Joumal of Advanced Nursing, 1990,15,1181-1187

The Patient Leaming Needs Scale: reliability and validity Natalie Bubela RN MSc(A) Director of Nursmg Practta, Scarborough Grace Hospital, Scarborough

Susan Galloway RN MScN Clirucal Nurse Speaalisl, Surmybrook Health Saence Centre

Elizabeth McCay RN MScN Research Assistant, Mount Sinai Hospitai

Ann McKibbon RN BScN Clinician, Sunnybrook Health Saence Centre

Lynn Nagle RN MScN Department of Nursmg, Sunnybrook Health Saence Centre

Dorothy Pnngle RN PhD Dean, Faculty of Nursing, Untverstty of Toronto, Toronto

Eleanor Ross RN MScN Department of Nursing, Sunnybrook Health Saence Centre, North York

and Judith ShamianRN PhD

Vice Prestdent, Nursing, Mount Sinai Hospital, Toronto, Canada

Accepted for publicahon 27 February 1990

BUBELA N, GALLOWAY S, McCAY E, McKIBBON A, NAGLE L, PRINGLE D, ROSS E & SHAMIAN J (1990) Journal of Advanced Nursmg 1 5 , 1 I 8 1 - I 1 8 7

Hie Patient Leaming Needs Scale: reliability and validity The article describes the development and initial psychometnc evaluation of an instrument to measure patients' perceptions of learning needs at tune of discharge from hospital to home Evaluation of the Patient Leaming Needs Scale was based on responses of 301 adults hospitalized with a medical or surgical illness Factor analysis isolated seven subscales medications, activities of living, feelmgs related to condition, community and follow-up, treatment and complications, enhancmg quality of life and skin care These seven factors accounted for 561% of the vanance Cronbach's alpha for the 50-item scale was 0 95

INTRODUCTION c 1. ^ t 1 u J u J 4.k , « Escalating costs of acute-care beds, combmed with an J J, • i u i u j u » n-o^n. increasing demand for each available bed, have preapi°

tated the trend for earher discharge of pahents from hospital to home Earlier hospitai discharge has come at a tune . , , ^ r ^ , ^ when individuals are requestmg more mfonnation about ^ f j ^L .. ^ e their condihons and many are raced with the prospect of learning to live With a chronic lUness To help individuals 1181

N fiufoiaetal regain independence in management of health care followmg hospitahzahon, nurses must idenhfy and attend to teaming needs However, a cnhcal problem in attendmg to these learning needs, namely identifying the learning needs, has not been adequately addressed Part of the difficulty in descnbing learning needs at discharge is due to the lack of rehable and valid measurement tools Therefore, an investigation was conducted to determine the mtemal consistency rebability and the construct validity of an mstrument to measure pahents' perceptions of learning needs at the time of discharge home from an acute-care setting


The work of Avenll (1973), Lazarus et al (1974) and Langer (1983) suggest that \he goal of coping responses is to mamtam or mcrease self-mtegnty by establishing a balance between the internal and extemal demands and the resources available to deal with the demands A sense of self-mtegnty mvolvmg the belief that one has personal control m life (Langer 1983) may be threatened in an illness expenence Dunng an illness expenence, mdividuals may have been dependent on health care providers but will stnve to regain personal control at the time of transihon from hospital to home Informahon-seeking is one response that may be used in Learning needs efforts to regam personal control m a stressful situahon Descnptions of patients' learrung needs dunng hospital(Cohen & Lazarus 1979) Avenll (1973) suggests that izahon (Dodge 1969) and at the time of discharge home the mfomnation sought by individuals will reflect their (Derdenan 1986, Hentinen 1986, Linehan 1966, Nicklm attempts to overtly manage the events which affect them 1986) indicate that homogeneity of leammg needs exists (behavioural control), create an overall image of the across patient populations in areas related to knowledge of sequence of events involved in the illness (cognitive concondihon, treatments, medicahons, managing achvities of trol) and identify choices which they have in managmg daily living and mterpersonal commumcahon The import- their hves (deasional control) Recognihon of the need for ance placed on learning needs was assoaated with edu- more mformation or skills whereby personal control of cahonal background, gender and age in one study (Dodge health care may occur would be reflected m the leammg 1969), however, other researchers noted that the import- needs perceived by that mdividual If these needs are truly ance of learning needs could not be related to easily identi- reflechve of attempts to re-estabhsh personal control, learnfiable vanables (Lauer et al 1982, Pfefferbaum & Levenson ing needs might cluster mto the domains of behavioural 1982, Derdenan 1986) The inconsistent findings of the cogruhve and 'deasional' control effect of personal factors may be the result of difiFerences m leammg needs when hospitalized as descnbed by Dodge METHODOLOGY (1969) compared to leammg needs for management of health care after discharge which were explored by the Development of the Patient Leammg Need Scale (PLNS) proceeded in two stages Thefirststage was the generahon other researchers The importance of determining leanung needs is empha- of an item list for the queshonnaire and detemiinahon of sized by studies that compared pahents and health care fare validity, content vahdity and pahent comprehension professionals' percephons of leammg need importance The next phase was to determme the reliability and Studies of pahents with cancer (Lauer et al 1982, beginnmg construct vahdity of the scale Pfefferbaum & Levenson 1982), rheumatoid arthnhs (&lvers et al 1985) and chronic renal failure (Goddard & Powers 1982) all demonstrated disagreonent m the importance of leammg needs as perceived by the physiaan or nurse and the patioit Conversely, studies of patients after myocardial uifarchon (dsey et al 1984, Gerard & Peterson 1984, KaHik & Yarcheski 1987) found some areas of congruence between pahents' and nurses' percephons m leanung need importance It was difficult to identify the reasons for the varymg results in the studies ated above Each study utilized instruments developed speaficafly for die target pc^nilahcnvs and results may not be truly comparable However,fiiKimgsemfrfusized the necessity of determmmg what pahoits fieel is important for tiion to know m onJer to numage their illness expenences 11S2

Develo{mient of the scale The PLNS is a self-admimstered questionnaire developed to ehat patient percephons of leammg needs pnor to discharge from an acute-care settmg to home Content validity was established by developmg an item pool from informal patient mterviews, findmgs m the hterature and the persona] clmical expenences of five nurse experts Items were exammed and rewntten mto 75 items to apply to a goteral pahent populahon. Statements speafic to a select expenence such as ch»notherapy were omitted as the intott was to develc^ a scale to be used with a vanety of patent groups the scale was individually reviewed by a grcn^ of 20 nurses, doctors, pih«its and healthy non-ho8{»ta}t»d

Learning needs

individuals to dteck for item danty, rqjresentativeness of items and ease or difi&culty m completion of the items The wording of several items was altered to increase danty and one item was added based on the comments The 76 items were randomly positioned for administration The revised item list was resubmitted to a group of 10 staff nurses as a final dieck of face and content validity


Patients m a large metropolitan hospital who had been told of their impendmg discharge home and were withm 72 hours of this discharge were asked to partiapate m the study Of the 339 pahents mvited to partiapate, 301 (88%) agreed and gave lnfonned consent Hie sample of 150 males and 151 females had a vanety of diagnoses of which 72% were benign and 28% were malignant The age of the subjects ranged from 18 to 80 (m = 53 8) and the majonty Categorization of item into domain of the subjects were mamed (59%) Employment outside Once the content of the instrument was complete, the eight the home was reported by 46%, with 32% being retired and nurse experts of the research team mdependently categor- 22% not working Forty-seven per cent were educated ized each item by type of control behavioural, cognitive or beyond high school, while 37% had at least grade II and dectsional Agreement on categonzation of item to type of 16% had grade six to ten education control could not be obtamed The difficulty expenenced Forty-three per cent of the subjects were hospitalized on by the eight nurse experts in attempting to categonze a medical unit and 5 7% were on a surgical unit The average items according to domain was an early mdication that the duration of hospitalization was 13 7 days with a range of selected theory might not be adequate m delmeahng a 2 to 84 days The time since diagnosis of the condition factor structure in the construct validation stage responsible for hospitalizahon ranged from a few days to Categonzatton of items mto domains was attempted years, with the mean time bemg 126 days usmg the five major areas of information descnbed by pahents as bemg important (Derdenan 1986, Dodge 1969, Hentmen 1986, Lmehan 1966) Agreement was obtamed Item analysis among the nurse experts on dassi^cation of items accord- Item deletion at early stages of instrument development is ing to the domains of symptomatology and condition, not favourable smce more items can diminish domam hvmg activities, management of treatments, community samplmg error, thereby enhancmg both reliability and and follow-up, and feelmgs related to condition validity However, individual items should be appbcable to the majonty of the sample under study and be related to the construct of interest Therefore, items were selected for Scaling metiiod the modified scale if less than 30% of the responses on the Items were worded m one direction to mcrease ease of item were m the 'does not apply' category, if the average understandmg for individuals who had been ill Subjects mter-item correlahon was greater than 0 20 or less than were asked to rate how important each item was to 0-80, and if there was a wide distnbuhon of responses on know so that they could manage their own care at home the item Response to each item was rated on a forced choice Likert There was concem that item delehon could be format which employed six response altematives 0 (does mfluenced by the effects of speafic subpopulahons, and not apply), 1 (of no importance) to 5 (extremely important) before deleting any item a companson of the percentage The scale was designed to yield a domam score (the sum of response m the 'does not apply' category was done the item scores withm the domam) and a total scale score between medical and surgical subjects, acute and chronic (the sum of all the domam scores) An mdividual item score disease subjects, subjects with benign and malignant was to be considered ordinal m nature, but once summed as disease and subjects younger than 30 years and older than a domain or total scale score the number would be treated 70 years Item delehon was not influenced by these subpopulations at the 30% level and it became the level for as interval data retenhon of items Twenty items were eliminated as 30% or greater of the sample had responded to the item m the INSTRUMENT ADMINISTRATION 'does not apply' category Five of the deleted items rebted The scale was administered to hospitalized adults to to management of equipment needed for care and were obtam the data required to examme construct validity probably too specific for a general population Seven and rehabihty Concurrent validity could not be exammed items about counselling, temporary or permanent housmg as tlwre was no parallel mstniment available for and detaining non-speafic community sCTvices, all m the domam of community and follow-up, were removed. admmistmtuni 1183

NBuiwk etal Addihonally, eight items were deleted related to diet when travelhng, managmg disabihhes, and retummg to work and communicatmg with an employer Five items had mter-item correlations of less than 0 20 and one item had a correlahon of above 0-80 with another item these six items were dropped The item analysis resulted m droppmg 26 of the ongmal 76 items Examination of the means for the remammg 50 items showed that the majonty fell just near or above the midpomt of 3 0 for the scale with standard deviations m the range of 15 to 2 The item means suggest that there is no ceilmg or floor effect for any of the retained items The standard deviations support the vanability of each item mdicahng that the subjects were usmg the full range of scale scores RELIABILITY AND VALIDITY OF THE SCALE Factor analysis and construct validity A factor analysis was conducted to identify underlymg pattems of relationships in the data and to provide an estimate of how strongly each item was correlated with each factor The R-technique was to assess the degree of assoaahon among vanables and pnnapal con^jonent analysis was done with orthogonal rotahon The 50 items retained after itan analysis were entered mto an initialfactoranalysis which provided a listmg of II factors with an eigenvalue above 10 However, when there are over 50 vanables, factors can be spht leadmg to an overeshmahon of the number of factors (Cattell 1978) A scree test (Cattell 1966) was done to obtam another guidelme for the number of factors The results indicated that four factors were substantially above chance levels Conceptual mterpretabJity as well as statistical cntena were used to ldaitify factors that were meanmgful enough to extract and rotate Sigmficant loadmg of items on factors was set at 0 30, the minimum as noted by Nunnally (1978) and Cattell (1978) Several factor soluhons were exammed and the seven factor structure was selected as it was the most mterpretable and was dose to the onginal scale dimensions No items were dropped from the seven factor soluhon When an item loaded at above 0 30 on more than one factor, it was set to the factor where it loaded highest unless the conceptual mterpretability guided that it would be better on the alterru^ve factor Factor structure, a shortened form of the itan, ami loadmgs are shown m Table 1 The rotatedfactormatnx indicated the possible existence of seven underiyu^ dimaisions which have been labelled medicahons, achvihes of livmg, community aiKi follow-up. 1184

feelmgs related to condihon, treatment and complications, enhancmg quality of life, and skm care These seven factors accounted for 561% of the vanance m the 50-item scale (see Table 2) The minimum number of items per factor was five The 50 mdividual items demonstrated item-to-total correlations rangmgfrom0 34 to 0-68, meetmg the 0 30 cntenon of acceptability as stated by Kerlmger (1973) The development of the scale had been guided by the supposition that five subscales would emerge Two of the predicted subscales, community and follow-up and feelmgs related to condihon, appeared as factors m the scale The domam of livmg achvities became two factors hvmg achvities and skm care Sjmiptomatology and condition and management of treatments did not remam as predicted domams but became three factors Items concerning treatments and comphcahons formed a factor labelled treatments and comphcahons Items relahng to the impact of illness and managonent issues formed a factor which was enhtled enhanang quality of hfe Items related to medicahons formed a strong separate factor A more detailed outlme of the factor structure follows The first factor of the PLNS is medications The seven items compnsmg thisfactorare concemed with knowledge required to care for medicahon admmistrahon The items addressed how medicahons work, when and how to take medicahons, when to stop takmg the medications, and what to do if an adverse reaction to a medicahon appeared The second factor is termed activihes of hvmg and encompasses items which deal with physical achvity, rest and sleep, and nutntion Items such as 'How to change my achvihes to save my energy', 'How to prepare foods I am to eat' and 'How much rest I should be gettmg' charactenze the content of the nme items The third factor is termed community and follow-up Seven items relate to knowledge of what is available m the health care system and how to get through the bureaucrahc network to be able to obtam services Items such as 'How to contact community groups for my health condihon' and 'What a Home Care Prc^ramme provides' are m the third factor The fourth factor, feelings related to condihon, has five items concemmg mformahon of the cause of the lUrtess and recognihon and expression of feelings assoaated with the illness expenence Items related to communication with family and friends about the illness and how to recognize personal feehngs towards the illness are m this factor The fifth iitdtor has nme items related to treatment and complicahons The purpose and possible side dfects of treatment and mfomiahcm coiuxming the prevention, recogcaiion and achcms related to complicahcHtt are addressed The eight items m factor six, enhancmg cpaMy

Leammg needs Table 1 Factors, items and loading

Factors" Items


How mediane works When to take medicine Why the need for mediane How to take medicine When to stop medicine What to do if react to mediane Possible reachons to medicine Exerase to get Amount of rest to get When home tasks can start Exerase prohibited What to do with bowel movement problem Alter to save energy How to prepare food Foods can/cannot eat What to do about msomnia V^iat home care gives Manage agency red tape Transport to clmic Manage commuiuty red tape Help family to deal with illness Contact commuruty groups Where to get mediane Who to talk to about dying How to talk about illness Help to hardle feelings Cause of illness Recogruze feelings Complications needing attention

77 77 74 69 68 62 60

Purpose of treatment Side-effects of treatment Recognize complication Who to see at follow-up Complications one might have Who to call for help How to prevent complications What to do if unne a problem How to manage symptoms What symptoms to expect How to manage stress How to avoid stress How to manage pam Which vitamins to take Impact of illness on life Implication for future

Care for feet •i=me4cabom,2=.«chvihestrf living;3ocoRiimaBtyu«dfoDow-up

4=fcelmgsrelatedioc«KttuMv 3=tTeitiiwntaiKlcom|AcatK>ns,6='

Care of cut/incision When albwed bath ,,



j L.

How to prevent red sbn How to prevent sore skin







74 62 59 54 54 49 41 40 37 7& 73 58 58 41 52 45 69 66 64 45 42 38 34 49 68 63 57 53 47 44 38 31 72 70 39 33 68 54 36 36 35 70 69


N Bubek^ai TaUe 2 Eigoivalue, percentage of vanance, cumulative percentage of vanance and alpha level for Pahent Learning Need Scale factors



% Vanance

Cumulative % vanance


Medicahons Achvihes of living Community and follow-up Feelings related to condition Treatment and comphcahons Enhanang quabty of hfe Skm care

16-6 28 24 21 17 16 13

32 2 56 49 42 33 32 27

32 2 37 7 426 468 501 53 4 561

086 0-84 085 0 79 0 83 0-85 069

Table 3 Intercorrelations of Pahent Learning Needs Scale total and factor scores

*1 = medicahons 2 = achvihes of kving, 3 = community and follow-up, 4 — feelmgs related to condition 5 — treatment and c(»nplicahons 6 = enhancmg quality of life

Factors* Vanable





Medications Achvihes of hvmg Community and follow-up Feelings related to condihon Treatment and complications Enhanang quality of life Skm care

0-74 0-82 0-82 0-78 0-83 0-85 0^9

0-46 0-50 049 0-62 0-57 0-42

0-60 0-59 0-60 065 056

065 0-59 0 5 7 0 6 1 0-65 0-71 0 5 3 0-44 0-47

of hfe, concem mformahon needed to form expectahons about the possible impact of the illness on present and future life Recognihon and management of symptoms related to the condihon, management of pam and management and avoidance of stress are addressed by items m this factor The





Reliability: coefficients oi internal c

The Patient Learning Needs Scale: reliability and validity.

The article describes the development and initial psychometric evaluation of an instrument to measure patients' perceptions of learning needs at time ...
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