DEVELOPMENT OF THE AMBULATORY CARE CLIENT CLASSIFICATION INSTRUMENT.

Abstract

The purpose of this research was the development of an instrument to measure the complexity of nursing care requirements in ambulatory care settings. Charles Perrow's sociological theory of organizations was adapted to nursng in order to define the complexity concept. Four research questions were investigated in this study. These questions related first, to the construct validity of the instrument's activity category system; second, to the criterion validity of the complexity weighting system; third, to the equivalent reliability to the instrument and fourth, to the instrument's clinical generalizability. Construct validity was evaluated through the regression of subjective estimations of complexity on the individual categories which make up the 154 ratings that contained measurement error, 641 independent client ratings remained for analysis. This data indicated that the classification instrument accounted for 52 percent of the total nursing care complexity in the ambulatory setting. An 18 variable equation was as statistically effective in explaining complexity as was the original 44 variable equation. Criterion validity was examined by comparing empirical complexity weights established through the regression of subjective complexity estimations on activity categories with theoretical weights determined by nurse experts in a Delphi exercise. Kendall's tau, a measure of rank association, was used for analysis. This examination revealed no statistically significant direct association between empirical and theoretical sets of complexity weights. Equivalent reliability was investigated by looking at the percent agreement among six trained raters using the classification instrument. The data indicated agreement on ratings was above 90 percent which met the criterion pre-established for interrater reliability. Finally, by a graphical analysis of residuals from regression equations, instrument generalizability across clinical services was examined. The Ambulatory Care Client Classification Instrument was not found to be generalizable in explaining the complexity of nursing care requirements across the clinical services used in this research.