT AFFILIATIVE

AGGRESSIVE DEPENDENCYPROTECTIVE

SEXUAL

- 12 -

determined developmentally and are continuously governed by a multitude of

biological, psychological and social factors that operate in a complex interlocking

fashion (Johnson, 1968; Johnson, 1980).

These subsystems are linked and open: a disturbance in one is likely to affect

others. Each subsystem has certain functional requirements that must be met for

continued viability, development and growth. These functional requirements are:

(1) protection, (2) nurturance and (3) stimulation. Each subsystem must be

protected from noxious influences with which the system cannot cope, nurtured

through appropriate supplies from the environment and stimulated to enhance

growth and prevent stagnation (Johnson, 1968; Johnson, 1980).

Each subsystem is made up of at least four structural components:

1. Goal - is defined as that which is sought. The manifest goal is the

immediate intention of the behavior, while the latent goal must be

inferred. For example, in the ingestive subsystem, the manifest goal

is appetite satisfaction and the latent goal is biological survival

(Johnson, 1977). Although goals for each of the subsystems may be the

same for all individuals, the goals may vary according to the value

placed on goal attainment (Johnson, 1977; Johnson, 1980).

Set - means the individual's predisposition to act. Through maturation,

experience and learning, an individual uses preferred ways of behaving

under particular circumstances with selected individuals (Johnson,

1977; Johnson, 1980).

Choice - is defined as the entirety of the behavioral repertoire

available to the individual for the achievement of a particular goal. In

other words, choice constitutes the scope of action alternatives from

which an individual can choose (Johnson, 1977; Johnson, 1980).

- 13 -

4. Action - is the individual's actual behavior that is observable (Johnson,

1977; Johnson, 1980).

These four structural components interact with one another to create an

overall goal or function for the subsystem. Although each subsystem has a

specialized function, the system as a whole is dependent upon an integrated

performance. The integrity of the system is maintained when: (1) conditions in the

internal and external environment of the system remain orderly and predictable

and (2) functional requirements of the subsystem as a whole are met through the

individual's own efforts or through an external regulatory force for the purpose of

restoring, maintaining and attaining stability at the highest possible level for the

individual (Johnson, 1980).

Johnson (1980) asserts that the goal of nursing actions in each case is to

restore, maintain or attain behavioral system balance for the individual. Johnson's

assertion is based on the following assumptions about nursing: (1) nursing's

traditional concern for the person who is ill and (2) nursing's primary goal to assist

the person in achieving and maintaining behavioral system balance and dynamic

stability (Johnson, 1968). Nursing, therefore, acts as an external regulatory force:

(1) by changing the structural components of the individual's behavioral subsystems

or (2) through the fulfillment of the functional requirements of the subsystems, to

preserve the organization and integration of the patient's behavior at an optimal

level.

Amplifications of the Model

A most notable difference between the Johnson Model as originally conceived

by Johnson and that as presented by Grubbs and Auger is the inclusion of an eighth

– 14 –

behavioral subsystem, the restorative subsystem. The rationale for the inclusion of

this additional behavioral subsystem was not, however, stated in either author's

writings. According to J. Grubbs (personal communication, April 4, 1985), eight

subsystems (restorative subsystem included) were taught by Johnson in 1966 when

she was a graduate student of Johnson's. J. Auger (personal communication,

April 11, 1985) states that her writings on the Johnson Model were based on class

papers presented to her by faculty while she was instructor of the undergraduate

course "Basic Nursing Science" at University of California, Los Angeles.

It was Johnson's rationale that the relief of fatigue was more a function of

the aggressive-protective subsystem than the restorative subsystem (Lovejoy,

1981). J. Auger (personal correspondence, April 18, 1985), however, states that the

"restorative subsystem, in and of itself, contains goals that define the subsystem

apart from all other subsystems. It is a most important subsystem to the survival

of the organism as a viable entity."

Although Grubbs and Auger had similar interpretations of the function of the

restorative subsystem, Auger's interpretation of the ingestive and eliminative

subsystems differs from that of Grubbs. According to Auger, (1976), the functions

of the ingestive subsystem include the "'taking-in'" (p. 35) of substances; for

example, food and fluids, as well as the "'taking-in'" (p. 35) of sensory

information. Sensory information (perception, sight and knowledge) enables the

individual to initiate required compensatory responses in order to maintain a state

of psychophysiological equilibrium with changes in the external environment.

Auger (1976) further states that "it is through this ingestive activity that the

individual is able to differentiate himself as a separate entity from all other

objects and persons existing in the outer world" (p. 53).

- 15 -

Grubbs considers communication as an input and output mechanism that

serves the same purpose for all subsystems; consequently, the "'taking-in'" (p. 228)

of information cannot be classified as ingestive behavior (Grubbs, 1980). Grubbs

(1980) concurs with Johnson (1980) that the function of the ingestive subsystem is

specific to the appetitive pleasures.

Grubbs (1980) views the function of the eliminative subsystem as primarily

that of expelling biologic wastes and bodily secretions. Auger is of the opinion that

eliminative behaviors also include such acts as speech, nonverbal gestures,

expression of affective states (crying, laughing, yelling) and other actions that

serve to communicate the general state of the individual to the environment

(Auger, 1976). A comparison of the subsystems' functions as defined by Johnson

(1980), Auger (1976) and Grubbs (1980) is shown in Table 1.

Although the concept of environment and its role as a regulator of behavioral

system activity was not addressed by Johnson (1968, 1977, 1980) in any detail, it

was given significant attention by Auger (1976). Environment as described by

Auger (1976) consists of both the external and internal environments. The external

environment includes all those persons, objects and phenomena that can potentially

permeate the boundary (sensory thresholds) of the individual. The external

environment surrounding an individual contains a wide variety of sources of

information; for example, climatic and seasonal changes, societal rules and values,

educational systems and religious beliefs, are forms of input into the behavioral

system. The internal environment is also an equally important source of input. It

originates from within an individual in the form of emotions, motivations, thoughts,

fantasies, attitudes and reflexive responses. The process by which the individual

comprehends and evaluates these complex stimuli for their meaning and intent is

– 16 -

:

Table 1

A Comparison of Behavioral Subsystems' Functions

JOHNSON (1980) AUGER (1976) GRUBBS (1980)

Affiliative: Security,Social inclusion,intimacy andformulation of strongbonds.

Ingestive: Appetitesatisfaction.

Dependency: Approval,attention, recognitionand physical assistance.

Eliminative: Excretionof wastes.

Affiliative: To belongor be associated withothers in some form of

specific relationship.This goal includes theprocess of interaction.

Ingestive: To bringinto the individual a

substancé, object orinformation that the

individual perceives ordetermines to be

lacking. This goal oftaking-in may be forpleasure, gratificatio■ ,relief of pain, safetyand knowledge.

Dependency: To seekhelp, to obtain anothergoal, or to seekassistance in a task

related activity.

Eliminative: To release,let gö, get rid of wasteproducts; excess ornonfunctional matter

within the system. Itmay be viewed as a goalof tension-reduction.

Affiliative: To relate

or belong to somethingor someone other thanoneself to achieve

intimacy and inclusion.

Ingestive: To take inneeded resources fromthe environment to

maintain the integrityof the organism toachieve a state of

pleasure; to internalizethe externalenvironment.

Dependency: To maintain environmentalresources needed for

obtaining help,assistance, attentio■ ,permission, reassuranceor security; to gaintrust and reliance.

Eliminative: To expelbiologic wastes; toexternalize theinternal environment.

– 17 -

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Table 1 (continued)

A Comparison of Behavioral Subsystems' Functions

JOHNSON (1980) AUGER (1976) GRUBBS (1980)

Aggressive: Selfprotection andpreservation.

Sexual: Courting,procreation andgratification, genderrole identity.

Achievement:

Exploration, masteryand/or control of selfand environment.

Aggressive-Protective;To protect oneself,others or property fromreal or imagined harm,or threat of harm inin the form of attack.

Sexual: To procreateand ensure survival of

collective individuals,or to obtain pleasurefrom sexual activities.

This goal includes thedevelopment andmaintenance of an

adaptive sexual identityfor the purposes ofseeking or attracting alove object.

Achievement: Tomaster or controloneself and theenvironment in such a

way as to obtain adesired object, positionor need.

Restorative: To

maintain energybalance throughout thesystem throughtransformation andredistribution of the

available energythroughout the system,in accordance with thedemands of the various

subsystems.

Aggressive-Protective;To protect oneself orothers from real or

imagined threateningobjects, persons orideas; to achieve selfprotection and selfassertion.

Sexual: To procreate,to gratify or attract,fulfill expectationsassociated with one's

sex; to care for othersand be cared about bythem.

Achievement: Tomaster or controloneself or one's

environment; toachieve mastery orControl.

Restorative: To relieve

fatigue and/or achievea state of equilibriumby reestablishing orreplenishing the energydistribution among theother subsystems; toredistribute energy.

- 18 -

referred to as the perceptual process. Perception is controlled by sensory

receptors and selectively regulates the nature and amount of stimuli allowed to

penetrate the system boundary. Perception is considered to be a major

determinant of how an individual will behave. However, this evaluative process

also involves the activity of the biologic, psychologic, social and cultural regulators

and their contribution to the transformation and differentiation of the stimulus

into an internal event (Auger, 1976).

Grubbs (1980) identified several "'variables'" (p. 236) that encompassed the

biological, psychological, social and cultural factors outside the boundary of the

behavioral system and have the capacity to alter or change behavior within the

system. These "'variables'" (p. 236) are considered by Grubbs to be synonymous

with the concept of environment. They are:

1. Developmental - abilities that are modified by experience or acquired

skills,

2. Ecological – the environment of a person's upbringing,

3. Level of Wellness - responses in relation to the health and illness

Continuum,

4. Cultural - factors affecting attitudes, beliefs and behaviors learned

through education, discipline and training,

5. Familial - those persons of common ancestry,

6. Pathological – anatomic and physiologic changes from the norm,

7. Sociological – expectations related to one's role based on rank, status

or position in society,

8. Psychological - factors relating to internal psychic processes,

including cognitive functioning, and

- 19 -

9. Biological - capacities based on maturation and growth that are

dependent on anatomic and physiological functioning.

Auger (1976) also identified a list of factors that regulate and influence

behavioral responses, namely: (1) genetic inheritance, (2) intelligence, (3) age, (4)

sex, (5) attitudes, values and beliefs, (6) creative and problem-solving abilities and

(9) self-concept. According to Auger, although some of these regulating factors

are enduring traits and are relatively stable such as sex and body height, other

factors including social class, role expectations, values and beliefs develop from an

interaction with the environment. All of these regulators, however, share the

ability to influence the goals, set, choice and acts associated with each of the

behavioral subsystems as well as to the system as a whole (Auger, 1976).

According to Auger (1976) and Grubbs (1980), the biological, psychological,

social and cultural factors represent the major regulators of ongoing behavioral

responses. They exist to guide and limit behavior and to monitor and coordinate

the inter-relationships between the subsystems.

Applications of the Model

The major utility of the model is in the assessment phase of the nursing

process. The model provides nursing with a framework in which to describe patient

behaviors. Although the delineation of the behavioral subsystems was made and

functions for each of the subsystems were provided, the model, as conceptualized

by Johnson (1968, 1977, 1980) was not operationalized for direct applicability to

the clinical setting. This limitation is actually a strength, as it allows the nursing

practitioner to describe behaviors specific to the patient population she serves and

– 20 -

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offers a systematic approach with which to evaluate behavior and to provide a

basis for determining what is needed for protection, nurturance and stimulation.

With the increasing acceptance of nursing theory, the model has been utilized

by nurse practitioners to guide their work with mentally retarded adolescents

(Holaday, 1980), patients with hepatitis (Damus, 1980), visually impaired children

(Small, 1980), patients on hemodialysis (Broncatello, 1980), patients with accidental

injury (Rawls, 1980), patients with asthma (Lovejoy, 1981) and patients with

ventricular tachycardia (McCauley, Choromanski & Liu, 1984). Auger and Dee

(1983) used the model as a framework for the development of patient classification

system with the capability to establish staffing levels based on patients' needs.

Several researchers have utilized the Johnson Model as a theoretical

framework for describing patient behaviors, and for the development of assessment

tools. Holaday (1981 & 1982) conducted two research studies in relation to the

affiliative subsystem of behavior. These studies were conducted to determine the

effect of a chronically ill infant's cry on the development of maternal response

patterns. The potential benefit of these studies is the development of nursing

intervention strategies, in which the nurse can assist the mother in interpreting the

meaning of the infant's cry and in developing a broader choice of maternal response

patterns.

Derderian (1983) and Derderian and Forsythe (1983) utilized the Johnson

Model as a comprehensive framework for the development of the Derderian

Behavioral System Model instrument. This instrument resulted in the

categorization of 193 items representing each subsystem of the behavior. It was

designed to assess the perceived behavioral changes of cancer patients. According

– 21 -

to Derderian (1983), the instrument provides a system for describing and

documenting patient behavioral changes as to their existence, direction, quality

and importance, and the illness effects associated with them. This systematic

documentation of patient behaviors renders nursing data potentially more fruitful

for clinical nursing research.

Lovejoy (1983) also based the construction of a 47-item projective assessment

tool on the Johnson Model. The projective assessment tool was designed to

measure the perceptions of family members of children with leukemia. With

further refinements and testing, this tool may be used by nurses to assess family

members' behavioral patterns that might adversely affect the growth and

development of the child with leukemia. Other research studies have also been

conducted to determine the specific characteristics of oncology patients (Newlin,

1976) as well as patients who have been isolated from others because of illness

(Fawzy, 1979).

Implications of the Model in Nursing Practice

The behavioral analysis approach provides a comprehensive framework in

which various types of data can be organized into a cohesive structure. Knowledge

of the relationship between current and past behavior facilitates the identification

of problem areas; the nurse can then assist the patient in developing adaptive and

functional behaviors. In addition, this knowledge provides a frame of reference for

establishing realistic goals for recovery based on an appraisal of the patient

behaviors prior to the onset of illness.

In summary, this section has presented the conceptualization and

amplification of the Johnson Behavioral System Model. The model's application as

- 22 -

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a theoretical base for the development of nursing assessment tools and implication

for nursing practice were described.

- 23 –

Literature Review

Patient Classification Systems (PCS)

Definition

A patient classification system refers to the identification and classification

of patients into groups of care categories and to the quantification of these

categories as a measure of nursing care required (Giovanetti, 1979). All patient

classification systems have in common the goal of categorizing patients according

to pre-established criteria for the purpose of determining the need for nursing care

resourceS.

Types of Patient Classification Systems

The two major types of patient classification systems identified by Abdellah

and Levine (1965) are: (1) Prototype evaluation and (2) Factor evaluation.

Characteristics of patients typical to each category of care are described in

prototype evaluation while indicators or descriptors of direct nursing care are

described in factor evaluation.

Levels of Categories

Both factor and prototype evaluation classification systems include

categories for rating patient's nursing care requirement ranging from little

assistance (Category I) to great need for assistance (Category IV). The PCS

developed by the University Hospital in Seattle, Washington (Pardee, 1968) provides

an example of a 3-category system based on the patient's ability to care for

- 24 -

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himself: for example, Category I - refers to patients requiring a minimal amount

of nursing care; Category II - refers to patients requiring a moderate amount of

care; and Category III - refers to patients requiring the most care.

Kingston General Hospital in Ontario, Canada utilized a 4-category PCS

based on Jelinek, Haussmann, Hegy vary and Neuman's work (1974) at the Medicus

Systems Corporation (Plummer, 1976). Several other PCS, such as those at

Presbyterian-Saint Luke's Medical Center in Denver, Colorado (Reinert and Grant,

1981) and Medical Center Hospital of Vermont at Burlington, Vermont (Dale &

Mable, 1983) have also utilized a k-category system. However, none of these

authors provided reasons for their selection of a 4-category system. Fray (1984)

selected a 4-category system on the basis that change on the number of categories

might result in problems with user compliance. Auger and Dee (1983) added a

fourth category to the original 3-category system to account for patients that

require continuous one-to-one intensive nursing care.

PCS at the William Beaumont Hospital in Troy, Michigan (Grant, Bellinger &

Sweda, 1982) provides an example of a 6-category system for rating nursing care

requirements. Since the primary objective of the article describing this system

was to measure productivity in staffing units and to make budgetary projections,

the authors did not describe the distinctive differences between the six category

levels.

The Medicus Systems Corporation recommended four levels of categories as

the most accurate classification of patients. Jelinek, Haussmann, Hegyvary and

Neuman (1974) found that the variance within a 3-category system was too large

and that the statistical probability of error was higher within a 5-category system.

The additional categories did not yield a significant increase in discrimination

- 25 -

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among patient types. The authors, however, did not provide statistical data or

further explanation to support their recommendation.

Indicators of Care

Indicators of care found in the prototype evaluation system include

statements that attest to the capabilities of the patient to care for

himself/herself; for example, his ability to ambulate, to feed himself, to bathe

himself and to care for his own eliminative needs. Indicators of care found in

factor evaluation system are those that include requirements for specific nursing

activities such as: taking wound culture, performing pre-operative scrub, doing

daily weights, and so forth.

A certain degree of rater subjectivity is inherent in both the prototype

evaluation and the factor evaluation systems. However, since the factor

evaluation system is based on quantitative observable variables, it has been

considered to be more objective than the prototype evaluation system.

Staff are usually more receptive to a prototype evaluation system because it

allows for simple explanation and understanding and does not increase paperwork or

time away from patient care (Roehrl, 1979; Schroeder, Rhodes & Shields, 1984). A

criticism of prototype evaluation design is that it may be difficult to monitor the

accuracy of ratings because of observer bias between individuals responsible for

classifying the patient (Reinert & Grant, 1981). Such results are often not distinct

enough to accurately predict the staffing required for a given acuity mix of

patients (Vaughn & McLeod, 1980). Auger and Dee (1983) recommended that staff

consistently identify and discuss their observations to develop a common frame of

reference and achieve a higher degree of agreement.

- 26 -

º

Early Developments (1940s through 1960s)

Patient classification systems have been in existence for many years. The

history of patient classification dates back to the period of Florence Nightingale,

when an intuitively-based information system was used. In this system, the most

seriously ill patients were placed closest to the ward sister's office in order to

facilitate observation while the less seriously ill patients who could take care of

themselves were placed at the far end of the ward to indicate their decreased

dependency on the nursing staff. A limitation of this approach is that its

application allows for differing views to surface as to the nature of high or low

dependency.

A major effort was made to classify patients according to intensity of nursing

care requirements in the late 1940s with the emergence of rising health care costs

and severe personnel shortages. The National League of Nursing in its Study of

Pediatric Nursing in 1947 published a patient classification system in which

patients were rated on a 3-category scale of intensity on each of four factors: (1)

degree of illness, (2) activity, (3) adjustment and (4) number and complexity of

procedures and treatments (Abdellah & Levine, 1965). Although an attempt was

made to relate the amount of required nursing time to patient classification, it was

done in global terms and therefore did not provide a sensitive tool for the planning

and allocation of staffing resources.

During the 1950s, the concept of patient classification shifted to a much

broader base. The patient classification system was used to determine the type of

facilities needed, the amount and kind of nursing services required, and the proper

allocation of patients. The development of the patient classification system began

by recording all services provided to the patient. Based on the assessment of over

– 27 —

* *

100 items of information collected on each patient, the patients were then grouped

into four categories: (1) critical, (2) intensive, (3) standard and (4) minimal

(Aydelotte, 1973).

In the early 1960s, the format for the development of patient classification

systems shifted beyond the assignment of patients to an estimate of nursing time

requirements for patients. Conner's work at Johns Hopkins Hospital served as a

model for the work of others. Conner, an industrial engineer, drew upon factors

associated with nursing problems such as mobility, consciousness, disturbance,

inadequate vision and isolation rather than the usual variables of census, age,

medical diagnosis and sex. Based on continuous observation of direct care provided

to patients presenting these problems, Conner developed a patient classification

system, isolating patients into discrete categories (Conner, 1961).

In 1963, a large group of Southern California hospitals under the guidance of

the Hospital Council of Southern California and Blue Cross of Southern California

established the Commission for Administrative Services in Hospital (CASH). The

first major effort of CASH was an in-depth survey of nursing services. With the

professional guidance of a nursing advisory committee consisting of four directors

of nursing appointed through the cooperation of the Hospital Council and California

Nurses Association, the CASH staff conducted work sampling studies involving six

hospitals. In each of the six hospitals, one nursing unit was selected for the study.

The primary objective of these studies was to determine an equitable workload for

staff between various shifts. Levels of categories were designated as low, average

and high. Twenty-eight nursing activities were identified; for example, back rub,

diet, meds-preparation, bath, report and meds-administration. These activities

were recorded by staff each hour over a 24-hour period. Analysis of this data

– 28 -

resulted in significant redistribution of peak hours of work and staff workload

assignments were then based on the amount of nursing care that patients required.

This approach resulted in an average reduction of 1.35 nursing care hours per

patient day on the test units (Edgecumbe, 1965).

The indicators of care found in most of these earlier PCS were bathing,

feeding, toileting, back rub and so forth. The attention given to these activities,

which were involved in ministering to the basic human needs of patients, attest to

nursing's traditional role and its distinct contribution to patient care which is not

shared by other health care providers (Kruetter, 1957).

A criticism of these earlier patient classification systems was that the

elements for classifying patients according to patient care requirements were

relatively limited in scope and complexity. The critical indicators of care were

primarily pathophysiological in nature and did not consider the sociopsychological

behavior of patient care requirements (Aydelotte, 1973). Emotional support and

patient teaching, two indicators of care viewed by nurses to have significant

clinical value to nursing, were not addressed (Hanson, 1979). The measurement of

time devoted to the nursing process was also not addressed (Thompson, 1984).

Current Developments (1970s through 1980s)

The PETO system was developed in the early 1970s by Poland, English,

Thornton and Owens (1970) for Eugene Talmadge Memorial Hospital in Augusta,

Georgia. Utilizing the factor evaluation design, all elements of direct nursing care

in the PETO system were denoted by points. A higher point value indicated more

nursing attention. The point values were obtained from time studies conducted on

the hospital's 32-bed pediatric unit.

– 29 -

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Based on the investigators' literature review, seven major elements were

found to be representative of a large measure of physical nursing care provided at

the study site. The seven major elements were: (1) diet, (2) toileting, (3) vital

signs and measurement, (4) respiratory aids, (5) suction, (6) cleanliness and (7)

turning. In addition to these seven major elements, there were five subcategories

included for diet: (1) feeds self without supervision, (2) feeds self with supervision,

(3) feeds self but needs constant presence of staff or gastrostomy feeding every

four hours, (4) total feeding by personnel and (5) tube feeding.

From the observation of all personnel over several days, average time periods

were obtained for each subcategory. Numerical values corresponding to five

intensities of care were developed; that is, services requiring 7.5, 15, 30, 60 or 90

minutes each. A two-point value assigned to the subcategory of 'feeds self' could

then be translated into 15 minutes of nursing care required. Based on the total

point value assessed and designated for each level of category, a category number,

i.e., Category I, II, III was then assigned to the patient.

The Grasp system developed for Grace Hospital in Morgantown, North

Carolina, (Meyer, 1973) is similar to the PETO system with the exception of two

modifications: (1) point values equivalent to six minutes each were assigned and (2)

emotional support and patient teaching were included as critical indicators of care.

The inclusion of emotional support and patient teaching were based on extensive

time studies showing that 14.5 minutes were required for each patient per shift.

The author did not provide a rationale for a change in the point value. Barham and

Schneider (1980) also found that depending on the levels of categories into which

the patients were classified, a range of six minutes to 20 minutes per patient were

required per shift for emotional support and patient teaching respectively.

– 30 -

*

In contrast to earlier PCS that failed to include emotional support and

patient teaching, recent PCS developed for Kaiser Permanente Centers in Northern

California (Barham & Schneider, 1980) and Presbyterian-Saint Luke's Medical

Center in Denver, Colorado (Reinert & Grant, 1981) have included emotional

support and patient teaching as critical indicators of care.

Reliability of Patient Classification Systems

A most important aspect of reliability in a PCS relates to inter-rater

reliability, or consistency of the classification tool in obtaining the same results

when used by different raters (Giovanetti, 1979). However, it is an area frequently

ignored by developers of PCS.

Grant, Bellinger and Sweda (1982) reported that reliability of PCS was

investigated by using intraclass correlation. Three raters made independent

observations of the same patients for three consecutive days and rated the care

provided for these patients. Findings showed that the intraclass correlation was

0.97 for items pertaining to activities of daily living, 0.89 for emotional cognitive

needs of patients and 0.91 for monitoring elimination.

Fray (1984) reported that reliability was investigated by utilizing paired

classifiers, consisting of the staff nurse caring for the patient and an observer.

One set of paired classifiers categorized 50 patients during the day shift while a

second set of paired classifiers, using the same methodology, categorized the same

patients during the evening shift. A total of 16 staff nurses and two observers

completed the classifications, utilizing different nursing units. Pearson product

moment correlation for the day and evening shifts were 0.983 and 0.924,

respectively.

- 31 -

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According to Abdellah and Levine (1965), a reliable classification system

required a 90 to 95% intraobserver and inter-rater reliability. This type of

reliability can be achieved only when the criteria for patient classification are

precise, specific and accurate and when there is sufficient time for observer

selection and training, staff orientation to practice using the tool and adequate

monitoring procedures.

Walidity of Patient Classification Systems

According to Williams (1977), a patient classification system can only

measure a portion of nursing care--those direct care activities that can be

observed and quantified. Consequently, it is questionable whether validity of

patient classification instruments can ever be shown satisfactorily in terms of

actual patient need (Giovanetti, 1979).

The literature describing the validity of PCS is scant. Fray (1984) reported

that content validity was established by a panel of 34 nurses representing

administration, management, inservice educators, staff nurses and clinical

coordinators. The panel was given detailed guidelines for arriving at the patient's

classification. An agreement rate of 89% was obtained from the panel's responses.

Conner, Flagle, Hsieh, Preston and Singer (1961) conducted two studies to

determine the predictive validity of the PCS. Utilizing work sampling techniques,

the first study was conducted to develop: (1) criteria for levels of categories, such

as self-care, partial care and total care; (2) critical indicators of care such as

ambulation, bathing, feeding, intravenous therapy; and (3) a specified number of

nursing care hours for each level of category. The second study was conducted to

test the predictive validity of the first study by utilizing similar work sampling

- 32

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techniques. Patients observed were classified according to three levels of category

prior to, and thus independently of, the observation of nursing care provided. The

nursing staff was not aware of the patient classification. This study verified

original conclusions about the amount of time nursing staff spent with patients for

each category. Findings from this study showed that patients classified in

Category I (self-care) received 27 minutes of direct care per shift. Patients in

Category II (partial care) received 53 minutes and patients in Category III (total

care) received 137 minutes. These time values were in agreement with those in the

first study.

Generalization of Patient Classification Systems

Few studies have been conducted to establish the reliability and validity of

PCS. Consequently, most PCS have been limited in their generalization to other

patient care settings.

Two studies were conducted to compare patient classification systems (PCS)

for their reliability in determining workload. Findings from the first study

conducted at the Medical Center of Vermont (Roehrl, 1979) showed a significant

correlation among the three patient classification systems selected for the study.

The patient classification systems selected were: (1) Tool A - PCS developed at

the Medical Center Hospital of Vermont, (2) Tool B - PCS developed by Hospital

System Study Group at University of Saskatchewan, Saskatoon, Canada, and (3)

Tool C - PCS developed by Hanson and adopted by San Joaquin Hospital in

Stockton, California.

Tool A addressed six overall items of patient care: (a) diet, (b) hygiene, (c)

mobility, (d) medications and intravenous therapy, (e) behavior and special

- 33 -

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emotional concerns and (f) physiological state. In addition to these patient care

indicators, three phases of hospitalization were also included: admission, discharge

and transfer of patients. Tool B identified four major components of care as

indicators of the patient's overall requirements: (a) personal care, (b) feeding, (c)

observation and (d) ambulation. Each of these major components was broken down

into individual determinants representing the patient's degree of dependency on

nursing care. These determinants were: (a) incontinence and (b) surgery. Tool C

utilized a checklist of parameters such as: (a) activity, (b) position, (c) intravenous

therapy and (d) observation. All three PCS are examples of the factor evaluation

design utilizing four category levels.

The study was conducted over a 9-week period and divided into three phases:

Phase I was from week 1 through 3, Phase II was from week l; through 6 and

Phase III was from week 7 through 9. All patients on the medical and surgical units

were classified daily between 2:00 p.m. and 7:00 p.m. using each of the three tools.

The classification of patients according to four levels of categories was done by

the registered nurse. Each of the nurses used a different tool for a 3-week period.

The finding showed that 34% of the time there was complete agreement

among the three tools. An additional 30% of the time, there was 99% correlation

between Tools B and C. The data indicated that 64% of the time there was

agreement between Tools B and C. The least amount of correlation occurred

between Tools A and C. One advantage of Tool A was its thoroughness; however, it

took significantly longer to complete. In contrast, Tool C took significantly less

time to complete but failed to address behavioral problems of patients. The

authors did not provide an explanation for the selection of the period of the day for

- 34 -

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the study or indicate the degree of inter-rater agreement among the three

registered nurses. These factors may have affected the study results.

A second study was conducted at Malcolm Medical Center in Washington,

D.C. for the purpose of evaluating two existing PCS and selecting one system that

would most meet the following criteria: (1) be able to recognize the intensity of

care, (2) be measurable and quantifiable, (3) be able to match nursing resources to

patient care requirements, (4) be economical and convenient to report and use, (5)

be directly related to time and effort spent on the activity, (6) be open to audit, (7)

be readily understood by those who plan, schedule and control the workload and (8)

be adaptable to changing requirements (Schroeder, Rhodes & Shields, 1984).

The two PCS evaluated were the CASH system, an example of the prototype

evaluation design and the Grasp system, an example of the factor evaluation design

which was designed for Grace Hospital at Morgantown, North Carolina. The study

was conducted over a 30-day period. Three inpatient units were finally selected as

test sites; (1) medical, (2) obstetrics, and (3) surgical. The charge nurse for each

unit was instructed on how to complete the sheets for the two systems. To prevent

any attempts to bias study results, charge nurses were not told of the purpose for

completing the forms and the forms were not totaled until the end of the 30-day

period. The results of the study showed that both CASH and Grasp systems

reflected similar staffing requirements and demonstrated generalization of these

two systems to patient care settings other than the institutions where these

systems were derived.

In summary, this section has presented an overview of patient classification

systems and examples of PCS in use by acute care hospitals for the past four

decades. Studies on the reliability and validity of PCS were also described.

– 35 -

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UCLA Neuropsychiatric Hospital - Patient Classification System (NPH-PCS)

The NPH-PCS incorporates both the prototype evaluation and factor

evaluation designs; therefore it consists of two parts. The first component lists

behaviors representing varying degrees of adaptiveness from adaptive behaviors

(actions that are meaningful and functional to the situation) to maladaptive

behaviors (actions that lack apparent relationship to events transpiring in the

environment). The second component lists nursing care activities based on the

amount of care the patient requires from minimal care to continuous one-to-one

care (see Appendix A, General Framework). The two component classification

system facilitates correlating patient behavior and need for nursing care.

Development of Patient Classification Instrument (NPH-PCI)

The first component of the NPH-PCS is referred to as the NPH-PCI. This

instrument was based on the Johnson Behavioral System Model as a theoretical

framework for three primary reasons (Auger & Dee, 1983):

1. The model focused on behaviors,

2. The model could be readily coordinated with existing treatment

programs based on social learning principles which emphasize

behavior, and

3. Universal patterns of behavior could be identified for applicability to

all individuals regardless of age.

The model addressed eight subsystems of behavior that are universal and of

primary significance to all persons. The eight subsystems are: ingestive,

eliminative, dependency, affiliative, aggressive-protective, achievement, sexual

– 36 -

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and restorative (Johnson, 1968; Johnson, 1977; Johnson, 1980; Auger, 1976; Grubbs,

1980).

The NPH-PCI was operationalized in terms of critical adaptive and

maladaptive behaviors for eight behavior subsystems as defined by Auger and

Grubbs (see Table 1). These behaviors represent the total spectrum of emotional

and behavioral disturbances and developmental disabilities from a wide age range

of patients admitted to the adult and child psychiatric inpatient services. Table 2

presents the operational definitions and characteristics for each behavior

subsystem (Auger & Dee, 1983). The behaviors were designed to meet four

criteria: measurable, observable, relevant to the clinical setting and specific to

the behavior subsystems. These behaviors were ordered into three categories based

on their degree of adaptiveness. The complete list of behaviors for the eight

subsystems and ordered into the three categories is shown in Appendix A (Auger &

Dee, 1985). A fourth category was added to include behaviors of acute intensity

and frequency as well as behaviors that may result in self-injury or injury to others.

Table 3 presents the criteria for the four categories (Auger & Dee, 1983).

Walidity and Reliability of Instrument

Content validity is defined as "representativeness or sampling adequacy of

the content of a measuring instrument" (Kerlinger, 1983, p. 458). It is guided by

the question--is the content representative of the universe of content of the

property being measured? As was previously described in this section, the

behaviors represent the total spectrum of emotional and behavioral disturbances

and developmental disabilities from a wide age range of patients. Content validity

was established through a panel of experts (clinical nurse specialists, nursing

- 37

Table 2

Definitions and Behavioral Characteristics of Subsystems

Critical Behavioral

Subsystem Definition Characteristics

Ingestive Behaviors associated with the intake Food/fluid intake;of needed resources from the sensory perception.external environment, includingfood, information, and objects forthe purpose of establishing aneffective relationship with theenvironment.

Eliminative Behaviors associated with the Bowel/bladder patterns;release of physical waste products. hygiene.

Affiliative Behaviors associated with the Attachment behaviors;development and maintenance of interpersonalinterpersonal relationships with relationships;parents, peers, authority figures; communication skills.establishes a sense of relatedness

and belonging to others.

Dependency Behaviors associated with obtaining Basic self-care skills,assistance from others in the emotional security.environment for completing tasksand/or emotional support; includesseeking of attention, approval,recognition.

Sexual Behaviors associated with specific Knowledge andgender identify for the purpose of behavior congruentpleasure and procreation. with biological sex.

Aggressive- Behaviors associated with real or Protection of selfProtective potential threats in the environment through direct or

for the purpose of ensuring survival. indirect acts;identification of

potential danger.

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- . . : - * - r

- - * - * : - -

* - - - -

* . . . - * * * *

* : - - -

- - - - * * * .- - - * ~ * - - * . . .

. . . . . . * * * - º -

Table 2 (continued)

Definitions and Behavioral Characteristics of Subsystems

Critical Behavioral

Subsystem Definition Characteristics

Achievement Behaviors associated with mastery Problem-solvingof oneself and one's environment for activities; knowledge ofthe purpose of producing a desired personal strengths andeffect. weaknesses.

Restorative Behaviors associated with Sleep behaviors;maintaining or restoring energy leisure/recreationalequilibrium; relief from fatigue, activities; sick role.recovery from illness.

- 39 –

*: : * > . . r -21, r i■ ■ º : , T = 1. I

. . . . . . . . . 2, 223: . . . . . . ºf . . . . iv. . . . . . . . . . . . . . i.

. . . . . . . . . . .

º . . . (, , , , , \ .-

- . . . . . .

… . º * * * w -. . . -

- - - * - -. . . . . . . . . . . . . . . . .• * .

. . . . . . . . . . . . . . . . . . . . . .* - - - - - - , :

- - - - - - - - - - -

• , . . . . . . . . . .

Table 3

General Framework for Categorization of Patient Behaviors

Category I Behaviors that are healthy; appropriate to developmental

stage and adaptive to the environment.

Category II Behaviors that are inconsistent; in the process of being

learned; may or may not be appropriate to the developmental

stage and maladaptive to the environment.

Category III Behaviors that are severely maladaptive to the environment

and inappropriate to developmental stage.

Category IV Behaviors in one or more subsystems of acute intensity and/or

frequency; includes self-destructive acts and aggressiontoward others.

- l;0 -

- * - - -† : " : * >'', \ . . . . . . . . . . . .

* * - - - º - - - * . .

. . . . - *- * , . . . . . . . * .

- - - - s * - -. . . . . -- - - - a • *

* - - - - - - * - - -

- - . . . . . . * . . . . . . . . . . * * * *

t * . . . . . . . - * ■ , , ºr . . . . . . . . "- -

* . . - - - t t -

. . . . . . . . . " - * * w " . . . . ■ . . . . . . . .

* - ... • - : ... r - - - . . . ... r-. . . . . . . . . . . . . . . . . . . . v . . . . . . - * * * * a

- t -* -* - - - -" . : . . . . - -º ... • . . .

* . . * . . . . . . (, : " . . . * * * * * ■ & s \ . . . ... " *

. . . . . . : , . . . . . . .-- - -"

- - - *

... . . . . . . . . . . .

coordinators and nursing administrators) representing both the adult and child

inpatient services. Each panel member independently evaluated each of the

behavioral indices for compliance according to four criteria: (1) measurable, (2)

observable, (3) relevant to the clinical setting of psychiatry and (4) specific to the

subsystem (Auger & Dee, 1983). The panel of experts also arrived at a general

consensus on the ordering of the behaviors according to the criteria specified in

Table 3. Essentially, content validation consists of judgment. Other types of

validity, including criterion-related validity and construct validity, were not

tested.

A pilot study was conducted to determine inter-rater reliability. A total

sample of 28 registered nurses (14 pairs of data collectors) were selected from

seven psychiatric inpatient units. Using a checklist, each pair of data collectors

identified behaviors of patients that were observed in each of the eight subsystems:

ingestive, eliminative, dependency, affiliative, achievement, sexual, aggressive

protective and restorative. The data collectors then rated a subsystem category

for each of the eight subsystems and a system category using the values of 1, 2, 3

or 4. These values were based on criteria specified for each category (Table 3).

Results showed that staff agreement on independent ratings of patient

behavior significantly exceeded chance, and that inter-rater agreements were all

within five percentage points of each other. Levels of agreement involving

assessment of behaviors that required a low level of observer inference were

highest; for example, such behaviors as handwashing, frequency of bowel

movements and clothes associated with specific gender. Levels of agreement

involving assessment of behaviors that required a high level of observer inference

— l;1 -

were lowest, for example, awareness of personal space, attachment and expression

of feelings (Auger & Dee, 1983).

In summary, the development of the NPH-PCI, including operational

definitions of the Johnson Model, criteria for four categories, content validity and

inter-rater reliability was described in this section.

— l;2 –

CHAPTER III

Methodology

Research Design

This predictive research study was designed to assess the reliability and

validity of the patient classification instrument developed for the UCLA

Neuropsychiatric Hospital (NPH-PCI). The data used in this study was derived

from an observational study designed under the auspices of the UCLA

Neuropsychiatric Hospital, Nursing Services. The observational study was

conducted on four child and adolescent inpatient units at the UCLA

Neuropsychiatric Hospital (NPH) in Los Angeles, California, from August, 1982, to

September, 1984. The objectives of the observational study were fivefold (Auger &

Dee, 1982b):

1. To assess the reliability of staff ratings of patient behaviors as

described in the NPH-PCI,

2. To examine the relationship between ratings of behavioral subsystem

categories and rating of system category,

3. To determine the relationship between patient behaviors and

corresponding levels of nursing care as defined in the NPH-PCS,

4. To measure the number of direct and indirect nursing care hours, and

- l;3 –

* * * * * , -

- - - 1 - I -

t - * : " - º - - - - - " - . - - . . .- - - -

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- - ( , , , , - V - . : . . . . . . . . . . . . . . . . . . . . . . . . . . . .- º -

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-- * * : . . .

- - . . . . • * , ! . . . v . .-

- * - - - - - - , - - - - - º - - i – f = i - * * * : " .

- - . . -- - -- " - - - - * * * - -

* - . . . . . . . . . * * * * . . . . - *

* * - - * * * , - " - " * - - * . . . * * . - " . .- *- - • . . . . . . * * * - * * , . . . . . . . . . . .

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, ,-

* - - - t t - , - - - * -: - * : - " - - : . * * * - * -. * * * * * - -

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- - -

- -

- - . . . . + * . . - - " " . . . . " : - * * * * -. . . . . . . . . . . . . . . . . . . . . . a . . . . . . . . . . . . . . . . . . . . .

- * * - * - -- - . . . . * -- * * *

* . . . . - * * : . - - - - - 1 - . . . ". . . . . . . . . . * * * * * : . . . . - - - . . . . . . . -- * * . . . . . . ( . --

- - * * * - - - - * * * - * * *& " " . . . * . . . . . . - ! . . . . . . ■ .

• - * - . * - - ? - - - - - - *

. . . : ; ; , . . . . . . . . . . . . . . . . . . . . . . .- - - I ‘. . . . [. **

- - - - • *. - - - . * - t - -- - - - - -

º - - . . . . . . . . . "- * * * * * * * * * : # * ** -

-- - -

- * * - * - - - * * * º - - - - - - - * - - - - - **. . . . . . . . . . . . ; * - - - . . . . . . C. . . . . . . . . . . . . . . . . .

5. To determine the number of nursing care hours required to provide

nursing care to patients categorized according to the NPH-PCS.

More specifically, this study addressed two of the five objectives of the

observational study: (1) to assess the reliability of staff ratings of patient

behaviors as described in the NPH-PCI and (2) to examine the relationship between

ratings of behavior subsystems' categories and rating of subsystem category.

Research strategies, procedures and data analyses related to these objectives are

described in this section.

Research Strategies

For an instrument to be used with confidence, the issues of reliability and

validity must be addressed. Equivalence reliability and criterion-related validity

were the two psychometric properties selected for investigation in this study.

Equivalence Reliability

The equivalence approach is utilized when one of the following circumstances

exists: (1) when different observers are using the same instrument to measure the

same phenomena at the same time or (2) when two parallel instruments are

administered to individuals at about the same time (Kerlinger, 1973). A basic

limitation of the latter method is the difficulty of constructing alternative forms

that are parallel (Carmines & Zeller, 1979).

Zeller and Carmines (1980) identified two additional measures of equivalence:

(1) split-half methods and (2) measures of internal consistency. In the split-half

- lºli –

method, the total number of items in the instrument is divided into two halves and

the correlation between the two halves is used to provide an estimate of the

reliability of the full set of items. A criticism of the split-half method is that the

different ways in which items can be grouped into halves have resulted in different

reliability estimates even though the same items are administered to the same

individuals at the same time. In contrast, measures of internal consistency do not

require the splitting or repeating of items. Reliability estimates can be obtained

by using statistical procedures to account for all the variance and covariance of

the items. The most popular of these reliability estimates is given by Cronbach's

alpha (Carmines & Zeller, 1979). However, the following conditions must exist: (1)

the items that make up the composite are homogenous in their relation to each

other; and (2) there is a large number of items (Zeller & Carmines, 1980).

For this study, the alternative form method, split-half methods and measures

of internal consistency were not selected for the following specific reasons:

1. The alternate form method was not selected because there was no

known parallel instrument available.

2. The split-half method was not selected because the nature of the

instrument is such that it could not be divided into parallel halves.

3. Measures of internal consistency was not selected because the items in

the NPH-PCI were not expected to show homogeneity.

Consequently, the method of utilizing different observers to observe and

categorize patients was the logical approach selected for this study. Reliability

estimates, in this instance, refer to the degree of agreement among different

observers when patient behaviors are observed and categorized independently using

the same instrument for the same period of time.

- l;5 -

*** •■

Criterion-Related Walidity

Criterion-related validity is determined by the degree of correspondence

between a measure and its criterion. Essentially, there are two types of criterion

related validity: (1) concurrent validity, which is assessed by correlating a measure

with its criterion at the same point in time and (2) predictive validity, which is

assessed when a future criterion is correlated with the relevant measure (Zeller &

Carmines, 1980). According to Nunnally (1978), criterion-related validity is

predictive validity, and in each case, a predictor measure is related to a criterion

measure. Predictive validity is at issue when the instrument is used to estimate

some important form of behavior that is external to the measuring instrument

itself, the latter being referred to as the criterion. Knapp (1985), however,

cautioned that criterion and predictor measures should be of the same construct.

The degree of correspondence between these two measures, therefore, determines

the predictive validity.

This study proposes that: (1) ratings of patient behavior indicators in each of

the eight subsystems will be positively associated with subsystem category ratings

and (2) subsystem category ratings will be positively associated with system

category ratings. In other words, patient behavior indicators are predictive

measures for subsystem category ratings and subsystem category ratings are

predictive measures for system category ratings. Subsystem category (in the first

instance) and system category (in the latter instance) are criterion measures.

- 46 –

~ ~ *- A. •• º· *→

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Research Questions

Research questions were posed to address reliability, validity and

generalization of the NPH-PCI. Specifically, these questions were:

1.

2.

4.

What is the percentage of agreement between staff, shift coordinator

and observer groups with respect to:

– observed patient behavior indicators?

- ratings of subsystem categories?

- ratings of system categories?

Which patient behavior indicators in each subsystem have the greatest

impact on subsystem category?

Which of the eight subsystem category ratings have the greatest

impact on system category ratings?

Does the model of NPH-PCI predict across age groups, sexes and

inpatient units?

Study Definition

For the purposes of this study, the following general definitions were used:

1. Patient behaviors - Direct observable non-verbal and verbal actions of

the patient. These behaviors represented the total spectrum of

emotional and behavioral disturbances and developmental disabilities

from a wide age range of psychiatric patients. These behaviors were

- l;7 -

* | * * * * : . 1 * * * : *------------------------------

. . - - - - - - - * . . . . - - -

-- . . . . . . . . . ( . . . . . . . . . * - . . º

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- - c . - * * - - - - º - - - * 1- - -

… + . . . * -- *** * * * - ** * - -- - - * * * * * * , I -

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- a ... * * * : . . . . . . . . . ;-

r - -*. + * -

* . * : - * * . * * * -

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* . . . . . . - * . . . . . . . s - . . . . . . .-

!-- ", , -",--

- - -- * . - - -. 1 * : . . . . . . . . . . . . .

* , * → - - - - - - - - - . -

- -- . . . . . . . . . . . . . . .

-~ * ( ; ; , , - - - - - - -- -

- " * - . * - - , ,* * - - * * * - * > . . .

- - - - - - - * - * - - * . . - - -

f : . . . . . . * - . . . . . . . . . . . . . . . .

* - . . . . . ■ .

- - - - - - - - - --■ : 3 ºf . . . . . . . . . .

- * - - - - * . . . º - - . . . . . * -

: : - . . . . . . . . . . . - - - . . . . . . . . . ." . . . . . .

- " - - - - - * * * : - " . . . * - -• * *- : * > . . . . . . . . . .- - - -- * - - - -

-, - - - - - - - - - - - - -. . . . . . ! . . .

- - " . . . . . - - . . - - -

-. . . . . . . . . . . . . . . * - - - * . . . . . . . . . . . . . . -

- - - - - - - - - - - - * - . . . -, - .

- * * * *- - - - * - * - - - - - - - - - - - t * - - - -

2.

6.

ordered into the first three categories according to the general

framework shown in Table 3.

Adaptive behaviors - Actions that are meaningful and functional to the

situation. Adaptive responses are characterized as appropriate to the

eliciting stimuli in the environment.

Maladaptive behaviors - Actions that lack apparent relationship to

events transpiring in the environment. Responses may be different or

excessive to the environmental event.

Environment – The social, cultural and physical factors contained

within the hospital setting, such as treatments, philosophy and patient

mix that influence and limit the behavior of the patient.

Subsystem category - Represents the data collectors' ratings on the

overall adaptiveness of a group of contrasting behaviors for the

Subsystem, which may include a mixture of adaptive and maladaptive

behaviors as well as divergent behavioral characteristics. For

example, in the ingestive subsystem, the patient may demonstrate

Category I adaptive behavior for food and fluid intake and Category III

maladaptive behavior in awareness of social and physical environment.

Rating values range from 1 to 4 based on the general framework shown

in Table 3.

System category - Represents the data Collectors' ratings of the

degree of nursing care required by the patient based on the overall

level of behavioral adaptiveness for all eight subsystems. The rating

values for care requirements ranged from 1 – 4. A value of 1

represents minimal nursing care designed to maintain and support

- l;8 -

7.

8.

9.

adaptive behaviors. A value of 2 represents moderate nursing care

designed to structure the environment for the purpose of reinforcing

newly learned adaptive behaviors and modifying maladaptive

behaviors. A value of 3 represents intensive nursing care designed to

structure the environment for the purpose of teaching new adaptive

behaviors and modifying severely maladaptive behaviors. A value of 4

represents one-to-one nursing care management of severely

maladaptive behaviors for the protection of the patient. A detailed

general framework for nursing care requirements is found in

Appendix A.

Shift coordinators - Persons assigned to a specific unit with primary

administrative responsibility for staffing and patient care for a given

8-hour shift (Administrative Nurse I). Relief shift coordinators were

those with primary administrative responsibility in the absence of shift

Coordinators and included Clinical Nurse I, II, III, Administrative Nurse

IV and Per Diem RN.

Observers - Master prepared staff who were recruited specifically for

the observational study and were randomly assigned to any of the four

inpatient study sites. Those recruited were knowledgeable about the

Johnson Model or had prior clinical experience working with patients

in the psychiatric/developmental disabilities settings.

Staff - Part-time and full-time professional and nonprofessional

persons identified as the patient's primary caregiver for a given 8-hour

shift during the observation period. These include Clinical Nurse I, II,

III and IV, Administrative Nurse I and IV, Per Diem RN, Float RN,

- l;9 -

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Mental Health Practitioner and Psychiatric Technician, Senior Nurses

Aide, and Nurse Interim Permittee assigned to a specific inpatient

unit.

Description of Research Setting

This research was conducted at NPH, a 209-bed tertiary care hospital and

major teaching medical center of the University of California at Los Angeles which

consists of the following inpatient units: two adult psychiatry, one geropsychiatry,

one neurology, one telemetry, two child psychiatry and two adolescent psychiatry.

Specifically, the research setting selected consisted of the Child Psychiatry/Mental

Retardation Division of the NPH: (1) A-West, a 19-bed unit for children aged

5 - 11 with emotional and behavioral problems, (2) A-South, a 19-bed unit for

adolescents aged 12 - 17 with emotional and behavioral problems, (3) 5-West, a 17

bed unit for children aged 2 - 11 with developmental disabilities and (4) 6-West, a

19-bed unit for adolescents and young adults aged 12 - 23 with developmental

disabilities. The average length of hospital stay on all four inpatient units is

approximately 2 to 3 months. The percent of occupancy on all four inpatient units

is approximately 63 to 78%.

Primary nursing is utilized on all four child and adolescent inpatient units.

The registered nurse (RN) as the patient's primary staff is responsible and

accountable for the planning, supervision and evaluation of all nursing care. An RN

or a non-RN; e.g., licensed psychiatric technician or mental health practitioner is

- 50 -

Aºr

*■

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;:,; ****

the patient's associate staff and participates in the assessment, planning, provision

and evaluation of patient care.

Each inpatient unit maintains a multidisciplinary treatment team composed

of psychiatrists, social workers, nurses, occupational and recreational therapists,

special education teachers and dentists. The treatment approach is eclectic and

consists of individual therapy, milieu therapy, behavioral and psychopharmacologic

interventions, group therapy and family therapy.

Sample

Major consideration was given to two factors in order to increase the power

of the analysis: (1) the selection of a large sample size and (2) determination of

the criteria for sample selection to increase variances in the variables under study

and to decrease variance in extraneous variables (Kerlinger, 1973).

The sample consisted of 683 patient observations on the four selected

inpatient units with each patient observation serving as the unit of analysis. A

purposive sample consisting of patients who met the criteria for each system

category was selected from four inpatient units for observation in order to have an

adequate representation of each category in the sample.

– 51 -

-

4.

* *- - *

- :- - - - -

- - - - :

-- - -

--f

• * ~ *

1 - .

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Data Collectors

Observers

Of the eight observers, seven had a Masters degree in Nursing and one was a

graduate student in Nursing. Five observers were former clinical nurse specialists

on the child inpatient units; their mean nursing experience was 15 years.

Training for the observers consisted of: (1) a 4-hour long course on the

concepts of patient classification systems, basic theoretical concepts of the

Johnson Model and an examination of patient behavior indicators for each of the

behavioral subsystems per category, (2) a 4-hour long pen and paper testing of

inter-rater reliability in rating patient behavior indicators and subsystem

categories based on taped series of patient situations and brief on-unit observations

and (3) a 10-day period of 20 hours on-unit observations in pairs. The inter-rater

agreements of observers ranged from 90 to 95% for patient behavior indicators and

subsystems categories.

Staff and Shift Coordinators

Since the patient classification instrument had already been utilized as a

clinical tool for patient assessment, nursing care planning, intervention and

evaluation of patient progress on the four child and adolescent inpatient units

beginning in April, 1981 (Dee & Auger, 1983a), staff and shift coordinators did not

receive additional training prior to the commencement of the study in August,

1982. However, subsequent new employees were given an hour-long orientation on

the purposes of the patient classification system as a clinical tool and as an

- 52

administrative tool for staffing. A videotape representing examples of three levels

of patient behaviors was shown to facilitate staff understanding.

Staff who had primary responsibility for the care of the patients observed

were the data collectors. Shift coordinators who had administrative

responsibilities for a given 8-hour shift during the observational period were also

data collectors.

Instrument

The Behavior Criteria Checklist is composed of three parts: Part A -

objective measure consists of lists of patient behaviors, Part B – subjective

measure consists of a rating scale for subsystem categories and Part C – subjective

measure consists of a rating scale for system categories. The Behavior Criteria

Checklist is shown in Appendix C.

In designing the Behavior Criteria Checklist, consideration was given to ease

of use. A simple check for each observed behavior would indicate the presence of

the behavior. A total of 61 behavior indicators were identified for the eight

subsystems (see Appendix B). Behavior indicators for each subsystem were

determined to have different variations. For example, limited awareness of

physical and social environment is an example of a Category II behavior while lack

of awareness of physical and social environment is an example of Category III

behavior. Both behavioral statements are variations of awareness of physical and

social environment which is an example of a Category I behavior of the ingestive

- 53 -

subsystem. A total of 166 patient behaviors of different variations were identified

to represent the 61 patient behavior indicators.

To control for internal validity (Cook and Campbell, 1979), these 166 patient

behaviors were listed in random order in the checklist. Category I indicators were

assigned values of 1. Category II indicators were assigned values of 2, and those

indicators that met the criteria for Category III were assigned values of 3.

Behavior indicators that were not observed or were absent were given values of

zero. A detailed discussion of the instrument's development, content validity and

inter-rater reliability is found in Chapter II.

Research Procedures

Observational Procedures

The primary data collection method utilized was direct observation of patient

behaviors by staff, shift coordinators and observers. Four-hour observational

periods were scheduled between the hours of 0700 and 2300 for all days of the

week. Observation on the night shift was not included for two reasons: (1) most of

the patients on the units were asleep and (2) the cost of night observation was

prohibitive. A 4-hour observational period was selected for two primary reasons:

(1) a 2-hour period would present a scheduling problem for observers who had to

report on duty for short periods of time and (2) a more than 4-hour long observation

may result in observer fatigue.

- 54 -

Scheduling of Patient Observations

The patients selected for observations were based on the shift coordinators'

best estimate of patients who met the criteria for each system category at the

beginning of the shift. Category I patients were those who required minimal

nursing care. Category II patients were those who required moderate nursing care.

Category III patients were those who required intensive care and those who

required one-to-one nursing care were Category IV patients.

Observers were randomly assigned for patient observations on the four

inpatient units while staff and shift coordinators remained on their assigned work

units. Scheduling of observations on all four inpatient units was arranged based on

the availability of each observer's work schedule and the availability of patients

who met the specified criteria during the specified H-hour time periods. External

validity was controlled for assignment of sampling by setting (inpatient units), by

time periods and according to criteria specified for system category.

Data Collection Procedures

At the completion of each of the H-hour periods, the shift coordinator,

observer and staff were asked to independently complete a Behavior Criteria

Checklist on each patient observed, identifying those behaviors present during the

observational period for each of the behavioral subsystems. Staff, shift

coordinator and observer also independently categorized each subsystem based on

observed behavior indicators for degree of adaptiveness using criteria specified in

Table 3. The rating values ranged from 1 (adaptive) to 4 (maladaptive). Based on

these eight estimates of subsystems' adaptiveness, raters also estimated the degree

- 55 -

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of nursing care required by each patient using the categories described in

Appendix A (1 = minimal care and 4 = one-to-one nursing care).

Pretesting Period

A 10-day period of observer training on the inpatient units was considered as

the pretesting phase. This period allowed patients to become familiar with the

presence of the observers on the units. Table 4 presents the timetable for observer

recruitment, training and data collection.

Data Analysis

The following statistical procedures were used to answer each research

question:

1. What is the degree of inter-rater agreement between staff, shift

coordinator and observer groups with respect to:

– observed patient behavior indicators in each of eight subsystems?

- ratings of subsystem categories?

– ratings of system categories?

A procedure to compute reliability as a function of agreements is to use the

following equation (Kerlinger, 1979):

Inter-rater number of agreementsagreement =

-number of agreements + disagreements

Inter-rater agreement for the three paired groups; e.g. (1) staff versus shift

coordinator groups, (2) staff versus observer groups and (3) shift coordinator versus

- 56 -

. . .

* * *

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- - - -

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º

º

Table l;

Timetable for Observer Recruitment, Training and Data Collection

DATES ACTIVITIES

June 15, 1982

July 13, 1982

July 20, 1982

July 20, 1982–

July 30, 1982

August 9, 1982

December 13, 1982

July 14, 1983

September 7, 1984

Recruitment of observers begins.

Four-hour long training seminar forobservers.

Pen and paper reliability testing forobservers.

A ten-day pretesting phase on inpatient units.

First scheduled patient observation onA-West.

Follow-up meetings with team leaders of

each inpatient unit.

Follow-up meetings with team leaders of

each inpatient unit.

Last scheduled patient observation on

A-South.

- 57 -

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observer groups was computed for each patient behavior (total of 166), four

categories for eight subsystems (total of 32) and system categories (total of 4).

According to Polit and Hungler (1983), inter-rater agreement in the vicinity of .70

or even .60 is sufficient for making group-level comparisons. Abdellah and Levine

(1965) suggested that inter-rater agreements for a patient classification instrument

must be in the vicinity of .90 or better. However, this criteria was established for

patient classification instruments which focused on objective nursing care

activities and not subjective estimates. Because of the diversity in educational

preparation, length of clinical experience, work classification and methodological

limitations of the observational procedure, inter-rater agreement of .60 was

determined to be acceptable for this study.

2. Which of the patient behaviors in each of the subsystems have the

greatest impact on subsystem category?

Prior to regression analysis, a correlation matrix was generated and examined

for redundancy and multicollinearity of the independent variables (Gordon, 1968).

According to Lewis-Beck (1980), for multiple regression to produce the " 'best

linear unbiased estimates'" (p. 58), none of the independent variables should be

perfectly correlated with another independent variable. Although independent

variables are almost always intercorrelated in nonexperimental social science data,

an extreme condition of multicollinearity can render the parameter estimates

unreliable. An estimated regression coefficient may also be unstable and fail to

achieve statistical significance. However, multicollinearity is not a problem when

bivariate correlations of independent variables are found to be less than .80 (Lewis

Beck, 1980). Consequently, for this study, a correlation coefficient of less than .80

was considered acceptable.

- 58 -

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Multiple regression analysis using the stepwise selection procedure was

utilized to determine the contribution of independent variables to the dependent

variable (Pedhazur, 1982). In this instance, patient behavior indicators in each

subsystem observed by shift coordinators were treated as independent variables and

served as predictor measures for subsystem category ratings. Each of the eight

subsystem category ratings by observers was treated as a dependent variable and

served as criterion measure for behavior ratings.

In order to ensure the reliability of the regression statistics, Pedhazur (1982)

recommended that the ratio of independent variables (patient behavior indicators)

to sample size (patient observation) be at least 30 per variable. Since patient

behavior indicators for each subsystem ranged from 5 to 11 and a total of 331

patient observations were completed by the shift coordinators, the sample size

obtained for this study met the necessary requirement for regression analysis.

Full equations using all independent variables (observed patient behaviors for

each subsystem) were analyzed for their effectiveness in explaining subsystem

category. The squared multiple correlation coefficient (R2) was used extensively

in data analysis to measure the proportion of total variation in the subsystem

category ratings explained by the regression. Once the effectiveness of the full

equation in explaining subsystem category ratings was investigated, reduced

equations were made which consisted of those patient behaviors with an F ratio

significant at p < .05 and a beta weight significantly different from zero at p < .05

(Pedhazur, 1982). This procedure assumed that the reduced equation would yield an

R2 statistically as effective in explaining subsystem category as the full equation.

It was desirable that the final instrument be parsimonious and yet remain effective

in explaining the subsystem category.

– 59 -

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A statistically significant relationship among the variables would mean that

the relationship exists in the universe from which the data have come and that such

a relationship does not occur by chance. According to Gold (1969), a substantively

significant relationship among the variables is equally important for it to be

meaningful in the practical situation. However, the magnitude of the relationship

required for substantive significance is a matter of subjective judgment based on

the nature of the problem.

To determine the criterion for significance as an explained variance for

subsystem category ratings (dependent variable), two factors were considered: (1)

most data which attempt to investigate social phenomena yield low R2 values often

below .50 (Werran and Ferketich, 1984) and (2) an R2 value of .70 would be an

acceptable criterion for a well-developed instrument (Verran, 1982).

Consequently, the criterion for statistical significance was set as an

explained variance for subsystem category ratings at a conservative R2 value of

.50 for two reasons: (1) data used in this analysis is derived from an observational

study on patient behaviors, and thus can be considered as social data and (2) data

used in this analysis is considered as an initial step toward a series of validation

studies for a well-developed instrument.

Although multiple regression is a robust statistical technique (Bohrnstedt and

Carter, 1971), violations of a combination of assumptions may lead to serious doubt

and a lack of confidence in the results of the regression analysis (Hey, 1974).

Verran and Ferketich (1984) suggest that the regression assumptions of zero mean,

homoscedasticity, independence and normal distribution can be examined directly

with residual analysis.

– 60 —

----·→·

* -- * * º

•••

For this study, residual analysis using the reduced equations of patient

behaviors was performed to test the assumptions of the regression model. The

following approaches were used for the examination of residuals: (1) frequency

distributions of unstandardized residuals were examined for zero mean; (2) plots of

standardized residuals against predicted dependent variables in the equation were

examined for homoscedasticity; (3) plots of standardized residuals against all

independent variables in the equation were examined for independence; and (4)

histograms of the frequency distribution of categorized residuals and Chi-square

goodness of fit statistical test were used to examine for a normal distribution. It

was expected that all plots would show an equal spread around the zero line, that

the mean would be zero or contained within a 95% confidence interval about zero

and that visual and statistical tests would show no significant difference from the

expected normal distribution (Werran & Ferketich, 1984; Pedhazur, 1982; Shavelson,

1981; Draper & Smith, 1981).

3. Which of the eight subsystems have the greatest impact on system

category?

Multiple regression using the stepwise procedure was also utilized to

determine the contribution of the eight subsystems to system category. In this

instance, the eight subsystems as rated by shift coordinators were treated as

independent variables and served as the predictor measures for system category. A

system category as rated by observers was treated as the dependent variable and

served as the criterion measure. Values for subsystem and system categories

ranged from 1 to 4 and were based on criteria specified in Table 3.

A full equation using all eight subsystems was analyzed for effectiveness in

explaining system category. The squared multiple correlation coefficient (R2) Was

- 61 -

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also used in this data analysis to measure the proportion of total variation in the

system category explained by the regression. Once the effectiveness of the full

equation in explaining system category was investigated, a reduced equation was

made which consisted of those subsystems with an F ratio significant at p < .05 and

a beta weight significantly different from zero at p3.05. This procedure assumed

that a reduced equation would yield an R2 statistically as effective in explaining

system category as the full equation. The criterion for statistical significance was

set as an explained variance for the dependent variable (system category) at 50%.

Residual analysis using the reduced equation was also performed to test the

assumptions of the regression model. An examination of residuals was done

through the use of plots, graphs and statistical tests.

4. Does the model of NPH-PCI predict across age groups, sexes and inpatient

units?

Data analysis to investigate the instruments's generalizability was conducted

by the examination of residuals. If the instrument's explanatory power worked

equally well across all units, age and sex groups, certain visual examination could

be completed to assess this assumption (Ferketich, 1982). Residual analysis, using

the reduced equation for patient behaviors and the reduced equation for

subsystems, was performed. Residuals from the equation were sorted by unit, age

and sex groups and plotted. It was expected that they would be evenly distributed

across age, sex and inpatient units. A Chi-square goodness of fit test was

performed to determine if the residuals tended to be especially high or low for

subsets within age, sex and inpatient units.

In summary, this chapter has presented a description of the research setting

and delineated research procedures and data analysis to investigate and answer

– 62 -

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each of the research questions posed. The issues of equivalence reliability,

criterion-related validity and generalization of the instrument were also addressed.

- 63 –

→·•■

CHAPTER IV

Research Results

This chapter presents the results of an observational study conducted to

assess the reliability and validity of the NPH-PCI. This study extended over a 25

month period. The first actual patient observation occurred on August 9, 1982, and

the last patient observation was September 7, 1984. The gradual decrease in

patients who met the criteria for system Category I and the infrequent admission

of patients who met the criteria for system Category IV contributed both to the

duration of the study period and the final decision to terminate the study.

The first section of this chapter presents the sample description of patient

observations sets included in the final data base and a profile of data collectors

who participated in the observational study. Results which relate to the

equivalence reliability, criterion-related validity and generalization are also

presented in this chapter.

Sample Description of Patient Observations

A total of 683 patient observation sets were completed in the course of the

study. However, to control for response bias in ratings, three criteria for the

inclusion of each patient observation set in the final data base were established:

- 64 -

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(1) a complete set of different raters; (2) a two-week time lapse between

observations of the same patient in the same system category; and (3) repeat

observation of the same patient in a different system category. A total of 451

patient observation sets (66%) met all three criteria and were therefore included in

the final data base. Table 5 presents the total number of patient observation sets

for all categories on all four inpatient units and those included in the final data

base. Table 6 presents the total number of patient observation sets on each unit

that were included in the final data base. A-South had the least number of patient

observation sets (86) while 6-West had the most patient observation sets (138)

included in the final data base. Tables 7 through 10 represent the number of

patient observation sets on each unit by categories and time periods. Patient

observation sets on 5–West and 6-West accounted for 59% of the total patient

observation sets for Category II and 60% of total patient observation sets for

Category III. Patients by age groups and sex are shown in Tables 11 and 12. Of the

229 patients observed, 189 (83%) were included in the final data base. A majority

of these patients (66%) were male and 89% were between 8 and 19 years old.

These patients represented 18 major psychiatric categories; 19% were found to

have major affective disorders and 20% had conduct disorders (see Table 13).

Profile of Data Collectors

A total of 112 staff, 42 shift coordinators and 8 observers participated in the

observational study, but the final data were drawn from ratings of 86 staff, 40 shift

coordinators and 8 observers. Table 14 presents the number of staff by

- 65 -

4.

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Table 5

Number of Patient Observation Sets Completed and Included in Final Data Base

Patient Observation Sets

Completed Included Percent

Category I 153 88 58

Category II 186 132 71

Category III 180 13t; 7t;

Category IV 16% —27. –22

N = 633 N = 451 66

Note. Percent represents the number of included sets divided by the number of

completed sets.

– 66 -

Table 6

Number of Patient Observation Sets Included in Final Data Base on Each Unit

Number Percent

Unit of Sets of N

A-West (A-W) 98 22.0

Child Psychiatry Unit

A-South (A-S) 86 19.0

Adolescent Psychiatry Unit

5-West (5–W) 129 28.5

Child Developmental Disabilities Unit

6-West (6–W) 138 30.2

Adolescent Developmental Disabilities Unit

N = 451 100.0

– 67 –

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+

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Table 7

Number of Patient Observation Sets Included in Final Data Base by Categories and

Time Periods for A-West (Child Psychiatry)

Time Periods

1 2 3 l;

Percent

(0700-1100) (1100–1500) (1500–1900) (1900–2300) of N

Category I 7 5 5 7 24.5

Category II 9 8 6 3 26. 5

Category III 6 8 l; 6 24.5

Category IV 6 7 6 5 24. 5

N = 98 100.0

- 68 -

* - - t ---

- * *

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Table 3

Number of Patient Observation Sets Included in Final Data Base by Categories and

Time Periods for A–South (Adolescent Psychiatry)

Time Periods

l 2 3 l;

Percent

(0700-1100) (1100–1500) (1500–1900) (1900–2300) of N

Category I l; 6 3 2 17

Category II 5 7 6 10 33

Category III 5 9 7 9 35

Category IV 2 l 5 5 15

N = 86 100

– 69 –

* -- - -

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Table 9

Number of Patient Observation Sets Included in Final Data Base by Categories and

Time Periods for 5–West (Child Developmental Disabilities)

Time Periods

l 2 3 l;

Percent

(0700-1100) (1100–1500) (1500–1900) (1900–2300) of N

Category I 5 6 6 5 17

Category II 7 10 10 12 30

Category III 8 9 11 10 30

Category IV 8 9 6 7 23

N = 129 100

- 70 -

Table 10

Number of Patient Observation Sets Included in Final Data Base by Categories and

Time Periods for 6–West (Adolescent Developmental Disabilities)

Time Periods

l 2 3 l;

Percent

(0700-1100) (1100–1500) (1500–1900) (1900–2300) of N

Category I 3 10 6 8 20

Category II 9 12 10 8 28

Category III 9 12 12 9 30

Category IV 9 7 6 8 22

N = 138 100

- 71 -

-- - - - - - - - - . . . . - - - * - - -, i < * : * * * - -

; : :------ ---------------------- - - -- -- - - - -

. . - - * . . . . * * * * * --- - - - - - - - --

, - * . . . . . . . . . . . . . . . --> * > * - * . .- - ------------------ - ----

- * *- - " -

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Table 11

Number and Sex of Patients for All Categories on Each Unit

Percent

A-W A-S 5–W 6–W n of N

Male l;5 20 29 30 12! 66

Female 11 18 17 12 62 _34

Total 56 38 l;6 l;9 189 100

N = 189

– 72 –

Table 12

Number of Patients by Age Groups

Percent

Groups Ages In of N

l l; – 7 Years 21 11

2 8 - 1 1 Years 70 37

3 12 – 15 Years l;5 24

l; 16 – 19 Years 52 28

5 20 – 23 Years —k –4

N = 189 100

- 73 -

Table 13

Number of Patients by Psychiatric Category per Unit

Percent

Psychiatric Categories A-W A-S 5–W 6-W of N

Organic Mental Disorder l 3 1 3 l;

Schizophrenic Disorder 5 l; 1 8 10

Major Affective Disorder 10 8 2 15 19

Psychotic Disorder Not Elsewhere 1 3 1 l; 5

Classified

Pervasive Developmental Disorder 1 O 6 2 5

Somatoform Disorder l O O O 1

Anxiety Disorder 2 1 O O 2

Personality Disorder 2 2 2 2 l;

Eating Disorder 3 7 O 2 6

Stereotyped Movement Disorder O 0 O 1 1

Other Disorder of Physical Manifestation O 0 0 l 1

Anxiety Disorder of Childhood/Adolescence l; 0 8 l 6

Conduct Disorder 16 7 8 6 20

Other Disorder of Infancy and Childhood 2 0 0 O 1

Attention Deficit 8 3 3 1 7

Mental Retardation O O 12 2 7

Specific Developmental Disorder O 0 2 l l

N = 189

- 74 –

* .

Table 14

Number of Staff by Classification on Each Unit

Percent

Classification A-W A-S 5–W 6–W of N

Senior Nurses Aide 0 O 0 1 1

Nurse Interim Permittee O O 1 O 1

Clinical Nurse II 11 8 9 7 l;1

Clinical Nurse III 1 3 1 2 8

Clinical Nurse IV O l O O 1

Administrative Nurse I l l 2 1 6

Per Diem RN O l O 1 2

Float RN O O 1 O 1

Mental Health Practitioner l; 2 2 2 12

Senior Mental Health Practitioner 0 l l 1 3

Psychiatric Technician 3 3 2 3 13

Senior Psychiatric Technician O 1 l 2 5

Registry Psychiatric Technician 1 1 2 O 5

Float PT –4 —% —% —k —k

Total 21 22 22 21 100

86N –

- 75 -

classification who observed on each unit. Of these 86, Clinical Nurse II was the

largest group (41%) followed by Psychiatric Technician (13%) and Mental Health

Practitioner (12%). In the staff group, nurses completed 54% of the total patient

observations, psychiatric technicians completed 27% and mental health

practitioners completed 19% of the total patient observations. Table 15 presents

the number and classification of shift coordinators on each unit. Of these, Clinical

Nurse II was the largest group (55%), followed by Administrative Nurse I (28%).

However, 331 patient observations (73%) were completed by the Administrative

Nurse I group. A total of 31 data collectors participated in both staff and shift

coordinator groups. The educational preparation of all staff and shift coordinators

is shown in Table 16. Of these 85 staff and shift coordinators, l;9% had Bachelor

Degrees and 19% had Masters Degrees.

Results Related to Equivalence Reliability

The issue of reliability was addressed by using the equivalence approach.

Inter-rater agreements were computed for staff, shift coordinator and observer

groups with respect to ratings of: (1) observed patient behavior, (2) subsystem

categories and (3) system categories.

Patient Behaviors

Table 17 shows that the mean inter-rater agreements for the three paired

groups with respect to patient behavior ratings for each subsystem were all above

the 60% pre-established criterion for inter-rater reliability. Agreements were

- 76 -

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- - - - -... " . . . . . 2 ºf * * * . . . . . . . . . . . . . . .

-

- t - - - - - - - -

- - º, . . . " * * - - º - * ! . . .

t - - * - -. . . . * - - *

- - - - - - r * - - * - - - - - - - º

- - - - - - - - - - e * - -- - ! . . - - - - - - - - - *

- - -

- - - - -- * * * * - - * * * * * * : a * * * -

- * * * - - - w. . . . . . . . . . . . . . *

- * - - - - - * * • . - - s - - - -

* * - - - * * * - - - - - - - * - - - - * - * . . . . . * *

- . - - - -, ... • " * - - - - - - - - - -

* - - - - - - º - - - - - * - - - -- -

- - - - * - * . . . . : * * *

- * * º - - * ~ * * * * * * * ~ * - - - - * - - i * - - - - -

- * * * * -- - * *-- - - * - - ? º -

* * : * * * : * : * ~ *

- - - - - - - - -

-- - , , , . " - : - - - - . . . .

- - - * - - - -

- - ... • - - - " . . . . . " - - -- - *

* * * . . . . ; - - - - ". . . . . . . . . . . . * , .*

- - - - - - - - - - - - - - - - - - - * * - - -- * \ . . . . . . * * * .* * : - * * *

- - - - *

. . . . . . . . . . . . . . . . . . . . .- - -

- . - - - " * - - - -- - - - ... - º -". . . . . . . . . . . . . . . - * * * - - - * * ! . . . . . . . . . . . .

- *-

; : - - * - - - * - - - - - - - - * - - * * * - - - -

* - - - - - - -. . . . . . . . . . . . - * * * - - - - - - - º - - -

* - -

* - . . . - - - - - - - - - * - . . . . . . "- - -

- - - - - - - * - * * - -- - - - - - - º . . . . . . . .- - -

- e.

Table 15

Number of Shift Coordinators by Classification on Each Unit

Percent

Classification A-W A-S 5–W 6–W of N

Clinical Nurse II 7 3 7 5 55

Clinical Nurse III 2 2 1 l 15

Administrative Nurse I 3 3 2 28

Administrative Nurse IV —% —% —% —k —é

Total 12 8 11 9 100

N = 40

- 77 –

Table 16

Educational Preparation of Staff and Shift Coordinators

Number Percent

Education of Staff of N

RN: Diploma in Nursing 7 8

RN: BA/BS 33 l;0

RN: MA/MS/MPH/MN 9 | 1

RN: AA 6 7

Undergraduate AA 1 1

PT: License 14 16

PT: BA/BS 1 l

PT: MA/MS 1 1

BA/BS 7 8

MA/MS —é –4

N = 85 100

Note. Staff who participated in the observational study on more than one unit

were counted once.

– 78 -

--- - - - - - - - ** • ** * - -, " * - - - * -- . . . . * *

2- : ; ; ; i■ ■ º. 334 of . . . . . . . . . i*i; ;

. -

. . .

- - * - --

º e

; ! - º

- * * * * * •- - - -

* *

- -

- - . . .-- - -

- - - * *

t

. . . . . . . . . . . . . . . . . . . . . . . " ; : . . . . . . .

º - - -

º , , . . . . . . . * * * *

Table 17

Mean Inter-Rater Agreement (%) for Three Paired Groups on Patient Behaviors for

Each Subsystem

Staff and Shift Staff and Shift Coordinator

Subsystem Coordinator Observer and Observer

Ingestive 82 79 80

Eliminative 84 80 81

Affiliative 73 67 68

Dependency 78 74 7t;

Sexual 84 83 84

Aggressive-Protective 81 79 82

Achievement 77 71 72

Restorative 81 76 77

- 79 -

- - - - - - - * - - - • * -ºf ºf T ºf tº ■ —- 3 f : .

. . . . . .

* * … . . * * f : . . . .

* -vº * -

s v . . . .

- * - - - - - -

- * * - \ . . . . .

- º-

. . . . .

- s º - -

- * - !,- -

º º - -* :

-

- ~ * - - * * > . . .

- -3 : … . • *- - * * ~ *

- - - " - - -

e * * * - - * *

within four percentage points of each other. Agreements were highest for the

staff and shift coordinator groups as compared to the remaining two comparison

paired groups. Agreements ranged from 73% on affiliative behaviors to 84% on

eliminative and sexual behaviors. Table 18 shows that the observer group noted

significantly more adaptive behaviors and significantly fewer severely maladaptive

behaviors than either of the two groups.

Subsystems Categories

A comparison of inter-rater agreements on subsystems (all categories) for the

three paired groups was consistently highest for staff and shift coordinator groups

as compared to the two remaining comparison paired groups (see Table 19).

Agreements on eliminative subsystem were consistently highest (66% - 68%) while

agreements on aggressive-protective subsystem were the lowest for all three

paired groups (37% - 57%). Agreements for staff and shift coordinator groups were

above the 60% pre-established criterion for inter-rater reliability on most

subsystems with the exception of sexual and aggressive-protective subsystems. A

breakdown of inter-rater agreements for subsystems by categories showed that

Category I ratings were consistently highest on all eight subsystems. Agreements

ranged from 59% for affiliative subsystem to 94% for eliminative subsystem

between staff and observer groups and 77% for affiliative subsystem to 96% for

ingestive subsystem between shift coordinator and observer groups (see Tables 20

and 21).

- 80 -

…

•■-|-·~!|-|-|-~!

•*••·-•.*

*

-§|·|-|-•-····→·

·*…~----------»ae

…

*----.*----·*•-••,

!·|-|-·--

-*…*|-•;----

•

•|---------|-■!----

|-··|-•|---------

-·*·|-•

•

•·~••·----

•••

+

·→·

•|-|-·

*-----…

*----·*•

•-,--

…·|-*…*·|-

----·*

--

-|-*-,

*|------

'

+■--------|-|-■-

···••

••

•·--

--------*

*--------

·

**-|-*|-

··•→

|-••→

·----|-*·,'

--------~~·|-r---------·

Table 18

Percentage (%) of Patient Behaviors Observed (N = 437 Possible Responses)

Severely

Adaptive Maladaptive Maladaptive

Observer lili 22 16

Shift Coordinator 31 20 26

Staff 24 21 26

- 81 -

º : ‘.

* -

. . . . . . . .",*

—-----' ------

- - - -

- - - * * -

- a º - I -

* - -

* * ~ *

Table 19

Inter-Rater Agreement (%) on Subsystems for Three Paired Groups

Staff and Shift Staff and Shift Coordinator

Subsystem Coordinator Observer and Observer

Ingestive 64 53 5l.

Eliminative 68 66 66

Affiliative 61 lili l; 5

Dependency 60 t! 3 l;0

Sexual 57 51 52

Aggressive-Protective 57 l;0 37

Achievement 64 t;5 l;6

Restorative 61 52 58

- 82 -

Q ', 1.

- * t - r - - º ... • - - e* * * * . . * * * : * ( ; ; ; ; • *.*, * is 3 --, * g :- - - *– --

- - - * ‘. . .• * º J J 1 ( , , .

- - - -

w * * * - I - - - - : 3 . . .

* - - -

: \ , , : .--

- - -

º ‘. . . . . . . .

** - - • * *- - - s * . . . .

* , * * . . º

- - - - - - - - *

* - e - -!

- - - , - * - - ... --> -

º . . . -: , , ,-

, -

"a -† : - . . . . . . .

- * * -: , , , , it -

Table 20

Inter-Rater Agreement (%). Between Staff and Observer Groups on Subsystems by

Category

Category Category Category Category

Subsystem I II III IV

Ingestive 90 17 l;3 3

Eliminative 9t; 15 25 0

Affiliative 59 51 l;0 13

Dependency 75 l;8 27 7

Sexual 92 12 15 O

Aggressive-Protective 78 33 21; 5

Achievement 78 l;2 35 0

Restorative 84 31 28 8

– 83 –

* : . . . 2, … - - , , . . . . . . . . . . . . . . . . . . . . . . . . .2-, ºf --, 3, .- -------- - --- --------- * - - - - - --------------------------- ----------- - - - ----------------- ---------

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- -

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- - - * * ~" . . " -* - . . . . . . - \ . . . . . .

- - - a : ". . . . . .

* - ** * - " - - * * * *- * - - - - - - - - *

Table 21

Inter-Rater Agreement (%) Between Shift Coordinators and Observer Groups on

Subsystems by Categories

Category Category Category Category

Subsystem I II III IV

Ingestive 96 23 36 2

Eliminative 93 15 20 O

Affiliative 77 5l; 38 12

Dependency 81 l;6 24 8

Sexual 95 10 20 0

Aggressive-Protective 86 37 23 7

Achievement 85 l;3 35 6

Restorative 88 33 30 10

– 84 -

-- - - - - * *! . . . . ; ; ; ; ; , , , ; ; ; ; ; ; ; ; ; . . . . .” -- * : *- - - - - - - - - - - - - - - - - - - - - - - - - --------------------

:- -* * - -2 * : * * * * -

-------------- - - - - - ----------- - ------- -

* * - e - * *-

* ... v - - * *

* , *

- -

- - e. - . *- - * . . . . . .

* - - + -

* - - ‘. ** * * -

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.* -

- - º -

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* * -- - - - - -

º * - - * * * - * - - - * * * * * *

- t - * * . . . .

- -- - - - -*

- - - º * - - * - ºr

System Categories

A comparison of the inter-rater agreements on system categories for the

three paired groups was highest for the staff and shift coordinator groups as

compared to the two remaining comparison paired groups. Agreements (67%) for

staff and shift coordinator groups met the 60% pre-established criterion for inter

rater reliability. Agreements for the remaining paired groups were 51% for staff

and observer groups and 52% for shift coordinator and observer groups.

Agreements for the latter two paired groups did not meet the 60% criterion. A

breakdown of inter-rater agreements for system by categories also showed that

Category I ratings were consistently higher than ratings for Categories II, III and

IV. Agreements between staff and observer groups for Category I ratings were

83% and 89% between shift coordinator and observer groups. Agreements for

Category II – IV ranged from 38% to 48% for the two paired groups.

Results Related to Criterion-Related Walidity

The issue of validity was addressed by determining the relationship between

the predictor measures and the criterion measure. In this study, the following

relationships were determined: (1) patient behaviors as predictor measures and

subsystems categories as criterion measures and (2) subsystems categories as

predictor measures and system category as the criterion measure. Ratings by the

shift coordinators were used as predictors while ratings by observers were used as

the criterion.

- 85 -

-

- -

*

4 -

--

- -

* - *

* - -

* *

. . . .- * *

-

*

-

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**.

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t :

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e-

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* *

* ,

º

--

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-

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. .

■ . "

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**e

.

■ st

-

-

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- - -

* -- -

* *

". . . . . . v c : , , ; ; ; ;

". . . . . . . " -■ ( ; , , , ;", " ( ; ; , ; ; ; , T 2: ; ; z < .

s - - : . -- … - - - -- " ' -. . . . . . . " tº a º' . . . . v.

- - - - - , , , * - - . . - - - - - - -

. . . . . . . . . . - - - - - : it , , j ■ - ‘

- - - - - . . . - • . * * * * -

(, . . . . . . . . . c. . . . . . . .

- - - * - - - - * - a - - - - -

- i. . . . . . . . * - - * -- i t . . . . . . . . .

-a - * - - ** - - -

* - - * . * - - - . * - º

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ;

- -

- - -

, - - - - -

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. . ."* - - * * * * -

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-

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. . . . . . . . .

- -

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j . . . . º

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a * *

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1: .

•

* - *- * -

-- -

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- *- - -

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-,

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-

As stated in Chapter III, a correlation matrix was generated to examine for

redundancy and multicollinearity of the independent variables. It was found that

all of the bivariate correlations of independent variables had a correlation

coefficient below .80 which was acceptable for this study. Summary statistics are

given for the independent variables in the regression in Appendix D. The standard

deviation ranged from .30 to 1.40 among the independent variables. Note that the

coefficient of variation, which measures the standard deviation as a percentage of

the mean, was moderately large for all variables (greater than 62%). Thus, there

was sufficient variation in each independent variable to apply standard regression

techniques.

Impact of Patient Behaviors on Subsystems Categories

The computed R2 values and significant levels of patient behaviors as

predictors of subsystems category ratings are shown in Table 22. The computed R2

values and significant levels of patient behaviors as predictors for each subsystem

are shown in Tables 23 through 30. These values are for the full equations, and

therefore include all possible independent variables. Reduced equations were made

which consisted of those patient behaviors with an F ratio significant at p < .05 and

a beta weight significantly different from zero at p < .05. Results for the reduced

equations of patient behaviors as predictors for each subsystem category ratings

are illustrated in Figure 2. Table 31 presents a comparison of the computed R2

values for the full and reduced equations. There were no significant differences

(range of one to three percentage points) noted in the R2 values computed for

either of these two equations. The R2 values for all subsystems categories ratings

were below the accepted criteria of .50, suggesting a substantial proportion of

- 86 -

·------·■■ ·|---,·→■■ -·→·

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·|-···--

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----|×---------

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,|-·■

1*|-·*…→••--

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-|-··-*…|-•·-------------

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|-----|-*……----*-----…*-·|---*|---|--•■

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|-*…*·-**--*→·|-|------

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|-|-~----------****----·|--|-|-|-·…··*,-|-

|-*-----------|-

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--------|-|-+|---**

--------••----|--*:*|-

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|-|-•|-|-----|-----|--■ |-----|-·

|-|-•-

-„**|-----|-----•

•----|-|-------|-----

*•*•~!|-·

·----|-*-"·

-

-→·----|-·-

-----|-----•••*-|-|-----•

•|-----·--------|----·--------•----··*·••

--------|-|-|---------■ ··|---------••----|-·----|-|-|--→·:--------------■!|-·|-|-«

…→·

|--·|-----|-*|-|-·|-·|---**■ ~,|-|-----·*…*■ ·|-|-|-

|-|-|---»----

-·|-••|-

:|-*·-*------|-----

·|-·|-|-------*…••------ -

---------·-|-|-~---

-|-|-----·|--

-|-·--------|--→·

·

|-·|---|-------·

·-|--*-|---*··*|-|-|---|-

----

--|----*·-----|-|--■■ --•|-··----------|---|-|-*…··|-|-|-■ ••

|--*|---·*----

-----|---------·*

•----*|-|-|--·…•|--*■ |-·

-

----|--|-|-·----|--■ ·**|-----·|-|-|--|-|-,■ ·|-|-

-·----|-·-*--|·--,

-a-•|-|--*…|--■-!\■ ·|-·

■ --------···--------|------|-J'

,|-------|-----→------|-*■ →·→·----

-~*|-|-·----·----|----*-----

Table 22

Patient Behaviors as Predictors of Subsystem Category (Full Equation)

Number of

Subsystem Variables in

Category Equations R2

Ingestive 11 . 33

Eliminative 5 .21

Affiliative 7 . 27

Dependency 9 .24

Sexual 6 .08

Aggressive-Protective 7 .23

Achievement 10 . 36

Restorative 6 . 32

Note. All values significant at p < .0001.

– 87 -

** . . . . . . . . . . . . . . . . "------------ - 1: * -------- ; ºf . , , f'. . . . . . . * * *

º º * * * º

- - , ,- - - - * -

- -: - - - , *

- * . . . . -

- * →-

* - - * * º * *

-. . . . . . .

- * * * * * * * * *

- . . . .

* , -

- - * * *

- - *. . .” -- . . . . . . .

* * * - . . . .- * . . . ! --

- - ... v . . . . . . . . .

- * - * -- " - - t -. . . . . " . i■ . . . . . . . . • ‘- * -------

Table 23

Patient Behaviors as Predictors of Ingestive Subsystem Category

(Full Equation, R2 = .33)

Patient Behaviors in Equations

By Entry Order Beta

Interpretation of Events . 1 3 +

Awareness of Social/Physical Environment . 13+

Distinguishing of Events - 12 +

Awareness of Social/Physical Boundaries .08

Food Choices .09

Sensory Perception . 16

Ingestion of Food/Fluids at Intervals .0l;

Ingestion of Substances .05

Sufficiency of Intake .03

Eating and Drinking Skills .02

Frequency of Intake .01

*Values significant at p < .05.

- 88 -

•***,'!

--------«-----

*

,••

*****·

■

1*…*<■ --·------

…-------------•~----**…|-**…··*·--

•

^••·-|-----|-■±·----·|-•

•|-■ ·|-·*|--……--

*…*■ •·----|-→··|-----·;--*…----!-·•·…------••---------·*----•■ →·*|-*

■ æ

æ----|------|-→·-------

|-|-v·

■ i

■ ·--------,-·•*----*·--------~~

ae**-*•!■

3*----|-*…■•-→-----£€----*----|-----••';|-****--------···

*·…----•...

•!±-.*---

-

-|-.--·*·

···

·----*-|-|-·~~

!*…*|-|-**.·

*

•→------r■

…

····*•-----"|-|-|------ae•■ --------~·----*•----■-****|-·|-|-|-·|-·----|-■!·*~]•|-|---|-|-•••------·|-----→----·--.-----••·|-

-

----|--*----→·•

*

•|-•·ae■

----------|-·|-•|-

…

****----···

·••----.*|-–

!•"----·----■ v•}-|------

-→··*,

----••----·*

,-------•■

!*|-|-----•*.-■

■ *-|-·;-*-

**-------·----·*

·*|-|-|-----

|-·•

*|-··|-----

·*!|*|*

------------*-·•·•···--------••~

~^<■ ------…º···|-·

*|+·

Table 24

Patient Behaviors as Predictors of Eliminative Subsystem Category

(Full Equation, R2 = .21)

Patient Behaviors in Equations

By Entry Order Beta

Bladder Control .25 +

Hygiene Care . 12 +

Disposal of Body Wastes ... 10 +

Bowel Control - . 14 *

Pattern of Elimination -.08

*Values significant at p < .05.

- 89 -

- • * * * * -

- -

- - I - - - -

- * -

- - -

- - - - - - - - * -

- * - - *- - * - - - * -

- - - - -

- * - - - - - - - * - - -

- --- " " " - - . - -

. - - i * -- a - -- - - - - - -

Table 25

Patient Behaviors as Predictors of Affiliative Subsystem Category

(Full Equation, R2 = .27)

Patient Behaviors in Equations

By Entry Order Beta

Communication of Ideas: Verbally, .23 +

Nonverbally and in Writing

Awareness of Personal Space .09 +

Emotional Attachments .08 +

Interpersonal Relationships with Groups .05

Interpersonal Relationships with Individuals .05

Expression of Feelings -.04

Adaptation to Change .01

*Values significant at p < .05.

– 90 -

*-i-º-º-º-º-º-º-º-º-º-º-º-º:

- - -. . . . . . . . . . . . . . . . - - - -

* * -

*. *-

s . . " - * *

º• * , : : J . . . . . . . . . . . ■ . ■ r.

- - - - ? -

. . . . . . • *- … • -

. . . . . . . . . . . . . . . . . . . .

* - - s -

º - fºr . . . . . . .

- - • * * - -- -

-. . . . . . . . . . . . . . . . . . . . .

- - - * * - * - - - -

* - * * I 1 º. . . … I

- • -- " - - ---

* * * ( , ; ; ; , .* - *

. . . . . . . . . . . . . .

Table 26

Patient Behaviors as Predictors of Dependency Subsystem Category

(Full Equation, R2 = .24)

Patient Behaviors in Equations

By Entry Order Beta

Self-Care Activities . 1 l; +

Decision-Making Ability . 1 1 +

Seeking of Assistance .09%

Separation with Ease . 07

Engages in Situational Attention-Seeking .0l;

Behaviors

Care of Personal Belongings .06

Relies on Own Resources .0l;

Feelings of Hopelessness and Helplessness .0l;

Questions Decision of Authority .01

*Values significant at p < .05.

– 91 -

. . . -* - -

- - * - - *

-* --

- - - * * * * , -

- * - * * * - -

* - * * - * * * --- -

-. . . - -

- * - - - . . * * *

- - * - - -- -* - - - * * ( . . . . ."

-

- * → ... -- -

* * * - * --. - a . . - ** - -

- - -

- ? i - - * *- . . ( * - -

.* -- - * - * ** ~ * * * - * * *

- t - -- - º - -

* - - - - * * t * - - -

- - . . . . . . . . . . . * *

Table 27

Patient Behaviors as Predictors of Sexual Subsystem Category

(Full Equation, R2 = .08)

Patient Behaviors in Equations

By Entry Order Beta

Distinguishes Between Sexual/Nonsexual . 12 +

Approach Behaviors

Engages in Socially Acceptable Behaviors .06 +

Acceptance of Gender Role . 07

Comfort with Body/Physical Changes .03

Distinguishes Between Males and Females -.03

Knowledge of Own Anatomy and Physiology .01

*Values significant at p < .05.

- 92 -

* . . . . . . . ; 2: . . . . . . . . . . . . . . c : . . . . . . . . . . . . . . . . . . . . . . ."------------------------- --- ----- - ----------- -----

- * - --

- - * * * * * * * = . *

- - -** ----- * . . º

- - - ** * * - - - * * - – f : . .

- - -*

- * * * - - * * - " - -

- * . . . “- I , * . - * * * * • * * -

* * * - -

- - - - - . . .

- - - - - - - • . -

-. . . . . . . . . . . . . . . . . c. * - * - *

º - - - -- -

-* ' ', r. º. . . . . . . .

- - * * - •. - -

- * - - - t . . . .- -

■ . . . . . . . .

t a - * . - - •, : . .- ** a * - - * . . . . . * * * : * ~. . . . ■ - 2

'' ... v.- - - º - . . . " , -

- . . . . . . . . - * ■ ( - . . - - - -

* - - - - - - - ---- * ~ * * : * * *

- * -

Table 28

Patient Behaviors as Predictors of Aggressive-Protective Subsystem Category

(Full Equation, R2 = .23)

Patient Behaviors in Equations

By Entry Order Beta

Identifies/Avoids Hazardous Situations ... 10 +

Engages in Acting Out Behaviors ... 10 +

Separation from Group ... 10 +

Ability to Maintain Control Over Stress .06

Selects Response to Threat/Dangerous .06Situations

Phobic Behavior -.05

Response to Threat with Self-Injury .02

*Values significant at p < .05.

– 93 -

. . . . . . . . .

- * - ■ - * * * * º - --

* , - - -

- - * -

-- - - - - - w - - - -

- - - ... ( . - • * * * * * • - -

- - - * * - - - - - . .

- - -- . * * - - * - -- - * * º s - - -

-- - - - - 4 - > * * * *

* * - - . . . * - - -

- ** * * * - - - - º -

- - * - , , " ; -; : . . . .

-

* - *

- - . " - - -* * * * * * * - * *

: - - -, - * * * -- º- - - - - * * * -

- - * . . . * : * I - - - - - * , . . . . . . . .* * s

- - - - - - ... t . .”- - - - . . . * * * * * - -

--- -

Table 29

Patient Behaviors as Predictors of Achievement Subsystem Category

(Full Equation, R2 = .36)

Patient Behaviors in Equations

By Entry Order Beta

Attention Span . 1 l; +

Initiates and Completes Tasks ... 10 +

Selects Goals from Alternatives .08 +

Utilizes Cognitive Abilities .09%

Experiences Successes and Failures - .08 +

Organizes Groups -.20

Identifies, Accepts Strengths and Weaknesses .0l;

Chooses Alternatives -.03

Utilizes Problem-Solving Skills .01

Accepts Direction -.01

*Values significant at p < .05.

– 94 –

* - ? .( . . . . .

- - - *, ** - - --> *‘. . . . . . ; tº j : " : , "t 3 ■ : ; * * * 3 ■ : i:--------- -- - - ----------- -

* *

*.*

- [ _ " - " - . . . . . . . . .

- - - -

.* . . - *- - -

. . . . . . . .

. . * - * . . . . .

- - . . . . . . . * * 1 * * - . .

: . . . . . . . . ‘. . . . . . * . . . . . .

- * - - -* - - -

- - - * - - - ! . . . . . . . . . . . . . . . . . . . .

* - * * . . . . . . . . . . .

- * " . - - - * . ... • - - -

* * * . . . . . . . . . . . . . . . . . . . of , ºf º

- - • . - - * *- ** - . . . . . . . . . . C

- -* 1: ... " . . . . . . . . . . . . . . . . .

! -- f : . . • J

* . • * : - -

- f : . . . . . . . . . . . . .- * º

Table 30

Patient Behaviors as Predictors of Restorative Subsystem Category

(Full Equation, R2 = .32)

Patient Behaviors in Equations

By Entry Order Beta

Engages in Recreational Activities .17%

Participates in Organized Social Group -. 36 +

Sleep Patterns . 12%

Involvement in Range of Activities ... 10 +

Participates in Treatment Regime .09%

Regulates Activities According to Physical .03

Requirements

*Values significant at p < .05.

– 95 -

:

-|*·••••·–''

s:* * *

|

·----·

|-.ae

·----

·

--------

*

----·

-----

Figure 2

Patient Behaviors as Predictors of Subsystem Category (Reduced Equation)

Independent Variables/Patient Variables (Standardized Betas)

Interpretation of Events (.31)Awareness of Social/Physical Environment (.21)

Distinguishing Events (.18)

Bladder Control (.34)

Disposal of Body Wastes (.18)Bowel Control (-.18)

Hygiene Care (.15)

Communication Ideas: Verbally, Nonverbally

and in Writing (.36)Awareness of Personal Space (.18)Emotional Attachments (. 13)

Self-Care Activities (.24)

Decision-Making Ability (.21)Seeks Assistance (.19)

R2 = .30Ingestive

R2 = .21Eliminative

R2 = .26Affiliative

R2 = .22Dependency

– 96 -

7

-******----...............

º

y**--*-

******-*******-----.....;...**....º

**-**--f:****** -----....■ .32(,!----

--

*-----*~*~*-,***** !...............t-***

--*-------------

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----.---

º-*-I-r→*>-r*r*****~* ............2:,D'........|

----

**>...-ººjº,....

----*-

**********-ar**;;;;;, -...r.º.-**--

-***------------

----------** ...................-,

--****,,,-.... -:*----**:*~*

------

**************--*...*--

-----***-

-----------

..;,...;...........---

-....-i----

....!............

-----------------------------

--.....;***-,--,-s•*,

--------***--º

-------------------------------------------------------------->-----------→----- •*:*~*>r*--..------------------------•...f.\!2".22..........2....................................

Figure 2 (continued)

Patient Behaviors as Predictors of Subsystem Category (Reduced Equation)

Independent Variables/Patient Variables (Standardized Betas)

Engages in Socially Acceptable Behaviors (. 13)

Distinguishes Between Sexual and Nonsexual > R2 = .07Behaviors (.20) Sexual

Identifies/Avoids Hazardous Situations (.22) R? = .21

Engages in Acting Out Behaviors (.25) > AggressiveSeparates from Group (.18) Protective

Attention Span (.29)Selects Goals from Alternatives (.17)

Experiences Successes and Failures (-.13) > R2 = .35Initiates and Completes Tasks (.18) Achievement

Utilizes Cognitive Abilities (.15)

Engages in Recreational Activities (.26)Participates in Organized Social Group (.24)

Sleep Patterns (.16) N- R2 = .32Participates in Treatment Regime (.11) 27 Restorative

Involvement in Range of Activities (.14)

- 97 -

Table 31

Comparison of Full and Reduced Equations of Patient Behaviors as Predictors of

Subsystem Category

Full Equation Reduced Equation

Subsystem Category R2 R2

Ingestive . 33 . 30

Eliminative .21 .21

Affiliative . 27 .26

Dependency .24 .22

Sexual .08 . 07

Aggressive-Protective .23 .21

Achievement . 36 . 35

Restorative . 32 . 32

– 98 -

* c 1 { . . . . . . .------- - ----------------

* - - - - -* * -

* * * . -

- - - - - - - -

- -- - *

*- - - - - * -

* -- - - * * * * * *

- - - " . . . . . .- -

- - - -

- - - -

- - : . . . . . . -- " . . . . .

- - - * * * * -

* * * * - \ . .-

* * * - . . . .- - - * * * - - -

unexplained variance for each subsystem category. Table 32 presents the results of

the significance tests to see if a full equation predicts significantly better than the

reduced equation. Results of these significance tests show that full equations do

not give significantly better prediction than the reduced equation. Therefore, the

more parsimonious reduced equations were substantially as effective as the full

equations.

Impact of Subsystems Categories on System Category

The computed R? values and significant levels of subsystems categories on

system category are shown in Table 33. These values are for the full equation and

therefore include all possible independent variables/subsystems categories in the

equation. A reduced equation was made which consisted of those subsystems

categories with an F ratio significant at p < .05 and a beta weight significantly

different from zero at p3.05. Results of the reduced equation for subsystems

categories are illustrated in Figure 3. Only three variables were significant in

influencing the system category and accounted for 51% of the variance. The

variables were: ingestive subsystem category, B = .28, p = .0001; restorative

subsystem category, B = .26, p = .0001 and achievement subsystem category,

B = .28, p = .0001. There was a slight decrease in the R2 values computed for the

reduced equation (.51) over the full equation (.52). Both of these R2 values met the

accepted criteria of 50% explained variance for the system category. Results of

significance tests show that the full equation does not give significantly better

prediction that the reduced equation. Again, the more parsimonious reduced

equation was substantially as effective as the full equation.

- 99 -

Table 32

Significance Tests on Full and Reduced Equations of Patient Behaviors as

Predictors of Subsystem Category

Differences

Subsystem in Number of

Category Variables F Ratio F Critical p Value

Ingestive 8 1.70 1.9l; 0.10

Eliminative 1 2.60 3.84 0.11

Affiliative l; 1.78 2. 37 0.13

Dependency 6 2.01 2. 10 0.06

Sexual l; 1.23 2. 37 0.30

Aggressive-Protective 3 2. 37 2.60 0.07

Achievement 5 1. 14 2.21 0.34

Restorative l . 57 3. 83 0. l;5

- 100 –

Table 33

Subsystems Categories as Predictors of System Category (Full Equation, R2 = .52)

Subsystems in Equation

By Entry Order Beta

Restorative . 2822 +

Ingestive . 2641 +

Achievement . 1953 +

Dependency . 1259

Sexual -.065!

Eliminative . Ol' 55

Aggressive-Protective .0239

Affiliative . 0133

* Values significant at p < .05.

- 101 -

* - º ~ : -1, ... " -- - - - - - -, * Z.” * - . . . -** - - - - * . - - -— — & lººk tº ºf fººl ºf ■ º, ■ º tº ºr

. . . . . * L.

*.

- - -: \ . . . . . . . . .

. . . . - . . . .

- * - ‘. . . . . . . .

. f : . .

- º

* * * * ‘

- * ~ * * . . . .

* - - : . . . - . . . . .

r- - º

- * * * \ . . .-

• * * ~ *- : - . . . . . . . -*

Figure 3

Subsystems Categories as Predictors of System Category (Reduced Equation)

Independent Variables/Subsystems (Standardized Betas)

Ingestive Subsystem Category.28

Restorative Subsystem Category .26 R2 = .51

28 System Category

Achievement Subsystem Category

- 102 -

Examination of Residuals for Violations of Regression Assumptions

Zero Mean. Examination of residuals from the reduced equation for all

patient behaviors and subsystems indicated, as expected, that when a constant

term is included in the equation the residual sets all have a mean equal to zero.

Homoscedasticity. Examination of plots for all standardized residuals against

predicted subsystem and system values indicated that variance was equal in all

regressions. Figure 4 provides an example of a plot for standardized residuals

against the predicted values of self-care activities in the dependency subsystem.

The broad band which the horizontal line cuts in half provides evidence for equal

variance (homoscedasticity).

Normal Distribution. The results of Chi-square goodness of fit tests for

distribution of residuals for patient behaviors and subsystems' regressions are

shown in Table 34. All residuals from the reduced equations of patient behaviors

and subsystems were not normally distributed. All observed Chi-square values

exceeded x2 critical (2, N = 331) = 5.99, p.<.05. However, violation of the

normality assumption was minor since F ratios are fairly robust to nonnormality

when there is no evidence of heteroscedasticity (Verran and Ferketich, 1984).

Histograms depicting categorized standardized residuals in groups according to

their distance from the mean are illustrated in Figure 5 for sexual subsystem (X2-

203.52) and Figure 6 for aggressive-protective subsystem (X2 = 9.97). The

histogram for the sexual subsystem appears to be the most nonnormal. However, it

is still unimodal, meeting the essential assumption for regression analysis (Neter,

Wasserman and Whitmore, 1982).

Independence. Residuals from the reduced equations for all patient behaviors

and subsystems were examined. Results from the plots indicated that there was no

- 103 -

f r

t -

º

*

t *

* -

- * .

- - - * -

- - - _º - a -

- - * .-- - - -

* . . . º ( -

-

- * - - * -s - -

- - - - - -

- - . . . -

º - - * - * * *- - * → - - -

- - -

- - * -

- • * * - - - -

- * - - - - * -- - - - - - - * *

. . . . * * * e

º - * * * * - - - - - - - -

* -

- º - - - - - -

- e. º - - e

* * - - - - * - - - -

- - • * * - - -

º º - * * * * - - -

- * : ... - - .* . . . . . . - * . . .

* . . . " +

-

- -

!

-

*

º

- *- º

* * *

* -

t

* -

- *

-

-

-

-

* -

*

-

* *

-

t - -

- - - -

- - - º

- - - - -

- º * * **-

- - - - .* * * * –

- - - * * * --

- - . . -". a - -

- - -. . . .

-* , * * *- . . . . . . . . . .

- - - -- º --

- - -

- - - - ** > * ~ * * =

- - - - -~ *

. . . . .

- - - *- * : * * : ■ .- --- - ---------

- * * * * *

-- - - - * - . .

Figure 4

iestiviPlot of Standardized Residuals Against Self-Care Act

•…u---+-----«

------••••vº■ -■z<b■c)-~uuuo

-------••…

----oocoquaeuw--

-■■■

>■■…oco-

■ ------>o

•v••r-•••roo

--·-o--~

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--------

3.4o

A C T I W i t i E SC A R ES E L F

2, etc.BNOTE: A=1;

- 104 –

; : -; it-

, , " * - -, - . . . - - . . . . . * : * : *

Table 3!,

Results of Chi-Squared Goodness of Fit Tests for Distribution of Residuals from

Patient Behaviors and Subsystems Regressions

Residuals X2 Observed

Subsystem Categories

Sexual 203. 52

Eliminative 127. 85

Dependency l;9. l;2

Restorative 33. 22

Ingestive 19.79

Affiliative 1 l; .. 32

Achievement 1 li. 11

Aggressive-Protective 9.97

System Category 16.80

X? critical (2, N = 331) = 5.99, p < .05.

- 105 -

; C-2 * *

* - - - - - - - - `- a r < … . . . . . . . . . .- * - . . . . . ; ; ; ; ; *ç i \ . . . . . . .- - - - -------

** I - -

, : . . . . . . . .

* - -

- - -

- - i , , , ,

• * . . . . .

- * -

- - * - - *

- . . . . . . .*-

º : . . . . . . . * *- - - * = * * * -

* * , , • ,- - - - - - - -

. : , , ; ; ; ; ; – " . . . . .

** *, * - . . . .-

- e - - - - - .*

- r = - - * * * * * * ** * - - . . . . . . . .

- - - t - – ‘ ---

Figure 5

Histogram of Standardized Residuals for Sexual Subsystem

FREQUENCY

240 +

||t4.2 to

180 +

12o +

3o

Residuals - Sexual Subsystem

x? = 203.52

- 106 -

:

Figure 6

Histogram of Standardized Residuals for Aggressive-Protective Subsystem

FREQUENCY

too +

Residuals - Aggressive-Protective Subsystem

- 107 -

evidence that the assumption of independence had been violated. All plots showed

an equal spread of residuals about the zero line.

Results Related to Generalization

The results of model consistency across inpatient units, sex and age groups

are shown in Table 35. If the NPH-PCI was generalizable, residuals from patient

behaviors and subsystem categories should be evenly distributed across age, sex and

inpatient units (p X.05).

Across Inpatient Units

Using the Chi-square goodness of fit statistical test, it was found that the

model of NPH-PCI tended to underestimate the maladaptive behaviors in the

ingestive subsystem (p = .03) for the child psychiatry inpatient unit (A-West), and

underestimate the maladaptive behaviors in the eliminative subsystem (p = .001)

for the adolescent developmental disabilities inpatient unit (6-West). It was also

found that the model tended to underestimate the maladaptive behaviors in the

sexual subsystem (p = .03) for all inpatient units, although this was less so for the

adolescent psychiatry unit (A-South). Note that the R2 value for the sexual

subsystem (.07) was exceptionally low (Figure 2). There was no evidence of

differences in model predictive ability among the four units for affiliative,

dependency, aggressive-protective, achievement or restorative subsystems

categories or for the system category.

- 108 -

º

tt

*

‘. . . -- * -

- - - º * - - ºI C - * * * * ~ * . . . . . . .

- * - - - * - - - - - -

- t º * - . .-

- **2 * .

... • - - * -

- º - = r - -

" . - • * * * * * * * * * *

t - - - - - . . .

• - * - * * - * *-*. -

º

-* * * - - -

- - -

--- - - I - , ,

* - - - - -* I - . . . . - - *

- * - - * *• . . .

- . . * * - •

- * , - . -. . . . - - - - - - - - - - * -

* . . - - - - - - - -- - * - - - - - * * * - - - -

* . - * --

- * * * * - - - - - - * -

- - -. * * * * º - -

* * * - - * = - - - - - - *--- -

• . . . .- - - - * . . * -

… " - - . . . .-

* * - - - - - - - - - -* -- , * = * * * * * - - - - -

* . . . . . . - * -- - - - -

* - . . "- -

- - - - * - • * ~ * - *

* - - - - - - - - .

Table 35

Tests on Model Consistency Across Units, Sex and Age Groups

Unit Sex Age

p Value p Value p Value

Subsystems Categories

Ingestive .03 .84 ... l;7

Eliminative .0001 . 39 .03

Affiliative .06 .21 . 16

Dependency .9l; .08 . 11

Sexual .03 . 07 . 50

Aggressive-Protective .08 .01 .04

Achievement ... 10 .03 .08

Restorative .26 .01 .25

System Category ... l;3 ..!!! . 12

Note. X2 test performed for lack of fit on the assumption that the frequency of

positive and negative residuals is constant across units, age groups or sex.

- 109 -

* - … " -‘. . . - * * * *

* * - -

-

-*.

* .- -

t -

-* . . . . ;

* * s

- - . . . . . . ! -

- * : * ~ *- - º *** , , , ; ; ;

* * * - ºf -

: … "- - - -

- - v -- \ . . . . . . .

- * - - - -- º a . - * * * * ~ *

- - - - * - * - - -

* - - -- - - *

- - - * * . . .-

- *** - - - * , - - * , . * - - º -, * *-> - - - : - - - - - - * * - - - * - -

- - - -

* - - ... -- - . . , -. . . . . . t * - - - • . . . . . . . . . -

:

Across Sex Groups

Results show that the model of NPH-PCI tended to underestimate the level

of maladaptive behaviors for females in the achievement (p = .03), aggressive

protective (p = .01) and restorative (p = .01) subsystems. There was no evidence of

differences in model predictive ability among the sexes for ingestive, eliminative,

affiliative or dependency subsystems categories or for the system category.

Across Age Groups

For the purpose of this analysis, patients in Groups l; and 5 were combined

(Group 5 had only 1 patient). It was found that the model of NPH-PCI tended to

underestimate the level of maladaptive behaviors in the aggressive-protective

(p = .0%) and eliminative (p = .03) subsystems for patients 16 to 19 years old

(Group 4). However, there was no evidence of differences in model predictive

ability among the remaining age groups for ingestive, affiliative, dependency,

sexual, achievement or restorative subsystems categories or for the system

category.

Summary of Results

This chapter has presented the results of this study to validate a patient

classification instrument for psychiatric patients based on the Johnson Model for

Nursing. The results were presented in terms of the equivalence reliability,

criterion-related validity and generalizability of the instrument across inpatient

units, sex and age groups.

– 110 –

|-{·

·*

·

*|-

--------·|-■

----·|-·|-■■

■

·-++|-|-•-----

…

…----

•

•··

Equivalence reliability was investigated by computing inter-rater agreements

with respect to patient behaviors, subsystems categories and system categories by

staff, shift coordinator and observer groups. Data indicated that agreement on

patient behavior ratings for the three paired comparison groups far exceeded the

60% criterion pre-established for inter-rater reliability. Ratings for subsystem

category on ingestivé, eliminative, affiliative, dependency, achievement and

restorative subsystems and system category were above the 60% criterion for staff

and shift coordinator paired groups but ratings for subsystems categories and

system category were below the 60% criterion for the two remaining paired groups.

Criterion-related validity was evaluated through the regression of subsystems

category ratings on patient behaviors and through the regression of system

category ratings on subsystems category ratings. Findings showed that the R2

values for all subsystems categories were below the 50% criterion pre-established

for criterion-related validity but that R2 values for system categories were above

the 50% criterion pre-established for criterion-related validity.

The results indicated that 28 patient behavior indicators were as effective as

the 61 patient behavior indicators identified for the eight subsystems in predicting

subsystems categories. The results also indicated that ratings for three subsystems

categories (ingestivé, achievement and restorative) were as effective as ratings for

eight subsystems categories in predicting system category.

The generalizability of the instrument's consistency across inpatient units,

sex and age groups was examined by an analysis of residuals from regression

equations. Data indicated that system category ratings were generalizable across

inpatient units, sex and age groups but that subsystem category ratings for only

two subsystems (affiliative and dependency) were similarly generalizable.

– 11 1 –

CHAPTER V

Discussion

The purpose of this research was to validate a patient classification

instrument for psychiatric patients based on the Johnson Model for Nursing.

Walidation was conducted through empirical investigation and hypothesis testing

using multiple regression. Equivalence reliability and criterion-related validity

were the two psychometric properties investigated in this study.

The results of the research were presented in the previous chapter. The

interpretation of these results, research issues limiting study findings, directions

for future research and implications of findings for nursing practice, theory

development and research are presented in this chapter.

Interpretation of Results

Interpretation of Results Related to Equivalence Reliability

Results of mean inter-rater agreements on patient behaviors for the three

paired groups exceeded the accepted criteria of 60% for equivalence reliability

(see Table 17). Mean inter-rater agreements were within four percentage points of

each other, suggesting that assessment of patient behaviors using the NPH-PCI will

yield clinically similar results when used by different individuals. These results

- 1 12

is

■*

*|-·■--------|-·----·

·|-••-

-••

.

*

·

→

·**a-

*~…••

•·*

•|---»

*…----|-·|×

•|-----

·*

*

→

·----º■

were within the range (.5 to .8) of reliability coefficients obtained in most

behavioral research (Pedhazur, 1982).

Results also showed that the eliminative and sexual subsystems had the

highest inter-rater agreements (see Table 17). These subsystems involve the

assessment of behaviors that require a low level of inference on the part of the

data collectors; for example, patient behaviors such as hand washing, disposal of

body wastes and clothing associated with specific gender. These behaviors are

readily identified and tend to be relatively stable over time. As expected,

affiliative, dependency and achievement behaviors were found to have lower levels

of inter-rater agreements. These behaviors, being associated with emotional

attachments, expression of feelings, and decision-making, require a higher level of

inference on the part of data collectors. These results were similar to earlier

preliminary findings by Auger and Dee (1983).

Results further showed that the staff and shift coordinator groups

consistently achieved higher inter-rater agreements on patient behaviors than the

remaining comparison paired groups. There are two possible reasons for this

finding. First, the staff and shift coordinator paired group was more homogenous

than the two remaining paired groups. Clinical Nurse IIs composed 41% of the

staff group and 55% of the shift coordinator group (Tables 14 and 15). Fifty-one

percent of these nurses had similar educational preparation (see Table 16). Second,

staff and shift coordinator group had more prior knowledge about the patient than

the observer group because they were members of the multidisciplinary team and

Consequently participated in patient care conferences.

Although data collectors completed the Behavior Criteria Checklist

independently, prior discussion of patient problems during patient care conferences

– 113 -

may have promoted uniform observation. Additionally, staff and shift coordinators

cared for patients over a longer period of time interval than observers, which

might facilitate drawing inferences about the meaning of behaviors. Examples of

behaviors which might be influenced by length of time exposed to patients

included: (1) comfort with body and physical changes, distinguishes between male

and female, and knowledge about own anatomy and physiology (sexual subsystem);

(2) established pattern of elimination (eliminative subsystem); and (3) feelings of

hopelessness and helplessness (dependency subsystem).

Interestingly, the observer group reported noting significantly more adaptive

behaviors and less severely maladaptive behaviors than the staff and shift

coordinator groups (see Table 18). These results suggest that staff and shift

Coordinator groups, although having more knowledge about patients' conditions,

were more likely to focus on pathology while the observer group, having less

knowledge about patients' conditions, were more likely to focus on a wider range of

possible behaviors, including those that were adaptive. The focus on adaptive

behaviors permits the use of patient strengths in the development of treatment

strategies (Dee & Auger, 1983a).

Inspection of inter-rater agreements between the two paired groups for

subsystems by categories (Tables 20 and 21) showed that there was lower

agreement between categories II, III and IV (0%–54%). The lack of agreement in

these categories most likely affected the results of the overall inter-rater

agreements for subsystems categories. Agreements ranged from 37% - 66%

(Table 19). These results indicated that data collectors had difficulty in

determining the degree of adaptiveness of the observed behaviors. One reason for

this difficulty is that criteria for rating categories II, III and IV lacked descriptive

– 114 –

adequacy and specificity. For example, there were no operational definitions for

Category IV "behaviors of acute intensity and frequency" (see Appendix A) to assist

the data collectors. A second reason is the inclusion of behaviors requiring

different levels of inference within a subsystem. For example: (1) ingestion of

food and interpretation of events in the ingestive subsystem and (2) basic self-care

skills and emotional security in the dependency subsystem. Theoretical or

mathematical weights for concrete and inferential behaviors were not determined

for this study nor were they available in published literature. Because of the

subjective nature of the behavior indicators, data collectors may have evaluated

the behaviors differently.

Results also showed that staff and shift coordinator groups achieved higher

inter-rater agreements for subsystem categories than the two remaining paired

groups (Table 19). As previously stated, staff and shift coordinator groups had

more knowledge about the overall condition of the patient than the observer group.

Ratings of varying degrees of overall subsystem adaptiveness may have been biased

by prior knowledge about the patient's background. According to Johnson (1980),

regulatory factors are assumed to influence the behavioral responses of the

individual. These factors include; for example, sociological background (external

regulator) or motivations (internal regulator) (Auger, 1976). It is therefore

reasonable to expect that information pertaining to such factors about the patient

may have facilitated agreements on ratings of subsystem categories.

A comparison of the results found in Tables 17 and 19 show that inter-rater

agreements for the three paired groups were significantly higher for the degree of

adaptiveness exhibited by individual patient behaviors than for observed behaviors

in subsystems. A possible reason for this difference is that the ratings for patient

– 115 -

behaviors involved indicating the presence or absence of behaviors that were

pre-specified for degree of adaptiveness or maladaptiveness. In contrast, ratings

of subsystems categories allowed the data collectors ample room for making

inferences and exercising judgements on the degree of subsystems' adaptiveness.

There were also lower inter-rater agreements between staff and observer

paired groups and shift coordinator and observer paired groups for system ratings in

Categories II, III and IV (38% - 48%) indicating that they had difficulty estimating

the level of nursing care required by the patient. These results may have been

caused by the lack of standardization in nursing care. The lack of agreement of

these categories most likely affected the results of the overall inter-rater

agreements of system categories since both inter-rater agreements were below the

60% criterion pre-established for inter-rater reliability.

Staff and shift coordinator groups achieved higher inter-rater agreements on

system categories than the two remaining paired groups probably because staff and

shift coordinators were patient's caregivers and were more knowledgeable about

the range (complexity and intensity) of nursing interventions provided in the

clinical setting and were also more familiar with the patient's nursing care plans

than the observers. It is reasonable to postulate that staff and shift coordinator's

estimation of nursing care required by the patient were most likely based on the

"usual" care received by the patient.

Interpretation of Results Related to Criterion-Related Validity

R2 values computed for the full (inclusion of all independent variables) and

reduced (inclusion of independent variables with an F ratio significant at p .05

and a beta weight significantly different from zero at p .05) equations on all

- 1 16

subsystems were below the 50% criterion for explained variance. The R2 values

ranged from .08 for sexual subsystem to .36 for achievement subsystem (full

equations) and .07 for sexual subsystem to .35 for achievement subsystem (reduced

equations) (Table 31).

Most research data from attempts to investigate social phenomena yield low

R2 values, often well below .50 (Verran & Ferketich, 1984). According to Cohen

(1977), R2 values of .10 would be considered by most researchers in the social

sciences as meaningful and being of medium magnitude. The low to moderate R2

values for all of the subsystems may be due to factors that relate to specification

errors, namely:

1. Subsystems may be inadequately defined, suggesting that patient

behaviors included in the model may not be adequately describing the

subsystems;

2. Subsystems may be incompletely defined, suggesting that relevant

patient behaviors may have been excluded from the model; or

3. Subsystems may be incorrectly defined, suggesting that irrelevant

patient behaviors may have been included in the model.

Errors of measurement--for example, low inter-rater agreements on

subsystems categories--will also lead to an underestimation of the regression

coefficient (Pedhazur, 1982). Note that the inter-rater agreements between shift

coordinator and observer groups for seven of the eight subsystems categories were

substantially below the 60% criterion for inter-rater reliability ranging from 37%

for the aggressive-protective subsystem category to 66% for the eliminative

subsystem category. Cochran (1970), commenting on studies in which complex

- 117 -

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human behaviors were measured, maintained that errors of measurement are

largely the result of data from disinterested data collectors.

Despite the lower than expected R2 values obtained, of particular interest in

this study were the results for the ingestive subsystem. Three of 11 ingestive

behavior indicators were predictors of the ingestive subsystem category rating. All

three of these behavior indicators are behavioral segments describing the concept

of sensory perception, one of two critical behavioral characteristics of the

ingestive subsystem. Auger (1976) argues that the functions of the ingestive

subsystem include not only the " 'taking-in'" (p. 35) of substances, such as food and

fluids, but also the " 'taking-in'" (p. 35) of sensory information, for example,

perception. Sensory information, according to Auger (1976), enables the individual

to initiate required compensatory responses in order to maintain a state of

psychophysiological equilibrium with changes in the external environment, and that

it is through the ingestive activity that the individual is able to differentiate

himself as a separate entity from all other objects and persons existing in the outer

world. This finding shows the relative importance of sensory perception of

psychiatric patients and partially supports the conceptual perspective of Auger

(1976).

Interestingly, ingestive behavior indicators describing food/fluid intake were

not shown to be predictors of the ingestive subsystem category ratings. It is

reasonable to expect that data collectors' ratings may have been biased by timing

of observations and frequency of behaviors associated with food and fluid intake.

These behaviors would most likely be confined primarily to mealtime periods. In

contrast, maladaptive behaviors associated with sensory perception most likely

- 1 18

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occurred throughout the observational period, thus contributing more significantly

to the overall adaptiveness of the behavioral subsystem.

The low to moderate R2 values indicate that subsystems categories had low

to moderate explanatory power. Further work is needed to identify additional

relevant patient behaviors for inclusion within each subsystem.

The computed R2 values for the full and reduced equations for system

categories were all above the pre-established criterion of .50 for explained

variance. The reduced equation showed that subsystems categories for ingestive,

achievement and restorative were the predictors for ratings of system category.

These results were surprising for two reasons: First, it was the clinical notion that

behaviors for the subsystems of dependency, affiliative, achievement and

aggressive-protective were most often maladaptive in the psychiatric population.

With the exception of the achievement subsystem, these subsystems were not the

same as those shown to predict the system category ratings of nursing care

requirements. One plausible conclusion is that although aggressive-protective,

achievement, dependency, and affiliative subsystems may have been descriptors of

clinical problems of psychiatric patients, these subsystems (with the exception of

achievement) may not necessarily impact/predict the level of nursing care required

over time. For example, in the aggressive-protective subsystem, behavior such as

"acting-out" often required periodic immediate and intensive nursing interventions

of 10 – 15 minutes to provide "limit-setting" on the behavior, while behavior such

as "perceptual distortion of the environment" in the ingestive subsystem often

requires continuous nursing intervention to provide reality testing, orientation and

redirection. It is reasonable, then, to expect that behaviors such as those requiring

nursing interventions consistently over a span of time would be predictors of the

- 1 19

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level of nursing care required: for example, those behaviors associated with

attention span, ability to initiate and complete tasks (achievement subsystems)

ability to engage in recreational activities, and participation in treatment regime

(restorative subsystem). It should be pointed out that although sexual and

eliminative subsystems were not statistically significant, they were clinically

meaningful to the practitioner in the planning of care.

Second, the model as originally conceived by Johnson included seven

subsystems. An eighth restorative subsystem was later added to the model. As

was previously discussed in Chapter II, Johnson argues against the inclusion of the

restorative subsystem in the model. It was her belief that the relief of fatigue was

more a function of the aggressive-protective subsystem than the restorative

subsystem (Lovejoy, 1981). Auger strongly supported the inclusion of the

restorative subsystem in the model. She states that the "restorative subsystem, in

and of itself, contains goals that define the subsystem apart from all other

subsystems. It is a most important subsystem to the survival of the organism as a

viable entity" (J. Auger, personal correspondence, April 18, 1985). The results of

this study support Auger's supposition of the importance of the restorative

subsystem relative to overall behavioral system functioning.

Results of this study support the criterion-related validity of system

category. These results indicate that the ratings of subsystems categories based on

the general framework of the NPH-PCI can be used with confidence to predict the

level of care the patient requires.

- 120 –

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Interpretation of Results Related to Generalizability

It was found that the model of NPH-PCI tended to underestimate the

maladaptive behaviors in the ingestive subsystem for the child psychiatry unit.

This underestimation may be due to: (1) absence of maladaptive ingestive

behaviors specific to the patient population; (2) lack of theoretical weights for the

two distinctively different behavioral characteristics in the ingestive subsystem;

and (3) lack of heterogeneity of sample. There was a disproportionately large

number of patients (n = 34, 40%) with conduct disorders, major affective disorders

and attention deficits on the child psychiatry unit (Table 13).

Results also showed that the model of NPH-PCI tended to underestimate the

maladaptive behaviors in the eliminative subsystem for the adolescent

developmental disabilities unit. This underestimation may be due to the inadequate

representation of maladaptive eliminative behaviors specific to this population in

the model or a lack of heterogeneity of sample. There was also a

disproportionately large number of patients (n = 29, 35%) with conduct disorders,

major affective disorders and schizophrenic disorders on the adolescent

developmental disabilities unit (Table 13).

The model of NPH-PCI also underestimated the maladaptive behaviors in the

sexual subsystems for all inpatient units. These results may be explained by the

exceptionally low R2 values for the sexual subsystem (.07). This lack of

generalizability and the low R2 values indicate that new behaviors in the sexual

subsystem must be developed, redefined and refined.

Results indicated that patient behavior indicators for ingestive, eliminative,

affiliative and dependency subsystems can be used to predict subsystem categories

for male and female. However, it was found that the model of NPH-PCI tended to

- 121 –

*

underestimate the maladaptive behaviors for females in the aggressive-protective,

achievement, and restorative subsystems, suggesting that female behaviors for

these subsystems may differ from those of males and that new achievement,

restorative and aggressive-protective behaviors specific to the female population

may need to be developed.

Results showed that patient behavior indicators for the ingestive, affiliative,

dependency, sexual, achievement and restorative subsystems can be used to predict

subsystem categories for patients tº to 15 years old. However, the model of

NPH-PCI tended to underestimate maladaptive aggressive-protective and

eliminative subsystems for patients 16 to 19 years old. These results suggest that

maladaptive eliminative and aggressive-protective behaviors of older adolescents

may differ from those of young children, latency-aged children and young

adolescents.

There was no evidence of differences in model predictability for the system

across the four inpatient units, four age groups ranging in ages from 4 to 23 years

old and between male and female. These results suggest that the model can be

used to predict levels of nursing care across inpatient units, age and sex groups.

Research Issues Limiting Study Findings

The limitations of this study were related to the research methodology;

specifically, certain aspects of the sample selection, patient observation schedules,

study period and observational procedures.

- 122 -

Sample Selection

As stated previously, the purposive sample consisted of patients who met the

criteria for system category. It was assumed that the large sample size and the

assignment of sampling by inpatient units (child and adolescent psychiatry; child

and adolescent developmental disabilities) would allow for an adequate

representation of patients by age, sex and psychiatric diagnosis. However, in

actuality the sample had a predominance of males (66%) and a predominance of

patients with conduct disorders (20%), major affective disorders (19%) and

schizophrenic disorders (10%). Young children aged 4 - 7 were underrepresented

(11%) in the sample. Greater attention given to these factors might have increased

the heterogeneity of the sample, thus increasing the generalizability of the

findings.

The issue of multiple observations of the same patient was addressed by the

control for dependence of subjects. Patient observations that did not meet the

following criteria were excluded from the sample: (1) a two-week time lapse

between observations of the same patient in the same system category and (2)

repeat observation of the same patient in a different system category. Evidence

from the study showed that the assumption of independence had not been violated.

Patient Observation Schedules

As was previously stated, the assignment of patient observations was based

on the observer's work schedule. Staff and shift coordinators who had primary

patient and administrative responsibilities for a given 8-hour shift, participated as

data collectors. The data collectors were not paired according to comparable skills

- 123 –

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or clinical expertise. Consequently, this procedure of assignment resulted in

greater variability in skills and clinical expertise among the raters.

Furthermore, observers were randomly assigned to the four inpatient units

for patient observations while staff and shift coordinators remained on their

primary work unit. Therefore, staff and shift coordinators were more

knowledgeable about the patient and his or her nursing care than the observer.

Higher inter-rater agreements may have been achieved if all data collectors were

paired according to their comparable skills and clinical expertise as well as the

assignment to a specific inpatient unit where they were most knowledgeable.

Study Period

The difficulty of obtaining a large sample size to represent each system

category resulted in an extended study period. The lengthy study period posed

several threats to the internal validity of the study. Specifically, the threats to

internal validity were:

1. History - With the passage of time, change in attitudes of data

collectors about the observational study may have occurred;

2. Maturation - Data collectors may have increased their knowledge

about the Johnson Model as well as skills in data collection;

3. Selection - Subjective estimation of the criteria for system category

may have changed, thus influencing the selection of subjects; and

H. Mortality - There was a gradual decrease in patients who met the

criteria for system Categories I and IV, thus affecting (although

minimally) the selection of a purposive sample.

- 124 –

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Because of the lengthy study period, observer training should have included

frequent retraining and reclarification of rating criteria to maintain the prestudy

level of inter-rater reliability. Data collected at initial and final phases of the

study should have been compared for reliability and validity. Again, greater

attention given to these factors may have reduced any threats to the internal

validity of the study.

Observational Procedures

A potential weakness of the observational data collection procedure is the

fallibility of the observer. Human perceptual biases are inherent in observational

procedures, the most common of which are expectations and attitudes of the

observers. For this study, subjective measures (rating scales) were used to rate

subsystems and system categories. Several types of errors may have been induced

by the use of rating scales. Raters could be influenced by nonrelated patient

characteristics, or the tendency to rate too positively or too harshly. The

importance of adequate observer training and inter-rater reliability cannot be

overstressed.

Despite the potential weakness of the observational procedure, the greatest

strength of direct observation is that it allows for the collection of data that would

otherwise be impossible to obtain. With this approach, important information

about behavioral patterns are described (Polit & Hungler, 1983).

- 125 -

Directions for Further Research

Despite the methodological limitations, this study has provided valuable

results that can be strengthened through further research. Clearly, there are

several measures that can be taken to increase the reliability, validity and

generalizability of the NPH-PCI. The directions for further research may be

divided into two major areas: (1) Instrument Development and (2) Research Design.

Instrument Development

As stated, the issues of reliability and validity must be favorably resolved for

an instrument to be used with confidence. Although reliability is a necessary but

not sufficient feature of an instrument, it is the basis of all other assessments that

occur. The validity of an instrument is established over time by examining results

across many related studies.

The reliability and validity of an instrument are not totally independent

qualities. Although high reliability provides no evidence of an instrument's

validity, low reliability is evidence of low validity (Polit and Hungler, 1983).

Further refinement of the NPH-PCI should result in higher reliability and

validity coefficients. A panel of experts (including those from a variety of

psychiatric settings) knowledgeable about the Johnson Model can be used to judge

the preciseness and completeness of the behavior indicators. The ways in which

the measurement of patient behaviors can be improved include:

1. Eliminating ambiguous items, such as those behaviors which are not

readily observable; for example, pattern of elimination, feelings of

- 126 -

hopelessness and helplessness, comfort with the body and physical

changes;

2. Decreasing the degree of observer inference by taking smaller

segments of behaviors as units of observation; such behaviors as

emotional attachments, expression of feelings and decision-making;

and

3. Adding relevant patient behavior indicators within each subsystem.

Kerlinger (1973), however, warns that categories which are too specific—

while reducing ambiguity-–tend to be inflexible, rigid and perhaps trivial as well.

Consequently, data collected may become less useful in behavioral research.

The identification of new behaviors can be accomplished by a thorough

review of literature, a review of the patient's medical record and by participant

observation. A panel of experts can also be used to judge the descriptive adequacy

of the subsystems:

1. Are the subsystems completely defined so that relevant behaviors

describing the subsystem are not excluded from the model?

2. Are the subsystems adequately defined so that behaviors included in

the model are describing the subsystem?

3. Should two distinctively different behavior characteristics be included

in the model to describe the same subsystem?

Once these steps have been taken, variations of behaviors can be ordered into

different categories. The influence of regulatory factors such as age, sex,

cognitive thinking, beliefs, values, physiological states, and so forth should also be

investigated in detail in regard to their influences on behavioral responses.

- 127 –

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Based on study results, smaller studies can be designed to compare behaviors

of subgroups, for example: (1) male patients, aged 9 – 12 with conduct disorders

and male patients, aged 9 – 12 with schizophrenic disorders, or (2) female patients,

aged 16 - 19 with major affective disorders from intact families and female

patients, aged 16 - 19 with major affective disorders from divorced families. Data

from these studies will provide further information about the variations of

behaviors as well as those behaviors that are common for these subgroups. Criteria

for subsystem categories can then be established with greater accuracy, adequacy

and specificity.

System category, as reflected in the concept of nursing care, also deserves

investigation in detail. Further work in this area should be directed toward the

delineation of nursing care activities in terms of: (1) complexity - the skill

necessary to carry out the task, and (2) intensity - the amount of time required to

complete the task. Earlier work done by Auger and Dee (Appendix A) has provided

a beginning taxonomy of activity categories which can be substantiated through

further research by comparing: (1) different skill levels of staff required to

perform the task, and (2) amount of time required by different skill levels of staff

for task completion. These tasks should include the components of the nursing

process (assessment, intervention and evaluation). Substantiation of the

complexity and intensity of nursing care will provide further data to establish

levels of nursing care with greater accuracy, adequacy and specificity. Levels of

nursing care can then be used for the cost-effective allocation of resources.

Studies should also be done to investigate whether specific demographic

attributes such as age and sex have an impact on system category (level of nursing

care) other than subsystems' categories (behavioral adaptiveness) themselves.

- 128 -

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Further work is also needed in evaluating the completeness of specific subsystems

in determining overall behavioral system functioning; for example, is the system

completely defined so that relevant subsystems describing the system are not

excluded from the model? Cost benefit analysis can then be done to determine the

relationship between levels of nursing care and patient outcomes based on an

analysis of behavioral adaptiveness.

Ways to decrease observer bias associated with the use of subjective

measures such as rating scales for subsystems and system categories should be

explored. For example, should mathematical weights be used for each patient

behavior shown to be a predictor of subsystem category and likewise, for each

subsystem shown to be a predictor of system category? The development of these

and other new methods and strategies will ultimately enhance the objectivity,

precision, accuracy and sensitivity of the NPH-PCI.

Research Design

As previously stated, human perceptual biases are inherent in observational

procedures. The training of observers in nursing research utilizing observational

methods deserves attention. Consideration should be given to the selection of

observers as well as the cost of observer training. In studies where there is a large

group of observer participants, costs can become prohibitive.

The research methodology for this observational study has required extensive

resources. A possible approach to decreasing the recruitment and training cost of

observers for further research is to utilize a resident nurse expert—-ideally, a

clinical nurse specialist where feasible, or shift coordinator/primary nurse--as the

data collector. There are several advantages of having the resident nurse expert

- 129 –

serve as the data collector. First, the availability of a resident nurse expert on

site reduces scheduling problems. Second, a well-coordinated schedule can result

in a shorter time study period and control of threats to internal validity such as

history, maturation, selection and mortality. Third, training efforts are minimal

for the resident nurse expert who already has the expert knowledge about patient

conditions for a specified patient population and knowledge about a full range of

nursing interventions for these patients. Lastly, an existing staff member is more

likely to remain in the study setting upon the completion of the study while a

recruited observer is more likely to leave upon the completion of the study.

Implications of Findings for Nursing

This research is a pioneering effort to quantify patient behaviors using an

amplified version of the Johnson Model for Nursing. The results of this study have

important implications for practice, theory development and research.

First are the implications that relate to the primary objective of this study:

to assess the reliability and validity of the NPH-PCI. The problems of defining and

quantifying psychiatric patient needs and required nursing care are ones that are

continuously faced by nursing administrators. The solution to these problems can

be optimized with data provided by patient classification systems that are well

tested for reliability and validity. However, to date there has been no comparable

research found which provides a classification system for psychiatric patients that

addresses the relationship between patient attributes/behaviors and the level of

nursing care the patient requires.

- 130 –

Although parts of the NPH-PCI are not yet fully developed, the value of the

NPH-PCI as a clinical tool to assess patient behaviors for the purpose of planning

nursing care is clear. It has provided practitioners with a framework to describe

clinical phenomena and to evolve domains for nursing practice. The utilization of a

single model of nursing has enhanced staff communication and agreement regarding

identified patient problems. It has immeasurably increased the systematic

assessment of patient behaviors by both professional and nonprofessional staff of

diverse educational backgrounds and clinical experiences.

The further development of the NPH-PCI is dependent upon the refinement

and testing of theoretical concepts of Auger-Grubbs interpretation of the Johnson

Model. With further research, the NPH-PCI will enhance its position as a valuable

administrative tool to quantify patient behaviors and accurately predict the level

of care each patient will require. Such an instrument will have direct benefits for

hospital administration in general and nursing administration in particular. The

most important of these benefits are: (1) the development of nursing interventions

based on patient outcome criteria; (2) the development of nursing workload indices

based on patient care needs; and (3) the identification of nursing care costs for

fiscal management.

Second are the implications that relate to the value of testing theory to

determine whether there is congruence between the idea of reality which the

theory suggests and the empirical evidence of that reality. The building of a

scientific knowledge base occurs through repeated testing of theories to

substantiate professional practice.

The major utility of the Johnson Model thus far has been in the assessment

phase of the nursing process; to date, there has been no research found that

- 131 –

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addresses the predictive elements of the Johnson Model for determining levels of

nursing care. With further development and research, it is anticipated that the

NPH-PCI based on the Johnson Model will achieve a higher degree of reliability

and validity. The validation of this model for nursing has direct benefits for

practice. The model will provide nurses with a framework not only to describe

phenomena, but also to explain, predict and control clinical phenomena for the

purpose of achieving desired patient outcomes. Levels of nursing care provided for

the patient can then be more purposeful, and nursing practice more meaningful to

the practitioner.

Finally, there are the implications that relate to the availability of sound

measures used to test the theoretical formulations underlying nursing practice and

methods that promote the study of complex behaviors. The emphasis for nursing

research should be on the systematic method of inquiry, the use of advanced

quantitative data analysis techniques for theoretical model testing and the

development of new methods and strategies to increase the precision, accuracy and

sensitivity of measurement systems.

- 132 –

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- 141 –

Appendix A

NPH-Patient Classification System

- 142 -

;|!*

UCLA NEUROPsyc++iatric Institute HospitaLa CLINKCs

nursing service

criteria For categorization of NURSING CARE REQUIREMENTS

Patient Ber-viors Nursing interventions

Behaviors that are:

a. Appropriate to developmentalstage;

b. Adaptive to environment.

Maintain and support healthy, develop-entally appropriate behaviors.

Reinforce independent behaviors inadaptive areas.

e tºes. The Regents of the University of Caniornia

Provide general supervision.Behavioral Subsystems that are currently inactive.

Physical Health status: Normal/orchronic health problem to which patientis fully adjusted.

Behaviors that are: Provide moderate/periodic supervision.

a. Inconsistent; Maintain behavioral programs/treatmentplans designed to modify maladaptive

b. In process of being learned; behaviors and maintain new adaptivebehaviors.

c. May or may not be appropriateto developmental stage; structure environment as needed to pro

I. vide limits on behavior.d. Maladaptive to the environment.

Provide care in the context of groupPhysical Health status: Chronic or settings.acute health problem of minor significance: e.g. cold. Provide nursing care appropriate to

illnesses and handicaps.

Implement medical treatment regime.

Behaviors that are: provide direct supervision.

a. Severely maladaptive to the Imple-ent behavioral programs/treat-entenviron-ent; plans to modify maladaptive behaviors.

b. Not appropriate to developmental Initiate teaching of new behaviors.stage.

Reinforce adaptive behaviors.Physical Health Status: Chronic or acutehealth problem of major significance: III structure environment to provide limite.g. seizures. on behaviors.

I-ple-ent medical treat-ent regime.

Provide intensive nursing care appropriate to illnesses and handicaps.

Critical activities: new admissions,Seclusion & Restraint, Ect.

Care provided on a 1:1 basis basedCategory III behaviors in one or more on category III patient behaviors ofsubsystems of acute intensity, duration acute intensity, frequency and/orand/or frequency. ºv duration.destructive acts and aggression towardother-. Care provided on a 1:1 basis for the

protection of patient.

Auger/De- 12/83 Page 1

– 143 –

$US$YSTEM: INGESTIVE

(FOOD/FLUID NTAKE, SENSORY INPUT: PERCEPTION)

PATIENT DEHAMORS MURSING INTERVENTIONS

1. Ingests sufficient food/fluids to maintain body weight within 10% of normal.

2. Ingests food/fluids at regular intervals.

3. Uses eating/drinking skills consistently.

4. Selects appropriate foods:a. Based on nutritional requirements;b. 8ise of portions.

5. Aware of physical/social environments:a. Maintains acceptable distance from

others;b. Orientation to time and place;c. Utilises visual/auditory attending

skills.

1. General supervision at meal times.2. Provide food/fluids between meals on

request.Provide alternative settings for ingestive activities: e.g. parks,beach.

Encourage participation in food preparation activities with general supervision.

5. Provide enriched physical, emotionaland social milieuta. Privacy and personal space;b. Leisure time materials;c. Cultural and current events.

3

4.

1. Ingests insufficient food/fluids resultins in body weight losséloz of normal.

2. Ingests food/fluids resulting in bodyweight gain?lor of normal.

3. Ingests food/fluids at irregular intervals.

4. Uses eating/drinking skills inconsistently: e.g. incorrect use of utensils.

5. Restricted/limited food choices.6. Interprets significance of events

inconsistently and inaccurately.7. Difficulty in distinguishing between

events happening in mind/dreams asopposed to external reality.

8. Difficulty in maintaining social andphysical boundaries as distinct fromthose of other people.

1. Refuses or fails to ingest food/fluids,2. Ingests insufficient food/fluids result

ing in body weight loss,”0% of normal.3. Ingests food/fluids resulting in body

weight gain;"zoz of normal.4. Unable or fails to use eating/drinking

skills: e.g. chewing or swallowingproblems.

5. Unaware of physical/social environments:e.g. self-stimulation behavior.

6. Ingests substances potentially harmfulto health: alcohol, drugs, laxatives.

7. Unable to interpret significance ofevents.

8. Unable to distinguish between eventshappening in mind/dreams as opposed toexternal reality.

9. Unable to maintain social and physicalboundaries as distinct from those ofother people.

10. Lack of awareness of personal space.

One or more Category III behaviors ofacute intensity, frequency and/orduration.

IV

1. Periodic supervision at meal times.2. Periodic verbal/physical reinforce

ment for specific eating/drinkingskills.

3. Monitor food selection and consumption.4. Supervise in alternative settings for

eating activities.5. Allow limited participation in food

preparation activities.6. Periodic orientation to staff, daily

activities and unit routine.7. Provide emotional support, counseling

during and following stressful situations.

8. Periodic verbal/physical reinforcementto assist in establishment of socialand physical boundaries.

9. Clarify interactions with others.10. Administer medication as prescribed.

1 Direct supervision & teaching at mealtimes to develop adaptive behaviors.

2. Assist with food/fluid intake betweenmeals.

3. Direct supervision in alternativesettings.

4. Implement treatment plan to developattending skills: e.g. eye contact.

5. Provide frequent orientation to time,place and daily activities.

6. Monitor environment for potentiallyharmful substances/objects.

7. Provide emotional support and counseling to assist in interpretation ofevents.

8. Provide emotional support during andfollowing stressful situations including removal from immediate situations.

9. Provide direction, reality orientation,and support when unable to distinguishreality.

10. Structure environment to provide verbal and physical limits on maladaptivebehaviors.

11. Administer medication as prescribed.

Level III care provided on a 1 : 1 basis.

t 1985 The Regents of the University of CaliforniaPage 2

– 14! -

$US$YSTEM, EUMINATIVE(PATTERN OF ELMINATION: HYGENECARE)

Partent GEMAvtoRº NURGING INTERVENTIONS

1. Total bowel and bladder control. 1. General supervision of elimination and2. Established pattern of elimination. hygiene activities.3. Disposes of body wastes in sanitary 2. Monitor pattern of elimination and

way: e.g. disposal of feces, urine, menstruation.menstrual pad/tampons, nasal 3. Observe for potential disruption indischarge, saliva, perspiration. pattern of elimination.

4. Washes hands following eliminativeactivities.

º

1. Partial/periodic bowel control. 1. Periodic verbal/physical reinforcements2. Partial/periodic bladder control. for elimination.3. Disruption of established pattern 2. Periodic verbal/physical reinforcements

of elimination resulting from and assistance for specific hygieneacute illness, poor eating habits tasks: e.g. handwashing, menstrualor excessive use of laxatives. care,

4. Disposes of body wastes incon- 3. Reinforce successful elimination.sistently: 4. Provide medications as prescribed bya. Fails to flush toilet; physician to alleviate eliminationb. Fails to wipe self following B.M. problems: e.g. antacids, analgesics

5. Lacks adequate knowledge of hygiene º for menstrual cramps.and menstrual care. 5. Monitor disrupted elimination patterns;

e.g. intake and output.6. Implement treatment plan to maintain/

reinforce established pattern of elimination: e.g. toileting schedules.

7. Provide minimal teaching of hygienec-re.

8. Administer medication as prescribed.

1. Absence of bowel control. 1. Implement treatment plan to establish2. Absence of bladder control. pattern of elimination: e.g. toilet3. Severe disruption of established training.

pattern resulting in potential 2. Total care of eliminative needs; e.g.dehydration: e.g. vomiting, diaper care, colostomy care, drains.diarrhea, diaphoresis. 3. Teach self-care, independent skills

4. Fails to dispose of body wastes in related to hygiene, eliminative tasks.sanitary manner: e.g. fecal 4. Direct supervision of hygiene care.smearing. 5. Attend closely to changes in elimina

tion pattern for signs and symptomsII. of physical problems.

6. Administer medication as prescribed.

One or more Category III behaviors Level III care provided on a 1:1 basis.of acute intensity, frequency IVand/or duration.

Page 3*** The Regents of the University of California

- 145 -

SUBSYSTEM: DEPENDENCY

(BASIC SELF-CARE, EMOTIONAL SECURITY)

PATIENT BEHaviors Nursing interventioxº

1. Performs own self-care activities: 1. Provide environment to facilitate in

e.g. bathing, hair washing, oral dependent performance of hygiene,hygiene. grooming activities and maintenance

2. Performs own self-care within a of personal belongings.reasonable length of time. 2. Provide assistance when requested.

3. Maintains personal belongings: e.g. 3. Reinforce independent behaviors.clothing, toiletries. 4. Provide information/explanations in

4. Seeks assistance when needed. preparation for separation related to5. Adjusts to separation from signifi- I hospitalization or placement.

cant others with ease. 5. Provide information regarding impend6. Makes decisions with comfort. ing changes in the milieu.7. Relies on own resources when appro

priate.8. Questions decisions of others when

indicated.

9. Engages in appropriate situationalattention seeking behaviors.

10. Adapts to change in milieu.

1. Requires assistance with bathing, 1. Assist in hygiene/grooming activities:hair washing, and/or oral hygiene. a. Provide periodic verbal/physical

2. Requires assistance with maintenance reinforcements;of personal belongings. b. teach area(s) of deficit.

3. Requires assistance with grooming 2. Provide or limit assistance when indiactivities. cated.

4. Does not seek assistance when needed. 3. Assist in identifying areas where help5. Seeks istance when not needed. is needed.

6. Separates from significant others with 4. Encourage discussion of loss/separadifficulty: e.g. whining, clinging. tion and assist in resolution.

7. Verbalises feelings of hopelessness 5. Periodic verbal/physical reinforceand helplessness. I. ments for independent decision making.

8. Relies periodically on others for 6. Maintain treatment plan to reduce ordecision making. extinguish persistent help seeking/

9. Reluctant to act without directives. attention seeking behaviors.10. Questions or rejects decisions of 7. Promote adaptation to change by:

others in authority frequently. a. Structuring environment;ll. Engages in appropriate situational b. Allowing participation in small

attention seeking behaviors inconsis- group meetings.tently.

12. Experiences difficulty in adaptingto change within milieu.

1. Unable to perform self-care activities: 1. Provide total assistance in self-caree.g. bathing, hair washing, oral activities that cannot be performedhygiene. independently.

2. Unable to complete own grooming/dressing. 2. Teach requisite skills.3. Unable to care for personal belongings. 3. Provide supervision and directives in4. Lack of awareness of need for assistance. area(s) of deficit.5. Experiences excessive difficulty when 4. Assist in identification and recogni

separating from others, or fails to tion of need for assistance in:respond to separation from others. a. Area(s) of skill/knowledge deficit;

6. Preoccupied with feelings of hope- b. Acute/chronic/progressive disabililessness and helplessne | ties.7. Questions or rejects decisions of 5. Provide structured activities toothers in authority constantly. encourage expression of feelings re

8. Relies on others for decision making garding separation, hopelessness, helpexclusivelyt e.g. with adults & peers. lessness: e.g. music, art, drama, etc.

9. Refuses to act without directives. 6. Implement treatment plan to develop10. Engages in negative attention independent decision making.

seeking behaviors. 7. Implement treatment plan to reduce or11. Resistant to change in milieu. extinguish negative attention seeking

behaviors.8. Promote adaptation to change by plan

ning and limiting number of changes.

One or more Category III behaviors of Level III care provided on a 111 basis.acute intensity, frequency and/or IVduration.

Page 4c 1965 The Regents of the University of California

- 146 –

$UCSYSTEM}: ACC00 V LM INT

(MASTERY OF SELF AND ENVIRONMENT)

Selects goals from alternative possibilities.

and completes tasks.Utilises problem-solving abilitiesto initiate and/or complete goaldirected activities.Organises group activities of asocial and/or work oriented nature.

4.

1. Provide opportunity for, and reinforee independent decision making.

2. Maintain abilities to acquire skillsand knowledge by providing challenging learning experieeces.

3. Provide environmental conditionsfor initiation and completion of goaldirected activities.

© 1965 The Regents of the University of California

5. Identifies and accepts strengths and [. 4. Provide opportunity for participationweaknesses in self and others; con- in competitive and cooperative actiºpetes according to these personal vities.factors. 5. Support efforts to improve area(s) of

weakness and maintain strengths.

1. Identifies available alternatives 1. Promote decision making by limitingbut unable to select a goal. number of alternatives.

2. Unable to identify realistic goals. 2. Provide direction in sequisition of3. Selects choices from limited range skill/knowledge.

of alternatives: e.g. two choices. 3. Provide direction for task completion4. Attention span limited: easily dis- by establishing specific steps and/or

tracted. time frames for completion.5. Utilises problem-solving skills in- 4. Structure competitive and cooperative

consistently. activities to permit experience of6. Initiates achievement activities success and provide support when

but fails to complete tasks or coa- EU failure occurs.pletes without optimal use of 5. Promote acceptance of success/failure

| problem-solving skills. of others.7. Limited awareness of strengths and 6. Give simple directions to facilitate

weaknesses of self and others. comprehension of instructions.8. Follows simple directions.

1. Unable to determine goals or identify 1. Provide direct supervision for taskalternatives. completion and assist in problem

2. Does not utilise cognitive abilities solving process.to acquire knowledge. 2. Select alternatives and identify

3. Does not accept direction from goals.others. 3. Identify strengths and weaknesses and

4. Lack of problem-solving skills: e.g. provide opportunity for utilisingengages in repetitive, rote tasks. acquired skills.

5. Lack of awareness of strengths and 4. Limit experiences of failure; provideweaknesses of self and others. opportunity for successful

6. Seeks unrealistic modes of competi- | experiences.tions with repeated experience of 5. Give instructions on very basic level.failure. 6. Assist in completion of tasks: e.g.

7. Limits self to experiences/tasks homework, projects.with guaranteed success. 7. Implement treatment plan to promote

8. Unable to accept responsibility for development of achievement skills.failure. 8. Assist in examining causes for failure

9. Fails to complete tasks. and resolution of feelings.10. Unable to perform tasks/skills appro

priate to developmental stage.

One or more Category III behaviors of Level III care provided on a 1:1 basis.acute intensity, frequency and/or IVduration.

Page 5

– 147 –

sussystEM, AFFILiarivº(DEVELOPMENT OF RELATIONSHIPS, COMMUNICATION SKILLS)

PATENT LENAMORS

1. Establishes and maintains emotional

attachments with significant others.2. Establishes and maintains interper

sonal relationships on an individualbasis with staff and/or peers.

3. Establishes and maintains interpersonal relationships in groupsettings.

1. Maintain effective communication,including spontaneous/plannedinteractions.

2. Encourage expression of feelings.3. Provide opportunities for individual/

group interactions with a variety ofpersons.

4. Support development and maintenance

e 1985 The Regents of the University of Cantornia

4. Communicates effectively: verbal, l of friendships and familynon-verbal, in writing. relationships.

5. Expresses positive and negativefeelings with comfort and as appropriate.

6. Affect congruent with content.

1. Difficulty in forming emotional 1. Provide specific time for establishingattachments to significant others. staff/peer relationships.

2. Establishes and/or maintains 2. Maintain treatment plan to facilitatelimited relationships with staff group participation.and/or peers. 3. Provide periodic prompts/reinforce

3. Relates in superficial or inappro- ment of effective patient communicapriate manner: e.g. teasing, inter- tion.rupting. 4. Maintain treatment plan to facilitate

4. Establishes and maintains limited interactions of patient with familyrelationships in group settings/ and significant others.activities. |

5. Difficulty in communicating ideasand feelings: verbal, non-verbalwritten.

6. Initiates and maintains communication infrequently and/orineffectively.

1. Absence of emotional attachment with 1. Provide regular, intensive 1 1 1 interothers; or excessive, intense actions to establish relationship.attachments. 2. Implement treatment plan to increase

2. Fails to establish or maintain rela- frequency of interactions with staff/tionships on an individual basis. peers.

3. Fails to establish or maintain rela- 3. Implement treatment plan to increasetionships in group interactions. participation in group activities.

4. Fails to initiate/maintain effective 4. Limit contact with family when indicacommunication: verbal, non-verbal ted; provide information regardingor in writing. denial of rights.

5. Indiscriminate attachment to others. | 5. Implement treatment plan to develop6. Unable to express positive/negative basic communication skills and role

feeling states in direct manner: e.g. model interactional techniques.denial of feelings. 6. Assist in identification and expres

sion of positive/negative feelings.

|

One or more Category III behaviors of Level III care provided on a 1 11acute intensity, frequency and/or V basis.duration.

Page 6

– 148 -

$USSYSTEMI; AGGRESSIVE-PROTECTIVE

(PROTECTION OF SELF FROM POTENTVAL/REAL HARM)

Pºrtºn GEMAMMOR$ NURSING INTERVENTIONS

I Identifies and avoids potentialhasardous/dangerous situations inenvironment to self and others.

. Create and maintain a safe environment.Monitor environment for potentiallyhazardous situations.

2. Selects appropriate verbal/ 3. Assess and reinforce adaptive copingnonverbal response to potentially strategies for identifying and avoidhazardous or dangerous situations. ing potentially hazardous and dangerous

3. Maintains control over actions in situations.

stress-producing situation. 4. Provide support when indicated.4. Elicits support from others if

needed.

1. Identifies obvious dangers but not 1. Assist in identifying subtle environsubtle cues of potential harm. mental/internal cues associated with

2. Fails to anticipate dangerous situa- potentially dangerous situations.tions. May be involved in frequent 2. Teach alternative methods for protectaccidents. ing/defending self; includes assertion

3. Selects indirect verbal/nonverbal training, self defense techniques.response to threat. 3. Continuously reinforce coping strate

4. Selects response to threat that ‘gies when present.contains potential for self injury 4. Establish environmental controls whenof minor magnitude. necessary to protect or defend patient.

5. Unable to consistently identify or I 5. Teach identification of, and verbalcontrol one's reactions to stress. expression of anger/frustration.

6. Wanders away from unit or group. 6. Administer medication as prescribed.

1. Lack of awareness of potentially 1. Provide environmental controls to prohasardous situations, or per- tect/defend patient from dangerousceives many situations as situations by:dangerous. a) Medications:

2. Engages in intense/frequent act- b) Locked door;

3. *: behaviors. 1 f d § Seclusion;. Fails to protect self in danger- D) Restraints.ous situations. 2. Closely monitor patient/environment

4. Demonstrates phobic behavior(s). for potentially hasardous situations:5. Selects inappropriate/inadequate e.g. sharp objects, toxic substances.

response to threat. 3. Implement treatment plan to assist in6. Lack of awareness of cause and II. development of internal controls.

effect. 4. Provide direct supervision to assist7. Refuses to remain on unit or with in selecting appropriate response to

group: e.g. elopement (AWOL) threat.8. Selects response to threat that 5. Administer medication as prescribed.

contains potential for self injuryof major magnitude.

One or more Category III behaviors Level III care provided on a 1:1of acute intensity, frequency IV basis.and/or duration.

Page 7c 1965 The Regents of the University of California

– 149 –

$ULSYSTEMI; $EXUAL

(KNOWLEDGE: BEHAVIOR)

PATIENT SEMAMMOR8 NURSING INTERVENTIONS

1. Verbalizes knowledge of one's ownanatomy and physiology.

2. Distinguishes between males andfemales in regards to:a) Self:b) Others.

3. Engages in socially accepted formsof sexual behavior; masturbates inprivate.

1. Model appropriate sex-role behaviors.2. Reinforce socially adaptive sex-role

behaviors.

3. Provide privacy.4. Clarify information and explore feel

ings regarding sexual behavior.

4. Werbalizes and demonstrates comfort Iwith own body and physical changes:a) Body posture:b) Grooming, dress.

5. Accepts own gender identity asexpressed in body movements,clothing and gestures.

1. Lacks adequate knowledge of anatomy/ 1. Clarify misconceptions and providephysiology; or has misconceptions. information to correct area(s) of

2. Discriminates own sexual identity deficient/absent knowledge. Teachbut not that of others (or vice in group setting.versa). 2. Teach alternative ways of dealing

3. Aware of, but fails to use socially with sexual approaches.acceptable forms of sexual behavior: 3. Periodic reinforcement of sociallye.g. exploring, touching others, adaptive behaviors.dressing provocatively. 4. Instruct in use of privacy.

4. Expresses verbally and nonverbally 5. Encourage expression of feelings offeelings of discomfort with body | discomfort/acceptance of one's body.and physical changes, include diet 6. Teach new materials through use ofrestriction to prevent body change. films, lectures, books.

5. Aware of gender identity difference 7. Identify body changes and assist inbut does not demonstrate acceptance process of adjustment.of gender identity in gesture ordress.

6. Unable to discriminate betweensexual and non-sexual approachbehaviors. -

1. Minimal or no knowledge of own 1. Comprehensive teaching to deal withanatomy and/or physiology. fantasies, fears and lack of knowledge.

2. Unable to discriminate between 2. Intensive emotional support/counselingmales and females. regarding sexual behavior/experiences

3. Fails to engage in socially of self and others.accepted sexual behavior: e.g. 3. Implement treatment plan to modify spetouching others excessively, cific sexual behavior including use ofexposing genitals and mastur- privacy.bating in public. 4. Provide feedback and assist in accept

4. Denies body change. ance of body changes.5. Fails or refuses to accept own BLE 5. Establish limits for sexual behavior

gender identity by engaging in and assist in identification of inactivities associated with appropriate behavior.opposite gender: e.g. dresses inclothing of opposite sex,verbalizes incorrect genderidentity.

6. Provokes sexual contact withinappropriate partner.

One or more Category III behaviors Level III care provided on a lilof acute intensity, frequency IV basis.and/or duration.

Page 8© 1985 The Regents of the University of California

- 150 -

$US$YSTEM; RESTORATIVE

(SLEEPBEHAVIOR; RECREATION, RESPONSE TO LLNESS)

Pºrtºn GEMAMMORS

1. Mormal sleep patterns, includingease of onset, maintenance ofsleep for adequate rest.

2. Engages in balanced variety ofphysical/mental recreational

. General supervision at bedtime.Arrange for a balanced variety ofrecreational activities.

. Observe and monitor daily patternsof activity.

activities. 4. Illness:

3. Participates in organized social a) Provide safe physical environment:groups. s b) Support selection of activities

4. Regulates patterns of activity appropriate to health status:according to physical/mental c) Provide medication/supplies/requirements. treatment as prescribed by

5. Participates in prescribed physician;treatment regime. d) Monitor physical status including

height, weight and immunisations.

1. Abnormal sleep pattern, including 1. Structure nighttime routine toperiodic awakenings at night; facilitate settling down.settling difficulties. 2. Monitor sleep patterns for nighttime

2. Engages in limited number and/or awakenings.range of recreational activities: 3. Periodic reinforcement of participae.g. all sedentary activities; tion in group activities.solitary play. 4. Provide environmental structure and

3. Engages in inconsistent pattern direction to regulate patterns ofof activities. activity; provide rest time when

4. Experiences difficulty in adapting º needed.activity level to limitations. 5. Periodic supervision, direction

5. Participates inconsistently in required for basic health behaviors.prescribed treatment regime. 6. Provide physical interventions for

injuries/minor illnesses.7. Administer medication as prescribed.

1. Sleep disruptions and disturb- 1. Direct supervision/close observationances resulting in minimal hours of sleep patterns throughout night.of sleep. 2. Direct supervision of recreational

2. Fails to engage in recreational activity patterns.activities. 3. Initiate activities for patient

3. Sleeps during waking hours: e.g. participation.daytime. 4. Structure daily routine to allow for

4. Participates in activity to a variety of activities throughout day.excessive degree, resulting in 5. Establish limits regarding selectionphysical exhaustion and fatigue. of possible activities.

5. Preoccupied with one form of 6. Close observation of physical healthactivity to exclusion of all status.

others. III 7. Provide complex/frequent physical in6. Does not adapt, or chooses to terventions for major illness/injuries:

ignore limitations imposed by e.g. tube feedings.illness or handicaps. 8. Provide extensive, complex teaching

7. Refuses to participate in pre- program for health problems: e.g.scribed treatment regime. diabetes, seizures.

9. Administer medication as prescribed.

One or more Category III behaviors Level III care provided on a 1:1of acute intensity, frequency IV basis.and/or duration.

Page 9& 1985 The Regents of the University of California

- 151 -

Appendix B

Subsystem Behaviors

- 152 –

Ingestive Behaviors

1.

4.

10.

11.

Eating and drinking skillsa. Consistentb. Inconsistentc. Unable/absence

Ingestion of food and fluids at intervalsa. Regularb. Irregular

Food choices

a. Appropriateb. Restricted

Awareness of social/physical environmenta. Normal awarenessb. Limited awarenessC. Lack of awareness

Sensory perceptiona. Normal

Ingestion of substancesa. Harmful

Interpretation of eventsa. Limited abilityb. Unable to interpret

Awareness of social/physical boundariesa. Limited abilityb. Unable to sense

Distinguishing of eventsa. Limited abilityb. Unable to distinguish

Frequency of intakea. Adequateb. FrequentC. Continuous

Sufficiency of intakea. Adequateb. Inadequatec. Insufficientd. Absence

- 153 -

Appendix CBehavior Criteria

Category Checklistof Corresponding

Behavior Item #

I 21;II 17III 1 l;

I 16II | 1

I 23II 3

I 22II 19III 15

I l

III 9

II 21III 18

II l;III 7

II 10III 25

I 13II 20III 5

I 6II 12II 8III 2

*.- -

Eliminative Behaviors

Bowel controla. Totalb. Partialc. Absence

Bladder controla. Totalb. Partialc. Absence

Pattern of eliminationa. Established

b. Disruptedc. Absence

Disposal of body wastesa. Sanitaryb. Inconsistent

C. Unsanitary

Hygiene Carea. Washes self

b. Lacks adequate knowledge

Appendix CBehavior Criteria

Category Checklistof Corresponding

Behavior Item #

I 11II 3III l;

I 11II 14III 2

I 5II lIII 12

I 10II 13III 6

I 7II 9

- 154 –

t

*

* -

º

Affiliative Behaviors

1.

5.

6.

7.

Emotional attachments

a. Appropriateb. Delayed abilityc. Indiscriminated. Absence

Interpersonal relationships with individualsa. Appropriateb. Limitedc. Fail to establish

Interpersonal relationships with groupsa. Appropriateb. Limitedc. Failure to establish

Adaptation to changea. Able to adaptb. Difficulty in adaptingc. Resistant to change

Communicating ideas: verbally, nonverbally andin writinga. Effective

b. Limited abilityC. Engage infrequentlyd. Fail to initiate

Expresses feelingsa. Appropriateb. Superficialc. Unable to express

Awareness of personal spacea. Appropriateb. Lack of awareness

Appendix CBehavior Criteria

Category ChecklistOf Corresponding

Behavior Item #

I 18II 14III lIII 3

I 13II 9III 19

I l;II 8III 17

I | 1II 15III 12

I 21II 10II 20III 6

I 7II 16III 22

I 2III 5

- 155 -

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is

Dependency BehaviorsAppendix C

Behavior Criteria

Category Checklistof Corresponding

Behavior Item #

1. Self-care activities

a. Able to perform I 14b. Performs in reasonable time I 16

c. Requires assistance with bathing II 20d. Requires assistance with grooming II 17e. Unable to perform III 5f. Unable to complete III 8

2. Care of personal belongingsa. Able to care I 18

b. Requires assistance II 19c. Unable to care III 6

3. Seeks assistance

a. Appropriate I 28b. Seeks when not needed II 27c. Fails to seek II ld. Lack of awareness of need III 24

4. Relies on own resources

a. Appropriate I 7b. Reluctance II 11c. Refuses to act III 12

5. Decision-making abilitya. Appropriate I 29b. Periodic reliance on others II 26c. Exclusive reliance on others III 3

6. Separation with easea. Able to adjust I 23b. Separates with difficulty II 21c. Extreme difficulty with separation III 2

7. Feelings of hopelessness/helplessnessa. Verbalizes II 13

b. Preoccupied III l;

8. Questions decision of authoritya. Occasional I 22

b. Frequently II 9c. Constantly III 25

9. Engages in situational attention seeking behaviorsa. Appropriate I 15b. Inconsistent II 10

c. Inappropriate III 30

- 156 -

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Sexual Behaviors

1.

5.

Knowledge of own anatomy/physiologya. Verbalizes

b. Lacks knowledgec. Minimal/no knowledge

Distinguishes between males and femalesa. Able to distinguishb. Distinguish self but not othersc. Unable to discriminate

Engages in socially acceptable behaviora. Appropriateb. Aware, but fail to engageC. Inappropriate

Comfort with body/physical changesa. Appropriateb. Expresses discomfortc. Denies changes

Acceptance of gender rolea. Appropriateb. Aware, but fails to demonstratec. Refuses to accept

Distinguish between sexual/nonsexual approachbehavior

a. Inability to discriminateb. Provokes sexual contact

Appendix CBehavior Criteria

Category Checklistof Corresponding

Behavior Item #

I 12II 8III 2

I 17II 6III 1 l;

I 13II lIII 3

I 5II 9III 7

I 11II 16III l;

II 10III 15

- 157 -

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Aggressive-Protective Behaviors

3.

4.

7.

Identifies/avoids hazardous situationsa. Avoids potential hazardsb. Identifies obvious hazards

c. Fails to anticipated. Lack of awareness

e. Unable to protect self

Selects response to threat/dangerous situationsa. Appropriateb. Inappropriatec. Unable to control

Response to threat with self-injurya. Minor injuryb. Major injury

Engages in acting out behaviorsa. Intense acting out

Ability to maintain controla. Appropriateb. Inconsistent

Phobic behaviora. Demonstrates

Separation from groupa. Wanders awayb. Elopes

Appendix CBehavior Criteria

Category Checklistof Corresponding

Behavior Item #

I 11II 6II 1 l;III l;III 7

I 9II 10III 2

II 13III 17

III 3

I 1II 12

III 8

II 5III 16

– 158 -

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Achievement Behaviors

1.

3.

5.

10.

Experiences success and failuresa. Repeated failuresb. Limits self to guaranteed successesc. Unable to accept failure

Chooses alternatives

a. Limited range

Selects goals from alternativesa. Able to select

b. Identifies, but not selectc. Unable to identifyd. Unable to identify or select

Initiates and completes tasksa. Able to initiate and completeb. Initiates, but does not completec. Fails to completed. Unable to perform

Utilizes problem-solving skillsa. Appropriateb. Inconsistent

c. Lack of problem-solving skills

Identifies, accepts strengths and weaknessesa. Able to acceptb. Limited abilityC. Lack of awareness

Attention spana. Limited abilityb. Short span

Organizes groupsa. Able to

Accepts directionsa. Does not acceptb. Follows simple directions

Utilizes cognitive abilitiesa. Does not use to acquire knowledge

Appendix CBehavior Criteria

Category Checklistof Corresponding

Behavior Item #

III 23III 13III 5

II 21

I 6II 17II 22III 19

I 12II | 1III 9III 15

I 18II lIII 16

I 10II 8III 20

II 7III 3

I l;

I 2II 1 l;

III 21;

- 159 -

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Restorative Behaviors

3.

4.

5.

Sleep patternsa. Normal

b. Periodic awakeningsc. Sleeps during daytimed. Sleep disruptions

Engages in recreational activitiesa. Balanced recreational activities

b. Engages inconsistentlyc. Fails to engaged. Engages excessively

Involvement in range of activitiesa. Limited

b. Exclusive preoccupation

Participates in treatment regimea. Appropriateb. Inconsistentc. Refuses

Regulates activity according to physicalrequirementsa. Appropriateb. Experiences difficultyc. Ignores limitations

Participates in organized social groupa. Appropriate

Appendix CBehavior Criteria

Category Checklistof Corresponding

Behavior Item #

I 11II 9III 2III 8

I 7II 12III 16III 13

II 14III 5

I 10II 6III l;

I lII 15III 3

I 17

- 160 —

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Appendix C

Behavior Criteria Checklist

- 161 –

BEHAVIORAL CRITERIA CHECKLIST

NAME OFRESPONDENT CLASS/OBSERVER

DATE UNIT TIME COMPLETED

INGESTIVE SUBSYSTEM

1 Normal sensory perception.2. Absence of food/fluid intake. Refusal or failure to eat.3. Restricted/limited food choices.4. Limited ability to sense mental and physical boundaries as distinct from those

of other people.5. Continuous eating/drinking resulting in weight gain 220% normal weight.6. Adequate food/fluid intake to maintain weight within 10% of normal body

weight.7. Unable to sense mental and physical boundaries as distinct from those of other

people.8. Insufficient food/fluid intake resulting in weight lossº 20% normal weight.9. Ingestion of substances potentially harmful to health: drugs, laxatives,etc.

10. Limited ability to distinguish between events happening in mind/dreams asopposed to external reality.

11. Food/fluid intake at irregular intervals.12. Inadequate food/fluid intake resulting in weight loss? 10% of normal body

weight.13. Meals are completed.

Absence of eating/drinking skills; e.g. chewing and swallowing problems.15. Lack of awareness of physical/social environment: self-stimulation behavior.16. Food/fluid intake at regular intervals.

Inconsistent use of eating/drinking skills: e.g. incorrect use of utensils.. Unable to interpret significance of an event; perceptual distortion.

Limited awareness of physical/social environments.20. Frequent intake resulting in weight gain = 10% normal body weight.21. Limited ability to interpret significance of event; perceptual distortions

elicited mainly in emotionally stressful circumstances.22. Awareness of physical/social environment: self in relation to others;

orientation to time & place; utilizes visual/auditory attending skills.23. Selection of appropriate food based on nutritional requirements & size of

portions.24. Consistent use of eating/drinking skills.25. Unable to distinguish between events happening in mind/dreams as opposed

to external reality.

E.-T1 :4.

ELIMINATIVE SUBSYSTEM

1. Disruption of established pattern of elimination due to acute illness, pooreating habits, excessive use of laxatives.

2. Absence of bladder control.3. Partial/periodic bowel control.4. Absence of bowel control.

5. Established pattern of elimination.

- 162 –

BEHAVIORAL CRITERIA CHECKLIST - continued

l

: .

:

6.7.8.9.

10.

ll.12.

I 3.

4.

;

: .10.

1 I -

17.

: ; :20.21.22.

Failure to dispose of body wastes in sanitary manner; e.g. fecal smearing.Washes hands following eliminative activities.Excessive diaphoresis.Lacks adequate knowledge of hygiene and menstrual care.Disposes of body wastes in sanitary way: disposal of feces, urine, menstrualpads/tampons, nasal discharge, saliva, perspiration,etc.Total bowel and bladder control.

Absence of established pattern of elimination; or disruption of establishedpattern resulting in dehydration.Inconsistent disposal of body wastes: failure to flush toilet; and failure towipe following bowel movement.Partial/periodic bladder control.

AFFILIATIVE SUBSYSTEM

Indiscriminate attachment to others.

Maintains acceptable distance from others.Absence of emotional attachment with others, or excessive, intense attachments.

Establishes and maintains interpersonal relationships in group settings.Lack of awareness of personal space.Failure to initiate/maintain effective communication: verbal, non-verbal andin writing.Expresses positive and negative feelings with comfort and as appropriate.Establishes and maintains limited relationships in group activities.Establishes and/or maintains limited relationships with staff and peers.Limited ability to communicate ideas and feelings: verbally, non-verbally andin writing.Ability to adapt to change in milieu.Resistant to change in milieu or daily routine.Establishes and maintains interpersonal relationships on an individual basis:includes relationships with staff and peers.Unstable, delayed ability to form emotional attachments to significant others.Experiences difficulty in adapting to change within the milieu.Relates in superficial or inappropriate manner: e.g. teasing, interrupting,etc.Failure to establish and maintain relationships in group interactions.Establishes and maintains emotional attachments with significant others.Failure to establish or maintain relationships on an individual basis. 2Initiates and maintains communication infrequently and/or ineffectively.Communicates effectively: verbally, non-verbally and in writing.Unable to express positive/negative feeling states in direct way: denial offeelings.

– 163 –

BEHAVIORAL CRITERIA CHECKLIST - continued

}.

–

: :

10.

; } .13.

19.2 O21.2 223.2 {} º

25.26.27.28.29.

6.

8.

DEPENDENCY SUBSYSTEM

Does not seek assistance when needed.Excessive difficulty when separating from others; or, lack of response toseparation from others.Exclusive reliance on others for decision-making-e-g- adults, peers.Preoccupied with feelings of hopelessness and helplessness.Unable to perform self-care activities: bathing, hair washing, oral hygiene.Unable to take care of personal belongings.Relies on own resources when appropriate.Unable to complete own grooming/dressing.Frequently questions or rejects decisions of others in authority.Engages inconsistently in appropriate situational attention seeking behaviors.Reluctance to act without directives.Refuses to act without directives.

Verbalizes feelings of hopelessness and helplessness.Performs own self-care activities: e.g. bathing, hair washing, oral hygiene.Engages in appropriate situational attention seeking behaviors.Performs own self-care within a reasonable length of time.Requires assistance with bathing, hair washing and / or oral hygiene.Maintains personal belongings: e.g. toys, clothings, toiletries.Requires assistance with maintenance of personal belongings.

. Requires assistance with grooming activities.Separates from significant others with apparent difficulty: whining, clinging.

. Occasionally questions decisions of others.Adjusts to separation from significant others with ease.Lack of awareness of need for assistance.Constantly questions or rejects decisions of others in authority.Periodic reliance on others for decision-making.Seeks assistance when not needed.Seeks assistance when needed.Able to make decisions.

SEXUAL SUBSYSTEM

Aware of, but fails to use socially acceptable forms of sexual behaviors;exploring, touching others; sexually provocative gestures and clothing.Has minimal or no knowledge of own anatomy/physiology.Failure to engage in socially accepted sexual behaviors: excessive touching ofothers; exposing genitals, masturbation in public.Failure or refusal to accept own gender identity by engaging in activitiesassociated with opposite gender: dressing in clothing of opposite sex; verbalizes incorrect gender identity.Verbalizes and behaviorally manifests comfort with own body and physicalchanges in body posture and grooming/dress.Can discriminate own sexual identity but not that of others(or vice versa).Denial of body changes.Lacks adequate knowledge of anatomy/physiology, or has misconceptions.

- 164 -

BEHAWIORAL CRITERIA CHECKLIST - continued

9.

10.ll.

12.13.

= 14.15.16.

l l -

7.

12.13.

4.1

15.16.

=1.2.3.4.5.

Expresses feeling of discomfort verbally and non-verbally with body andphysical changes: includes restricted diet to prevent body changes; avoidanceof dressing in communal setting.

-

Inability to discriminate between sexual and non-sexual approach behavior.Acceptance of own gender identity as expressed in body movements, clothing& gestures.Knowledge of one's own anatomy/physiology.Engages in socially accepted forms of sexual behavior; masturbates in privacy.Unable to discriminate between males and females.Provokes sexual contact with inappropriate partner.Awareness of gender identity difference but does not behaviorally demonstrateacceptance of gender identity.Able to distinguish between males and females in regard to self and others.

AGGRESSIVE-PROTECTIVE SUBSYSTEM

Maintains control over actions in stress producing situations and elicits supportfrom others if needed.Unable to control response to threat.Engages in intense/frequent acting-out behaviors.Lack of awareness of potentially hazardous situations or perceives many situations as dangerous.Wanders away from unit or group.Able to identify obvious dangers, but not subtle cues of potential harm.Unable to protect self in dangerous situations.Development of phobic behavior.Able to select appropriate verbal/non-verbal action in potentially hazardous ordangerous situation: direct response to threat; neutralizes source of threat;withdrawal; protecting oneself, or others.

-

Selects verbal/nonverbal action for response to threat in indirect way; actionnot directed toward source of threat.

Able to identify and avoid potential hazardous/dangerous situations in environment to: self and others.

Unable to consistently identify or control one's reactions to stress.Selects response to threat that contains potential for self-injury of minormagnitude.Unable to predict potential danger beforehand, but able to do so once insituation. May be involved in frequent accidents.Lack of awareness of cause/effect.Refuses to remain on unit or with group:e.g. elopement risk.

ACHIEVEMENT SUBSYSTEM

Utilizes problem-solving abilities inconsistently.Does not accept direction from others.Short attention span.Organizes group activities of a social and.or work oriented nature.Unable to accept failure.

– 165 –

BEHAVIORAL CRITERIA CHECKLIST - Continued

17.

Able to select goals{identify and select from alternative possibilities).Attention span limited: easily distracted.Limited awareness of strengths and weaknesses of self and others.Fails to complete tasks.

-

Able to identify and accept strengths and weaknesses in self and others andcompete according to these personal factors.Utilizes skills to initiate achievement behaviors, but either fails to completetask or completes without optimal use of problem-solving skills.Able to initiate and complete tasks.Limits self to experience/tasks with guaranteed success.Follows simple directions.

-

Unable to perform tasks/skills appropriate to developmental stage.Lack of problem-solving skills. Engages in repetitive, rote tasks.Able to identify available alternatives but cannot select one goal.Utilizes problem-solving abilities to initiate and/or complete goal-directedactivities.

Unable to determine goals or identify alternatives.Lack of awareness of strengths and weaknesses of self and others.Able to make choice from limited range of alternatives: e.g. two choices.Unable to identify realistic goals.Seeks unrealistic modes of competition with repeated experience of failure.Does not utilize cognitive abilities to acquire knowledge.

RESTORATIVE SUBSYSTEM

Able to regulate patterns of activity according to physical and mental requirements.Sleeps during daytime.

-

Does not adapt to or chooses to ignore limitations imposed by illness orhandicaps.Refuses to participate in prescribed treatment regime.Exclusive preoccupation with one form of activity to exclusion of all others.Inconsistent participation in prescribed treatment regime.Engages in a balanced variety of physical/mental/ recreational activities.Sleep disruptions and disturbances resulting in minimal hours of sleep.Abnormal sleep pattern, including periodic wakenings at night; settling difficulties.

Participates in prescribed treatment regime.Normal sleep patterns, including ease of onset, maintenance of sleep foradequate rest.Inconsistent pattern of activities.

. Participates in activity to excessive degree resulting in physical exhaustion/fatigue.Engages in limited number of recreational activities; may also be a limitedrange of activities such as all sedentary activities; solitary play.Difficulty in adapting activity level to limitations.Fails to engage in recreational activities.Participates in organized social groups.

- 166 -

BEHAVIORAL CRITERIA CHECKLIST- continued

II. RATE THE OBSERVED LEVEL OF PATIENT BEHAVIOR FOR EACH OF THESUBSYSTEMS LISTED BELOW.

-

1. INGESTIVE 5.SEXUAL

2. ELIMINATIVE 6-AGGRESSIVE-PROTECTIVE

3. AFFILIATIVE 7.ACHIEVEMENT

4. DEPENDENCY 3.RESTORATIVE

OVERALL LEVEL OF PATIENT BEHAVIOR

- *-

- 167 -

Appendix D

Summary Statistics of Patient Behaviors

- 168 -

tº is tº i■ . . is cºiºit 12 tº

Standard Coefficient of

Patient Behaviors Mean Deviation Variation (%)

IngestiveEating and drinking skills .63 .76 120

Ingestion of food and fluids at intervals .42 .64 150

Food choices . 5l; .82 151

Awareness of social/physical environment 1.02 1.04 102

Sensory perception ... l;7 . 50 105

Ingestion of substances .08 ... l;9 599

Interpretation of events .95 1. 30 136

Awareness of social/physical boundaries .76 1. 16 153

Distinguishing of events . 50 1.01 201;

Frequency of intake .61 .67 109

Sufficiency of intake ... l;9 .72 1 l;7

Eliminative

Bowel control .73 .66 90

Bladder control .75 .68 90

Pattern of elimination .73 . 59 80

Disposal of body wastes .68 .96 1 l;0

Hygiene care . 52 .79 152

Affiliative

Emotional attachments 1. l;9 1. 38 91

Interpersonal relationships with individuals 1. 50 1. 17 78

Interpersonal relationships with groups 1.73 1.08 62

Adaptation to change 1. 52 1.25 83

Communicating ideas 1.65 1. 17 71

Expression of feelings 1.82 1. 32 73

Awareness of personal space 1.27 1.25 98

- 169 –

Standard Coefficient of

Patient Behaviors Mean Deviation Variation (%)

DependencySelf-care activities 1. 35 .98 72

Care of personal belongings 1. 17 1.08 92

Seeks assistance 1. 39 1. 30 93

Relies on own resources 1.0l; 1.0l; 100

Decision-making ability 1. 10 1. 20 108

Separation with ease . 55 1.05 192

Feelings of hopelessness/helplessness . 36 .96 262

Questions decision of authority . 92 1.05 115

Engages in situational attention-seeking 1. 39 1. 29 92behaviors

Knowledge of own anatomy/physiology . 89 1. 10 125

Distinguishes between male and female .7l; .6l; 86

Engages in socially acceptable behavior ..!!! .85 196

Comfort with body/physical changes . 58 .79 136

Acceptance of gender role .48 . 59 119

Distinguishes between sexual/nonsexual . 31 .78 255approach behavior

Aggressive-ProtectiveIdentifies/avoids hazardous situations 1. 36 1. 30 96

Selects response to threat/dangerous 1. 16 1.28 1 11situations

Response to threat with self-injury . 53 1.04 197

Engages in acting out behaviors .62 1.22 196

Ability to maintain control 1. 53 1. 17 77

Phobic behavior . 14 .62 l;60

Separation from group .5l; 1.07 200

- 170 -

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Patient Behaviors Mean Deviation Variation (%)

Achievement

Experiences successes and failures .78 1. 32 169

Chooses alternatives . 32 .73 230

Selects goals from alternatives 1.20 1. 30 108

Initiates and completes tasks 1. 35 1.27 95

Utilizing problem-solving skills 1.51 1. 18 78

Identifies, accepts strengths/weaknesses 1.72 1.28 75

Attention span 1.25 1. l;0 112

Organizes groups . 11 . 31 292

Accepts directions 1. 16 .9l; 81

Utilizes cognitive abilities . 52 1. 13 220

Restorative

Sleep patterns .73 1.01 137

Engages in recreational activities 1. 12 1. 10 97

Involvement in range of activities .60 1.06 176

Participates in treatment regime 1. 18 1.00 85

Regulates activity according to physical .67 .90 135requirements

Participates in organized social group .41 ... l;9 121

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