Instrument's Reliability and Validity For Evaluating The Nursing Risk Assessment of Acute Kidney Injury Tools For The Surgical Department-A Pilot Study

Asian Journal of Fundamental and Applied Sciences
e-ISSN: 2716-5957 | Vol. 3, No. 1, 9-21, 2022

http://myjms.mohe.gov.my/index.php/ajfas
Instrument’s Reliability and Validity for Evaluating the Nursing

Risk Assessment of Acute Kidney Injury tools for the Surgical
Department: A Pilot Study
Nooreena Yusop1*, Rasidah Mohamed1, Muhammad Ishamuddin Ismail2,
Ruslinda Mustafar3
1
Faculty of Nursing, PICOMS International University College, Malaysia
2
Head of Cardiothoracic, Head of Heart and Lungs Centre, Hospital Canselor Tunku Muhriz, University
Kebangsaan Medical Centre, Malaysia
3
Nephrology Unit, Hospital Canselor Tunku Muhriz, University Kebangsaan Medical Centre, Malaysia
*Corresponding Author: nooreena@picoms.edu.my
Accepted: 15 February 2022 | Published: 1 March 2022
DOI: https://doi.org/10.55057/ajfas.2022.3.1.2
_____________________________________________________________________________________________
Abstract: Acute Kidney Injury (AKI) is common but is often under-recognized. Delayed diagnosis
may lead to patients’ increased morbidity and mortality. AKI is fully established with various
guideline but remained lacking in early detection through knowledge, understanding, assessment,
and poor identification. High incidence and mortality rate of AKI in Malaysia could be assumed
to be due to inadequate early nursing assessment and intervention. Hence an education
programme for nurses with valid and reliable tools need to be developed. The aim of this study to
develop a valid and reliable research tools for nursing risk assessment education programme in
the detection of AKI from surgical patients. The tools were developed within four phases. Phase
1, the development of instruments through research and literature review. Phase 2, the validity
process. The tools were submitted for relevancy and validation by expert panels. Phase 3, a pilot
study conducted to test the instruments and phase 4 involved analyzing the tools. Two types of
research tools developed in the study. Type 1: The Knowledge, Attitude and Practice (KAP) of AKI
questionnaire and Type 2: The Nursing Risk Assessment AKI form. Overall Content Validity Index
value for type 1 instrument was 0.96 and type 2 instrument was 0.95 indicating adequate standard
of acceptability. Overall Cronbach’s Alpha value was at 0.81. KAP of AKI questionnaire and the
Nursing Risk Assessment AKI form are valid tools to assess nurses KAP level and the early
detection of patients at risk of AKI respectively.
Keywords: Acute Kidney Injury; nursing risk assessment; reliability and validity
______________________________________________________________________________
1. Introduction
The occurrence of Acute Kidney Injury (AKI) amongst patients in the hospital setting commonly
resulted in increased morbidity and mortality. To reduce the occurrence of AKI and its
complications, patients can be identified using a clinical scoring system with high predictive value
alongside a newly developed renal biomarker. Although the diagnosis of AKI is fully established,
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e-ISSN: 2716-5957 | Vol. 3, No. 1, 9-21, 2022
it is frequently underrecognized, with patients developing AKI presumed to have inadequate

assessment and intervention due to lack of understanding leading to poor identification.
AKI is a common complication following major surgeries, with similar risk factors and outcomes
linked to the type of surgery performed. In Malaysia the incidence of AKI has frequently been
discussed in the ICU settings, but insufficient findings were reported. The level of knowledge and
understanding on the risk of AKI among healthcare providers remain lacking. Several studies
found that non-nephrology doctors and nurses lacks in knowledge and understanding when it
comes to recognizing patients with AKI. This is made worst as the awareness of AKI prevention
among nurses for hospitalized patients specifically in the surgical department remained low. To
improve the knowledge, attitude and practice (KAP) among nurses in the detection and prevention
of AKI, a nursing risk assessment education programme is developed as a strategy. The
expectation is to improve nursing skills in the early detection and prevention of AKI and its
complication as well as helping them to be more competent in their delivery of care.
2. Literature Review
AKI is frequently associated with poor mortality outcomes. A prospective observational study to
measure AKI complication among hospitalized patients in Malaysia reported its incidence rate to
be at 7.06%. From a total of 21,621 screened patients, 209 patients (13.7%) developed AKI in the
ICU. In this study, the overall AKI mortality rate was at 15.8% and the length of hospital stay
ranged from 1 to 55 days with a median of 6 days (Hamid et al., 2018).
Although AKI is currently fully established in terms of diagnosis it is often under recognized due
to lack of understanding leading poor patient identification, presumably caused by inadequate
assessment and intervention. The United Kingdom National Confidential Enquiry into Patients’
Outcomes and Death (NCEPOD, 2009) reported 50% of the patients died due to AKI as they did
not receive appropriate medical care. Furthermore, 43% of the patients developed AKI on
admission were due to delayed diagnosis and treatment (Aitken et al., 2013). In managing AKI,
in-depth understanding of fluid and electrolyte management, the use of Renal Replacement
Therapy (RRT) and dialysis incorporating knowledge and familiarity of risk factors and its early
manifestation are required.
Understanding the onset, characteristics and the risk factors associated with AKI’s prognosis could
improve the clinical prevention and treatment. However, inadequate knowledge and understanding
of the risk of AKI development among healthcare providers including doctors and nurses remain
unacceptably low. A study in Nigeria showed only 1.2% of the respondents had good knowledge
of AKI, 69.2% had fair knowledge while the remaining 29.6% had poor knowledge among non-
nephrology doctors in a government hospital (Adejumo et al., 2017). Similarly, nursing staff were
also found to have a lack of knowledge and understanding in recognizing patients with AKI. A
study in Malawi reported the majority of AKI cases at the hospital were unrecognized or referred
late in the advance phase due to lack of awareness amongst the doctors and nurses (Kirwan et al.,
2016). A similar study in Brazil revealed more than 50% of nurses do not have adequate knowledge
to identify early AKI. Lack of properly trained professional awareness of the problem may delay
the detection and referral to specialized service leading to worse result (Prata et al., 2016).
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As earlier stated, AKI has constantly been discussed in the ICU settings, but inadequate findings
pertaining to its incidence were reported among surgical patients. In addition, limited studies on
detecting AKI through risk factors and clinical manifestations have not adequately been discussed
among nurses, especially in Malaysia. Result of a study in a Malaysian teaching hospital revealed
the mortality rate was at 92.5% due to severe AKI and multi organ failure (Hamid et al., 2018).
Most of the AKI patients were admitted to ICU (67%), followed by CCU (26.4%), Surgical ICU
(3.8%) and HDU (2.8%).
In a larger perspective, nurses can play a fundamental role in the early detection, prevention and
‘rescue’ of errors and adverse events through assessing patients at clinical risk. Nurses, like other
health carers, need skills that will enable them to recognize and respond appropriately to clinical
risks and to respond effectively to meet quality improvement and clinical risk management
processes towards mitigating the risk on patient care.
Assessing risk has become part of the process of supporting patients and maintaining patient safety
in the hospital setting. Documentation of risk is an important key to review and improve patient
care to form the basis of future investigations. Prediction of risk is typically carried out using a
systematic and proven method in identifying people or conditions who may be likely to deteriorate
or to suffer an exacerbation of a pre-existing risk. It can also provide an early-warning system to
maximize the probability of a positive outcome.
3. Research Method
Phase 1 entailed the creation of an instrument through research and a review of the literature.
Several studies related to knowledge on AKI among healthcare providers were reviewed. The type
1 instrument reviewed the following studies were analyzed: closed-ended structured questionnaire
(Adejumo O. et al.,2017). This questionnaire was validated in a pilot study and the Cronbach’s
Alpha internal consistency coefficient was 0.92. The questions were mainly to assess knowledge
of AKI by healthcare providers consisting of features, types, and risk factors of AKI, nephrotoxic
medications, AKI diagnosis criteria, and important vital signs that needed to be monitored on a
regular basis in patients at risk of AKI. Apart from that, a study to evaluate the nurse’s knowledge
on early detection of AKI by Prata et.al., 2016 was reviewed. The tool undergoing validation
procedure from six experienced expert nurses from intensive care, emergency, and hospitalization
units.
In assessing the nurses’ attitude towards AKI, a study on improvement the overall care and
understanding of AKI patients was determined and 8 questions were scored on a scale of; 10
representing ‘strongly agree’ to 0 representing ‘strongly disagree’ to justify impact of the nurses
attitude on the knowledge and clinical skill in management of AKI (Kirwan et al., 2016). Similarly,
the Cronbach’s Alpha internal consistency coefficient was not stated in the study. To identify the
risk assessment, an instrument by Silva et.al, 2020 involving 22 items regarding nurses’
knowledge, risk assessment and self-efficacy towards venous thromboembolism (VTE) were
determined. The result of this study showed, majority of the nurses produced good knowledge of
VTE assessment and able to perform a thorough VTE assessment. However, the lack of objective
knowledge was detected regarding VTE risk factors, and clinical manifestation. This may impair
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the nurse’s knowledge in recognizing the development of pulmonary embolism in deep vein
thrombosis (Silva et.al, 2020).
The developed questionnaires, went through an assessment process which was submitted to a
group of healthcare providers consisting of instrument’s assessors who were selected based on
their specialties as a Nephrologist academician, and a Cardiothoracic surgeon. The nurses are those
specializing in critical care and a nephrology lecturer who had their advance education in critical
care and renal nursing with a minimum of Master educational level. All respective assessors were
invited to participate via e-mail, and they were required to fill up a survey assessment tool form.
Questions in the domains of knowledge, attitude on AKI and practice of risk assessment were
assessed for: i, consistently and accurately measuring variables in the objectives, ii, items in the
questionnaire are sufficient to cover the research topic and objective, iii, the questionnaire is
framed in a clear and simple language to avoid confusion and iv, the questionnaire can generate
data to be used in nursing practice and concerned study objectives. Assessors were given 14 days
to complete the forms. Items considered unclear or need to be re-arranged according to the
comments and suggestion by any assessors were revised and adjusted accordingly by the
researchers.
Each of the items were finalized and modified to simpler version to suit for the nurse’s level of
knowledge and understanding. Total items in the KAP survey on AKI were 30 questions consisting
of four sections; Section A: Characteristic of respondents as to provide respondents’
demographics. Section B, assess the respondent’s knowledge on AKI. There are 15 items in this
section of clinical features, types and risk factors of AKI, potentially nephrotoxic medications,
criteria for diagnosis and staging of AKI, newer biomarkers and indications for renal replacement
therapy in AKI. The questions in this section were developed based on a study by Adejumo et al.,
(2017). Section C consisted of 6 questions on domain of practice to determine nurses’ practice in
identifying AKI through risk assessment which were adapted from VTE knowledge, risk
assessment practices, perceived barriers to risk assessment, and prevention self-efficacy (Silva
et.al, 2020). There is a combination of YES-NO and multiple selection answers. Section D was
the final section of the questionnaire consisting of 8 items for the attitude domain Nurses will rate
their attitude based on a 5-points Likert Scale the in delivery of care towards patients based on
knowledge and clinical skills regarding AKI. These questions were developed and adopted from
Kirwan et al., (2016).
The type 2 instrument is designed to measure and predict the risk of AKI through a Nursing Risk
Assessment format. The items were developed based on Simple Postoperative AKI Risk (SPARK)
index which include a summation of the integer scores of the following variables: age, sex,
expected surgery duration, emergency operation, diabetes mellitus, use of renin-angiotensin-
aldosterone inhibitors, baseline Renal Profile blood result, dipstick albuminuria hypoalbuminemia,
anemia, and hyponatremia. Each patient’s admission or interfacility transfer will be assessed for
their risk of AKI and could be calculated for their SPARK index scores and classification. The
score will be calculated according to the following criteria of:- Class A (low risk) score < 20, Class
B (mild risk) score 20-39, Class C (high risk) score 40-59 and Class D (extremely high risk) score
>60 (Park et al., 2019). SPARK has undergone a study of 51,041 patients with a discovery of
39,764 patients’ pre-operative assessment in a validation cohort. The discrimination power of the
SPARK index was acceptable in both the discovery (c-statistic 0.80) and validation (c-statistic
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0.72) cohorts. The developed SPARK index and classiﬁcation fairly predicted the risk of PO-AKI
and related patient-oriented outcomes with a simple summation of risk scores. Clinicians may
consider implementing the index system before performing a noncardiac surgery.
In phase 2, the instrument undergoes the content validity process. In this process, the previous
assessors were again recruited as panels to review and rate the relevancy of each item in the
questionnaire. The four panels were required to rate on the relevancy online. Panels were given
instruction to rate each item based on a Likert scale ranging from 0 (item found to be not relevant),
1 (somewhat relevant), 3 (quite relevant) and 4 (highly relevant). Rating from the four panels were
measured and analyzed to obtain a Content Validity Index (CVI). There are two forms of CVI, in
which CVI are for items (I-CVI) and CVI for scale (S-CVI).
There are two methods for calculating S-CVI, namely the average of the I-CVI scores for all items
on the scale (S-CVI/Ave) and the proportion of items on the scale that achieve a relevance scale
of 3 or 4 by all experts (S-CVI/UA). Then the relevance rating must be recoded as 1 for relevance
scale of 3 or 4 or 0 for relevance scale of 1 or 2 which need to be converted prior to the calculation
of CVI (Polit et al., 2006, Yusoff, 2019). All the scores from four expert panels were gathered and
entered Microsoft Excel referring standard formula (Lynn, 1986, Davis, 1992, Polit & Beck, 2006
and Polit et al., 2007).
Approval from PICOMS International University College Research Management Centre were
obtained prior to the pilot study. During phase 3, the pilot study was conducted at a teaching
hospital in Selangor. The setting was selected due to its similar characteristics with the actual study
location. In this study, 20% of the actual sample size were recruited which is equivalence to 18
staff nurses working in similar wards to the actual study setting.
A total of 18 permanent or contract nurses from the general surgical wards with at least a 1 year
working experience participated in the pilot study. The respondents were requested to sign the
consent form attached with the questionnaire to provide evidence of voluntary participation. The
participants who agreed and met the inclusion criteria for this study were given a Participants
Information Sheet containing objectives of the study. Anonymity will be ensured and their rights
to withdraw at any time is without any penalty. The researcher informed the Unit Leader to
distribute the survey on KAP of AKI among her surgical department nurses. Each of the item in
the questionnaire Cronbach’s alpha value were determined. Items with Cronbach alpha value
below than 0.600 will be deleted. Items that require adjustment and modification will be discussed
following recommendation and suggestions from the expert panels. The modified items will be re-
piloted and the instrument to undergo re-test procedure to ensure its stability and reliability.
Phase 4 involve generating full report from the pilot study. The study procedure is as illustrated in
the figure 1.
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Figure 1: Research methodology procedure
4. Data Analysis
Each item from type 1 and type 2 instruments underwent content validation (CVI) and its relevancy
assessed by the panel of experts. The four panels recruited based on the required specialties were
to rate each item based on a Likert scale ranging from 0 (item not relevant), 1 (somewhat relevant),
3 (quite relevant) and 4 (highly relevant).
There are two forms of CVI, namely CVI for items (I-CVI) and CVI for scale (S-CVI). Two
methods for calculating S-CVI, in which the average of the I-CVI scores for all items on the scale
(S-CVI/Ave) and the proportion of items on the scale that achieve a relevance scale of 3 or 4 by
all experts (S-CVI/UA). Then the relevance rating must be recoded as 1 for relevance scale of 3 or
4 or 0 for relevance scale of 1 or 2 which need to be converted prior to the calculation of CVI (Polit
et al., 2006, Yusoff, 2019). All the scores from the four expert panels were gathered and entered
Microsoft Excel referring standard formula as recommended (Lynn, 1986, Davis, 1992, Polit &
Beck, 2006 and Polit et al., 2007).
The first method was to get obtain the sum of I-CVI value and divide it by the number of items.
The second method was to obtain the average proportion of each relevance judged by all experts.
The proportion relevant is the average of relevance rating by the individual expert. Then, S-CVI/
UA was calculated by obtaining the number of items which had 100% agreement and divided by
the total number of items in that specific domain (Polit & Beck, 2006). A new tool should achieve
at least 80% or higher agreement to be considered as acceptable content validity (Polit et al.,2007).
Calculation of I-CVI, S-CVI/Ave and S-CVI/UA were performed for both instruments.
Apart from that the IBM Statistical Package for the Social Science (SPSS version 26.0) is used for
the analysis of the data. KAP of AKI questionnaire were analyzed to measure the Cronbach’s
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Alpha. Scale of overall KAP on AKI questionnaire, Domain 1; Knowledge on AKI, Domain 2;
Practice on AKI risk assessment and Domain 3; Attitude on AKI were determined on each item as
well as the overall Cronbach’s Alpha value according to the section.
5. Result
5.1 Validity Test for Content Validity Index (CVI)

CVI for type 1 instrument; KAP of AKI questionnaire and type 2 instrument; Nursing Risk
Assessment for AKI were calculated. The number of agreements rated by Expert 3 (Surgeon) and
Expert 4 (Nephrologist) achieved excellent number of agreements of a 100%. Expert 1
(experienced nurse) and Expert 2 (Nursing Lecturer) achieved good number of agreements with a
total of 29 and 26 out of 30 respectively. As for content validity index of item, all four experts
agree the items were relevant (I-CVI= 1.00) except item no. 10, 14, 16, 21, 28, and 30 which had
I-CVIs of 0.75. The content validity index of the entire instrument by average (Ave-CVI) was 0.96
and scale-level content validity index universal agreement method (UA-CVI) was 0.80. This
indicate both rates achieved adequate standard of acceptability (Polit et al.,2007). The relevancy
result for type 1 instruments is as displayed in Table 1.0.
Table 1.0: Four experts rating on the relevance of Type 1 instrument

ITEM Expert 1 Expert 2 Expert 3 Expert 4 Number of Item-
(Experience (Nursing (Surgeon) (Nephrologist) agreement CVI1
Nurse) Lecturer)
1. Received previous education on AKI 1 1 1 1 4 1.00
2 Mode of education received 1 1 1 1 4 1.00
3 Rate of current knowledge on AKI 1 1 1 1 4 1.00
4 True definition of AKI 1 1 1 1 4 1.00
5. Stages of AKI 1 1 1 1 4 1.00
6. Causes of AKI i-Pre-Renal, ii- Renal, 1 1 1 1 4 1.00
iii- Post Renal
7. Clinical symptoms of AKI 1 1 1 1 4 1.00
8. Condition causes by AKI 1 1 1 1 4 1.00
9 Rapid increase in serum creatinine 1 1 1 1 4 1.00
≥50% from baseline
10 Prolonged surgical time in a major 0 1 1 1 3 0.75
surgery may not cause AKI
11 Increment of serum creatinine impact 1 1 1 1 4 1.00
on patient’s mortality
12 Agents (drugs) caused AKI 1 1 1 1 4 1.00
13 History of radio-contrast agent can 1 1 1 1 4 1.00
cause AKI
14 (Scenario) Does patient have AKI? 1 0 1 1 3 0.75
15 In your opinion, hemodialysis is a 1 1 1 1 4 1.00
therapy option for AKI
16 Rate AKI risk assessment 1 0 1 1 3 0.75
17 Perform thorough AKI assessment to 1 1 1 1 4 1.00
patients
18 Barrier when performing AKI 1 1 1 1 4 1.00
assessment
19 In your opinion, all hospitalization 1 1 1 1 4 1.00
patient at risk of AKI?
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20 Emergency surgery is at risk of AKI? 1 1 1 1 4 1.00

21 State the risk factors of AKI 1 0 1 1 3 0.75
22 Educating patient/family regarding 1 1 1 1 4 1.00
AKI
23 Every patient admitted in surgical 1 1 1 1 4 1.00
ward we need to measure urine output
in AKI?
24 How important we record fluid input 1 1 1 1 4 1.00
in AKI?
25 AKI is major problem and will be 1 1 1 1 4 1.00
prolonged patient stay in the ward
26 Assessing AKI could prevent 1 1 1 1 4 1.00
complication in patients admitted to
hospital
27 Patient is at risk of AKI; therefore, I 1 1 1 1 4 1.00
must notify physician
28 Patient/ family members need to be 1 1 1 1 4 0.75
taught on the risk of AKI
29 I feel comfortable with the detection of 1 1 1 1 4 1.00
cases of AKI within my working hours
30 I feel confident with my level of AKI 1 0 1 1 3 0.75
knowledge is sufficient
Ave-CVI2 0.96
UA-CVI3 0.80
Number of agreements 29 26 30 30 Ave- 0.96
Proportion of agreement 0.97 0.87 1 1 proportion
of
agreement
across
expert4
(mean
expert
proportion)
The CVI for type 2 instrument; Nursing Risk Assessment on AKI consisted of 10 items and the
number of agreements rated by Expert 1 (experience nurse), Expert 3 (Surgeon) and Expert 4
(Nephrologist) achieved excellent 100% agreement. Expert 2 (Nursing Lecturer) achieved good
number of agreements with a total of 8 out of 10. Content validity index of item, all experts agree
the items were relevant (I-CVI= 1.00) except for item number 3 and 7 which had I-CVIs of 0.75
as it was rated with ‘somewhat relevant’ by a nursing lecturer. The content validity index of the
entire instrument by average (Ave-CVI) was 0.95 and scale-level content validity index universal
agreement method (UA-CVI) was 0.80 indicating both rates achieving adequate standard of
acceptability (Polit et al.,2007). The relevancy result for type 2 instruments is as displayed in Table
1.1.
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Table 1.1: Four experts rating on the relevance ratings of Type 2 instrument
ITEM Expert 1 Expert 2 Expert 3 Expert 4 Number of Item-
(Experience (Nursing (Surgeon) (Nephrologist) agreement CVI1
Nurse) Lecturer)
1 Respondents rate the confident level in AKI 1 1 1 1 4 1.00
assessment
2 Risk factor of age ≥65 years old 1 1 1 1 4 1.00
3 Risk factor of gender (male) 1 0 1 1 3 0.75
4 Risk factor of co-morbidity 1 1 1 1 4 1.00
5 Risk factor of Clinical/ Laboratory Parameters 1 1 1 1 4 1.00
6 Risk factor of surgical procedure 1 1 1 1 4 1.00
7 Risk factor of type of surgery 1 0 1 1 3 0.75
8 Risk factor of medications 1 1 1 1 4 1.00
9 Identify the patient has AKI 1 1 1 1 4 1.00
10 Nurses perform notification to the physician 1 1 1 1 4 1.00
within 6 hours of assessment
Ave-CVI2 0.95
UA-CVI3 0.80
Number of agreements 10 8 10 10 Ave- 0.95
Proportion of agreement 1 0.8 1 1 proportion
of
agreement
across
expert4
(mean
expert
proportion)
5.2 Reliability Test

A set of 18 KAP on AKI questionnaires were distributed to the 18 respondents with 100% response
rate.
5.2.1 Cronbach’s Alpha

The type 1 research instrument; KAP of AKI among surgical wards nurses consists of three
domains mainly i) Knowledge on AKI, ii) Practice on AKI risk assessment and iii) Attitude on
AKI with 30 items altogether. The overall Cronbach’s Alpha was 0.81. The result for reliability
test is displayed in Table 2.0.
First domain on knowledge of AKI consists of 15 items, however 3 items was removed from the
scale due to zero variance. The Cronbach’s Alpha result for 12 items is 0.70 as shown in table 2.1
Table 2.0: The overall Cronbach’s Alpha value for KAP on AKI among surgical wards nurses
Cronbach's Alpha Cronbach's Alpha Based on N of
Standardized Items Items
Overall 0.808 0.829 27
Domain Knowledge 0.701 0.768 12
Domain practice on AKI risk 0.670 0.674 7
assessment
Domain attitude on AKI 0.709 0.676 8
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Table 2.1: Values of Cronbach’s Alpha for domain knowledge on AKI

No.of Domain 1: Knowledge on AKI Cronbach's Alpha if Item Overall Cronbach's
item Deleted Alpha Value
B1 Received previous education on AKI 0.663
B2 Mode of education received 0.663
B3 Rate of current knowledge on AKI 0.662
B4 True definition of AKI 0.632
B5 Stages of AKI 0.609
B6 Causes of AKI
i-pre-Renal
0.682
ii- Renal
iii- Post Renal
B7 Clinical symptoms of AKI 0.685
B8 Condition due to AKI 0.641
B9 Rapid increase in serum creatinine 25% *The following component variables
from baseline has zero variance and is removed 0.701
from the scale
B10 Prolonged surgical time in a major surgery 0.775
may not causing AKI
B11 Increment of Sr. Creatinine impact on 0.746
patient’s mortality
B12 Agents (drugs) caused AKI 0.663
B13 History of radio-contrast agent can cause *The following component variables
AKI has zero variance and is removed
from the scale
B14 (Scenario) Does patient have AKI? 0.704
B15 In your opinion, hemodialysis is a therapy *The following component variables
option for AKI has zero variance and is removed
from the scale
For the second domain, Practice on AKI risk assessment inclusive of 7 items were mainly
developed to determine the nurses’ practice on risk assessment of the surgical patient towards
detection of AKI. Cronbach’s Alpha value is 0.67 meanwhile, detail each of the item’s domain
practice on AKI risk assessment as shown in Table 2.2
Table 2.2: Values of Cronbach’s Alpha for domain practice on AKI risk assessment
No.of Domain 2: Practice on AKI risk assessment Cronbach's Alpha if Overall Cronbach's
item Item Deleted Alpha Value
C16 Rate AKI risk assessment 0.558
C17 Perform thorough AKI assessment to patients 0.638
C18 Barrier when performing AKI assessment 0.759
C19 In your opinion, all hospitalization patient at risk 0.661
0.670
of AKI?
C20 Emergency surgery is at risk of AKI? 0.635
C21 State the risk factors of AKI 0.553
C22 Educating patient/family regarding AKI 0.517
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There are 8 items presenting the third domain of nurses’ attitude towards delivery of care for the
surgical ward’s patients related to AKI. In this domain, there are 8 items measured by 5-points
Likert scale. Cronbach’s Alpha value is 0.71 and detail each of the items in domain attitude on
AKI risk presented in Table 2.3.
Table 2.3: Values of Cronbach’s Alpha for domain attitude on AKI

No.of Domain 3: Attitude on AKI Cronbach's Alpha if Overall Cronbach's
item Item Deleted Alpha Value
D23 Every patient admitted in surgical ward we need 0.644
to measure urine output in AKI?
D24 How important we record fluid input in AKI? 0.768
D25 AKI is major problem and will be prolonged 0.665
patient stay in the ward
D26 Assessing AKI could prevent complication in 0.643
patients admitted to hospital
D27 Patient is at risk of AKI; therefore, I must notify 0.726 0.709
physician
D28 Patient/ family members need to be taught on 0.678
the risk of AKI
D29 I feel comfortable with the detection of cases of 0.692
AKI within my working hours
D30 I feel confident with my level of AKI knowledge 0.552
is sufficient
6. Discussion
Risk assessment provides useful information in the delivery of patient care. It is also a strategy
that can minimize and prevent patient complications such as adverse event, permanent injury, or
death after surgery. To foster risk assessment application and practice on a day-to-day basis, an
education programme for nurses should be designed to enhance the nurses’ skill in identifying and
detecting potential risk aimed at improving patient outcomes. The implementation of nursing risk
assessment in prevention of acute kidney injury (AKI) in surgical units’ patients is particularly
targeted to reduce the AKI and mortality rates. In preparing the nursing risk assessment education
programme, specific tools such as KAP of AKI questionnaire is developed to measure the level of
understanding and practice amongst nurses pre and post programme delivery. A nursing risk
assessment of AKI form is also developed to identify patient or conditions who are likely to
deteriorate or suffer an exacerbation of pre-existing risk. Even though there were limited formal
or informal education programme on AKI, this future study will support existing studies
recommendation for education to be extended to nursing staff as they can provide accurate
documentation of the patients’ clinical and diagnostic result (Bhagwanani et al., 2014, Prata et al.,
2016, and Adejumo et al., 2017).
In terms of research tools, both KAP on AKI questionnaire and Nursing Risk Assessment AKI
form had undergone validity process, pilot study and reliability test to analysis of its feasibility
prior to conducting the main study. In this pilot study, the overall value of Cronbach Alpha is
found to be 0.81 which is considered good and acceptable (Norkett, 2013). The three items B9:
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Rapid increase in serum creatinine ≥50% from baseline, B13: History of radio-contrast agent can
cause AKI and B15: In your opinion, hemodialysis is a therapy option for AKI, indicated zero
variance. In relation to this finding, all respondents answered YES for item B9, B13 and B15
caused the inability to calculate the Cronbach’s Alpha values Rewording and modification those
statements to improve the variance of the items were made. Another pilot study will be conducted
on modification of those items.
The research instruments from the previous studies did not underwent the content validity index
analysis to provide evidence of degree to which elements from the assessed instrument are
relevant. As such the CVI analysis and reporting an overall CVI result were performed.
Nevertheless, content validity index is mostly used by researchers because it is simple for
calculation, easy to understand and provide information on each item, which can be used for
modification or deletion of instrument items (Polit et al.,2007). As for the relevancy of the
instruments, researchers were able to prove that both adopted and modified instruments are valid,
to provide information on the representativeness of items and help to improve the instrument
through achieving recommendations from an expert panel.
7. Conclusion
This study showed the KAP of AKI questionnaires and Nursing Risk Assessment format of AKI
are valid tools. Despite assessing nurses’ level of knowledge, the understanding of the
measurement can be applied to detect patients at risk of AKI through assessment. Overall, content
validation processes and its result should be reported as important as any other types of construct
validation. It is also eligible in providing invaluable input for the quality of the newly developed
instruments.
8. Limitation
One of the limitations encountered was the small sample size conducted in the pilot study which
is not representative of the whole nurses working in the surgical department. This study was
delayed around 2 weeks to complete the data collection as the anesthetist was involved with
examination and annual scientific meeting, hence the patient’s admission for elective surgery was
postpone to available dates. The nursing AKI risk assessment form used as research tools does not
indicate a specific score to conclude whether the patient is at risk or not of AKI; it is only based
on the nurses’ judgment from the listed risk factors. Therefore, a thorough discussion with the
nephrologist and supported with literature review are needed to determine the appropriate risk
assessment scoring system
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Instrument's Reliability and Validity For Evaluating The Nursing Risk Assessment of Acute Kidney Injury Tools For The Surgical Department-A Pilot Study

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Instrument's Reliability and Validity For Evaluating The Nursing Risk Assessment of Acute Kidney Injury Tools For The Surgical Department-A Pilot Study

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Asian Journal of Fundamental and Applied Sciences

e-ISSN: 2716-5957 | Vol. 3, No. 1, 9-21, 2022

Instrument’s Reliability and Validity for Evaluating the Nursing

*Corresponding Author: nooreena@picoms.edu.my

Accepted: 15 February 2022 | Published: 1 March 2022

it is frequently underrecognized, with patients developing AKI presumed to have inadequate

Figure 1: Research methodology procedure

5.1 Validity Test for Content Validity Index (CVI)

Table 1.0: Four experts rating on the relevance of Type 1 instrument

20 Emergency surgery is at risk of AKI? 1 1 1 1 4 1.00

5.2 Reliability Test

5.2.1 Cronbach’s Alpha

Table 2.1: Values of Cronbach’s Alpha for domain knowledge on AKI

Table 2.3: Values of Cronbach’s Alpha for domain attitude on AKI

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