Development of an Agitation Rating Scale for Use with Acute Presentation Behavioral ...

197 Pages·2014·1.13 MB·English

Development of an Agitation Rating
Scale for Use with Acute Presentation
Behavioral Management Patients
Author: Tania Denise Shaffer Strout
Persistent link: http://hdl.handle.net/2345/1839
This work is posted on eScholarship@BC,
Boston College University Libraries.
Boston College Electronic Thesis or Dissertation, 2011
Copyright is held by the author, with all rights reserved, unless otherwise noted.
Boston College
William F. Connell Graduate School of Nursing
DEVELOPMENT OF AN AGITATION RATING SCALE FOR USE WITH
ACUTE PRESENTATION BEHAVIORAL MANAGEMENT PATIENTS
a dissertation
by
TANIA D. S. STROUT
submitted in partial fulfillment of the requirements
for the degree of
Doctor of Philosophy
May, 2011
©copyright by TANIA D. S. STROUT
2011
Acknowledgements
My most sincere thanks to those who have supported the development of my
work; I would not have been able to complete this work without their support:
•
June Andrews Horowitz, Ph.D., R.N., F.A.A.N., Professor, William F.
Connell School of Nursing, Boston College, my committee chair, advisor,
and guide through this work;
•
Patricia A. Tabloski, Ph.D., R.N., F.A.A.N., Associate Dean for Graduate
Programs and Associate Professor, William F. Connell School of Nursing,
Boston College, an agitation expert who makes me think in new ways;
•
Michael R. Baumann, M.D., Professor, Tufts University School of Medicine
and Vice-Chair/Medical Director Maine Medical Center, my research
partner and consummate supporter;
•
Alyce A. Schultz, Ph.D., R.N., F.A.A.N., EBP Concepts, my first research
mentor and agitation advisor who instilled in me a love of research;
•
My wonderful family, without their patience, support, encouragement,
and sacrifice, I would not have come this far; and
•
My incredible classmates: Rachel DiFazio, Douglas Schlichting, Brian
French, Martha Healey, and Lisa Wolf – each one of you gave me your
unending support, love, and pushes when I needed them.
iii
Thank you so very much to each of you. I will be forever grateful.
Dedication
I am honored to dedicate this work to my loving family, who has always
supported me in my quest to learn more:
•
To my wonderful parents, who have selflessly sacrificed to support my
education for as long as I can remember. Thank you so much. I would
not be in this place without you.
•
To my beautiful, smart, incredible children: Meighan Li and Molly
Xiao Yu. I am sorry that I had to go to school so much. I missed you
every minute that I was away but I hope that my example has taught
you to work diligently to accomplish your goals.
•
To my amazingly supportive husband, Ken. Thank you so much for
encouraging me to do this, for supporting me, for picking up my slack,
and for sticking it out. I love you.
I love you all so much and am so grateful to have each of you in my life. Thank
you.
iv
DEVELOPMENT OF AN AGITATION RATING SCALE FOR USE WITH
ACUTE PRESENTATION BEHAVIORAL MANAGEMENT PATIENTS
Abstract
Tania D. S. Strout
Advisor: June Andrews Horowitz, Ph.D., R.N., F.A.A.N.
Agitation is a distressing set of behaviors frequently observed in
emergency department psychiatry patients. Key to developing and evaluating
treatment strategies aimed at decreasing and preventing agitation is the
availability of a reliable, valid instrument to measure behaviors representative of
agitation. Currently, an agitation rating instrument appropriate for use in the
emergency setting does not exist and clinicians are left without standard
language for communicating about the phenomenon. The Agitation Severity
Scale was developed to fill this void using facilitated focus groups to generate an
initial item pool. Beginning evidence of content validity was established through
a survey of clinical providers and a panel of content experts. The objectives of
this methodological study were to: (a) develop an observation-based rating scale
to assess the continuum of behaviors known as agitation in adult emergency
department patients, and (b) to evaluate the psychometric properties of the
newly developed instrument. Psychometric evaluation was conducted using a
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sample of 270 emergency department psychiatric patients. A 17-item instrument
with a standardized Cronbach’s alpha coefficient of 0.91 resulted, providing
evidence of a high degree of internal consistency reliability. Principle
components analysis revealed a 4-component solution accounting for 69% of
observed variance. Internal consistency reliability ranged from 0.71 to 0.91 for the
scale components. Equivalence reliability was established through the evaluation
of Agitation Severity Scores assigned by independent evaluators, r = 0.99, Κ =
0.98. Construct validity was established through comparison of mean scores for
subjects in the highest and lowest scoring quartiles. A statistically significant
difference in scores was noted when comparing these groups, t = -17.688, df = 155,
p < 0.001. Convergent validity was evaluated by testing the association between
Agitation Severity Scores and scores obtained using a well-established
instrument, the Overt Agitation Severity Scale. Pearson’s correlation coefficient
for the associations between the scores ranged from 0.91 to 0.93, indicating a
strong, positive relationship between the scores. Finally, the Rasch measurement
model was employed to further evaluate the functioning of the instrument. In
sum, the Agitation Severity Scale was found to be reliable and valid when used
to measure agitation in the emergency setting.
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Table of Contents
Page
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii
Dedication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iv
Abstract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v
List of Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi
List of Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii
CHAPTER 1
1. Overview of the Proposed Study
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Statement of the Problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Purpose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Significance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Theoretical
Influences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Research Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Assumptions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
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Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
CHAPTER 2
2. Review of the Literature
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Agitation, Anxiety, and Aggression . . . . . . . . . . . . . . . . . . . . . . . . . 19
Research Related to the Measurement of Agitation . . . . . . . . . . . . 24
Agitation Assessment Instruments . . . . . . . . . . . . . . . . . . . . 24
Mania Assessment Instruments . . . . . . . . . . . . . . . . . . . . . . . 36
Psychiatric Symptoms Assessment Instruments . . . . . . . . . 38
Aggression Assessment Instruments . . . . . . . . . . . . . . . . . . 41
Instrument Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Defining the Construct . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Reliability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Validity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Rasch Models of Measurement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
CHAPTER 3
3. Methodology
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Development of the Scale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
viii
Setting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
Sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Study Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
Agitation Severity Scale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
Overt Agitation Severity Scale . . . . . . . . . . . . . . . . . . . . . . . . 67
Analytic Methods. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Protection of Human Subjects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
CHAPTER 4
4. Results
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Data Preparation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Characteristics of the Study Subjects . . . . . . . . . . . . . . . . . . . . . . . . . 76
Research Question 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Research Question 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
Research Question 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
Research Question 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
Research Question 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Summary of Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
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