Journal of Neuroscience Nursing:
Functional Capacity Scale in Assessment of Patients With Intracranial Aneurysms: Reliability and Validity
Ślusarz, Robert; Biercewicz, Monika; Rybicka, Roksana
Questions or comments about this article may be directed to Robert Ślusarz, RN MA CNS PhD, at firstname.lastname@example.org. He is a Clinical Nursing Specialist in Neurological and Neurosurgical Nursing and Head of the Neurological and Neurosurgical Nursing Department,Collegium Medicum, Nicolaus Copernicus University, Torun, Poland.
Monika Biercewicz, MA RN CNS, is an Assistant at the Clinic of Geriatrics, Collegium Medicum, Nicolaus Copernicus University, Torun, Poland.
Roksana Rybicka, MA, is a Senior Lecturer at the Department of Applied Linguistics, Collegium Medicum, Nicolaus Copernicus University, Torun, Poland.
Author contributions: Robert Ślusarz was responsible for the study conception and design. Robert Ślusarz, Monika Biercewicz, and Roksana Rybicka made critical revisions to the article for important intellectual content.
Ethics approval: To conduct the research, the consent of the Bioethical Commission of Nicolaus Copernicus University in Torun, Collegium Medicum in Bydgoszcz, was obtained (Consent no. KB: 27/2002, 697/2007).
The authors declare no conflicts of interest.
ABSTRACT: The aim of the study was to investigate the use of the Functional Capacity Scale (FCS) to measure functional outcome of patients who had undergone surgical removal of an intracranial aneurysm in the early postoperative period. Reliability and validity of the tool were tested as well as its utility in nursing practice. The study included 120 patients, operated on for intracranial aneurysm. Phase I included 23 patients. Reliability of FCS and the amount of time used for the assessment were tested using observation and direct measurement methods. Phase II included 97 patients, and the tool was administered along with standard outcome assessment tools (Barthel Index, Functional Index “Repty,” Glasgow Outcome Score, and Rankin Scale) to determine concurrent validity. Kendall’s coefficients of concordance (W) between particular care markers of FCS ranged from 0.910 to 1.000. Mean amount of time used for assessment was 90 seconds. Differences between time used for measurements by individual examiners were insignificant (p > .05). Correlation of FCS with the following scales was statistically significant: Functional Index “Repty” (p < .001), Glasgow Outcome Score (p < .01), Rankin Scale (p < .01), and Barthel Index (p < .001). The FCS appears to be a reliable, valid, and practical assessment tool for neuroscience nurses to use with patients who have undergone surgical removal of an intracranial aneurysm.
In nursing practice, the patient’s condition is assessed holistically. Thus, there is great interest in scoring scales, which help make a nursing diagnosis and estimate patient’s deficits in the scope of self-care ability and, consequently, determine the most important areas of nursing intervention to eliminate the deficit and optimize nursing care (Adamczyk, 2000; Kaniewska, Jędrys, Stadnicka, & Turowski, 1994; Rola & Turowski, 2002; Stadnicka, Sieplińska, & Turowski, 1993).
In the practice of a neuroscience nurse, scoring scales are commonly used. They are used for measuring the degree of damage (neurological deficit), for the functional assessment of a patient (motor abilities), and for the assessment of the patient’s comfort (the effects the illness may have on psyche and the patient’s social life; Adamczyk, 2000; Książkiewicz, 1996; Mazur, Kozubski, & Prusiński, 1998; Opara, 1996, 2005).
Functional outcome scores deal with assessing patient’s independence on the grounds of everyday life. They are used for assessing the treatment results, pertinence of treatment assignment, long-term prognosis, and independence (ability to function independently of others) as well as for estimating the need for further nursing care (Opara, 1996, 1999, 2005). There exist multiple ways of describing the nursing needs of a patient (Rola & Turowski, 2002), hence the categorization of patients under the appropriate nursing category is important. In nursing, however, categorization of patients is understood more extensively as the division of patients according to their nursing requirements and depending on the time when such needs occur and on the functional outcome of the patient (Rola & Turowski, 2002).
Scoring scales for functional outcome are usually universal and may be used for assessment of neurologically diagnosed patients as well as patients with other conditions. The Barthel Index (BI; King, Tsevat, & Roberts, 2009; Mahoney & Barthel, 1965) is the oldest point scale assessing patients’ functional capacity. It is used for assessment of patients with hemiparesis. In case of subarachnoid aneurysm hemorrhage (SAH), functional capacity is usually assessed using Rankin Scale (RS; Greebe, Rinkel, Hop, Visser-Meily, & Algra, 2010; Rankin, 1957), Functional Independence Measure (Kara, Yozbatiran, & Arda, 2007; Saciri & Kos, 2002), Glasgow Outcome Scale (GOS; Jennett & Bond, 1975; Koivisto et al., 2000), and Functional Status Examination (FSE; Dikmen, Machamer, Miller, Doctor, & Temkin, 2001; Kirkness et al., 2002) as well as Extended Glasgow Outcome Scale (GOSE; Wilson, Pettigrew, & Teasdale, 1998) and Karnofsky Performance Scale (Chiang, Claus, & Awad, 2000; Karnofsky, 1961).
Specialist literature presents well-documented results of studies on clinical assessment of patients with intracranial aneurysm or SAH performed using clinical scales such as World Federation of Neurosurgical Societies (Rosen & Macdonald, 2004; Teasdale et al., 1988), Hunt and Hess Scale (Hunt, & Hess, 1968), and Glasgow Coma Scale (GCS; Teasdale & Jennett, 1974). In case of functional capacity assessment, most reports concern long-term period after the operation (long-term outcome), for example, 3, 6, and 12 months or even several years after surgery (Al-Khindi, Macdonald, & Schweizer, 2010; Frazer, Ahuja, Watkins, & Cipolotti, 2007; Hackett, & Anderson, 2000; Koivisto et al., 2000). On the contrary, little is known about an early assessment of patient’s functional capacity after an operation (on the day of discharge), which is related to the nursing care. This early period along with the early assessment may significantly influence long-term results.
In neuroscience nursing, various functional scales are used for patient’s assessment (Al-Khindi et al., 2010; King et al., 2009; Kirkness et al., 2002). Nevertheless, the authors of this study would like to expand this list of functional scales by adding a new tool, which is particularly useful for an early assessment of patients after surgical intervention. The aim of the study was to investigate a tool for measuring the functional outcome of patients who had undergone surgical removal of an intracranial aneurysm in the early postoperative period. Reliability and validity of the tool were analyzed as well as its utility in nursing practice.
This prospective study was conducted in two phases: testing of interrater reliability and usefulness of the scale in daily nursing practice was conducted in phase I, and testing of concurrent validity against established tools was done in phase II. Subjects included 120 patients hospitalized in the Neurosurgery Clinic, Collegium Medicum (CM), Bydgoszcz, Nicolaus Copernicus University (NCU) in Torun, operated on for intracranial aneurysm.
The research was carried out in Neurosurgical Department and Clinic, CM in Bydgoszcz, NCU in Torun, within the group of 120 patients with a single vascular anomaly (intracranial aneurysm) removed by means of surgery. Most patients assessed using the Hunt and Hess Scale (Hunt & Hess, 1968) were classified into groups I–III. According to world neurosurgical standards, group “0” patients are patients with a diagnosed intracranial aneurysm that has not yet ruptured; groups I–III patients are patients in a relatively good general condition, with little surgical risk and good treatment results; and groups IV–V patients are in a very bad condition, with high surgical risk and unsatisfactory treatment results (Table 1). During 12 consecutive months, 187 patients were admitted to the neurosurgery ward and operated on for intracranial aneurysm. One hundred twenty patients met the following criteria and were included into the study. Criteria for subject inclusion were being (1) diagnosed vascular anomaly (intracranial aneurysm) on the basis of angiography, (2) in the postoperative phase of care after surgical treatment of an intracranial aneurysm through clipping and wrapping, (3) conscious on admission to the unit (able to hold a conversation).
To conduct the research, the consent of the Bioethical Commission of Nicolaus Copernicus University in Torun, CM in Bydgoszcz, was obtained (Consent no. KB: 27/2002, 697/2007).
The process consisted of two phases. Phase I included 23 consecutive patients who met the inclusion criteria. Interrater reliability was assessed using the coefficient of concordance (Kendall’s coefficient) between measurements performed by five competent examiners (Ślusarz, Beuth, & Kasprzak, 2003). Practicality of FCS was assessed based on the mean amount of time used for the assessment. The FCS measurements were performed on the day before operation and on the day of discharge. Each patient was assessed by five examiners. The examiners neither consulted the scoring of their peers nor commented on their own work.
Phase II included 97 consecutive patients (who met the inclusion criteria) and was an attempt to estimate concurrent validity of the FCS. In validation analysis, authors decided to compare FCS results with standardized tools used worldwide for functional assessment, such as BI, GOS, and RS. Because Functional Index Repty (FIR) is commonly used in Poland for functional assessment of neurological patients, its results are also shown in this study. All measurements were performed on the day of discharge in accordance with criteria of each applied scale (Ślusarz, Beuth, & Książkiewicz, 2008; Table 1).
This study used the FCS, BI, FIR, GOS, and RS. Each scale is described in the following section. The FCS is designed to assess the functional capacity of patients in the early postoperative period (Ślusarz, Beuth, & Książkiewicz, 2006, 2009). The scale has 12 markers (ambulation , alimentation , personal hygiene , physiological needs , life functions measurement—GCS , breathing , diagnosis , presurgical and post surgical treatment , dressing and drainage , acuteness of pain , pharmacotherapy , and neuropsychological outcome ). Each marker is displayed by means of four points (from 4 to 1) depending on the group within the range of a particular marker (Table 2). On observing the patient and using the markers of this scale, the patient may be ascribed to one of the four nursing groups: group I (patient does not need assistance; 48–40 p.), group II (patient needs assistance; 39–31 p.), group III (patient needs significant help; 30–21 p.), and group IV (patient needs intensive care; 20–12 p.). Criteria and description of each group are shown in Tables 2 and 1.
Development and Construction of the Scale
The FCS has been developed in the Clinic of Neurosurgery, CM in Bydgoszcz, Nicolaus Copernicus University in Toruń. It was created for the nursing assessment of a patient’s condition in the early period after an operative procedure. It can be used when the patient is hospitalized in the ward. The scale ranges from 12 to 48 points. Scoring 48 points signifies full functional capacity, whereas scoring 12 points indicates that the patient has considerable functional deficit. Thus, the higher the patient scores on the scale, the better their functional capacity. This scale is predominantly used in the early postoperative period as it does not contain any predictors of long-term quality of life (e.g., 3, 6, and 12 months). It does not contain any typical determinants of the assessment of a widely understood quality of life, which are included in scales such as Short Form-36 (SF-36) or Sickness Impact Profile, which assess psychosocial or occupational areas.
Underlying the methodological creation of FCS were two crucial elements connected with the vascular patient who underwent operative procedure, that is, (1) a profile of a patient with subarachnoid hemorrhage and (2) early period after operation.
The patient after subarachnoid hemorrhage from a ruptured intracranial aneurysm should undergo the nursing assessment in three areas:
* early clinical diagnosis and an operative procedure (FCS markers: diagnosis , preoperative and postoperative treatment , dressing and drainage , and pharmacotherapy );
* patient’s self-care ability—a functional condition (FCS markers: ambulation , alimentation , personal hygiene , physiological needs , and breathing );
* self-observation and self-control (FCS markers: life functions measurement , acuteness of pain , and neuropsychological outcome ).
The GOS (Jennett, & Bond, 1975) assesses the patient’s postoperative condition, level of self-reliance, and ability to perform social and professional roles. It is the most common scale used for measurement of the results of intensive care and long-term assessment of the recovery process after head and nervous system injuries. It is a relatively simple measurement tool used worldwide, which facilitates a comparison between reports including GOS outcomes. There are five grades with grade 5 representing good recovery, resumption of normal life; grade 4 = moderate disability, independent lifestyle; grade 3 = severe disability, dependent for daily support; grade 2 = persistent vegetative state; and grade 1 = death. In accordance with the criteria given by the authors, GOS measurements were performed on discharge (Table 1).
The FIR (Opara, 1996) is a universal tool for assessment of activities of daily living (ADL) in patients with various neurological and motor system disorders. It is simple and easy to use. The minimum and maximum scores range from 15 to 105. For the study, the following classification was adopted: group IV (105–85 points) = full independence, group III (84–65 points) = partial independence, group II (64–41 points) = partial dependence, and group I (40–15 points) = full dependence (Table 1).
The BI (Mahoney & Barthel, 1965) is the most common scale used for assessment of ADL. Many authors (Herndon, 2006; Kim, Haney, & Van Ginhoven, 2005; Quinn, Langhorne, & Stott, 2011) use this scale for assessment of patients with cerebral stroke and/or subarachnoid hemorrhage. Scores 0, 5, 10, and 15 are assigned for everyday activities (dressing, feeding, grooming, etc.) performed by the patient. For the study, the following classification was adopted: group V (100 points) = full functional capacity, group IV (95–75 points) = slight limitation of functional capacity, group III (70–50 points) = partial limitation of functional capacity, group II (45-25 points) = considerable limitation of functional capacity, and group I (20–0 points) = very serious limitation of functional capacity (Table 1).
The RS (Greebe et al., 2010; Rankin, 1957). Many modifications of this scale are used. Classic version of the scale contains scores between 0 (patient does not show any symptoms) and 5 (patient is severely disabled). Because of its clarity, the scale is often used for functional assessment of patients in multicenter trials. For the study, the following classification was adopted: 0 = no symptoms at all, 1 = no significant disability despite symptoms, 2 = slight disability, 3 = moderate disability, 4 = moderately severe disability, and 5 = severe disability (Table 1).
The analysis was conducted using the Microsoft Excel software and STATISTICA version 9.1. Descriptive statistical analysis was used (arithmetic average x¯ and the standard deviation) for the presentation of general characteristics of the examined patients and their functional state in FCS, GOS, FIR, BI, and RS in consecutive measurements. To assess interrater reliability, Kendall’s coefficient of concordance was used. Difference between time used for FCS measurements performed by the five ob servers was measured using multifactor analysis of variance (F). Correlation was calculated using Spearman’s rank correlation coefficient (rS; Brzeziński, 2002; Ferguson & Takane, 2002). Statistical hypotheses were verified according to relevance level of p < .05.
Interrater Reliability of FCS
W-Kendall coefficient of concordance is a method of examining the concordance between assessments performed by competent examiners such as experienced doctors, tutors, and so forth. The value of the coefficient may vary from 0 to 1, where 1 indicates complete concordance of the assessing parties and 0 indicates the lack of concordance (Brzeziński, 2002; Ferguson & Takane, 2002). For assessing this coefficient, the values are interpreted as follows: 0 = lack of concordance, 0.01–0.20 = weak concordance, 0.21–0.40 = low concordance, 0.41–0.60 = moderate concordance, 0.61–0.80 = typical concordance, 0.81–0.99 = very high concordance, and 1.00 = total concordance. Table 3 presents the W-Kendall coefficients for the measurements taken by five people during the preoperative period (on the day before surgery) and on the day of discharge. As shown in Table 3, the reliability of FCS is satisfactory, that is, the W-Kendall coefficients for each nursing categories were quite high in both measurements (within the range between 0.910 and 1.000), showing high concordance of assessments of patients’ conditions performed by five different people. Only three care markers (breathing , acuteness of pain , and neuropsychological outcome ) in the first measurement (before operation) and two markers (life functions measurement—(GCS)  and neuropsychological outcome ) in the measurement performed on the day of discharge were lower than W-Kendall’s 0.900.
Practicality of FCS
To determine the practicality of FCS, criterion of time was used, that is, how much time an examiner needed to assess one patient. A group of 23 patients was assessed by five independent examiners, and the measurements were statistically analyzed. Mean time of measurements performed by each observer was shown (expressed in seconds). Factors such as standard deviation and minimum and maximum length of measurement time were taken into consideration. Mean amount of time used for the assessment using FCS was 90 seconds. Multifactor analysis of variance (F) did not show differences between the time used for measurements by different examiners (p > .05; Table 4).
Validity of FCS
For the needs of the study, an assessment of concurrent validity has been performed—diagnostic FCS or, in other words, validity oriented toward the external criteria. The external criteria may stand for a measuring tool (calculation sheet, score, index, etc.) widely used in practice (Brzeziński, 2002; Ferguson & Takane, 2002). Accuracy of FCS was measured on the basis of correlations of scores on BI, FIR, GOS, and RS with scores on FCS (Table 5). The scales (BI, RS, FIR, and GOS) belong to the group of functional assessment scales used for the estimation of patient’s independence in ADL. The highest values of the coefficient were obtained in correlations between FIR and BI (rS = .971) and between FIR and RS (rS = −.960) and BI and RS (rS = −0.961). High, statistically significant (p < .001) values of Spearman’s rank coefficient (rS = 0.932), specified for the correlation between FCS and FIR, result from the similarity of structures of these scales. The FCS components are similar to FIR components, as well as both scales classify patients into four groups. In the case of GOS, RS, and BI scales, correlation coefficients are lower but also statistically significant.
In this study, functional capacity assessment of patients with intracranial aneurysm/SAH in the early postoperative period was performed. Psychometric analysis of FCS was performed, and its basic parameters—reliability and validity—were determined. The assessment criteria were the markers/components of particular scoring scales (e.g., ambulation, alimentation, personal hygiene, etc.).
Psychometric analyses of reliability and validity of the scales described in this study were mostly satisfactory. In case of the BI scale, the internal consistency coefficient according to various studies ranges between 0.87 and 0.90, whereas validity coefficient with relation to other scales ranges between 0.65 and 0.69 (Bowling, 1997). In GOS studies, it is shown that both reliability (0.94) and validity are satisfactory (Côté et al., 2011). For RS, coefficients of concordance range from 0.81 to 0.95; validity coefficient with relation to other scales ranges from 0.60 to 0.86 (Banks & Marotta, 2007; Quinn, Dawson, Walters, & Lees, 2009). Also analyses performed in Poland show that coefficients of concordance for FIR range between 0.44 and 1.0 and validity coefficients range from 0.70 to 0.99 (Opara, 1996).
A literature review shows that measurements performed using most scales for clinical assessment of functional capacity and quality of life are time consuming (Herndon, 2006). Particular scales may be used by trained professionals only (doctors, nurses, physical therapists, etc.). Owing to the 12 markers for patients’ assessment, FCS can be used by nurses without special FCS training. The authors are convinced that specialists in neurological and neurosurgical nursing will have no difficulties with incorporating the scale into daily nursing practice.
The study shows that the FCS measurement takes approximately 90 seconds. Although it takes only a few seconds to assess patient’s condition using GOS or RI (Herndon, 2006), these scales do not fully reflect functional capacity of patients operated on for intracranial aneurysm (FCS, in contrast to the other scales, has specific care markers to assess this group of patients). Measurements using BI and FIR take longer, which results from the scales’ markers (Herndon, 2006; Opara, 1996, 2005).
Correlations between particular scales prove the usefulness of these assessment scales in the case of patients with SAH and/or intracranial aneurysms. Other authors (Hackett & Anderson, 2000; Kim et al., 2005; Raaymakers, 2000) also confirm the correlation between scales for the assessment of functional capacity in patients after SAH, directly after the surgery and at the remote period. Kirkness et al. (2002) show correlations between two recently improved scales—GOSE and FSE—used for the final assessment (functional capacity: recovery) of patients after subarachnoid hemorrhage, 3 months after discharge. They suggest that final outcomes measured by GOSE and FSE are closely related and show statistically significant relationship with other clinical scales, for example, GCS, BDI, SF-36, and GOS. Kim et al. examined and compared correlations between functional scales on a group of 385 patients between 3 and 12 months after SAH. They analyzed GOS, BI, RS, and SF-36 and also compared National Institutes of Health Stroke Scale and Mini Mental State Examination (Kim et al., 2005).
The latest reports (2010, 2011) on functional assessment scales focus on evaluation of their reliability and practicality (time needed for assessment; Bruno et al., 2010; Lu, Marmarou, Lapane, Turf, & Wilson, 2010; Quinn et al., 2011; Saver et al., 2010). According to the authors, criteria of BI, RS, and GOS are clear and practical. However, the results are not the same and thus hard to compare. The authors suggest that the methodology and terminology should be the same so the scales could be used in multicenter clinical studies.
Relevance to Neuroscience Nurses
The study reports that FCS is a very useful tool for functional capacity assessment in patients at the early stage after intracranial aneurysm surgery. The findings and simple care markers describing early postoperative stage indicate that the scale usefulness is twofold. First, the measurement performed using the scale is not time consuming and might be performed several times during one nursing shift. Second, the scale might be used for the assessment of most neurosurgical patients because of simple care markers related to early postoperative period. These observations confirm that FCS is a practical tool, which means it can be easily used in clinical practice for monitoring patient’s condition and planning care for patients with nervous system disorders. At the same time, it significantly correlates with other scales used for functional assessment of patients with SAH or intracranial aneurysm.
Limitations of the Study
First of all, FCS is used for an early functional assessment of patients after intracranial aneurysm surgery; therefore, psychometric analyses of the tool cannot be based on large population, because of a limited number of hospitalized patients. Second, for reliability tests, only two measurements (on the day before the operation and on the day of discharge) were taken into consideration to obtain objective results of functional assessment. Further measurements on consecutive days (3, 6, or 9) after surgery could be biased or inaccurate because people who diagnose patients usually remember the earlier condition of the patient and such knowledge may affect the assessment. Third, the study was performed only in Poland; therefore, it is difficult to compare the results with other authors’ results and, consequently, generalize the conclusions.
Statistical procedures for verification confirmed that FCS reliability (interrater reliability) and validity (concurrent validity) are stable. The FCS is a practical tool, successfully applied to clinical practice, allowing to monitor the clinical condition of a patient and to plan nursing care for patients who had undergone surgical treatment of intracranial aneurysm.
The authors are grateful to Janice L. Hinkle, PhD, RN, CNRN, the Catholic University of America, School of Nursing, for assistance and valuable suggestions.
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Functional Capacity Scale; functional outcomes study; intracranial aneurysm; reliability; validity
© 2014 American Association of Neuroscience Nurses
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