Nursing Check List
Content
A Methodological study to develop a 'Nursing Checklist'
for receiving patients in ICUs
Raj Kumari Kaushal, Surinder Kapoor, Sukhpal Kaur, Hemant Bhagat
Abstract: The current study was carried out to develop a 'Nursing Checklist' for receiving
patients in ICUs of a tertiary care hospital.Using methodological study design, the study was carried
out in total five phases. First, a blue print of the checklist was prepared after identifying the needs and an
exhaustive review literature. In 2nd phase, face and content validity of the nursing checklist was
established with Delphi technique. Feasibility of the checklist was checked by conducting a pilot study
in 3rd phase. In 4th phase, Inter-rater agreement between two raters was checked with Cohen's Kappa.
Then checklist was implemented by 30 subjects in ICUs of a tertiary care hospital and internal
consistency reliability of the items was established with Cronbach's alpha in 5th phase. The data was
analyzed by using SPSS version 16.
Final draft of the Nursing checklist had 12 main steps with 105 items. The checklist was found
feasible after conducting pilot study. The Nursing checklist was homogeneously reliable with a very
good inter-rater agreement between raters. Cohen's Kappa value was 0.98-1.00. The checklist was
found internally consistent. Cronbach's alpha value was 0.97. Results of the nursing checklist indicate
that it is valid and reliable and it can be applied in daily practice and in the clinical research context.
Keywords
Checklist, Intensive Care Unit, Nursing
checklist.
Correspondence at
Raj Kumari Kaushal
Public Health Nurse
Postgraduate Institute of Medical Education and
Research, Chandigarh, India
Introduction
Intensive care units (ICU), are sections
within a hospital that look after patients
whose conditions are life-threatening and
need constant, close monitoring and support
from equipment and medication to keep
1
normal body functions going. They have
higher levels of staffing, specialist,
monitoring and treatment equipment
available in these areas.
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The patient related issues in the
Intensive care units (ICUs) are complex.
Studies have shown that a patient in an ICU
requires 178 interactions (like suctioning,
1
feeding etc.) in his/her care in a whole day.
All these interactions are prone to human
error because of the natural limitations of
human memory. In an epidemiological
finding in United States, it was revealed that 1
million injuries and nearly 100,000 deaths
occurred annually as a result of mistakes in
medical care.2 A checklist standardizes the
process to ensure that all elements or actions
are addressed. The structure and
predictability of checklists facilitate the
careful and systematic delivery of care,
which reduces variability and improves
performance.1
Many intensive care units (ICUs)
operate near full capacity. Maximum ICUs in
India do not have 1:1 nurse patient ratio as
India is a developing country and has
3
shortage of skilled staff. Further, aging
population and limited resources place
increasing demands on space and
personnel, with little capacity to adjust to
4
increased workload.
For critically ill patients, increasing dayto-day demands on ICU resources could
create an environment of increased risk.
Pressure of work and tension makes it more
prone to commit mistakes. To deter mistakes
wherever possible, 'Checklists' are must.
‘Patient safety' is a fundamental
component of good quality health care and
has become a global concern since studies
illustrate that between 3-16% of patients
admitted to hospital suffer from adverse
events that is harm caused to a patient as a
4
result of medical care and not the disease.
So, ‘checklists' have been proposed as a
method of improving patient safety.
The present study was undertaken to develop
a ‘Nursing checklist' to receive patients in
ICUs as there was no such checklist available
in our ICUs.
Material and methods
The study was conducted in five phases as
discussed below:
Phase I: Preliminary preparation of the
Nursing Checklist. It was divided into two
steps. The first step dealt with review of
relevant literature. An exhaustive literature
review was done to collect recent evidences
related to receiving patients in ICUs. The
review of literature for present study was
done for assessment, documentation, and
maintenance of records related to admission
of patient in the ICU along with identification
of various needs of the patient in our
hospital. Further, a rigorous review of
literature related to instrument construction
and standardization of the tool was done.
Sources of literature included electronic data
bases (Pubmed, Medline, CINHAL) as well as
printed material from the Institute library.
Second step was the preparation of blue print
of nursing checklist. In 2nd step, an item pool
was generated to develop a preliminary
Checklist. In this draft, there were total 81
items to receive patients in ICUs. These were
categorized under 23 steps. Firstly,
Permission from ICU consultant or HOD is
required and nurses should be informed 15
minutes before. Then there were six steps
before receiving a patient to ICU like
preparation of article checklist, bed with
alpha mattress, equipments, patient bedside
trolley, patient records and shifting trolley.
Information is also collected from shifting
ward or Emergency staff. Patient receiving
had eight steps and quick assessment
afterwards had nine steps. Then follow stat
Nursing and Midwifery Research Journal, Vol-11, No. 1, January 2015
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orders and medications. Check patient for
bed sores, write admission notes and enter
to census. Relatives are given orientation and
supervisor is informed in case the patient is a
VIP/ NRI/ MLC/ Staff member/ Foreign
national or prisoner.
Phase II: The face and content validity of the
Checklist was done with Delphi technique. It
included three steps. Step- 1 Selection of
panel of experts: A panel of experts
consisting of 11 members from the field of
medical, surgical, nursing and Intensive care
staff was formulated. Step- 2 Delphi rounds:
The first draft of the tool 'Nursing checklist'
to receive patient in ICU was circulated
among the selected panel of experts. They
were requested to validate the content for its
relevance, clarity, language, organization,
level of understanding, and sequence of
items. Delphi rounds were continued until
there was common consensus among the
panel of experts. Four Delphi rounds were
done to obtain the consensus to prepare final
draft of the tool.
Step- 3 Modifications as per suggestions:
As per the expert's opinion, the modifications
in the checklist were made after every Delphi
round. Final draft had 105 items categorized
under 12 steps. Nursing Checklist also had
separate list for required items so that it is
easy for staff to separate it out and give it to
the relatives after checking.
Phase III: This consisted of testing feasibility
of the Nursing Checklist. In order to assess
feasibility of the Checklist, a pilot study was
conducted on 4 patients in selected ICUsi.e
Main ICU, Respiratory ICU and
Gastroenterology ICU of Institute. Results of
the pilot study revealed that the language of
the tool was clear and it was feasible to carry
out the final study.
Phase IV: It considered testing inter-rater
agreement of the Nursing Checklist. The
inter-rater reliability of the checklist was
established after making necessary changes
based on Delphi technique and pilot study. To
test inter-rater agreement, checklist was
applied on 5 patients in Liver ICU of the
Institute by two raters independently. Interrater agreement was calculated at 0.95 C.I.
by using Cohen's Kappa. K value is
5
interpreted as given by Altman 1991.
Table 1 shows the Kappa value for all the five
cases. The agreement values of the 'Nursing
checklist' vary from 0.98 - 1.00. Kappa value
for cases 1, 2 & 5 was 1.00 and for cases 3 &
4 was 0.98. Table 2 depicts the inter-rater
agreement interpretation. As the kappa value
vary between 0.98 – 1.00. So, according to
Altman this shows that all the items had a
very good inter-rater agreement5.This means
that modified draft of the checklist was
homogeneously reliable with a very good
inter-rater agreement between raters.
Table 1: Kappa values for the Inter-rater agreement of the Nursing Checklist
Rater
R1-R2
N
5
N=5
Kappa value (k)
Case 1
Case 2
Case 3
Case 4
Case 5
1.000
1.000
0.981
0.981
1.000
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Table 2: Interpretation of k value
Value of k
<0.20
0.21-0.40
0.41-0.60
0.61-0.80
0.81-1.00
Strength of Agreement
Poor
Fair
Moderate
Good
Very Good
*Source: Altman D G Practical Statistics for Medical
Research London: Champman and Halt 1991.5
Phase V: It consist testing internal consistency
reliability of developed Nursing Checklist. It
included implementation of the tool on patients
received in ICUs and checking internal
consistency (reliability) of the developed tool.The
selected ICUs i.e. Respiratory ICU, Main ICU and
Gastroenterology ICU were taken as a research
setting for implementation of the tool. Written
permission from head of department of all ICUs
was taken. Ethical clearance was sought by
Institute Ethical Committee.The sister in charge
of the respective wards was also informed about
the study. Target population was nurses
receiving patients in ICUs. Using purposive
sampling technique, 30 nurses were selected and
given a formal training of 10-15 minutes in a
group of 4-5 nurses depending on the availability
in all the three ICUs. Subjects were explained
about how to use the 'Nursing checklist'. A set of
introduction and instructions regarding how to
use the checklist was also written on 1st page of
checklist i.e.it is a tool to ensure that all elements
are taken care of while receiving a patient in ICU.
Instructions included read and follow all the
steps and put tick mark in the appropriate yes or
no box. First written informed consent was
obtained and identification data sheet was filled
by the subjects. Then 'Nursing Checklist' was
given to them to receive patients in ICUs. Nonparticipatory observation was done in order to
observe the application and related nursing
activities carried out by nurses while receiving
patients in ICUs by using 'Nursing checklist'.
After the procedure was over 'Nursing checklist'
was taken back. Tool was implemented by 30
nurses while receiving patients in ICUs by using
checklist and marked in yes and no boxes in front
of steps of checklist. It took near about 25-30
minutes to implement a checklist. Data was
collected using identification data sheet and
nursing checklist tool. Data collected was coded
and analysed by using SPSS version 16.Internal
consistency of checklist was calculating
Cronbach's alpha coefficient.
Results
Final Nursing checklist to receive patients
in ICUs was prepared.Tables3-7(Part 1 to 5 of
Nursing checklist tool) shows reliability analysis
of the items of Nursing checklist by using
Cronbach's alpha. The sample size was 30. The
overall Cronbach's alpha coefficient of the
developed tool was 0.97, which indicates the
reliability and internal consistency of the tool
(Ideally Cronbach's alpha coefficient should be
0.70 or more than 0.70).
Corrected item to total correlation was
applied on all 105 items of the tool, only 2 items
in the scale had an item to total score correlation
less than 0.2 showing the incompatibility with the
overall tool i.e item 3.6d- intake/ output record
and item 10- entry to admission and census
register.
To check the individual contribution of
items, each item was deleted one by one to see
the changes in the value of Cronbach alpha
coefficient. But none of the items showed any
increase, in value of Cronbach alpha coefficient.
Rather, the value of Cronbach alpha coefficient
remained same or it decreased. This indicates
that all the items contributed to the tool. Even on
deleting certain items, having item to total
correlation less than 0.2, the value of Cronbach
alpha did not increase. Hence, these 2 items were
also contributing to the reliability of the tool. The
average scale mean was 126.68. When scale
mean if item deleted was applied on 105 items of
the tool, the scale mean if item deleted was in the
range of 126.43 to 126.83 and none of the items
had shown an increase in the value of average
scale mean rather it remained same or it
decreased. It means tool is internally consistent
Nursing and Midwifery Research Journal, Vol-11, No. 1, January 2015
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by taking all 105 items. Result of Cronbach's
alpha revealed that all items were uniformly
contributing for the reliability of the tool.
Table 3 (Part1 of tool) shows reliability
analysis of first two steps along with sub parts of
step 3 of nursing checklist tool i.e consultation
with head, prior information and preparation
before receiving patient. Cronbach's alpha varies
between 0.969 to 0.970 which is above 0.70
showing reliability of tool. Corrected item to total
correlation was also above 0.2 for all the items
that all these items were contributing to the
reliability of the tool.
Table 4 (Part 2 of tool) shows reliability
analysis of two sub-steps of step 3 i.e preparation
of patient bedside trolley and patients charts of
the nursing checklist tool. Cronbach's alpha
varies between 0.969 to 0.970 which is above
0.70 showing very good reliability. Corrected
item to total correlation was above 0.2 for all the
items except item 3.6d i.e intake/output chart
showing incompatibility with the overall tool. To
check the individual contribution of this item, it
was deleted to see the changes in the value of
Cronbach alpha coefficient and scale mean. But
value of Cronbach alpha coefficient and scale
mean remained same rather than increasing.
This indicates that this item was contributing to
the reliability and internal consistency of the tool.
So it was kept and not deleted from the tool.
Table – 3 Reliability analysis of the items of 'Nursing checklist' to receive patients in
ICUs by using Cronbach's alpha (Part 1)
Items of the tool
1. Consultation with ICU consultant or Head of
Department
2. Nurses and Technicians informed 30 minutes
before the admission
3. Before receiving the patient
3.1) Carbolization of bed
3.2) Fumigation of room
3.3) Preparation of bed with air mattress
3.4) Preparation of following equipments and
check their working condition:
3.4a) Cardiac monitor with ECG leads and electrodes
3.4b) Pulse oximeter.
3.4c) NIBP/Invasive pressure monitoring.
3.4d) Ambubag
3.4e) Ventilator with circuits.
3.4f) O2 supply and compressed air
3.4g) Suction jar (emptied and disinfected) with
tubing connected to suction.
3.4h) I/V fluids and necessary tubings
3.4i) Infusion pumps and syringes as per need.
3.4j) Defibrillator (charged)
Scale Mean if
Item Deleted
126.57
Corrected Item - Cronbach's Alpha
Total Correlation If Item Deleted
.355
.970
126.43
.714
.969
126.83
126.83
126.47
126.80
126.80
.332
.332
.300
.456
.614
.970
.970
.970
.970
.970
126.80
126.83
126.77
126.80
126.70
126.70
126.73
.625
.495
.543
.690
.766
.347
.467
.970
.970
.970
.969
.969
.970
.970
126.73
126.70
126.63
.612
.642
.473
.969
.969
.970
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Table – 4 Reliability analysis of the items of 'Nursing checklist' to receive patients in
ICUs by using Cronbach's alpha (Part 2)
Items of the tool
Scale Mean if
Item Deleted
3.5) Preparation of patient bedside trolley:
126.67
3.5a) Injection tray.
126.73
3.5b) Spirit Swabs
126.73
3.5c)Handrub
126.77
3.5d) Heparinised saline
126.53
3.5e) Emergency Drugs
126.73
3.5f) Clean glove box
126.77
3.5g) Adhesive Plaster
126.70
3.5h) Sterile blade/ Pair of scissors
126.63
3.5i ) Sterile pair of gloves
126.70
3.5j) Sterile Drape sets and Sterile gauze/ sponges
126.57
3.5k) Procedure trolley
126.57
3.5l) Intubation kit
126.57
3.5m) Syringes
126.80
3.5n) I/V cannula (different sizes) and
126.60
Intra arterial cannula
3.5o) Ryles tube and lubricating jelly
126.70
3.5p) Foleys catheter, Urobag/ Urometer
126.73
3.5q) Betadine lotion
126.70
3.6) Preparation of patient records:
126.77
3.6a) Vital signs and ventilator settings
126.80
progress record.
3.6b) TPR Sheet
126.77
3.6c) GCS Chart
126.47
3.6d) Intake/output record.
126.77
3.6e) RBS Chart
126.73
3.6f) Abdominal Girth Chart.
126.63
3.6g) Medicine prescription sheet.
126.80
3.6h) Nursing instructions chart
126.70
3.6i) Nurses shift Report.
126.60
Table 5 (Part 3 of tool) shows reliability analysis
of two sub-steps i.e preparation of shifting trolley
and information collected from emergency staff.
Alpha value for all items is above 0.70 showing
Corrected Item - Cronbach's Alpha
Total Correlation If Item Deleted
.609
.969
.235
.970
.414
.970
.481
.970
.456
.970
.705
.969
.601
.970
.638
.969
.592
.969
.584
.969
.272
.970
.617
.969
.366
.970
.549
.970
.363
.970
.551
.550
.367
.270
.397
.970
.970
.970
.970
.970
.328
.595
.137*
.292
.348
.581
.396
.341
.970
.969
.970
.970
.970
.970
.970
.970
reliability of tool. Corrected item to total
correlation was also above 0.2 for all the items
showing that all these items were contributing to
the reliability of the tool.
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Table – 5 Reliability analysis of the items of 'Nursing checklist' to receive patients in
ICUs by using Cronbach's alpha (Part 3)
Items of the tool
Scale Mean if
Item Deleted
Corrected Item - Cronbach's Alpha
Total Correlation If Item Deleted
3.7) Preparation of shifting/ transfer trolley:
126.77
.717
.969
3.7a) Bed sheet
126.77
.515
.970
3.7b) Diaper sheets/ Diaper
126.73
.537
.970
3.7c) O2 Cylinder with breathing circuit
126.63
.618
.969
3.7d) Portable monitor/ Ventilator
126.50
.411
.970
3.7e) Ambubag
126.73
.647
.969
3.7f) Emergency drugs
126.70
.396
.970
3.7g) Intubation kit
126.57
.568
.970
3.7h) Torch
126.60
.599
.969
3.7i) Scissors/ blade
126.57
.648
.969
3.8) Information collected from ward or
Emergency staff:
126.83
.612
.970
3.8a) Identification Data i.e Patients name, age,
sex and CR No.
126.83
.612
.970
3.8b) Diagnosis.
126.73
.318
.970
3.8c) Admitted under which unit/ consultant
126.70
.708
.969
3.8d) GCS, Pupillary response
126.50
.324
.970
3.8e) Vital parameters
126.67
.438
.970
3.8f) Existing ventilator parameters
126.50
.274
.970
3.8g) Presence of Invasive lines/ ICD/ RT/
Drains/ Catheters.
126.60
.309
.970
3.8h) Date of insertion of lines.
126.50
.337
.970
3.8i) Details about ongoing Ionotropic medication
126.67
.617
.969
3.8j) Existing medication orders and
administration timings.
126.67
.458
.970
3.8k) Details regarding limb/ body, movement/
restriction/ specific position.
126.53
.293
.970
3.8l) Presence of bedsores.
126.57
.522
.970
3.8m) Any other ongoing therapy i.e Application
of TED stockings/ traction/ P.D/H.D.
126.47
.248
.970
3.8n) Existing Diet orders.
126.50
.454
.970
3.8o) Payment system.
126.63
.682
.969
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Table 6 (Part-4 of tool) shows reliability
analysis of remaining sub-steps of step 3 and
step 4 i.e preparation of article checklist, giving
article checklist and orientation to relative and
checking items received. Step 4 is regarding
steps performed while receiving the patient.
Alpha value for all steps and items is above 0.70
which shows reliability of tool. Corrected item to
total correlation for all these was also above 0.2
showing that all these items were contributing to
the reliability of the tool.
Table – 6 Reliability analysis of the items of 'Nursing checklist' to receive patients in
ICUs by using Cronbach's alpha (Part 4)
Items of the tool
3.9) Preparation of article checklist
3.10) Give article checklist and Orientation to
relative about:
3.10a) Contact details
3.10b) Waiting Room
3.10c) Visiting timings
3.10d) Location of pharmacy, reception, chemist
shop etc.
3.10e) Ward policy of wearing cap, gown, mask
and hand washing.
3.11) Checking items received from patients
relative with list
4. While receiving patient
4.1) Identification of patient.
4.2) Check airway and breathing.
4.3) Check Circulation.( Pulse & Heart Rate)
4.4) Check GCS, pupil reaction
4.5) Change to ICU clothing
4.6) Remove ornaments & handover to attendants.
4.7) Transfer patient to Shifting trolley
4.8) Take inside ICU and Shift from trolley to ICU bed.
Table 7 (Part-5 of tool) shows reliability
analysis of step 5 i.e quick assessment soon after
admission and further final steps of nursing
checklist tool. Cronbach's alpha for all of them
varies between 0.969 to 0.970, which is above
0.70 showing very good reliability of tool. When
Scale Mean if
Item Deleted
126.80
126.80
Corrected Item - Cronbach's Alpha
Total Correlation If Item Deleted
.489
.970
.489
.970
126.63
126.67
126.63
126.60
.314
.223
.485
.452
.970
.970
.970
.970
126.63
.626
.969
126.73
.454
.970
126.80
126.77
126.77
126.70
126.60
126.70
126.57
126.70
126.73
.489
.251
.332
.282
.506
.658
.652
.691
.700
.970
.970
.970
.970
.970
.969
.969
.969
.969
corrected item to total correlation was applied, it
was above 0.2 for all steps and items except on
step 10 i.e Entry to admission and census
register, showing incompatibility with the overall
tool. To check the individual contribution of this
item, it was deleted to see the
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Table – 7 Reliability analysis of the items of 'Nursing checklist' to receive patients in
ICUs by using Cronbach's alpha (Part 5)
Items of the tool
Scale Mean if
Item Deleted
Corrected Item - Cronbach's Alpha
Total Correlation If Item Deleted
5. A quick assessment soon after admission
126.77
.645
.969
5.1) Airway and Breathing
126.77
.645
.969
5.2) Check ET / T.T tube placement, tip marking
and bilateral air entry
126.60
.420
.970
5.3) Connect Ventilator and adjust settings
126.63
.377
.970
5.4) Connect monitor for parameters like ECG,
B.P, H.R, R.R, Temp., arterial B.P, Saturation
and other parameters.
126.77
.404
.970
5.5) Check oxygen saturation, B.P, H.R, E.C.G,
R.R & Temp.
126.77
.332
.970
5.6) Check patency/ working of invasive lines.
126.73
.344
.970
5.7) Discard previous I/V lines & change to new lines.
126.67
.734
.969
5.8) Connect infusion pumps/ syringe pumps as needed.
126.70
.498
.970
5.9) Check chest drainage, Foleys catheter,
Ryle's tube and other drainage tubes.
126.70
.646
.969
6. Check & Follow stat instructions.
126.83
.384
.970
7. Check for medications and adjust medication
frequency timings.
126.73
.410
.970
8. Check for impaired skin integrity & assess for
bedsore, document if any.
126.70
.654
.969
9. Once patient stabilized, write Admission notes
126.70
.564
.970
10. Entry to admission & census register
126.77
.199*
.970
11. Diet requisition to dietary department.
126.67
.442
.970
12. Inform to the supervisor if the patient is a VIP/
NRI/ MLC/ Staff member/Foreign national/prisoner.
126.67
.601
.969
Overall scale mean is 126.68, *- Items in the tool which shows item to total correlation < 0.2
Overall reliability of the tool is 0.97 (Cronbach's alpha)
changes in the value of Cronbach alpha
coefficient and scale mean. But value of
Cronbach alpha coefficient and scale mean
remained same rather than increasing. This
indicates that this item was contributing to the
reliability and internal consistency of the tool. So
it was kept and not deleted from the tool.
Discussion
Patient in ICU are admitted with multiple
clinical problems related to brain, heart, lungs,
liver, kidneys and other body systems. So, the
ICU staff needs high level of skills and
knowledge. While receiving patients in ICUs,
staff nurses have to carry out a number of steps
Nursing and Midwifery Research Journal, Vol-11, No. 1, January 2015
9
and procedures. Busy environment and critical
situations makes them more prone to commit
mistakes.
So, present methodological study was
planned with objective to develop a tool 'Nursing
Checklist' for receiving patients in ICUs. A
Checklist is a comprehensive list of important
and relevant actions or steps which are to be
carried out in a specific manner. The checklist is
meant to assist staff and others in providing
adequate, safe, and efficient client care and
improvement in communication by reducing the
gaps in communication.1
Tool was validated with Delphi technique
and reliability was assessed with inter-rater
agreement and Cronbach's alpha. In Phase II,
content and face validity was undertaken with
Delphi Technique. We found that four rounds
were needed for all experts to come to a
consensus for final draft of the tool. In a similar
study, Delphi technique was used by Kirkwood et
al., to determine the nursing research priorities in
the North Glasgow University hospitals,4 they
found that three Delphi rounds were sufficient to
reach to a common consensus.
In phase IV, inter-rater reliability of the tool
was calculated by inter-rater agreement by using
Cohen's kappa, which removes the probability of
chance agreement. Cohen's kappa value for the
checklist varied between 0.98-1.00 which shows
very good inter-rater agreement. Similar findings
were also reported by Ottenbacheretal. and
Rupinder et al., who reported inter-rater
agreement of functional assessment of elderly in
which the Kappa value ranged from 0.90 to 0.99
and of cardiac catheterization checklist with the
Kappa value ranging from 0.88-0.97
6,7
respectively.
In the present study, the internal
consistency (reliability) of the Nursing Checklist
was checked in phase V by Cronbach's alpha by
using SPSS version 16. The Cronbach's alpha
coefficient value of the 'Nursing checklist to
receive patient in ICU' tool is 0.97, which satisfies
the criteria for the reliability of the tool. Similarly
in a methodological study by Rupinder et al. on
development of nursing checklist for cardiac
catheterization, value of Cronbach alpha was
0.86.7 Katz et al. reported similar findings on the
internal consistency of “The Dynamic
Occupational Therapy Cognitive Assessment for
Children”.8 The reported Cronbach's alpha was
0.77. May-Benson et al. also reported almost
similar findings.9 They assessed the internal
consistency of the “Gravitational Insecurity”
outcome measure. The alpha of the total test
score was 0.71.Similar findings were reported by
Bandana et al.on the internal consistency of the
'audit tool'.10 An 'audit tool' was developed for
auditing the family records. Internal consistency
of the tool was checked with Cronbach alpha and
the value was 0.73.Ho- Chung et al. also used
Cronbach's alpha to find out the reliability of tool
on ‘short form of Chinese version of anxiety state
for children'.11 The Cronbach alpha coefficient of
their tool was 0.83 which determined the
reliability of the tool. Another study by Wood was
on development of ‘initial psychometric
evaluation of patient perspective of arrhythmia
12
questionnaire'. In this study also Cronbach
alpha coefficient was used which was 0.84 that
determined the internal consistency of the tool.
Similarly a study on reliability and validity of
‘sexual pressure scale for women' (Revised),
Jones et al. also used Cronbach's alpha to find
out the internal consistency of their tool and
value of Cronbach alpha coefficient was 0.88
13
which suggested the reliability of the tool.
This study concludes that the developed
‘Nursing checklist' to receive patients in ICUs is a
valid and reliable tool. It consisted of 105 items
categorized under 12 steps. It can be applied in
daily practice and in the clinical research context
in the intensive care settings.In daily routine, it
can help in reducing nursing errors and thus will
enhance the effectiveness of care and promote
safe quality care.
Nursing and Midwifery Research Journal, Vol-11, No. 1, January 2015
10
References
1.
Winters BD, Gurses AP, Lehmann H,
Sexton JB, Rampersad CJ, Pronovost PJ.
Clinical review: Checklists – translating
evidence into practice. Critical Care 2009;
13:210
2.
Rolland P. Occurrence of dispensing
errors and efforts to reduce medication errors
at the central Arkansas veteran's healthcare
system. Drug Saf. 2004;27(4):271-82
3.
Report of National Commission on
macroeconomics and health, Ministry of health
and family welfare, Government of India, New
Delhi. Aug 2005:57
4.
Kirkwood M, Wales A, Wilson A. Delphi
study to determine nursing research priorities
in North Glasgow university hospitals.
International Journal of Nursing Studies 2005;
43: 560-63
5.
Altman DG. Practical statistics for medical
research. London : Champman and Halt
Publication 1991.
6.
Ottenbacher KJ, Mann WC, Granger CV, Tomita
M, Hurren D, Charvat B. Inter-rater agreement
and stability of functional assessment in the
community-based elderly. Archives of Physical
Medicine and Rehabilitation 1994; 75(12):
1297-1301
7.
Kaur R, Gupta JV, Sharma Y, Gupta PK.
Development of cardiac catheterization nursing
checklist and evaluating its usability. 2012
(Unpublished MSc Nursing thesis submitted in
PGIMER, Chandigarh)
8.
Katz N, Golstand S, Bar-IIan RT, Parush
S. The Dynamic Occupational Therapy
Cognitive Assessment for Children (DOTCACh): a new instrument for assessing learning
potential. Am J OccupTher 2007 Jan;61(1):4152
9.
Benson M, Koomar JA. Identifying
gravitational insecurity in children: A pilot
study. American Journal of Occupational
Therapy 2007 Mar; 61:142–47
10.
Bandana, Walia I, Saini SK.
Development of audit tool : A methodological
study for auditing the family health records.
Nursing and Midwifery Research Journal 2009
Oct; 5(4): 166-75
11.
Ho-Chung WL, Violeta L. Development
and validation of short form of Chinese version
of state anxiety tool. International Journal of
Nursing Studies 2005; 44:566-73
12.
Wood KA. Development and initial
psychometric evaluation of the patient
perspective of arrhythmia questionnaire.
Research in Nursing and Health 2009;32: 50416
13.
Jones R, Gulick E. Reliability and
validity of the sexual pressure scale for womenRevised. Research in Nursing and Health 2009;
32: 71-8
Nursing and Midwifery Research Journal, Vol-11, No. 1, January 2015
11
for receiving patients in ICUs
Raj Kumari Kaushal, Surinder Kapoor, Sukhpal Kaur, Hemant Bhagat
Abstract: The current study was carried out to develop a 'Nursing Checklist' for receiving
patients in ICUs of a tertiary care hospital.Using methodological study design, the study was carried
out in total five phases. First, a blue print of the checklist was prepared after identifying the needs and an
exhaustive review literature. In 2nd phase, face and content validity of the nursing checklist was
established with Delphi technique. Feasibility of the checklist was checked by conducting a pilot study
in 3rd phase. In 4th phase, Inter-rater agreement between two raters was checked with Cohen's Kappa.
Then checklist was implemented by 30 subjects in ICUs of a tertiary care hospital and internal
consistency reliability of the items was established with Cronbach's alpha in 5th phase. The data was
analyzed by using SPSS version 16.
Final draft of the Nursing checklist had 12 main steps with 105 items. The checklist was found
feasible after conducting pilot study. The Nursing checklist was homogeneously reliable with a very
good inter-rater agreement between raters. Cohen's Kappa value was 0.98-1.00. The checklist was
found internally consistent. Cronbach's alpha value was 0.97. Results of the nursing checklist indicate
that it is valid and reliable and it can be applied in daily practice and in the clinical research context.
Keywords
Checklist, Intensive Care Unit, Nursing
checklist.
Correspondence at
Raj Kumari Kaushal
Public Health Nurse
Postgraduate Institute of Medical Education and
Research, Chandigarh, India
Introduction
Intensive care units (ICU), are sections
within a hospital that look after patients
whose conditions are life-threatening and
need constant, close monitoring and support
from equipment and medication to keep
1
normal body functions going. They have
higher levels of staffing, specialist,
monitoring and treatment equipment
available in these areas.
Nursing and Midwifery Research Journal, Vol-11, No. 1, January 2015
1
The patient related issues in the
Intensive care units (ICUs) are complex.
Studies have shown that a patient in an ICU
requires 178 interactions (like suctioning,
1
feeding etc.) in his/her care in a whole day.
All these interactions are prone to human
error because of the natural limitations of
human memory. In an epidemiological
finding in United States, it was revealed that 1
million injuries and nearly 100,000 deaths
occurred annually as a result of mistakes in
medical care.2 A checklist standardizes the
process to ensure that all elements or actions
are addressed. The structure and
predictability of checklists facilitate the
careful and systematic delivery of care,
which reduces variability and improves
performance.1
Many intensive care units (ICUs)
operate near full capacity. Maximum ICUs in
India do not have 1:1 nurse patient ratio as
India is a developing country and has
3
shortage of skilled staff. Further, aging
population and limited resources place
increasing demands on space and
personnel, with little capacity to adjust to
4
increased workload.
For critically ill patients, increasing dayto-day demands on ICU resources could
create an environment of increased risk.
Pressure of work and tension makes it more
prone to commit mistakes. To deter mistakes
wherever possible, 'Checklists' are must.
‘Patient safety' is a fundamental
component of good quality health care and
has become a global concern since studies
illustrate that between 3-16% of patients
admitted to hospital suffer from adverse
events that is harm caused to a patient as a
4
result of medical care and not the disease.
So, ‘checklists' have been proposed as a
method of improving patient safety.
The present study was undertaken to develop
a ‘Nursing checklist' to receive patients in
ICUs as there was no such checklist available
in our ICUs.
Material and methods
The study was conducted in five phases as
discussed below:
Phase I: Preliminary preparation of the
Nursing Checklist. It was divided into two
steps. The first step dealt with review of
relevant literature. An exhaustive literature
review was done to collect recent evidences
related to receiving patients in ICUs. The
review of literature for present study was
done for assessment, documentation, and
maintenance of records related to admission
of patient in the ICU along with identification
of various needs of the patient in our
hospital. Further, a rigorous review of
literature related to instrument construction
and standardization of the tool was done.
Sources of literature included electronic data
bases (Pubmed, Medline, CINHAL) as well as
printed material from the Institute library.
Second step was the preparation of blue print
of nursing checklist. In 2nd step, an item pool
was generated to develop a preliminary
Checklist. In this draft, there were total 81
items to receive patients in ICUs. These were
categorized under 23 steps. Firstly,
Permission from ICU consultant or HOD is
required and nurses should be informed 15
minutes before. Then there were six steps
before receiving a patient to ICU like
preparation of article checklist, bed with
alpha mattress, equipments, patient bedside
trolley, patient records and shifting trolley.
Information is also collected from shifting
ward or Emergency staff. Patient receiving
had eight steps and quick assessment
afterwards had nine steps. Then follow stat
Nursing and Midwifery Research Journal, Vol-11, No. 1, January 2015
2
orders and medications. Check patient for
bed sores, write admission notes and enter
to census. Relatives are given orientation and
supervisor is informed in case the patient is a
VIP/ NRI/ MLC/ Staff member/ Foreign
national or prisoner.
Phase II: The face and content validity of the
Checklist was done with Delphi technique. It
included three steps. Step- 1 Selection of
panel of experts: A panel of experts
consisting of 11 members from the field of
medical, surgical, nursing and Intensive care
staff was formulated. Step- 2 Delphi rounds:
The first draft of the tool 'Nursing checklist'
to receive patient in ICU was circulated
among the selected panel of experts. They
were requested to validate the content for its
relevance, clarity, language, organization,
level of understanding, and sequence of
items. Delphi rounds were continued until
there was common consensus among the
panel of experts. Four Delphi rounds were
done to obtain the consensus to prepare final
draft of the tool.
Step- 3 Modifications as per suggestions:
As per the expert's opinion, the modifications
in the checklist were made after every Delphi
round. Final draft had 105 items categorized
under 12 steps. Nursing Checklist also had
separate list for required items so that it is
easy for staff to separate it out and give it to
the relatives after checking.
Phase III: This consisted of testing feasibility
of the Nursing Checklist. In order to assess
feasibility of the Checklist, a pilot study was
conducted on 4 patients in selected ICUsi.e
Main ICU, Respiratory ICU and
Gastroenterology ICU of Institute. Results of
the pilot study revealed that the language of
the tool was clear and it was feasible to carry
out the final study.
Phase IV: It considered testing inter-rater
agreement of the Nursing Checklist. The
inter-rater reliability of the checklist was
established after making necessary changes
based on Delphi technique and pilot study. To
test inter-rater agreement, checklist was
applied on 5 patients in Liver ICU of the
Institute by two raters independently. Interrater agreement was calculated at 0.95 C.I.
by using Cohen's Kappa. K value is
5
interpreted as given by Altman 1991.
Table 1 shows the Kappa value for all the five
cases. The agreement values of the 'Nursing
checklist' vary from 0.98 - 1.00. Kappa value
for cases 1, 2 & 5 was 1.00 and for cases 3 &
4 was 0.98. Table 2 depicts the inter-rater
agreement interpretation. As the kappa value
vary between 0.98 – 1.00. So, according to
Altman this shows that all the items had a
very good inter-rater agreement5.This means
that modified draft of the checklist was
homogeneously reliable with a very good
inter-rater agreement between raters.
Table 1: Kappa values for the Inter-rater agreement of the Nursing Checklist
Rater
R1-R2
N
5
N=5
Kappa value (k)
Case 1
Case 2
Case 3
Case 4
Case 5
1.000
1.000
0.981
0.981
1.000
Nursing and Midwifery Research Journal, Vol-11, No. 1, January 2015
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Table 2: Interpretation of k value
Value of k
<0.20
0.21-0.40
0.41-0.60
0.61-0.80
0.81-1.00
Strength of Agreement
Poor
Fair
Moderate
Good
Very Good
*Source: Altman D G Practical Statistics for Medical
Research London: Champman and Halt 1991.5
Phase V: It consist testing internal consistency
reliability of developed Nursing Checklist. It
included implementation of the tool on patients
received in ICUs and checking internal
consistency (reliability) of the developed tool.The
selected ICUs i.e. Respiratory ICU, Main ICU and
Gastroenterology ICU were taken as a research
setting for implementation of the tool. Written
permission from head of department of all ICUs
was taken. Ethical clearance was sought by
Institute Ethical Committee.The sister in charge
of the respective wards was also informed about
the study. Target population was nurses
receiving patients in ICUs. Using purposive
sampling technique, 30 nurses were selected and
given a formal training of 10-15 minutes in a
group of 4-5 nurses depending on the availability
in all the three ICUs. Subjects were explained
about how to use the 'Nursing checklist'. A set of
introduction and instructions regarding how to
use the checklist was also written on 1st page of
checklist i.e.it is a tool to ensure that all elements
are taken care of while receiving a patient in ICU.
Instructions included read and follow all the
steps and put tick mark in the appropriate yes or
no box. First written informed consent was
obtained and identification data sheet was filled
by the subjects. Then 'Nursing Checklist' was
given to them to receive patients in ICUs. Nonparticipatory observation was done in order to
observe the application and related nursing
activities carried out by nurses while receiving
patients in ICUs by using 'Nursing checklist'.
After the procedure was over 'Nursing checklist'
was taken back. Tool was implemented by 30
nurses while receiving patients in ICUs by using
checklist and marked in yes and no boxes in front
of steps of checklist. It took near about 25-30
minutes to implement a checklist. Data was
collected using identification data sheet and
nursing checklist tool. Data collected was coded
and analysed by using SPSS version 16.Internal
consistency of checklist was calculating
Cronbach's alpha coefficient.
Results
Final Nursing checklist to receive patients
in ICUs was prepared.Tables3-7(Part 1 to 5 of
Nursing checklist tool) shows reliability analysis
of the items of Nursing checklist by using
Cronbach's alpha. The sample size was 30. The
overall Cronbach's alpha coefficient of the
developed tool was 0.97, which indicates the
reliability and internal consistency of the tool
(Ideally Cronbach's alpha coefficient should be
0.70 or more than 0.70).
Corrected item to total correlation was
applied on all 105 items of the tool, only 2 items
in the scale had an item to total score correlation
less than 0.2 showing the incompatibility with the
overall tool i.e item 3.6d- intake/ output record
and item 10- entry to admission and census
register.
To check the individual contribution of
items, each item was deleted one by one to see
the changes in the value of Cronbach alpha
coefficient. But none of the items showed any
increase, in value of Cronbach alpha coefficient.
Rather, the value of Cronbach alpha coefficient
remained same or it decreased. This indicates
that all the items contributed to the tool. Even on
deleting certain items, having item to total
correlation less than 0.2, the value of Cronbach
alpha did not increase. Hence, these 2 items were
also contributing to the reliability of the tool. The
average scale mean was 126.68. When scale
mean if item deleted was applied on 105 items of
the tool, the scale mean if item deleted was in the
range of 126.43 to 126.83 and none of the items
had shown an increase in the value of average
scale mean rather it remained same or it
decreased. It means tool is internally consistent
Nursing and Midwifery Research Journal, Vol-11, No. 1, January 2015
4
by taking all 105 items. Result of Cronbach's
alpha revealed that all items were uniformly
contributing for the reliability of the tool.
Table 3 (Part1 of tool) shows reliability
analysis of first two steps along with sub parts of
step 3 of nursing checklist tool i.e consultation
with head, prior information and preparation
before receiving patient. Cronbach's alpha varies
between 0.969 to 0.970 which is above 0.70
showing reliability of tool. Corrected item to total
correlation was also above 0.2 for all the items
that all these items were contributing to the
reliability of the tool.
Table 4 (Part 2 of tool) shows reliability
analysis of two sub-steps of step 3 i.e preparation
of patient bedside trolley and patients charts of
the nursing checklist tool. Cronbach's alpha
varies between 0.969 to 0.970 which is above
0.70 showing very good reliability. Corrected
item to total correlation was above 0.2 for all the
items except item 3.6d i.e intake/output chart
showing incompatibility with the overall tool. To
check the individual contribution of this item, it
was deleted to see the changes in the value of
Cronbach alpha coefficient and scale mean. But
value of Cronbach alpha coefficient and scale
mean remained same rather than increasing.
This indicates that this item was contributing to
the reliability and internal consistency of the tool.
So it was kept and not deleted from the tool.
Table – 3 Reliability analysis of the items of 'Nursing checklist' to receive patients in
ICUs by using Cronbach's alpha (Part 1)
Items of the tool
1. Consultation with ICU consultant or Head of
Department
2. Nurses and Technicians informed 30 minutes
before the admission
3. Before receiving the patient
3.1) Carbolization of bed
3.2) Fumigation of room
3.3) Preparation of bed with air mattress
3.4) Preparation of following equipments and
check their working condition:
3.4a) Cardiac monitor with ECG leads and electrodes
3.4b) Pulse oximeter.
3.4c) NIBP/Invasive pressure monitoring.
3.4d) Ambubag
3.4e) Ventilator with circuits.
3.4f) O2 supply and compressed air
3.4g) Suction jar (emptied and disinfected) with
tubing connected to suction.
3.4h) I/V fluids and necessary tubings
3.4i) Infusion pumps and syringes as per need.
3.4j) Defibrillator (charged)
Scale Mean if
Item Deleted
126.57
Corrected Item - Cronbach's Alpha
Total Correlation If Item Deleted
.355
.970
126.43
.714
.969
126.83
126.83
126.47
126.80
126.80
.332
.332
.300
.456
.614
.970
.970
.970
.970
.970
126.80
126.83
126.77
126.80
126.70
126.70
126.73
.625
.495
.543
.690
.766
.347
.467
.970
.970
.970
.969
.969
.970
.970
126.73
126.70
126.63
.612
.642
.473
.969
.969
.970
Nursing and Midwifery Research Journal, Vol-11, No. 1, January 2015
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Table – 4 Reliability analysis of the items of 'Nursing checklist' to receive patients in
ICUs by using Cronbach's alpha (Part 2)
Items of the tool
Scale Mean if
Item Deleted
3.5) Preparation of patient bedside trolley:
126.67
3.5a) Injection tray.
126.73
3.5b) Spirit Swabs
126.73
3.5c)Handrub
126.77
3.5d) Heparinised saline
126.53
3.5e) Emergency Drugs
126.73
3.5f) Clean glove box
126.77
3.5g) Adhesive Plaster
126.70
3.5h) Sterile blade/ Pair of scissors
126.63
3.5i ) Sterile pair of gloves
126.70
3.5j) Sterile Drape sets and Sterile gauze/ sponges
126.57
3.5k) Procedure trolley
126.57
3.5l) Intubation kit
126.57
3.5m) Syringes
126.80
3.5n) I/V cannula (different sizes) and
126.60
Intra arterial cannula
3.5o) Ryles tube and lubricating jelly
126.70
3.5p) Foleys catheter, Urobag/ Urometer
126.73
3.5q) Betadine lotion
126.70
3.6) Preparation of patient records:
126.77
3.6a) Vital signs and ventilator settings
126.80
progress record.
3.6b) TPR Sheet
126.77
3.6c) GCS Chart
126.47
3.6d) Intake/output record.
126.77
3.6e) RBS Chart
126.73
3.6f) Abdominal Girth Chart.
126.63
3.6g) Medicine prescription sheet.
126.80
3.6h) Nursing instructions chart
126.70
3.6i) Nurses shift Report.
126.60
Table 5 (Part 3 of tool) shows reliability analysis
of two sub-steps i.e preparation of shifting trolley
and information collected from emergency staff.
Alpha value for all items is above 0.70 showing
Corrected Item - Cronbach's Alpha
Total Correlation If Item Deleted
.609
.969
.235
.970
.414
.970
.481
.970
.456
.970
.705
.969
.601
.970
.638
.969
.592
.969
.584
.969
.272
.970
.617
.969
.366
.970
.549
.970
.363
.970
.551
.550
.367
.270
.397
.970
.970
.970
.970
.970
.328
.595
.137*
.292
.348
.581
.396
.341
.970
.969
.970
.970
.970
.970
.970
.970
reliability of tool. Corrected item to total
correlation was also above 0.2 for all the items
showing that all these items were contributing to
the reliability of the tool.
Nursing and Midwifery Research Journal, Vol-11, No. 1, January 2015
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Table – 5 Reliability analysis of the items of 'Nursing checklist' to receive patients in
ICUs by using Cronbach's alpha (Part 3)
Items of the tool
Scale Mean if
Item Deleted
Corrected Item - Cronbach's Alpha
Total Correlation If Item Deleted
3.7) Preparation of shifting/ transfer trolley:
126.77
.717
.969
3.7a) Bed sheet
126.77
.515
.970
3.7b) Diaper sheets/ Diaper
126.73
.537
.970
3.7c) O2 Cylinder with breathing circuit
126.63
.618
.969
3.7d) Portable monitor/ Ventilator
126.50
.411
.970
3.7e) Ambubag
126.73
.647
.969
3.7f) Emergency drugs
126.70
.396
.970
3.7g) Intubation kit
126.57
.568
.970
3.7h) Torch
126.60
.599
.969
3.7i) Scissors/ blade
126.57
.648
.969
3.8) Information collected from ward or
Emergency staff:
126.83
.612
.970
3.8a) Identification Data i.e Patients name, age,
sex and CR No.
126.83
.612
.970
3.8b) Diagnosis.
126.73
.318
.970
3.8c) Admitted under which unit/ consultant
126.70
.708
.969
3.8d) GCS, Pupillary response
126.50
.324
.970
3.8e) Vital parameters
126.67
.438
.970
3.8f) Existing ventilator parameters
126.50
.274
.970
3.8g) Presence of Invasive lines/ ICD/ RT/
Drains/ Catheters.
126.60
.309
.970
3.8h) Date of insertion of lines.
126.50
.337
.970
3.8i) Details about ongoing Ionotropic medication
126.67
.617
.969
3.8j) Existing medication orders and
administration timings.
126.67
.458
.970
3.8k) Details regarding limb/ body, movement/
restriction/ specific position.
126.53
.293
.970
3.8l) Presence of bedsores.
126.57
.522
.970
3.8m) Any other ongoing therapy i.e Application
of TED stockings/ traction/ P.D/H.D.
126.47
.248
.970
3.8n) Existing Diet orders.
126.50
.454
.970
3.8o) Payment system.
126.63
.682
.969
Nursing and Midwifery Research Journal, Vol-11, No. 1, January 2015
7
Table 6 (Part-4 of tool) shows reliability
analysis of remaining sub-steps of step 3 and
step 4 i.e preparation of article checklist, giving
article checklist and orientation to relative and
checking items received. Step 4 is regarding
steps performed while receiving the patient.
Alpha value for all steps and items is above 0.70
which shows reliability of tool. Corrected item to
total correlation for all these was also above 0.2
showing that all these items were contributing to
the reliability of the tool.
Table – 6 Reliability analysis of the items of 'Nursing checklist' to receive patients in
ICUs by using Cronbach's alpha (Part 4)
Items of the tool
3.9) Preparation of article checklist
3.10) Give article checklist and Orientation to
relative about:
3.10a) Contact details
3.10b) Waiting Room
3.10c) Visiting timings
3.10d) Location of pharmacy, reception, chemist
shop etc.
3.10e) Ward policy of wearing cap, gown, mask
and hand washing.
3.11) Checking items received from patients
relative with list
4. While receiving patient
4.1) Identification of patient.
4.2) Check airway and breathing.
4.3) Check Circulation.( Pulse & Heart Rate)
4.4) Check GCS, pupil reaction
4.5) Change to ICU clothing
4.6) Remove ornaments & handover to attendants.
4.7) Transfer patient to Shifting trolley
4.8) Take inside ICU and Shift from trolley to ICU bed.
Table 7 (Part-5 of tool) shows reliability
analysis of step 5 i.e quick assessment soon after
admission and further final steps of nursing
checklist tool. Cronbach's alpha for all of them
varies between 0.969 to 0.970, which is above
0.70 showing very good reliability of tool. When
Scale Mean if
Item Deleted
126.80
126.80
Corrected Item - Cronbach's Alpha
Total Correlation If Item Deleted
.489
.970
.489
.970
126.63
126.67
126.63
126.60
.314
.223
.485
.452
.970
.970
.970
.970
126.63
.626
.969
126.73
.454
.970
126.80
126.77
126.77
126.70
126.60
126.70
126.57
126.70
126.73
.489
.251
.332
.282
.506
.658
.652
.691
.700
.970
.970
.970
.970
.970
.969
.969
.969
.969
corrected item to total correlation was applied, it
was above 0.2 for all steps and items except on
step 10 i.e Entry to admission and census
register, showing incompatibility with the overall
tool. To check the individual contribution of this
item, it was deleted to see the
Nursing and Midwifery Research Journal, Vol-11, No. 1, January 2015
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Table – 7 Reliability analysis of the items of 'Nursing checklist' to receive patients in
ICUs by using Cronbach's alpha (Part 5)
Items of the tool
Scale Mean if
Item Deleted
Corrected Item - Cronbach's Alpha
Total Correlation If Item Deleted
5. A quick assessment soon after admission
126.77
.645
.969
5.1) Airway and Breathing
126.77
.645
.969
5.2) Check ET / T.T tube placement, tip marking
and bilateral air entry
126.60
.420
.970
5.3) Connect Ventilator and adjust settings
126.63
.377
.970
5.4) Connect monitor for parameters like ECG,
B.P, H.R, R.R, Temp., arterial B.P, Saturation
and other parameters.
126.77
.404
.970
5.5) Check oxygen saturation, B.P, H.R, E.C.G,
R.R & Temp.
126.77
.332
.970
5.6) Check patency/ working of invasive lines.
126.73
.344
.970
5.7) Discard previous I/V lines & change to new lines.
126.67
.734
.969
5.8) Connect infusion pumps/ syringe pumps as needed.
126.70
.498
.970
5.9) Check chest drainage, Foleys catheter,
Ryle's tube and other drainage tubes.
126.70
.646
.969
6. Check & Follow stat instructions.
126.83
.384
.970
7. Check for medications and adjust medication
frequency timings.
126.73
.410
.970
8. Check for impaired skin integrity & assess for
bedsore, document if any.
126.70
.654
.969
9. Once patient stabilized, write Admission notes
126.70
.564
.970
10. Entry to admission & census register
126.77
.199*
.970
11. Diet requisition to dietary department.
126.67
.442
.970
12. Inform to the supervisor if the patient is a VIP/
NRI/ MLC/ Staff member/Foreign national/prisoner.
126.67
.601
.969
Overall scale mean is 126.68, *- Items in the tool which shows item to total correlation < 0.2
Overall reliability of the tool is 0.97 (Cronbach's alpha)
changes in the value of Cronbach alpha
coefficient and scale mean. But value of
Cronbach alpha coefficient and scale mean
remained same rather than increasing. This
indicates that this item was contributing to the
reliability and internal consistency of the tool. So
it was kept and not deleted from the tool.
Discussion
Patient in ICU are admitted with multiple
clinical problems related to brain, heart, lungs,
liver, kidneys and other body systems. So, the
ICU staff needs high level of skills and
knowledge. While receiving patients in ICUs,
staff nurses have to carry out a number of steps
Nursing and Midwifery Research Journal, Vol-11, No. 1, January 2015
9
and procedures. Busy environment and critical
situations makes them more prone to commit
mistakes.
So, present methodological study was
planned with objective to develop a tool 'Nursing
Checklist' for receiving patients in ICUs. A
Checklist is a comprehensive list of important
and relevant actions or steps which are to be
carried out in a specific manner. The checklist is
meant to assist staff and others in providing
adequate, safe, and efficient client care and
improvement in communication by reducing the
gaps in communication.1
Tool was validated with Delphi technique
and reliability was assessed with inter-rater
agreement and Cronbach's alpha. In Phase II,
content and face validity was undertaken with
Delphi Technique. We found that four rounds
were needed for all experts to come to a
consensus for final draft of the tool. In a similar
study, Delphi technique was used by Kirkwood et
al., to determine the nursing research priorities in
the North Glasgow University hospitals,4 they
found that three Delphi rounds were sufficient to
reach to a common consensus.
In phase IV, inter-rater reliability of the tool
was calculated by inter-rater agreement by using
Cohen's kappa, which removes the probability of
chance agreement. Cohen's kappa value for the
checklist varied between 0.98-1.00 which shows
very good inter-rater agreement. Similar findings
were also reported by Ottenbacheretal. and
Rupinder et al., who reported inter-rater
agreement of functional assessment of elderly in
which the Kappa value ranged from 0.90 to 0.99
and of cardiac catheterization checklist with the
Kappa value ranging from 0.88-0.97
6,7
respectively.
In the present study, the internal
consistency (reliability) of the Nursing Checklist
was checked in phase V by Cronbach's alpha by
using SPSS version 16. The Cronbach's alpha
coefficient value of the 'Nursing checklist to
receive patient in ICU' tool is 0.97, which satisfies
the criteria for the reliability of the tool. Similarly
in a methodological study by Rupinder et al. on
development of nursing checklist for cardiac
catheterization, value of Cronbach alpha was
0.86.7 Katz et al. reported similar findings on the
internal consistency of “The Dynamic
Occupational Therapy Cognitive Assessment for
Children”.8 The reported Cronbach's alpha was
0.77. May-Benson et al. also reported almost
similar findings.9 They assessed the internal
consistency of the “Gravitational Insecurity”
outcome measure. The alpha of the total test
score was 0.71.Similar findings were reported by
Bandana et al.on the internal consistency of the
'audit tool'.10 An 'audit tool' was developed for
auditing the family records. Internal consistency
of the tool was checked with Cronbach alpha and
the value was 0.73.Ho- Chung et al. also used
Cronbach's alpha to find out the reliability of tool
on ‘short form of Chinese version of anxiety state
for children'.11 The Cronbach alpha coefficient of
their tool was 0.83 which determined the
reliability of the tool. Another study by Wood was
on development of ‘initial psychometric
evaluation of patient perspective of arrhythmia
12
questionnaire'. In this study also Cronbach
alpha coefficient was used which was 0.84 that
determined the internal consistency of the tool.
Similarly a study on reliability and validity of
‘sexual pressure scale for women' (Revised),
Jones et al. also used Cronbach's alpha to find
out the internal consistency of their tool and
value of Cronbach alpha coefficient was 0.88
13
which suggested the reliability of the tool.
This study concludes that the developed
‘Nursing checklist' to receive patients in ICUs is a
valid and reliable tool. It consisted of 105 items
categorized under 12 steps. It can be applied in
daily practice and in the clinical research context
in the intensive care settings.In daily routine, it
can help in reducing nursing errors and thus will
enhance the effectiveness of care and promote
safe quality care.
Nursing and Midwifery Research Journal, Vol-11, No. 1, January 2015
10
References
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Winters BD, Gurses AP, Lehmann H,
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Report of National Commission on
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Kirkwood M, Wales A, Wilson A. Delphi
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Altman DG. Practical statistics for medical
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Ottenbacher KJ, Mann WC, Granger CV, Tomita
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Jones R, Gulick E. Reliability and
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32: 71-8
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