ht. .I. Nurs. Stud, Vol. 34, No. 3, pp.

222-230, 1997
0 1997 Elsevier Smnce Ltd. All rights reserved
Pergamon Printed in Great Britam
0020-74X9/97 1617.00+0.00
PII: SOO20-7489(97)00009-6

Measuring clinical nurse performance: developmentof

the King’s Nurse Performance Scale
Joanne M. Fitzpatrick, Alison E. While and Julia D. Roberts

Department of Nursing Studies, King’s College London, Cornwall House, Waterloo Road, London SE1 8WA, U.K.

(Received 20 September 1996;revised 3 December 1996;accepted 14 January 1997)

Abstract

The development of the King’s Nurse Performance Scale to measure clinical nurse performance is described. Instrument
construction was informed by the Slater Nursing Competencies Rating Scale [Wandelt, M. A. and Stewart, D. S. (1975)
Slater Nursing Competencies Rating Scale. Appleton-Century Crofts, New York] together with key literature and the use of
expert opinion. The instrument was utilised to observe the clinical performance of senior student nurses (n = 99) and data
which were at the ordinal level were statistically analysed using a variety of non-parametric tests. Key findings of students’
observed nursing practice are presented in a separate paper (While et al., unpublished document). Internal consistency testing
of the King’s Nurse Performance Scaleusing Cronbach’s alpha coefficient revealed a promising alpha for the total instrument
(r = 0.93). The subsection alphas indicated that further refinement may enhance the strength of the instrument as a tool for
the measurementof performance in different domains of practice. The possible useof the Scalein the professional development
of newly qualified nurses is suggested.0 1997Elsevier ScienceLtd.

Keywords: Clinical performance; measurement; instrument development.

Background required regarding how people behave in their natural

environment, whether and how they actually use their
This research formed part of a larger English
skills, or the events which occur in the course of nor-
National Board (ENB) commissioned study to com-
mal activities (Crow, 1984).However, methodological
pare the outcomes of pre-registration nurse education
challenges associated with observation research, for
programmes in the United Kingdom (While et al.,
example, related to effective instrument development
1995). At the time of the study, three different pro-
and operationalisation, are well acknowledged in the
grammeswere available: registered general nurse pro-
literature (Fitzpatrick et al., 1996) and may partly
grammes, diploma RN programmes, and integrated
account for its limited use to date. A further com-
degreeprogrammes.
pounding issue concerns the fact that: “development
Since pre-registration education aims to equip stu-
of a tool, implementation and abandonment occurs
dents with sound knowledge and clinical skills, and
too frequently” (Wood, 1982).
with attitudes and values favourable to the pro-
Acknowledging these issuesit was decided to draw
fessional nurse role (ENB, 1994), it is essential to
upon the strengths of an existing instrument and of
investigate how nurses actually practice in the clinical
particular interest to the researchers was the Slater
environment (While, 1994). One approach is direct
Nursing Competencies Rating Scale (Wandelt and
observation of nurses’ practice, however, this method
Stewart, 1975). This is a generic tool which focuses
has only been utilised to a limited extent in nurse
observation upon nurse performance as a whole and
education research. The present research sought to
has been tested for reliability and validity (Ager and
address this gap by exploring the performance of
Wandelt, 1975).Generic instruments are those which:
senior student nurses from the three programmes
“contain scalesand are designed to assessor measure
using the King’s Nurse Performance Scaleduring non-
the quality of nursing care in general, rather than
participant observation in the ward setting.
nursing care associated with specific problems” (Tom-
alin et al., 1992).
The Slater Nursing Competencies Rating Scale
Observing actual-situated behaviour (Wandelt and Stewart, 1975)consists of 84 observable
Direct observation has been advocated as the items which have been arranged into six subsections:
research method of choice when information is ‘psychosocial individual’ (18 items); ‘psychosocial

222
 J. M. Fitzpatrick et a/./Clinical
group’ (13 items); ‘physical’ (13 items); ‘general’ (16
items); ‘communication’ (7 items); and ‘professional
implications’ (17 items). Reliability testing has been
conducted (using inter-rater reliability, stability and
internal consistency tests) and construct, content, pre-
dictive and discriminant validity have been examined
by Ager and Wandelt (1975).
For example, as an index of inter-rater reliability
interclass correlation coefficients were selected by
Ager and Wandelt (1975) and were calculated using
the scores of pairs of observers who had rated the
performance of three student groups (n = 74) sim-
ultaneously but independently. Values of 0.72, 0.75
and 0.78 were achieved, indicating a modest reliability
when compared to the criterion of 0.80 which Nunally
(1978) has specified. As a measure of the instrument’s
internal consistency the odd-even split half reliability
and Cronbach’s alpha techniques were employed. The
odd&even split half technique produced a reliability
coefficient of r = 0.98 which compares favourably
with Nunally’s (1978) criterion of 0.80. Cronbach’s
alpha technique, however, yielded a coefficient of
r = 0.74 for the total instrument using 71 of the 84
items (13 items had inadequate sample sizes).
Coefficients for the six subsections have not been
reported by Ager and Wandelt. The variation between
the two coefficient measures may be explained by the
possibility of different reliability estimates being
obtained when different combinations of splits have
been used (Polit and Hungler, 1987). Further, Ager
and Wandelt (1975) have suggested that the Cron-
bath’s alpha measure in this instance may be under-
estimated due to unequal sample sizes for the various
intercorrelations (p. 55). To explore the instrument’s
underlying dimensions, factor analysis was conduc-
ted, using 7 1 of the 84 items which had sufficient cases.
Factors with an eigenvalue > 1 were retained and 12
in total were identified accounting for 83% of the
total variance, with factor 1 accounting for 55%. The
authors reported that on the varimax rotation items
from the six subsections demonstrated some tendency
to load on separate factors, which indicates that items
were not exclusive to their subsections. Further details
regarding where the factors drew their items from
have not been reported by Ager and Wandelt.
The original version of the Slater Nursing Com-
petencies Rating Scale (Slater, 1967) was used in a
pilot study by Christman (1971) to examine bacca-
laureate nurses’ performance (n = 42) using the
organisation of nursing care as the independent vari-
able. In another United States (U.S.) study, Petti
(1975) utilised the tool to obtain head nurse and pati-
ent ratings of nurse performance. Unfortunately,
neither Christman (1971) nor Petti (1975) reported
having carried out further reliability and validity test-
ing of the Scale. Interestingly, the quality assessment
instrument Qualpacs (Wandelt and Ager, 1974)
which was also developed from the Slater Nursing
Competencies Rating Scale, has been found to be the
most valid of three popular generic quality assessment
nurse performance 223
instruments in use in the United Kingdom (Redfern
et al., 1994).
Enhancing content specificity
The King’s Nurse Performance Scale drew sub-
stantially upon the Slater Nursing Competencies Rat-
ing Scale (Wandelt and Stewart, 1975). The latter,
however, was not without its limitations, for example,
it was developed for use in the US over twenty years
previously. It was essential therefore to ensure, as far
as possible, that content was specific to and rep-
resented a current understanding of nurse per-
formance in the United Kingdom (Anastasi, 1976;
Nunally, 1978; Cronbach, 1984; Linn et al., 1991).
Indeed, it has been asserted that failure to establish
this requirement: “increases the probability that
reliability estimates will simply describe the con-
sistency of irrelevant measures of subject effec-
tiveness” (Peterson et al., 1985). Thus, while
acknowledging that an index of content validity can-
not be computed, it was nevertheless imperative to
maximise quality of content.
In previous attempts to design performance evalu-
ation tools, a variety of strategies to generate and
validate the content domain have been adopted,
including: incorporating current literature; drawing
upon programme curricula; seeking expert opinion;
and preliminary observation of people engaged in the
activity under consideration to identify key indicators
(Sommerfield and Accola, 1978; Stecchi et a/., 1983;
Cottrell et al., 1986; Gould, 1993). The Critical Inci-
dent Technique has also been explored as a potentially
useful approach to generate a valid content base (Gor-
ham, 1962; Gorham, 1963; Brumback and Howell,
1972; Sims, 1976; DeBack and Mentowski, 1986). For
example, DeBack and Mentowski (1986) interviewed
staff nurses and nurse supervisors (n = 83) from three
health care settings to elicit critical incidents of effec-
tive and ineffective nursing practice. A model of nurse
competencies was developed from the interview data
and was subsequently used to score perceived differ-
ences in the performance of baccalaureate (n = 37)
associate degree (n = 8) and diploma (n = 30) nurses,
as well as nurses with a higher degree (n = 5). Once
again, however, the instrument was utilised to explore
perceived differences rather than actual-situated per-
formance. Strategies adopted to enhance the content
specificity of the King’s Nurse Performance Scale are
discussed in the forthcoming sections.
The construction of scale items
Taking into consideration the above information,
the King’s Nurse Performance Scale was constructed
with the aim of producing a generic set of observable
nursing actions reflective of nurse performance in the
United Kingdom (UK) and amenable to accurate dis-
crimination. An analysis of the concept of nurse per-
formance identified key facets of the nurse role which
 224 J. M. Fitzpatrick et aL/Clinical nurse performance
informed the development of the instrument, together etition and the inclusion of non-specific items. Analy-
with a critical review of the Slater Nursing Com- sis ofitems in the Slater Nursing Competencies Rating
petencies Rating Scale (Wandelt and Stewart, 1975). Scale informed the developmental process in this
Within the King’s Nurse Performance Scale, seven study. For example, items one and two of the ‘psy-
domains of nurse performance were formulated and chosocial: individual’ subsection of the Slater instru-
these are detailed below. Items generated from the ment highlighted the difficulty of generating discrete
literature as well as items drawn from the Slater Nurs- items. Specifically, item 2 refers to the nurse being a
ing Competencies Rating Scale (Wandelt and Stewart, receptive listener, however, this overlaps with item 1,
1975) were assembled to represent each area of prac- the focus of which is the need to give full attention to
tice and the first draft of the instrument consisted of the patient. No similar items were incorporated in the
67 items grouped into the seven domains of nurse King’s Nurse Performance Scale. Further challenges
performance. Items were illustrated with cues, the pur- included ensuring item mutual exclusiveness and logi-
pose of which was to facilitate the observer training cal coherence, as well as achieving discrete subsec-
programme, specifically, enabling the accurate identi- tions. For example, associated with attending to
fication and discrimination of items during obser- clients’ personal hygiene needs (physical domain) is
vation and minimising observer inference. For working in collaboration (use of the nursing process
example, the cues provided for item 4 ‘Ensures patient in planning care domain), and attending to clients’
receives fluid intake as appropriate’ were as follows: sensitivities (psychosocial domain). This challenge is
‘Ensures intravenous fluid is administered according highlighted further when examination of the internal
to regimen’; and ‘Acts upon the evidence of a main- consistency and construct validity of the instrument
tained intake and output chart’. To further facilitate is discussed.
quick and accurate recording in the field setting, each
item was identified as one whose rating will usually be
Validation of content
direct, one whose rating will usually be indirect (e.g.
from a written record) or one whose rating may be Key criteria for maximising content validity include
direct or indirect. The first subsection ‘physical an adequate collection of items which represent the
domain’ (14 items) focused upon nursing actions to domain of investigation (i.e. nurse performance) and
address the physical needs of clients. The ‘psycho- appropriate methods of test construction (Nunally,
social domain’ (6 items) referred to nursing actions 1978; Messick, 1989; Streiner and Norman, 1989).
which addressed the psychosocial needs of clients. The From the outset of instrument development, the
‘professional domain’ (9 items) centred upon actions objective was to select items which provided the most
directed towards fulfilling the professional role. Meet- accurate and representative description of effective
ing the knowledge needs of clients, self and others was nurse performance and this process was informed by
the focus of the ‘promotion of health and teaching an extensive review of the literature. The use of experts
skills domain’ which consisted of four items. Man- is also an accepted strategy to validate the content
agement of self and others was the focus of the ‘care domain of instruments (Anastasi, 1976; Cronbach,
management skills and organisation of workload 1984; Streiner and Norman, 1989) and a panel of nine
domain’ and was represented by six items. Com- experts drawn from clinical, educational and research
munication with clients and others was reflected in settings, together with the Steering Group of the larger
subsection six which consisted of five items. The final study, were involved in the process of instrument
subsection encompassed the use of the nursing process review.
approach to the planning and delivery of care (21 The King’s Nurse Performance Scale items and cues
items). The subsections were designed to reflect the were sent to each member of the expert panel and the
training regulations of pre-registration courses of Steering Group of the larger study who were asked to
nurse preparation (Statutory Instrument No. 1456, respond independently. Experts were asked for their
1989) the Code of Professional Conduct (UKCC, comments upon the Scale as a whole, and the appro-
1992) and criteria for effective nurse performance priateness of subsections and individual items. The
which were derived from a wide literature base. For experts were asked to review the instrument for clarity,
example, it is expected that the newly qualified nurse comprehensiveness, mutual exclusiveness and to sug-
should be able to devise, implement and evaluate a gest any additional items for inclusion. They were also
plan of care (Statutory Instrument No. 1456, 1989; asked to score each item as an observable indicator of
UKCC, 1992). The conceptual framework under- effective nurse performance and to assign a rating on
pinning this, the nursing process, was therefore a scale of O-5 (0 being totally irrelevant and 5 being
reflected in the subsection: ‘use of the nursing process absolutely essential). It emerged, however, that the
in planning care’ and the work of several key authors scoring system did not always correspond with com-
contributed to item generation (Mayers, 1978; Yura ments regarding the technical quality of items. Thus
and Walsh, 1978; Kratz, 1979; Brooking, 1986; Hunt while an item may have been considered an important
and Marks-Maran, 1986). indicator of effective nurse performance its con-
Some of the challenges associated with the process struction required modification. Further, in some
of instrument development included avoiding rep- cases experts chose to note comments rather than
 J. M. Fitzpatrick et uI/Clinical nurse performance 225

assign ratings to items, Thus refinement or deletion of

items was made on the basis of consistently critical
comments.
Items not explicitly related to the content domain
may introduce measurement error since potentially
they may discriminate among participants on a dimen-
sion which is different from that which the researcher
intends to investigate (Streiner and Norman, 1989).
In view of this, one important function of the expert
review system was the identification of any erroneous
items. Distribution of the Scale to the expert panels
on the first occasion resulted in the deletion of 10
items: ‘physical domain’ (two items), ‘psychosocial
domain’ (one item); ‘professional domain’ (three
items); and ‘use of the nursing process in planning
care domain’ (five items). Other modifications
included item refinement to prevent replication. For
example. items 42 and 43 in the ‘physical domain’ of
the Slater Nursing Competencies Rating Scale were
reflected in the first draft of the King’s Nurse Per-
formance Scale in a modified format. Item 42 read:
‘Recognises hazards to patient safety and takes appro-
priate action to maintain a safe environment and to
give patient a feeling of being safe’ and item 43 read:
‘Carries out safety measures developed to prevent pat-
ients from harming themselves or others’. The concept
(0 vmk. Rtq.mlk d E&N. ,592)
of safety was acknowledged as vital and was therefore
reflected in the following item: ‘Acts to maintain a Fig. 1 Exemplar of Scale domain.
safe environment for patient/others’ in the instrument.
Other modifications, to facilitate quick and accurate petencies Rating Scale, for example, like many clinical
recording in the field setting, included verbalising and evaluation instruments (Moritz and Sexton, 1970;
identifying each item as one whose rating will usually Gennaro et al., 1982; Bond and Jackson, 1990) incor-
be direct, one whose rating will usually be indirect, porates the use of a rating scale to score the items.
(e.g. from a written nursing record) or one whose Purported advantages of this format include its ability
rating may be direct or indirect. Some adjustments to to direct observation towards specific and clearly
item cues were also made on the basis of panel review. focused aspects of behaviour, thereby providing a con-
The process of reduction and refinement resulted in a venient method for recording observer judgements
second draft of the instrument which consisted of 54 (Gronlund, 1981; Polit and Hungler, 1987). Further.
items, grouped into seven subsections, the capacity to have a range of rating scale points has
The second draft of the instrument was distributed the potential to convey more meaningful information
to each member of the expert panels for independent about the quality of performance and discriminate
review. This resulted in some further minor refinement more accurately between groups (Bondy, 1983).
of item wording on the basis of consistent critical The use of ratings, as Guilford (1954) has empha-
comments. For example: ‘Gives verbal/written evi- sised. rests upon the assumption that: “the human
dence of insight into patient’s deeper problems/needs’ observer is a good instrument of quantitative obser-
was modified to read: ‘Gives verbal/written evidence vation, that he is capable of some degree of precision
of insight into patient’s psychosocial needs/problems’. and some degree of objectivity” (p. 278). One strategy
Deletion of one item from: ‘use of the nursing process to enhance accuracy of ratings is by defining rating
in planning care domain’ was made on the basis of scale points. It is known, for example, that inadequate
potential overlap producing a 53-item instrument (see or omitted explication of rating scale points compro-
Fig. 1 for exemplar of Scale domain). The Scale was mises the reliability and validity of this format
redistributed to the experts on a third occasion, (DeMers, 1978; Atwood, 1980; Horn, 1980; Gron-
however, no further refinements were suggested. lurid, 1981; Popham, 1981; Bondy, 1983). This is
partly owing to the difficulties of interpretation associ-
ated with a variety of formats (e.g. qualitative labels
Identifying rating criteria
and numerical labels) where criteria are not identified
The next stage of developmental work focused upon for the scale labels. Moritz and Sexton (1970) for
identification of appropriate criteria to score the Scale example, used normative labels to score student prac-
items during the observation process and several alter- tice on a five-point rating scale (superior, above aver-
natives were considered, The Slater Nursing Com- age, average. needs improvement and unsatisfactory).
 226 J. M. Fitzpatrick et u/./Clinical
In their discussion regarding instrument admin-
istration Moritz and Sexton concluded that agreement
was never reached on use of the ‘average’ label and
they recognised the advantages of clear definitions.
Similar problems coupled with the desire to perform
a fair and objective evaluation have stimulated the
development or refinement of instruments by several
researchers (Gennaro et al., 1982; Bond and Jackson,
1990).
Similar challenges are associated with the use of an
individual or general frame of reference to measure
subject performance. For example, items in the Slater
Nursing Competencies Rating Scale (Wandelt and
Stewart, 1975) are scored using a rating scale and
observers adopt an individual or general frame of
reference to operationalise a standard of measure-
ment. Using an individual frame of reference,
observers using the Slater Nursing Competencies Rat-
ing Scale are required to identify exemplars of nurses
on a five-point scale: ‘best, between best and average,
average, between average and poorest and poorest’
against which performance is rated. Alternatively, a
general frame of reference may be adopted to rate
performance using qualitative labels such as ‘excellent,
above average, average, below average and poor’.
Undefined or vague definitions, however, may
increase the potential of observer error owing to
interpretation difficulties (Gronlund, 198 1; Popham,
1981; Bondy, 1983). Thus it may be argued that Wan-
delt and Stewart’s (1975) individual or general frame
of reference has a professional base which may be
idiosyncratic. In an attempt to minimise such prob-
lems careful definition of the criteria by which to judge
behaviour was considered paramount.
Of the alternative rating criteria reviewed, Bondy’s
(1983) five-point criterion-referenced rating scale
appeared to be the most robust and was adopted for
use in the present study. Bondy (1983) developed her
rating scale in an attempt to avoid the pitfalls associ-
ated with the process of student clinical performance
evaluation. She suggested five levels of performance,
namely: independent; supervised; assisted; marginal;
and dependent, together with a ‘not observed’ cate-
gory. The ‘not observed’ category was not included in
this study and instead an ‘omitted care’ category was
created since Redfern et al. (1993) have argued with
reference to Qualpacs (Wandelt and Ager, 1974) that
there is a potentially informative distinction between
‘poorest care’ and ‘omitted care’. During observation
Bondy’s (1983) levels of performance were considered
under three key categories. The first category, pro-
fessional standards and procedures for the behaviour,
encompasses the issues of safety (for clients, self and
others), accuracy (incorporates the application of
research-based knowledge to practice), effect (achiev-
ing the intended purpose of the behaviour) and affect
(the manner in which the behaviour is performed).
The focus of the second category is the qualitative
aspects of performance and includes the use of time,
space, equipment and energy. Additionally, dem-
nurse performance
onstration of persistence under adverse circumstances
was incorporated into this category since it was con-
sidered to be an important contributor and dis-
tinguisher between high and low quality nursing care
(Fordham, 1991, personal communication). The final
category addresses the type and degree of assistance
required to carry out the nursing activity.
The positive effect of Bondy’s (1983) criterion-ref-
erenced rating scale on accuracy and reliability of
ratings has been demonstrated in an experimental
study in which videotapes depicting nursing activities
(e.g. drug administration, nurse-client interview pro-
cedure and a dressing technique) were produced to
reflect the five levels of performance (Bondy, 1984).
An observation schedule was also constructed, con-
sisting of items reflecting the cognitive (five items),
affective (five items) and psychomotor (four items)
domains which were rated using Bondy’s five-point
scale. The scale points were numerically labelled (5,4,
3, 2, 1 and X for not observed) for the control group
and I, S, A, M, D and X (not observed) for the exper-
imental group. Explanatory information about the
study and the 14-item schedule was presented to both
groups. Only the experimental group, however,
received an explanation of the rating criteria. Results
indicted that using the rating criteria enhanced accu-
racy in the rating process and as student performance
improved the beneficial effect of using the criteria
became more pronounced. Further, there was evi-
dence of discrimination using the five-point scale.
Bondy’s (1983) criterion-referenced rating scale was
therefore judged a potentially sensitive method to rate
the Scale items during observation of nurse perform-
ance.
Extraneous variables influencing clinical performance
It is impossible to examine nurse performance with-
out taking account of potentially influencing factors.
Human performance is influenced by a variety of
extrinsic and intrinsic variables (Fitzpatrick et al.,
1996) and taking these into consideration, contextual
data which reflected the ward environment at the time
of observation were recorded for each session.
Further, participants were observed continuously for
a period of 2’;* hr on three separate occasions at
different times of the day in an effort to accommodate
the possible influence of any such variations.
Additional refinements
Further refinements were made to the Scale as a
result of pilot work which was undertaken over a
three-month period and involved observation of final
year diploma students (n = 7) and nursing degree stu-
dents (n = 5) drawn from a location separate from the
main study. Ethical approval was obtained for all
participating institutions and informed consent was
gained from all participants. As a result of this phase
of the research minor adjustments were made to Scale
 J. M. Fitzpatrick et al./Clinical nurse performance 221

items and Bondy’s (1983) rating criteria were modified
(Fitzpatrick et al., 1996). No item reduction occurred.
Internal consistency testing of the tool and principal
components analysis were not conducted at this stage
due to the small data set. Examination of inter-
observer reliability and observer drift are discussed in
a separate paper which details operationalisation of
the instrument (Fitzpatrick et al., 1996).
Reliability and validity testing of the instrument
As highlighted previously, the target population for
this research were students completing their nursing
programmes for Part 1 (RGN) and Part 12 (Adult
Nursing) of the Register. Non-participant observation
of senior students representing the three programmes
(n = 99) took place in the hospital setting and each
participant was observed on three separate occasions
at different times of the day, totalling 742.5 hr of
observation. Data analysis, which commenced on
completion of data collection, involved calculating a
total mean performance score and a mean score for
each of the seven domains for each participant. The
formula used was: the sum of weighted totals divided
by the total number of ratings. The sum of the total
weighted scores reflected the performance levels: inde-
pendent (4) assisted (3) marginal (2) and dependent
(1). The omitted column was not assigned a numerical
weighting but was reflected in the total number of
ratings for each observation period. Non-parametric
tests were applied to explore relationships between
the different participant groups and key findings are
presented elsewhere (While et al., 1996). The data were
used to conduct reliability and validity testing of the
instrument, details of which are presented below.
Internal consistency testing of the instrument
The data were used to examine the internal con-
sistency of the King’s Nurse Performance Scale using
Cronbach’s alpha technique. The latter provides a
good estimate of reliability in most situations since
the major source of measurement error focuses upon
sampling of content (Nunally, 1978). The total Scale
yielded an alpha of Y = 0.93 using the means of the
subsection scores (n = 98, 1 missing case due to
insufficient data for analysis). Since the Scale com-
prised of seven subsections it was also important to
examine the internal consistency of each (Waltz et al.,
1991). Using the item means it was only possible to
calculate an alpha coefficient for 3 of the 7 subsections
(where >50 cases were included). The coefficient
alphas were: ‘physical domain’ Y = 0.74 (n = 51); ‘pro-
fessional domain’ Y = 0.70 (n = 60); and ‘promotion
of health and teaching skills domain’ r = 0.71
(n = 61). The subsection alphas did not reach
Nunally’s (1978) criterion of 0.80 which suggests
independent components within the instrument.
Interestingly, insufficient score data in the ‘psycho-
social: group’ section for Qualpacs (Wandelt and
Ager, 1974) ratings was a significant problem in the
research of both Carr-Hill et al. (1992) and Redfern
et al. (1994).
An alternative method was also used to compute
coefficient alphas for the subsections, that is, using the
mean score for each observation period. Using this
method it was possible to compute coefficient alphas
for the seven subsections, however, once again they
did not reach the criterion of 0.80 (Nunally, 1978):
‘physical domain’ Y = 0.58 (n = 99); ‘psychosocial
domain’ Y = 0.53 (n = 62); ‘professional domain’
r = 0.60 (n = 99); ‘promotion of health and teaching
skills domain’ Y = 0.46 (n = 93); ‘care management
skills and organisation of workload domain’ r = 0.60
(n = 99); ‘communication skills domain’ r = 0.65
(n = 99); and ‘use of the nursing process in planning
care domain’ r = 0.72 (n = 99).
In summary, internal consistency testing suggested
some independence within the subsections of the
instrument. There was evidence nonetheless of overall

Table1
Content and percentage of variance for each component

Component Description % of Variance

I Provides for the psychological, social and physical needs of patients using a 43.5
multidisciplinary approach to planning and delivery of care
2 Self-directing care management and organisation of workload 9.3
3 Attention to patient safety with adherence to regulations. policy directives and 1.4
research findings
4 Attention to patients’ physical care needsfor hygiene with sensitivity and 5.2
encouraging patient participation in care
5 Attention to patients’ activity in accordance with their current and potential 4.6
health status
6 Safe administration of intravenous/parenteral fluids with patient consultation 4.2
and teaching
I Effective communication about patient supported by patient participation in the 3.x
evaluative process
8 Attention to patients’ dietary intake appropriate to associated actual/potential 3.2
problems
 228 J. M. Fitzpatrick et &./Clinical nurse performance
Table 2 ency to load on separate factors (Table 2). The 14
Number of items within each component items which loaded on component 1 are set out in
Table 3 and it was noteworthy that the items were
Component Number of items
drawn from six of the seven subsections. Component
1 15 (11. 14, 16, 21-23, 27-29, 32-35, 38, 41) 1 appears to focus upon two inter-related areas of
2 14 (4, 7, 11-12, 20-21,23,27-28, 32, 37-38, nursing: (i) an individual and holistic plan of care
41,51) including skilled communication, performing effec-
3 11 (&9, 12, 16, 19, 27,40,4748) tively and responsibly in the planning and delivery of
4 9 (24, 16, 22, 38, 41, 47, 51) care with a multidisciplinary approach (derived from
5 8 (1, 11-12, 20, 24, 29, 40, 51 10 items); and (ii) the psychosocial component of nurs-
6 7 (6, 21-22, 24, 28, 32, 47) ing care and in particular developing and maintaining
7 4 (16, 29, 37, 51) a therapeutic nurseslient relationship (derived from
8 3 (5,20,40) four items).

Examination of convergent validity

coherence and the total alpha coefficient of Y = 0.93
is superior to that published for the Slater Nursing
Competencies Rating Scale of r = 0.74, as reported
by Ager and Wandelt (1975). Unfortunately,
coefficients for the 6 subsections of the Slater Nursing
Competencies Rating Scale have not been reported by
Ager and Wandelt.
Examination of the instrument’s construct validity
Principal components analysis was conducted to
explore the instrument’s underlying dimensions (Kim
and Mueller, 1978; Dunteman, 1991) and 33 items
had sufficient cases to be included in the analysis.
Eight components with eigenvalues > I were extracted
from the rotated component matrix with the first prin-
cipal component explaining 43.5% of the total vari-
ance and the second accounting for just under 10%.
Interpretation was based on part loadings with values
>0.30. The contents of the components and their
percentage of variance have been summarised in Table
1. Similar to findings regarding the internal con-
sistency of the Slater Nursing Competencies Rating
Scale (Ager and Wandelt, 1975) and Qualpacs instru-
ment (Fox and Ventura, 1984) items in the King’s
Nurse Performance Scale demonstrated some tend-
As well as observation of practice, senior students’
performance in a care planning simulation exercise
was examined as part of the larger study (While et al.,
1995). These data were used to examine convergent
validity and using Spearman’s rank correlation
coefficient test, the results showed a modest cor-
relation between the total score for observed practice
and the global score for the care plan (v = 0.185,
PcO.05). Statistically significant associations also
emerged between: a higher observation score for use
of the nursing process in planning care in the ward
setting and a higher global care plan score (Y = 0.18 1,
P<O.O5); a higher score for observed practice in the
psychosocial domain and a higher score for the psy-
chosocial domain in the care plan (Y = 0.227,
PcO.025); a higher total score for observed practice
and a higher score for problem identification in the
care plan (r = 0.192, P < 0.05). It is possible that these
findings reflect the complexity of the link between
nurses’ performance in the clinical environment and
their care planning. Thus, further methods refinement
and testing may enhance convergent validity,
however, it is also possible that the tools measure
different aspects of nurse performance which may in
part explain the modest convergent validity.

Table 3
Items loading on first principal component

Item Description Loading

14 Attends to or helps appropriately the distressed/emotional state of the patient 0.83

35 Establishes rapport with patient/family/significant other 0.82
34 Spendstime with patient as appropriate 0.81
27 Provides information in a comprehensible way to patient/significant other/staff 0.71
33 Contributes as nurse member of multi-disciplinary team caring for patient 0.69
22 Is reliable; seeksguidance/help when necessary 0.63
32 Is a constructive team member and leader where appropriate 0.62
16 Gives verbal/written evidence of insight into patient’s psychosocial needs/problems 0.55
38 Communicates clearly in speechabout patient 0.50
21 Cares for assignedpatients; knows where and how they are 0.46
29 Adapts care to patient’s physical and mental abilities 0.40
II Acts to provide relief for the physically distressedpatient 0.38
28 Distributes her/his time appropriately between her/his allocated patients 0.37
23 Is self-directing; takes initiative 0.31
 J. M. Fitzpatrick et al./Clinical nurse performance
Conclusion
The development of the King’s Nurse Performance
Scale was informed by the Slater Nursing Com-
petencies Rating Scale (Wandelt and Stewart, 1975)
together with key literature and expert opinion. The
Scale is able to measure performance in the different
domains of nursing practice, however, its particular
strength lies in its ability to measure overall nurse
performance in the clinical setting as demonstrated by
the favourable Cronbach’s alpha coefficient (v = 0.93)
of the total instrument. The subsection alphas indi-
cated that further refinement may improve the
strength of the instrument as a tool for the measure-
ment of performance in different domains of practice.
Further refinement of the observation method is
therefore required in order to enhance both the val-
idity and reliability of this method as a means of
measuring actual-situated nurse performance. Never-
theless, the King’s Nurse Performance Scale is an
empirically based generic tool with a content domain
specific to nurse performance in the UK which permits
detailed examination of nurses’ practice of care deliv-
ery thus enabling the identification of strengths and
weaknesses in nurse clinical performance which could
be utihsed in the professional development of newly
registered nurses. However, it is acknowledged that
this 53 item Scale demands significant non-participant
observation skills which will require a major training
programme before its competent use by nurses in clini-
cal practice.
Acknowledgements
The authors were engaged in a comparative study
of outcomes of pre-registration nurse education pro-
grammes commissioned by the English National
Board for Nursing, Midwifery and Health Visiting.
This article draws upon this work. Responsibility for
the views expressed, issues of interpretation questions
of inclusion and omission, remain as always with the
research team and do not necessarily reflect the views
of the English National Board for Nursing, Midwifery
and Health Visiting.
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