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Revista da Escola de Enfermagem da USP

Print version ISSN 0080-6234

Rev. esc. enferm. USP vol.46 no.6 São Paulo Dec. 2012 



Development and validation of an instrument for initial nursing assessment


Desarrollo y validación de un instrumento para la evaluación inicial de enfermería



Cayetano Fernández-SolaI; José Granero-MolinaII; Judith Mollinedo-MalleaIII; María Hilda Peredo de GonzalesIV; Gabriel Aguilera-ManriqueV; Mara Luna PonceVI

IRN. M.Sc. in Humanities. Ph.D. Professor, Nursing and Physiotherapy Department, Universidad de Almería. Almería, Spain.
IIRN. M.Sc. in Humanities. Ph.D. Professor, Nursing and Physiotherapy Department, Universidad de Almería. Almería, Spain.
IIIM.Sc. in Nursing. Professor, School of Human Health Sciences, Universidad Autónoma Gabriel René Moreno. Santa Cruz de la Sierra, Bolivia.
IVM.Sc. in Nursing. Full Professor, School of Human Health Sciences, Universidad Autónoma Gabriel René Moreno. Santa Cruz de la Sierra, Bolivia.
VRN. Ph.D. Full Professor, Nursing and Physiotherapy Department, Universidad de Almería. Almería, Spain.
VIPh.D. in Nursing. Full Professor, School of Human Health Sciences, Universidad Autónoma Gabriel René Moreno. Santa Cruz de la Sierra, Bolivia.





The objective of this study, conducted in Bolivia from April to July of 2008, is the design and validation of an initial nursing assessment instrument to be used in clinical and educational environments in Santa Cruz (Bolivia). Twelve Bolivian nurses participated; both document analysis as well as consensus techniques were used to determine the categories and criteria to be assessed. Categories included in the nursing assessment instrument are a physical assessment and the eleven Gordon's Functional Health Patterns. The nursing assessment instrument stands out as being concise, easy to complete and utilizing a nursing approach. It does not include items for advanced nursing assessment. However, it incorporates items regarding lifestyle and the patient's autonomy. The nursing assessment instrument contributes to improving the quality of clinical records, supports the nursing diagnosis and implementation of the nursing process, promotes the nurse's role and helps to standardize practice.

Descriptors: Nursing process; Nursing assessment; Nursing records


Este estudio, desarrollado de abril a julio de 2008, objetiva desarrollar y validar un instrumento para orientar la evaluación de enfermería en parámetros asistenciales y docentes en Santa Cruz, Bolivia. Participaron doce enfermeras bolivianas y se utilizaron el análisis de documentos y técnicas de consenso para definir las categorías y criterios a ser incluidas en el instrumento. Estas categorías son: la evaluación física y los 11 Patrones Funcionales de Salud de Gordon. El instrumento se caracteriza por ser breve, de sencilla comprensión y por centrarse en el enfermero. No incluye elementos de evaluación física avanzada, pero sí criterios de estilos de vida y autonomía del paciente. El desarrollo de estos instrumentos contribuye a la calidad de los registros, favorece el juicio clínico y la aplicación del proceso a la enfermería, refuerza el papel del enfermero, favoreciendo la sistematización de su práctica.

Descriptores: Procesos de enfermería; Evaluación en enfermería; Registros de enfermería




The Nursing Process (NP) is a term used to refer to the scientific method applied to nursing practice and has been defined as a systemized humanistic care delivery method, based on the efficient achievement of objectives, which comprises five phases: assessment, diagnosis, planning, execution and evaluation(1).

In nursing literature, a consensus exists on the utility of the NP for the advancement of the profession, research and to facilitate management(2-3). Therefore, efforts to standardize nursing practice, using instruments that join all phases of the NP, range from primary care contexts to hospitalization rooms(4-5), including departments as different as critical care(6), nuclear medicine(7) or orthopedic surgery(8).

The first phase of the NP is assessment. In this phase, the nurse collects information to establish a clear image of the patient's health status, which constitutes the base for the diagnosis, interventions and which further events in the course of the care process can be compared with(1).

This initial assessment phase, however, is not always performed systematically, either due to a lack of time(9-10) and sufficiently useful instruments to guide patient assessment(4,9,11-12) or to nurses' lack of awareness on the application of the NP or health institutions' lack of involvement(2,13).

Another problematic aspect in the assessment is the lack of a focus on the application of the NP(9,14-15). In that sense, some authors have appointed that the availability of a well-designed assessment instrument presupposes help for nurses to gain critical thinking skills with a view to acknowledging what is relevant(1), integrating the patient's psychosocial and physiological responses(16). Moreover, if a nursing model is adopted in its design, this further a consensus on what nursing terminology to use, contributing to the definition and enhancement of nurses' role(14,17).

Although not free from obstacles, the trajectory of the NP in Western countries has been long, as opposed to countries like Bolivia, where its implantation is more limited and nurses manifest the need to adhere to a language and work method that at the same time puts them in tune with international nursing trends and results in local advances, such as greater visibility and acknowledgement(3,5,18).

In this context, encouraged by the desire to enhance nurses' role in the Bolivian health system, nurses in that country demand an Interuniversity and Scientific Research Cooperation Program (PCI) from Spanish cooperation with a view to the implementation of the NP. The aim of the PCI is for faculty from Universidad Autónoma Gabriel René Moreno (UAGRM) and nurses from affiliated health centers to put in practice the NCP and develop Care Plans in teaching to guide their professional practices, incorporate nursing registers into the patient's clinical history and reinforce the autonomous role of Bolivian nurses(5). Initial research reveals that Bolivian nurses demand simple instruments to guide and register the different phases of the Nursing Process(18).

The aim in this study is to design and validate the contents of an initial nursing assessment form for application in the care and teaching contexts in Santa Cruz de la Sierra, Bolivia.



A mixed study was developed, including an interpretative qualitative phase to design the instrument and a quantitative phase for content validation by experts.

Study participants were 12 female clinical nurses with a mean age of 48 years and average professional experience of 21 years. The criteria to include participants in the study were: professionally active nurses with an M.Sc. degree, with hospital and community health care experience in patient assessment and care. Stratified sampling was used to represent the distinct centers that participated in the PCI: Three representatives were selected from each of the four healthcare centers where the implementation of the instrument was planned: Hospital Universitario Japonés, Hospital Hernández Vera de la Villa 1º de Mayo, Hospital Municipal San Juan de Dios and Centro de salud María Cecilia. Other participants in the different phases were the six members of the research team, all of whom are familiar with patient assessment and application of the NCP in teaching and/or health care.

In accordance with other studies on the design and validation of initial assessment forms(11,19), the procedure was followed that is schematically represented in Figure 1, based on Pasquali's instrument construction and validation model, which includes theoretical, empirical and analytic procedures(20). The incipient experience in instrument validation studies for the nursing process in our context justifies the choice of theoretical content validation(8).



Qualitative Phase. Instrument Development: The first phase of the model involves an analysis of the literature and of participants' clinical experience with a view to the construction of items or criteria(20). This first phase is focused on the theoretical background of the construct for which an instrument is to be developed and involves an operational definition through the inclusion of representative items(21). In our case, the researchers designed the instrument based on the theoretical constructs of Gordon's Functional Health Patterns, as well as comprehensive bibliography on initial nursing assessment(1,4,7-9,14-15,17,19). Thus, the following 12 categories are included: Physical assessment, Health perception-management, Nutritional-metabolic pattern, Elimination, Activity-exercise, Sleep-rest, Cognitive-perceptual pattern, Self-perception-self concept, Role-relationship, Sexuality-reproductive, Coping-stress tolerance and Value-belief. These patterns are concepts and, as such, they cannot be measured except through operational indicators, which in our case are the criteria or items to assess each category.

For the operational definition, the 12 categories were distributed in three work groups, each of which was coordinated by a Bolivian researcher and included a Spanish researcher and four clinical nurses (three from hospitals and one primary care nurse). To define the criteria for the assessment of each category, the Nominal Group Technique (NGT) was used, in which work group members independently write down the ideas that, according to their own clinical experience, correspond to each. Then, they compared and analyzed their data and reached a consensus on what criteria to assess in each pattern, based on the criteria's conceptual pertinence and relation with the domains or patterns. Based on the criteria the three groups defined, the research team developed version-1 of the Initial nursing assessment instrument.

Quantitative phase. Instrument validation: The theoretical validation procedures used in this phase included content validation by experts and global evaluation, which presupposes semantic and instrument applicability analysis(20-21).

Content validity is the extent to which an instrument contains an adequate set of elements or criteria to represent the construct under evaluation(19), in this case the criteria of the patient assessment instrument. For content validity assessment, version-1 of the instrument was submitted to experts, based on the selection criterion of knowledge on patient assessment and the NP in nursing teaching or care. An adequate number of experts ranges between three and ten(19). In this study, six judges were selected, who assessed all criteria included in each category. In version-2, only those criteria were maintained on which agreement levels were superior to 80%.

For the global assessment, version-2 was forwarded to all participating clinical nurses (n=12), in order to get to know the criteria all groups had defined. The participants answered a questionnaire to indicate their level of disagreement-agreement with five statements on the instrument's pertinence, simplicity and applicability and the understandability, clarity and appropriateness of its assessment elements or criteria, using a scale from 1 to 10, in which 1 indicated total disagreement and 10 total agreement with the statement. Means (), standard deviations (S) and coefficients of variation ()were calculated for each questionnaire item. A mean score of 7 or higher and variation coefficient below 15% are accepted as satisfactory for each investigated aspect. The general validity score was obtained by adding up the scores for the five questions(22). In addition, the participating nurses could comment on or suggest changes, which were debated on and incorporated if 100% of the experts agreed, resulting in the final version of the instrument.

Ethical aspects

The study received approval from the Research Ethics Committee at the School of Human Health Sciences of UAGRM on March 12th 2008, under protocol number 37/08. Participation was voluntary and confidentiality and anonymity were guaranteed. Participants were informed that they could drop out of the research at any time and signed an informed consent term.



In the instrument design, all groups agreed to include criteria to facilitate the nursing focus and application of the NP, such as lifestyles, personal resources or degree of autonomy. The use of a checkbox was proposed as the preferred completion method, as well as a space to mark the date, name and signature of the nurse performing the assessment. In total, version-1 included 205 criteria, distributed among 12 categories, resulting in an average 17 assessment criteria per category.

In the expert evaluation of the first version, advanced or specialized assessment criteria were eliminated, considering that these were characteristic of a medical assessment. Also, criteria were eliminated which the experts considered of little prevalence or relevance. The second version consisted of 145 assessment criteria, with an average 12 per category. The expert considered that the appropriate instrument size would be an A4 page, front and back, and agreed to include a blank space in each category, under the title Other considerations, to mark data not included in the instrument, but which could be relevant for a given case.

Table 1 displays the mean agreement level among the six experts about the criteria in each category, which was high for more physiological categories, such as Physical assessment, Elimination pattern or Nutritional-metabolic pattern, but lower for more psychological and social categories like Role-relationship, Coping-stress tolerance and Value-belief patterns.



The 12 clinical nurses' global evaluation results of the instrument are displayed in Table 2.



In this phase, small modifications were proposed, such as including an option to mark if the assessment of a specific pattern is not pertinent or does not offer data of interest and space to summarize the most relevant assessment information. The assessment criteria for each category included in the final version are displayed in Figures 2 and 3.



The instrument we designed attended to the shortness, easy completion and nursing focus criteria the Bolivian nurses demanded in the care and teaching contexts(5-18). It will serve for these nurses to improve their documentation, starting with registers on the first phase of the NP. The choice of the Functional Health Patterns provides a standard assessment framework independently from the patient's age, care level or clinical problems. Another advance of its choice is that it facilitates the use of international taxonomies for nursing diagnoses like NANDA, whose Domains correspond to Gordon's Functional Health Patterns.

An instrument can be considered valid(22) when the experts' mean scores correspond to 80% or more of the maximum possible score and the coefficient of variation remains below 10%. The scores obtained in our study (46.6 points out of 50 and a CV of 7.5%) confirm its validity for use by nurses in clinical practice, as a guide and document to register the initial nursing assessment, and in teaching about nursing assessment as the first phase of the NP.

The utility and goal of good clinical records have been widely described in literature: they support care planning, provide information on patients' evolution, attend to legal requisites, enhance care continuity, offer information for clinical and resource management purposes, for service evaluation, for performance audits, for quality policies and research(2-3,12). Moreover, improvements in patient evaluation and concomitant documentation can influence the general quality of patient care(3,9).

As some authors have alerted(2,16), however, with a view to the success of attempts to put in practice or modify registration systems, it is important to guarantee the nursing staff's participation in their design and development. Also, nursing education is important, which is why NP implementation experiences are frequently accompanied by educational workshops(4-5,11,13). This additional education by itself does not guarantee success but, without it, we assume that changes will happen individually and without coordination(16). In our case, at the same time as nursing faculty and clinical nurses were involved in our design of an initial assessment form, educational activities on the NP were programmed, which included clinical interview workshops for assessment purposes, which were extremely important for the nurses to incorporate a structured initial assessment in their care delivery(5,16).

The attempt to achieve a nursing focus is a growing concern in the orientation of nursing assessment(4,9,11). The inclusion of physical assessment among nursing competencies is a process with some history in Western countries. Nevertheless, nursing assessment is frequently put on a level with physical assessment, so that the assessment nurses are taught is based on medical models, in which they learn procedures that are part of physicians' competency and which nurses will rarely use(9,14-15). Therefore, the inclusion of physical assessment to complement psychological and social evaluation is recommended to guarantee comprehensive instead of fragmented care(12,16-17). In that sense, the initial assessment instrument we have designed includes criteria related to lifestyles, autonomy level and dependence for activities of daily living, besides a succinct physical assessment.

The participating nurses identified the shortness of the instruments as a requisite for its successful implementation. Also, they manifest the need for easy completion, using checkboxes and short open spaces to include brief textual clarifications. That is in line with other studies and published forms(7) and can encourage professionals who argue that they do not apply the NP nor complete the records due to lack of time or simple instruments(9-11).


Among the present study limitations, its local context and reduced sample are highlighted, which is why our results cannot be generalized and are only applicable to the context in which the action research was developed. Another limitation is that the instrument was only submitted to theoretical expert validation, but not to empirical-analytic validation.



The design of an initial assessment tool with the help of the nurses involved represents a necessary base to put in practice the Nursing Process and to improve the quality of clinical patient files by incorporating nursing activities. The instrument's nursing focus contributes to the development of nurses' own role and to its incorporation into the international nursing trend that enhances the standardization of practice and the development of a universal nursing language to express nursing phenomena.

The assessment instrument we designed received approval from the clinical history commissions at the participating centers and was incorporated into clinical patient files as the base of nursing records. After the approval of the new study plan for the Undergraduate Program in Nursing at Universidad Autónoma Gabriel René Moreno, it has also been used as a tool to teach subjects like Nursing Fundamentals or Medical-surgical Nursing.



To the participating nurses, faculty and academic authorities at UAGRM and to the Spanish International Cooperation Agency for funding this study through PCI A/6907/06 and A/8374/07.



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Correspondence addressed to:
Cayetano Fernández Sola
Departamento de Enfermería y Fisioterapia,
Facultad de Ciencias de la Salud, Universidad de Almería
Carretera Sacramento, S/Nº - 04120 – Almería, España

Received: 07/04/2011
Approved: 04/18/2012

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