8
The person-centred care of older people with cognitive impairment in acute care scale (POPAC) DAVID EDVARDSSON RN, PhD 1,2 , ANITA NILSSON RN, PhD 3 , DEIRDRE FETHERSTONHAUGH RN, PhD 4 , RHONDA NAY RN, PhD 5 and SHANE CROWE RN 6 1 Associate Professor/Director of Nursing Research, School of Nursing and Midwifery, La Trobe University, Melbourne, Victoria, Australia, 2 Associate Professor, Department of Nursing, Umea ˚ University, Umea ˚, Sweden, 3 PhD Candidate, Department of Nursing, Umea ˚ University, Umea, Sweden, 4 Deputy Director/Senior Research Fellow, Australian Centre for Evidence Based Aged Care (ACEBAC), La Trobe University, Melbourne, Victoria, 5 Professor and Director, Australian Institute for Primary Care and Ageing (AIPCA), La Trobe University, Melbourne, Victoria and 6 Deputy Director, Ambulatory and Nursing Services, Austin Health, Heidelberg, Victoria, Australia Background Providing cost-effective and high quality care of older people has been established as one of the major chal- lenges of this century due to a rapidly increasing ageing population, and the consequential long-term burden imposed on health and aged care systems throughout the Western world through the ageing societies and the increasing prevalence of older people with dementia, which has risen globally from an estimated 29 million in Correspondence David Edvardsson School of Nursing and Midwifery La Trobe University Level 4 Austin Tower, PO Box 5555 Heidelberg Victoria 3084 Australia E-mail: [email protected] EDVARDSSON D., NILSSON A., FETHERSTONHAUGH D., NAY R. & CROWE S. (2012) Journal of Nursing Management The person-centred care of older people with cognitive impairment in acute care scale (POPAC) Aim To construct and evaluate psychometric properties of the person-centred care of older people with cognitive impairment in acute care settings (POPAC) scale. Background Older people with cognitive impairment are admitted frequently to acute care, with needs not always met through standard practice. Best practice models have been suggested, but few assessment scales exist. Methods Psychometric evaluation using statistical estimates of validity and reli- ability based on an Australian sample of acute care nursing staff (n = 212). Results The final 15-item questionnaire consists of three subscales, Ôusing cognitive assessments and care interventionsÕ, Ôusing evidence and cognitive expertiseÕ and Ôindividualizing careÕ. Estimates of validity and reliability were highly satisfactory. Conclusion The POPAC scale makes a valuable contribution by providing valid and reliable measures of the extent to which acute nursing staff report using best practice care processes to identify and consider cognitive impairment and to employ nursing interventions to meet the needs associated with old age and cognitive impairment. Implications for nursing management The POPAC scale is short, easy to administer and not time consuming to complete, but still provides clinically relevant infor- mation. It can be used as a conceptual fundament in developing best practice nursing care in the acute clinical setting, as well as for nursing research. Keywords: dementia, evidence-based practice, hospitals, nurseÕs practice patterns, psychometrics Accepted for publication: 13 March 2012 Journal of Nursing Management, 2012 DOI: 10.1111/j.1365-2834.2012.01422.x ª 2012 Blackwell Publishing Ltd 1

The person-centred care of older people with cognitive impairment in acute care scale (POPAC)

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The person-centred care of older people with cognitive impairmentin acute care scale (POPAC)

DAVID EDVARDSSON R N , P h D1,2, ANITA NILSSON R N , P h D

3, DEIRDRE FETHERSTONHAUGH R N , P h D4,

RHONDA NAY R N , P h D 5 and SHANE CROWE R N6

1Associate Professor/Director of Nursing Research, School of Nursing and Midwifery, La Trobe University,Melbourne, Victoria, Australia, 2Associate Professor, Department of Nursing, Umea University, Umea, Sweden,3PhD Candidate, Department of Nursing, Umea University, Umea, Sweden, 4Deputy Director/Senior ResearchFellow, Australian Centre for Evidence Based Aged Care (ACEBAC), La Trobe University, Melbourne, Victoria,5Professor and Director, Australian Institute for Primary Care and Ageing (AIPCA), La Trobe University, Melbourne,Victoria and 6Deputy Director, Ambulatory and Nursing Services, Austin Health, Heidelberg, Victoria, Australia

Background

Providing cost-effective and high quality care of older

people has been established as one of the major chal-

lenges of this century due to a rapidly increasing ageing

population, and the consequential long-term burden

imposed on health and aged care systems throughout

the Western world through the ageing societies and the

increasing prevalence of older people with dementia,

which has risen globally from an estimated 29 million in

Correspondence

David Edvardsson

School of Nursing and Midwifery

La Trobe University

Level 4

Austin Tower, PO Box 5555

Heidelberg

Victoria 3084

Australia

E-mail:

[email protected]

E D V A R D S S O N D . , N I L S S O N A . , F E T H E R S T O N H A U G H D . , N A Y R . & C R O W E S . (2012) Journal of

Nursing Management

The person-centred care of older people with cognitive impairment in acute carescale (POPAC)

Aim To construct and evaluate psychometric properties of the person-centred careof older people with cognitive impairment in acute care settings (POPAC) scale.

Background Older people with cognitive impairment are admitted frequently to

acute care, with needs not always met through standard practice. Best practice

models have been suggested, but few assessment scales exist.

Methods Psychometric evaluation using statistical estimates of validity and reli-

ability based on an Australian sample of acute care nursing staff (n = 212).

Results The final 15-item questionnaire consists of three subscales, �using cognitive

assessments and care interventions�, �using evidence and cognitive expertise� and

�individualizing care�. Estimates of validity and reliability were highly satisfactory.

Conclusion The POPAC scale makes a valuable contribution by providing valid and

reliable measures of the extent to which acute nursing staff report using best practice

care processes to identify and consider cognitive impairment and to employ nursing

interventions to meet the needs associated with old age and cognitive impairment.

Implications for nursing management The POPAC scale is short, easy to administer

and not time consuming to complete, but still provides clinically relevant infor-

mation. It can be used as a conceptual fundament in developing best practice

nursing care in the acute clinical setting, as well as for nursing research.

Keywords: dementia, evidence-based practice, hospitals, nurse�s practice patterns,

psychometrics

Accepted for publication: 13 March 2012

Journal of Nursing Management, 2012

DOI: 10.1111/j.1365-2834.2012.01422.xª 2012 Blackwell Publishing Ltd 1

2005 to about 34 million in 2009 (Wimo et al. 2010). It

is well known that the rate of hospital use increases

with age, as does the average number of days per stay in

hospitals. In 2004–05, people older than 65 years rep-

resented 35% of all hospital admissions in Australia,

and accounted for 48% of all patient days (Australian

Institute of Health and Welfare 2006), and similar data

have been reported for the United States (DeFrances &

Hall 2007). In addition, older people often present with

co-morbidities and a high prevalence of dementia dis-

orders or other forms of cognitive impairment that add

risks to the hospitalization. Samson et al. (2009)

showed recently that the prevalence of dementia disor-

ders among older people admitted to acute hospital care

was as high as 42.4%, and they further showed that in

comparison with cognitively unimpaired patients, three

times as many patients with dementia and five times as

many with scores on the mini mental state examination

(MMSE) below 15 died during their hospitalization,

even after controlling for age and severity of acute

physical illness (Samson et al. 2009). People with

dementia have also been shown to have a fivefold risk of

developing delirium in hospitals (Royal College of

Psychiatrists 2005), and delirium is rarely detected by

staff even though frequently occurring in older patients

(Joray et al. 2004, Soderqvist 2007). It has been esti-

mated that as much as 30–40% of incident delirium

may be preventable, for example, through screening and

preventive measures (Inouye 2006). Thus, high quality

care of patients with cognitive impairment and delirium

prevention depends to a large extent on the ability of

staff to identify specific patients at risk, to evaluate

cognition and to intervene against potential risk factors

(Dick 1998, Zeleznik 2001, Waszynski 2007).

It has further been described that best practice models

of acute care for older people with cognitive impair-

ment consists of using gerontological expertise, targeted

assessment techniques, discharge planning and en-

hanced interdisciplinary communication (Hickman

et al. 2007). In addition, the development of staff

geriatric expertise, using standardized care protocols,

evidence-based assessments and environmental modifi-

cations have also been identified as central to the

development of best practice models (Moyle et al.

2008). Others have argued that older patients with

cognitive impairment would benefit if acute hospital

wards would increasingly apply person-centred princi-

ples such as a holistic philosophy of care; use interdis-

ciplinary assessments and individualized interventions:

establish and maintain relationships; adapt the envi-

ronment and involve family members (Edvardsson &

Nay 2010). Literature reviews indicate a shortness of

psychometrically sound tools for measuring the extent

to which best practice nursing care of older people with

cognitive impairment is delivered in acute care settings.

This makes it difficult therefore to study the association

between person-centred care practices and health out-

comes in hospitalized older people with cognitive

impairment. Thus, the aim of this study was to con-

struct and evaluate psychometric properties of the per-

son-centred care of older people with cognitive

impairment in acute care settings (POPAC) scale, a self-

report staff questionnaire measuring the extent to which

acute nursing staff report using best practice care pro-

cesses, to identify and consider cognitive impairment

and to employ nursing interventions to meet the needs

associated with old age and cognitive impairment.

Methods

The study utilized methods for scale construction

(Streiner 2008) and a cross-sectional psychometric de-

sign (Nunnally 1994) to evaluate the validity and reli-

ability of a measurement scale for assessing the extent

to which staff report providing person-centred best

practice care of older people with cognitive impairment.

Scale construction

The theoretical foundation of the scale was developed

from the following contemporary nursing research lit-

erature into best practice nursing care of older people

with cognitive impairment in acute hospital settings

(Hickman et al. 2007, Day et al. 2008, Moyle et al.

2008, Edvardsson & Nay 2010). From these articles,

eight dimensions of best practice were identified, and

further used as a base for the development of the tool:

recognizing cognitive impairment, consulting specialist

expertise, using evidence-based care protocols or

guidelines, making environmental adjustments, provid-

ing social enrichments, prioritizing staff continuity and

close interactions, avoiding restraints, and individual-

izing care. These theoretical dimensions were translated

into items to form the preliminary version of the scale.

All items were designed as statements about different

best practice procedures, and participants were asked to

respond how often they estimated these procedures

being used on their ward. The conceptual approach to

this linguistic formation of items was that the scale as a

whole would indicate a set of optimal processes in

providing best practice care of older people with cog-

nitive impairment in acute care settings. Thus, the

scores on the scale indicate the extent to which staff

estimated that such processes generally were happening

D. Edvardsson et al.

ª 2012 Blackwell Publishing Ltd2 Journal of Nursing Management

on the ward, with higher scores representing that such

best practice processes were perceived as occurring

more often. The first draft preliminary tool consisted of

21 items relating to best practice and eight items relat-

ing to staff attitudes towards older people with cogni-

tive impairments. The scaling utilized a six-point Likert-

type scale with the following response options rated as

1–6: never, very rarely, rarely, frequently, very fre-

quently and always.

An international multidisciplinary expert panel

(n = 12) consisting of internationally recognized

researchers within medicine, nursing and sociology with

a strong publication record relating to older people with

cognitive impairment in acute care settings was invited

to comment on the preliminary tool. The expert panel

members were invited to comment on the relevance and

specificity of items in recognizing procedures that

facilitate valid recognition of cognitive impairment, and

in describing best practice care that could meet the

needs associated with cognitive impairment. Responses

were received from two-thirds of the panel (n = 8), and

these comments confirmed the theoretical relevance of

the items, and suggested revisions to increase the clarity

of the aim and instructions to participants; personalize

the phrasing of statements; and enhance the clinical

applicability of the scale. The preliminary scale was

revised according to comments from the panel, which

resulted in a final preliminary pool of 21 items for

further testing.

Sampling

The 21-item preliminary scale was distributed to an

eligible sample of 360 nursing staff at 12 wards in a

metropolitan acute hospital in Melbourne, Australia.

The wards had the following focus: respiratory care (1),

colorectal/urology (1), neurosurgery (1), cardiology (1),

oncology (2), liver/transplants (1), renal (1), orthopae-

dics (1), general medicine (2), neurology (1). All data

were collected between June and August 2011, and in

July 2011, 1345 patients were cared for at these wards,

58% were 65 years or older, and the mean length of

stay for all patients across these wards was 6.6 days.

Ward participation was based on self-reported frequent

admission of older patients (>65 years). Participating

staff had the option of completing the survey online or

paper based. A 59% response rate was achieved, pro-

viding a final total sample of 212 nursing staff. In

addition, a sample of 25 nursing staff from the ortho-

paedic ward participated in test–retest evaluation,

which involved completion of the final version scale at

two time points within a 2-week interval.

Psychometric evaluation

Item performance was evaluated through assessments of

item means and standard deviations, item-total corre-

lations, Cronbach�s alpha if item deleted, and indepen-

dent samples t-test. The cut-off for acceptable

homogeneity contribution on item level was set to item-

total correlations of >0.3 and <0.7, and that the total

scale Cronbach�s alpha would not increase by deleting

any single item. The discriminative ability of items was

investigated by comparing item mean scores for

respondents in the top and bottom quartile of the scale

total scores, and a value of P < 0.05 was considered

appropriate. The cut-off for using explorative factor

analyses to assess construct validity was set to a sig-

nificant Bartlett�s test of sphericity, and a Kaiser-Meyer-

Olkin (KMO) measure of sampling adequacy of >0.7.

Construct validity was then assessed using principal

component analysis with oblimin rotation as factors

were expected to be correlated. Assessment of content

validity was based on literature and the expert panel

review process. Internal consistency reliability was

evaluated using Cronbach�s alpha on total scale and

subscale levels, and the cut-off for acceptable internal

consistency was set to >0.7. Test–retest reliability was

assessed using the paired samples t-test and intraclass

correlation coefficient, and the cut-off for acceptable

test–retest reliability was set to a value of P > 0.05 be-

tween test and retest scores, and/or a correlation coef-

ficient of >0.3. Missing values (<10%) in surveys were

replaced with the item mean so as not to distort the

analyses (Shrive et al. 2006). Item five was negatively

worded and was reversed prior to all calculations.

Higher scores on item, subscale and total scores indicate

a higher level of person-centredness, and all aggregated

scores were calculated using sum scores divided by

number of items. The PASW statistics version 18 (SPSS

Inc., Chicago, IL, USA) was used to analyse all data.

Results

The sample consisted mostly of females (93%), with a

mean age of 35 years ± 11.5, with an average of

10 years ± 9.2 work experience in acute care, and

5 years ± 5.0 on the ward in question. The majority of

participants (93%) had no postgraduate qualifications

in the care of older people, and most participants (85%)

acknowledged that older people with cognitive impair-

ments were frequently or very frequently admitted to

their wards. The mean POPAC total score was

3.77 ± 0.65 (range 1.73–5.80), with a skewness of

)0.12.

Construction and psychometric evaluation of the POPAC

ª 2012 Blackwell Publishing LtdJournal of Nursing Management 3

Item performance

Six items from the preliminary 21-item pool were de-

leted as they failed to meet the cut-off for acceptable

homogeneity (>0.3). As reported in Table 1, the

remaining 15 items showed satisfactory homogeneity

estimates as evidenced by item-total correlations

ranging between 0.40 and 0.67, and by the fact that

the total scale Cronbach�s alpha would not have been

increased by deleting any of these 15 items. All items

showed a discriminative ability through generating

significant mean score differences, with higher item

mean scores in the top quartile group as expected

(P < 0.01).

Validity

The content validity of the POPAC was deemed satis-

factory as the conceptual content of the scale covered

key dimensions of best practice nursing care of older

people with cognitive impairment as described in con-

temporary nursing research journal publications

(Hickman et al. 2007, Day et al. 2008, Moyle et al.

2008, Edvardsson & Nay 2010). In addition, the expert

panel review comments supported the content validity

of the tool. The appropriateness of using explorative

factor analyses to assess construct validity was sup-

ported by a KMO of 0.88 and a significant Bartlett�s test

of sphericity. As reported in Table 2, the explorative

factor analysis resulted in a stable three factor model

with satisfactory explanatory power, and the structure

of the model followed an underlying theoretical logic.

Based on the factor structure, it was decided that the

final 15-item questionnaire consists of three subscales

that were given the following interpretative labels based

on their conceptual content: �using cognitive assess-

ments and care interventions�, �using evidence and

cognitive expertise�, and �individualizing care�.

Table 1Item performance of the final POPAC scale

Item Mean SDCorrected Item-total

correlationCronbach�s Alpha

if item deleted

1. We assess the cognitive status of our older patients onadmission

4.34 1.34 0.50 0.87

2. We make environmental adjustments to avoid over-stimulationin older people with cognitive impairment (e.g. single rooms,noise reductions etc.)

3.87 1.06 0.67 0.86

3. We diagnose symptoms of cognitive impairment (e.g.dementias, delirium etc.)

3.91 1.04 0.53 0.86

4. We spend more time with older patients with cognitiveimpairments compared with cognitively intact patients

3.99 1.11 0.48 0.87

5. We leave older people with cognitive impairments alone in theward

4.52 1.12 0.40 0.87

6. We use evidence-based tools to assess cognitive status ofolder patients (e.g. the MMSE, SPMSQ, CAM etc.)

3.03 1.40 0.48 0.87

7. We consult specialist expertise (e.g. psychologist,gerontologist) if we find that a patient has cognitiveimpairment

3.83 1.20 0.62 0.86

8. We use evidence-based care guidelines in the care of oldercognitively impaired patients

3.69 1.11 0.60 0.86

9. We use biographical information about older patients� (e.g.habits, interests and wishes etc.) to plan their care

3.31 1.01 0.48 0.87

10. We involve family members in the care of older patients withcognitive impairment

4.26 0.95 0.52 0.86

11. We provide staff continuity for older patients with cognitiveimpairments (e.g. the same nurses providing care to thesepatients as often as possible)

3.45 0.96 0.42 0.87

12. We systematically evaluate whether or not older patientswith cognitive impairment receive care that meets their needs

3.69 0.99 0.60 0.86

13. We involve older patients with cognitive impairment in decisionsabout their care (e.g. examinations, treatments etc.)

3.65 0.93 0.54 0.86

14. We ensure that older patients with cognitive impairment havetests/examinations/consultations in the unit rather than havingto go to another department

3.26 0.98 0.49 0.87

15. We discuss ways to meet the complex care needs of peoplewith cognitive impairment

3.80 1.09 0.53 0.86

D. Edvardsson et al.

ª 2012 Blackwell Publishing Ltd4 Journal of Nursing Management

Reliability

Internal consistency reliability was high for the 15-item

POPAC scale, as evidenced through a total Cronbach�salpha of 0.87. The subscales also had satisfactory reli-

ability, with the subscales showing the following

Cronbach�s alpha values: subscale one �using cognitive

assessments and care interventions� scoring 0.74, sub-

scale two �using evidence and cognitive expertise� scor-

ing 0.79, and subscale three �individualizing care�scoring 0.78. Furthermore, the assumption that all

items reliably measure a single underlying construct was

supported by the item-total correlations ranging be-

tween 0.40 and 0.67 as shown in Table 1.

Regarding test–retest reliability, the paired sample

t-test showed that there were no significant mean dif-

ferences between test and retest scores for the total scale

or the subscales, thus indicating a satisfactory temporal

stability as reported in Table 3. In addition, the intra-

class correlation coefficient between scores at test and

retest showed that scores for the total scale and for the

subscale �individualizing care� exceeded the r > 0.3 cut-

off for satisfactory test–retest reliability. However, two

of the subscales, �using cognitive assessments and care

interventions� and �using evidence and expertise in

cognition� did not meet the r > 0.3 cut-off.

Discussion

This study aimed to evaluate the psychometric proper-

ties of the POPAC, and the findings support a valid and

reliable use of the scale based on a sample of Australian

Table 2Factor loadings of final items included in the POPAC (N = 212)

Items in factor

Using cognitiveassessments and careinterventions (factor 1)

Using evidenceand expertise in

cognition (factor 2)Individualizingcare (factor 3)

(1) We assess the cognitive status of our older patients on admission 0.702 )0.271 )0.173(2) We make environmental adjustments to avoid over-stimulation in

older people with cognitive impairment (e.g. single rooms, noisereductions etc.)

0.498 )0.177 0.308

(3) We diagnose symptoms of cognitive impairment (e.g. dementias,delirium etc.)

0.564 )0.168 0.083

(4) We spend more time with older patients with cognitiveimpairments as compared to cognitively intact patients

0.723 0.072 0.066

(5) We leave older people with cognitive impairments alone in theward

0.616 0.076 0.063

(6) We use evidence-based tools to assess cognitive status of olderpatients (e.g. the MMSE, SPMSQ, CAM)

)0.065 )0.859 0.059

(7) We consult specialist expertise (e.g. psychologist, gerontologist)if we find that a patient has cognitive impairment

0.347 )0.714 )0.069

(8) We use evidence-based care guidelines in the care of oldercognitively impaired patients

0.062 )0.681 0.023

(9) We use biographical information about older patients� (e.g. habits,interests and wishes etc.) to plan their care

)0.196 )0.341 0.607

(10) We involve family members in the care of older patients withcognitive impairment

0.345 0.065 0.470

(11) We provide staff continuity for older patients with cognitiveimpairments (e.g. the same nurses providing care to thesepatients as often as possible)

)0.128 )0.097 0.664

(12) We systematically evaluate whether or not older patients withcognitive impairment receive care that meets their needs

0.338 0.013 0.533

(13) We involve older patients with cognitive impairment in decisionsabout their care (e.g. examinations, treatments etc.)

0.162 0.149 0.737

(14) We ensure that older patients with cognitive impairment havetests/examinations/consultations in the unit rather than having togo to another department

0.073 )0.218 0.467

(15) We discuss ways to meet the complex care needs of people withcognitive impairment

0.346 )0.026 0.415

Eigenvalue 5.50 1.40 1.08Variance explained by factor 37% 9% 7%Total variance explained by the factor model 53%

Bold values indicate that items (1)-(5) belong to factor 1, (6)-(8) belong to factor 2 and (9)-(15) belong to factor 3.

Construction and psychometric evaluation of the POPAC

ª 2012 Blackwell Publishing LtdJournal of Nursing Management 5

acute hospital staff. The POPAC scale makes a valuable

contribution to the literature by being the first valid and

reliable scale to measure the extent to which acute

nursing staff report using best practice care processes to

identify and consider cognitive impairment and to em-

ploy nursing interventions to meet the needs associated

with old age and cognitive impairment. The scale can

enable descriptions and comparisons between wards,

correlating care practices and patient outcomes, and/or

evaluating the impact of interventions.

It seems that the POPAC scale can make a contribu-

tion to the literature by enabling studies of the extent to

which various acute care settings are �older people

friendly�, i.e. the extent to which the assessments, pro-

cedures, protocols and routines incorporate aspects

such as valid and reliable screening for cognitive

impairment, consulting adequate expertise and using

individualized and needs-based nursing interventions.

This first subscale of the POPAC capture aspects pre-

viously described as being central to best practice care

of older people with cognitive impairment, such as

making environmental adjustments and cognitive

assessments, diagnosing symptoms, spending time with

and not leaving these patients alone in the ward

(Hickman et al. 2007, Day et al. 2008, Moyle et al.

2008, Edvardsson & Nay 2010). The POPAC contrib-

utes by providing a staff-based measure of the extent to

which these important dimensions actually are in place

in acute care settings.

The second subscale illuminates three aspects relating

to evidence-based practice, and measures the extent to

which acute care staff members use evidence-based

tools for their cognitive assessments, consult specialist

expertise, and use evidence-based guidelines/protocols

for the care of older people with cognitive impairment.

Moyle et al. (2010) recently highlighted a number of

shortcomings in the acute care management of older

people with dementia, and they encouraged the in-

creased use of evidence-based practices relating to older

people with cognitive impairment to become part of

hospital policy. The POPAC can assist in highlighting

the extent to which such evidence-based practices are

reported across acute care wards and settings, and if

used in concordance with measures of patient health

outcomes, it could potentially also provide evidence of

the extent to which such practices are associated with

beneficial health outcomes in older patients. Thus, this

scale would seem to have a central place in nursing

research that test and report on best practice models of

care for this population, and such evidence is urgently

needed (Moyle et al. 2008, Cowdell 2010). The POPAC

as a whole might also be relevant to use as a part in

developing a clinical best practice model of care, as it

incorporates some of the most commonly described

central aspects to consider when providing high quality

care of older people with dementia disorders and other

forms of cognitive impairments (Hickman et al. 2007,

Day et al. 2008, Moyle et al. 2008, Edvardsson & Nay

2010). Thus, the item level content can be used to form

a base for developing best practice interventions, have

reflective discussions, and the whole questionnaire as a

pre–post intervention measure to explore if staff report

any practice change as a result of an intervention.

The third subscale of the POPAC illuminates the ex-

tent to which care of older people with cognitive

impairments is individualized or person-centred. There

is evidence to support that the aspects covered by the

third subscale indicates the use of a person-centred

approach in care, such as using biographical informa-

tion, involving family members and patients in care,

using staff continuity as a way to promote therapeutic

relationships, and continuously evaluating and dis-

cussing how to meet the unique needs of these frail

patients. Person-centred care is a contemporary buzz

concept used to describe best practice nursing care in a

range of settings. The concept has recently been sug-

gested as a national safety and quality health services

standard by Australian Commission on Safety and

Quality in Health Care (2011), and it has influenced

health care policy in several western countries, for

example such as Australia, Norway, and Sweden

(Norwegian Ministry of Health and Care Services 2008,

Table 3Test–retest reliability estimates for the final POPAC (n = 25)

Scale dimensionTest

mean € SDRetest

mean € SDTest–Retestmean € SD P

Intra-classcorrelation (CI)

Total score 4.79 € 0.43 4.90 € 0.47 )0.11 € 0.55 0.33 0.41 ()0.31–0.74)Using cognitive assessments and care interventions 4.96 € 0.42 5.06 € 0.59 )0.10 € 0.72 0.51 0.05 ()1.13–0.58)Using evidence and expertise in cognition 4.99 € 0.68 5.00 € 0.51 )0.01 € 0.83 0.94 0.11 ()0.99–0.61)Individualizing care 4.59 € 0.56 4.75 € 0.61 )0.16 € 0.64 0.23 0.56 (0.01–0.80)

SD, standard deviation; CI, confidence interval.

D. Edvardsson et al.

ª 2012 Blackwell Publishing Ltd6 Journal of Nursing Management

Swedish National Board of Health and Welfare 2010,

Victorian Government Department of Human Services

2011). The concept is most often used to describe a

holistic model care that is based on the patients� prior-

itized needs and wishes, involves the person and their

significant others, promoting beneficial relationships,

and incorporates the use of individually tailored psy-

chosocial and complementary interventions inasmuch

as traditional medical interventions (McCormack &

McCance 2006, Edvardsson et al. 2008). Thus, it seems

that the POPAC can be used as a measure to indicate

the extent to which care not only is evidence-based, but

person-centred, and this supports both the theoretical

and clinical relevance of this scale as these two con-

ceptual dimensions arguably are central to nursing care

quality.

Limitations

There are some limitations to this study that need

consideration. The 59% response rate makes it possible

that the results of the study might have been different if

a larger number of staff had chosen to participate, given

that non-responding staff members could have been

different from the responders. As the study employed

voluntary and anonymous participation for ethics pur-

poses, the reasons for not participating remains un-

known and comparative analyses between responders

and non-responders were not possible. Thus, we can

only speculate to what extent the final study sample is

truly representative of the overall sample. However, this

limitation indicates a need for further application and

evaluation of the POPAC in additional samples. An-

other limitation is the non-randomized, cross-sectional

design of the study, which puts constraints on the extent

to which these finding can be generalized to other set-

tings and samples. These design issues underscore the

value of additional testing of the POPAC to further

confirm or reject the psychometric properties of this

scale in various samples and cultures. In addition, as the

scale makes use of self-reporting on behalf of staff, it

needs to be complemented with other observational

approaches if information is sought about the extent to

which staff reporting corresponds to what actually

happens in the wards.

Furthermore, as reported in Table 1 the test–retest

estimates provided slightly contrasting data for two of

the subscales, �using cognitive assessments and care

interventions� and �using evidence and expertise in

cognition�. The intraclass correlation coefficient did not

exceed the cut-off of r > 0.3, whilst the paired samples

t-test showed that the scores for these subscales was not

significantly different between test and retest. These

findings, together with the fact that test–retest reliability

was based on a limited sub-sample of nursing staff on

one orthopaedic ward, indicate that the extent to which

the POPAC and its subscales have temporal stability in

other settings need further testing.

To conclude, this study presented promising tentative

data to support a valid and reliable use of the POPAC

based on an Australian sample of acute hospital nursing

staff. However, further studies are needed and invited

to explore the psychometric properties and the clinical

applicability of the scale in other samples and settings.

Conclusions and implications for nursingmanagement

The new POPAC scale is relevant to nursing manage-

ment as it is short, easy to administer and not time

consuming to complete, but still provides clinically rel-

evant, valid and reliable information on the extent to

which acute nursing staff report using best practice care

processes to identify and consider cognitive impairment

and to employ nursing interventions to meet the needs

associated with old age and cognitive impairment. The

main contribution to nursing management might be that

the scale can be used as a conceptual fundament in

developing best practice models of nursing care in the

acute setting, as it draws upon and contains most com-

monly described aspects relating to high quality nursing

care of older people with cognitive impairments. Thus, it

can help clinical staff to develop interventions increas-

ingly to apply best practice care of older people with

cognitive impairments. It can also be relevant for nursing

management, by providing a valid and reliable tool for

clinical audits of how �older people friendly� their wards

and/or units are. In a time where population ageing im-

pacts on most acute care settings in the Western world, it

seems reasonable to argue for a high clinical relevance

for a measure providing relevant, valid and reliable data

on the extent to which such acute settings are experi-

enced to incorporate evidence-based, best practice

nursing care of older people with cognitive impairment.

Conflict of interest statement

The authors have no conflicts of interest to declare.

Sources of funding

The study was funded by grants from the Swedish Re-

search Council, and the Gothenburg Centre for Person-

Centred Care.

Construction and psychometric evaluation of the POPAC

ª 2012 Blackwell Publishing LtdJournal of Nursing Management 7

Ethical approval

Ethics approval for the study was obtained from La

Trobe University and the hospital Human Research

Ethics Committees.

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ª 2012 Blackwell Publishing Ltd8 Journal of Nursing Management