Assessing the reliability of patient, nurse, and family caregiver symptom ratings in hospitalized advanced cancer patients.

PURPOSE: The purpose of this study was to examine the reliability of symptom assessments in advanced cancer patients under various conditions, including multiple raters (patients, nurses, and family caregivers), occasions, and symptoms. PATIENTS AND METHODS: The study sample consisted of 32 advanced cancer patients admitted to a tertiary palliative care unit. Symptom assessments were completed for each patient on two separate occasions, approximately 24 hours apart. On each occasion, the patient, the primary care nurse, and a primary family caregiver independently completed an assessment using the Edmonton Symptom Assessment System (ESAS). The ESAS is a nine-item visual analogue scale for assessing symptoms in palliative patients. The reliability of the assessments (r) was examined using generalizability theory. RESULTS: Three important findings emerged from this analysis. First, the analysis of individual symptom ratings provided a more meaningful representation of the symptom experience than total symptom distress ratings. Secondly, patients, nurses, and caregivers varied in their ratings across different patients, as well as in their ratings of shortness of breath, which may have been a result of individual rater variability. Finally, reliability estimates (r), based on a single rater and one occasion, were less than.70 for all symptoms, except appetite. These estimates improved substantially (r >/=.70) for all symptoms except anxiety and shortness of breath, using three raters on a single occasion or two raters across two occasions. CONCLUSION: The findings from this study reinforce the need for the development of an integrated symptom assessment approach that combines patient and proxy assessments. Further research is needed to explore individual differences among raters.

Morbidity assessment index for newborns: a composite tool for measuring newborn health.

OBJECTIVE: The objective was to develop, validate, and recommend a scaling model for a discriminative obstetric outcome measure named the Morbidity Assessment Index for Newborns. The purpose of this tool is to allow comparison of obstetric therapeutic strategies on neonatal morbidity, particularly in the mild to moderate morbidity range. STUDY DESIGN: A list of 66 check-mark (yes or no) items of readily available clinical and laboratory data from the early neonatal period was compiled by a panel of obstetric and neonatal experts. These data were collected on 411 neonates born at >/=28 weeks' gestation and representing all grades of morbidity. Detailed psychometric testing included dimensionality testing and item analysis with the item response theory. The scores obtained with this new assessment tool were correlated with newborn and maternal disease conditions or events and with other measures of newborn morbidity. RESULTS: The Morbidity Assessment Index for Newborns is easy to apply in prospective or retrospective studies. Detailed psychometric evaluation resulted in modification of the list to 47 items, each item with a relative scale value according to severity of morbidity. The test was demonstrated to be a reliable and generalizable scaled index that performs optimally for the mild to moderate neonatal morbidity range. CONCLUSION: The Morbidity Assessment Index for Newborns is a validated outcome measurement scale of neonatal morbidity. This new tool may facilitate the conduct of obstetric clinical trials or epidemiologic population-based studies in obstetrics.

Structuring the meaning of hope in health and illness.

The purpose of this paper is to describe a conceptual model for hope that captures the personal meaning of this construct within the context of health and illness. To identify this model, a research tool was created based on the semantic differential technique, a well-validated and often used approach for quantifying personal or connotative meaning. This tool was distributed in the form of a questionnaire to a voluntary sample (n = 550), consisting of three primary subsamples: a healthy adult subsample (n = 146), a chronic and life-threatening illness subsample (n = 159) and a nursing subsample (n = 206). A multidimensional structure for the concept, Hope, was identified, using principal components analysis. Three primary factors defined this structure: personal spirit (personal dimension), risk (situational dimension) and authentic caring (interpersonal dimension). Personal spirit, a dominant factor, is characterized by a holistic configuration of hope elements, revolving around a core theme of meaning. Risk is primarily a predictability factor, targeted with an underlying component of boldness. The authentic caring factor has a substantial credibility component, linked with the theme of comfort. Three distinctive features characterize this model: (a) its ability to capture the dynamic qualitative experience of hope within a holistic multidimensional quantitative framework, (b) its representation of hope as a location in three-dimensional space and (c) its sensitivity to individual and group variability. This integrative model deepens our understanding of the experience of hope within health and illness at the theoretical, clinical and methodological levels.

A comparison of patient and proxy symptom assessments in advanced cancer patients.

The purpose of this study was to compare patient and proxy (physician and nurse) assessments of symptoms in advanced cancer patients. The sample consisted of 49 patients with advanced cancer admitted to an acute palliative care unit. Three independent assessments were completed for each patient on two occasions within 11 days of admission. On each occasion, symptoms were rated independently by the patient and two proxies (treating physician and nurse), using the Edmonton Symptom Assessment System (ESAS). The ESAS is a nine-item visual analogue scale (VAS) for assessing pain, activity, nausea, depression, anxiety, drowsiness, appetite, well-being and shortness of breath. Symptom ratings were compared using a repeated-measures ANOVA procedure and correlations. Average physician ratings were generally lower than average patient ratings for both occasions. Average nurse ratings agreed more closely with patient ratings, with a trend towards lower ratings on occasion 1 and higher ratings on occasion 2. There was a significant rater (person rating the effects) effect (P < 0.01) for three of the nine symptoms: physicians rated drowsiness, shortness of breath and pain significantly lower than patients. For drowsiness and shortness of breath, these differences were clinically relevant, representing a difference of more than 12 mm on a 100-mm VAS. The accuracy of assessments amongst those rating the symptoms did not improve over time. Proxy assessments of symptom intensity, particularly by physicians, were significantly lower than patient assessments for three of the nine symptoms. Further research regarding the reliability of patient and proxy assessments is needed to assess and manage symptoms in advanced cancer effectively.

Intra-individual stability of rate of gross motor development in full-term infants.

The purpose of this study was to evaluate the intra-individual stability of gross motor scores obtained by normally developing full-term infants on the Alberta Infant Motor Scale (AIMS). The gross motor skills of 47 infants were assessed monthly in their homes by pairs of physical therapists. Infants were followed from two weeks of age until they achieved independent walking. A developmental pediatrician assessed each infant at 18 months of age, and classified the infant's gross motor skills as normal, suspicious or abnormal. Only the data of infants receiving a normal classification at 18 months were included in the analyses (n = 45). Individual infants' percentile ranks varied considerably from month to month, with no systematic pattern of change noted across infants. As a group, the mean percentile range over 13 assessments was 66.78 (S.D. 13.47). Fourteen infants (31.1%) received a score below the 10th percentile on at least one occasion. The results suggest that normally developing infants are not stable in the rate of emergence of gross motor skills. This instability has implications for infant screening programs, and supports the premise of serial assessments to identify accurately those infants with a motor delay.

Informational coping styles: a validity study.

Informational coping style may be an important determinant of coping with threatening situations that has important implications in terms of matching nursing interventions to patients. Two studies were conducted to examine aspects of the construct validity of a pen-and-paper instrument designed to measure informational coping style, the Miller Behavioral Style Scale (MBSS). In Study I, the MBSS was administered to 271 university students to examine item response frequencies, item correlations and internal consistency of the subscales. In Study II the coping responses to a series of different hypothetically threatening situations were examined in a sample of 60 students drawn from the sample used in Study I. The results of Study I indicate a need for revision of the items in the MBSS. The results of Study II provide modest evidence of construct validity and underrepresentation of the MBSS in terms of coping strategies. Furthermore, there was evidence to suggest that the structural approach used in the MBSS fails to capture the precise context in which a coping strategy would be applied and the extent to which a strategy would be used.

Undergoing cardiac catheterization: the effects of informational preparation and coping style on patient anxiety during the procedure.

OBJECTIVE: To examine the effects of coping styles and preparatory informational treatments on patient anxiety during cardiac catheterization. DESIGN: Prospective, experimental, random assignment, repeated measures design. SETTING: Canadian, university-affiliated, large urban hospital. SUBJECTS: 145 adult patients (107 men and 38 women) scheduled for their first cardiac catheterization. Age range was from 34 to 78 years. Mean educational level was 10.72 years. OUTCOME MEASURES: Subject's coping style, "monitoring" (information seeking) or "blunting" (information avoiding) was assessed by means of Miller's Behavioral Style Scale. Subjects' anxiety was assessed using three measures: (1) a self-report measure, the Subjective Units of Distress (SUDS) Scale; (2) a behavioral measure, the Cardiac Catheterization Adjustment (CA) Scale; and (3) physiologic measures, heart rate and systolic and diastolic blood pressure. INTERVENTION: After coping style assessment, monitors and blunters were randomly assigned to receive one of three preparatory informational treatments: (1) videotaped procedural modeling information, (2) videotaped procedural-sensory modeling information, and (3) procedural-sensory information booklet. RESULTS: Analysis of variance techniques applied to the anxiety data revealed the following: (1) significant changes in self-reported patient anxiety occurred as a function of occasion rather than preparatory informational treatment or coping style, (2) subjects receiving the three preparatory informational treatments demonstrated significantly different behavioral adjustments during cardiac catheterization, and (3) most subjects demonstrated heart rate and blood pressure readings in the normal range; however, significant changes in cardiovascular reactivity were found to be associated with contrast dye insertion. CONCLUSIONS: Subjects who received the videotaped modeling treatments demonstrated greater behavioral adjustment than patients who received the information booklet. Questions remain as to whether the procedural modeling treatment is more efficacious than the procedural-sensory modeling treatment. Increases in subjects' SUDS levels were found to be associated with changes in ideational content. Changes in blood pressure and heart rate were attributed to physiologic and psychologic factors. Coping style did not appear to significantly influence any of the measures of patient anxiety.

Preparing adult patients for cardiac catheterization: informational treatment and coping style interactions.

OBJECTIVE: To examine the interacting effects of coping style and type of preparatory informational treatment on cardiac catheterization patient anxiety. DESIGN: Pretest-posttest randomized control group design. SETTING: Canadian, university-affiliated, large urban hospital. SUBJECTS: 145 adult patients (107 men and 38 women) scheduled for their first cardiac catheterization. Age range was from 34 to 78 years. Mean educational level was 10.72 years. OUTCOME MEASURES: Subject's coping style (monitoring [information seeking] or blunting [information avoiding]) was assessed by means of Miller's Behavioral Style Scale. Subject's anxiety was assessed by means of Speilberger's A-Trait and A-State Inventory. INTERVENTION: After coping style assessment, monitors and blunters were randomly assigned to receive one of three preparatory informational treatments: (1) videotaped procedural modeling information; (2) videotaped procedural-sensory modeling information; and (3) procedural-sensory information booklet. RESULTS: Subjects' anxiety was assessed before and after intervention (Time 1 and Time 2) and before and after catheterization (Time 3 and Time 4). Analysis of variance techniques applied to the anxiety data largely confirmed the hypothesized interaction between subjects' coping style and type of preparatory informational treatment. Monitors who received the procedural-sensory modeling video treatment and blunters who received the procedural modeling video treatment reported significant reductions in A-state anxiety at Time 2 and maintained that decrease at Time 3. In contrast, monitors and blunters who received the other preparatory informational treatments reported a significant increase in A-state anxiety or a nonsignificant change in A-state anxiety at Time 2 and Time 3. At Time 4 monitors and blunters in each of the treatment groups reported a significant decrease in A-state anxiety. CONCLUSIONS: Two unexpected findings emerged from the study: (1) female monitors and blunters reported significantly higher A-state anxiety levels than their male counter-parts at preintervention, and (2) significant differences were observed among the preintervention A-state anxiety means of male monitors in the three preparatory treatment groups. These findings limit the conclusions that can be drawn from the study but provide direction for future research in the preparatory area.

An Application Of Inferential Statistics To The Factorial Invariance Problem.

Attention has been drawn to the lack of standards for evaluating the degree of goodness of fit of patterns resulting from a principal components analysis of two data sets. An empirical sampling distribution of the statistic average trace (E'E), as E is obtained in the orthogonal Procrustes problem for various orders of A matrices was developed through a Monte Carlo approach. A method is presented which can be used as a guideline in determining whether factor is structures obtained from two data sets are congruent.

A COMPARISON BETWEEN THE STRUCTURES OF DIVERGENT PRODUCTION ABILITIES OF CHILDREN AT TWO LEVELS OF INTELLECTUAL FUNCTIONINg.

Twelve divergent production tests were administered to 46 adolescents whose average WISC full scale IQ was 69.5 and t o a similar group of 48 adolescents whose average WISC full scale IQ was 104.6. Six divergent production factors were extracted in each group and rotated t o a target derived from Guilford's Structure of Intellect Model. In general the subnormal group produced a better fit to the hypothesized structure than the normal group, although the results from the normal group were not considered to be unsupportive of Guilford's theory.