Independent Living Skills Inventory (ILSI) and the Nurses

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Independent Living Skills Inventory (ILSI) and
the Nurses Observational Scale for Inpatient
Evaluation, 30-item version (NOSIE) predict
length of hospitalizationYuliana E. Gallegos,
Charlie A. Davidson, Elizabeth A. Cook, William
D. Spaulding, Ph.D.University of Nebraska-Lincoln


Hypotheses Methods
Background Materials
Length of inpatient hospitalization is an
important indicator of rehabilitation progress
and efficiency for people with treatment-resistant
serious mental illness. Furthermore, research
has demonstrated that ward behavior is predictive
of outcome measures such as length of
hospitalization (LOH). An individuals
psychosocial skill acquisition and milieu
behavior are important criteria by which
discharge decisions are made, and these are
quantified in the Independent Living Skills
Inventory (ILSI) and the Nurses Observation
Scale for Inpatient Evaluation 30-item version
(NOSIE), respectively. The NOSIE
(Honigfield, Gillis, Klett, 1966) is an
observational measure that identifies behavioral
strengths and weaknesses of ward patients. In
addition to computing a Total Assets score, its
components form six subscales Social Competence,
Social Interest, Personal Neatness, Irritability,
Psychoticism, and Motor Retardation. The ILSI
(Sanchez, 1986) is a functional assessment that
consists of ten domains relevant to independent
community living Personal Skills, Hygiene,
Clothing, Basic Functioning, Interpersonal
Skills, Home Management, Money Management,
Cooking Skills, Resource Utilization, and General
Occupational Skills.  The relationship
between ILSI and symptom severity was assessed
using the Brief Psychiatric Rating Scale (BPRS
Lukoff et al., 1986). BPRS scores were
transformed to factor dimensional measures of
Thought Disturbance (positive symptoms,
approximately) and Anergia (negative symptoms)
based on the 16-item, four factor structure of
the BPRS (Long Brekke, 1999).
It was hypothesized that LOH would be
significantly negatively related to ILSI and
NOSIE summary scores, thus demonstrating both the
validity and clinical utility of these measures
and the importance of behavioral assessment in
psychiatric rehabilitation. This study
examined archival longitudinal data collected at
the Lincoln Regional Centers Community
Transition Program, a 40-bed inpatient unit.
Individuals in this program spent about 35 to 40
hours per week participating in structured
treatment and rehabilitation activities, such as
skills training (e.g., social skills training,
occupational therapy, therapeutic recreation) and
contingency management (e.g., behavior management
program). The CTP treated chronic,
treatment-refractory individuals with severe
mental disorders. Data consisted of 3, 6 and
12-month administrations of the NOSIE and ILSI.
Month 3 is presented here for sample size and
interest in predictive ability, although results
were not substantially different at the other
time points. Data were cleaned to ensure
normality. Pearsons correlations were used to
assess each scales relationship with length of
hospitalization, and Steigers Z-tests were used
to compare their predictive value. It was
hypothesized that both ILSI and NOSIE would be
significantly negatively correlated with LOH.
The relationship between symptoms and living
skills was examined in a divergent validity
design. As demonstrated in similar settings
(Brill et al., 2009), it was hypothesized that
negative symptoms would be strongly correlated
with ILSI, whereas positive symptoms would be
less or non-correlated.


Results
Conclusions
This study demonstrates the predictive
validity of the NOSIE and ILSI and bolsters their
clinical value. Strong significant correlations
were demonstrated between these measures and
length of hospitalization. Although these scales
serve different clinical purposes and assess
different behavioral constructs, this study
demonstrates their convergent validity, clinical
utility, and the importance of behavioral and
skills assessment to efficient psychiatric
rehabilitation. Future studies should
examine relationships between these measures and
other levels of assessment, such as
neurocognition and social cognition. NOSIE and
ILSI subscales should be examined in multivariate
analyses with outcomes such as LOH to determine
the unique contributions, interactions, and
longitudinal aspects of different skills and
behaviors. Finally, the lack of a relationship
between LOH and NOSIE or ILSI should be followed
up in similar and other designs with a larger
sample size.
Significant correlations were found between
LOH and ILSI total (n98, r.448, plt.001) and
NOSIE total (n147, r.542, plt.001). Follow-up
analyses showed that this relationship is most
relevant for predicting shorter LOH. For
participants with below average LOH, the
correlation did not change substantially (ILSI
n60, NOSIE n94). However, for those with
higher-than-average LOH, this correlation was not
significant (ILSI n38, r.263, p.11 NOSIE
n53, r.214, p.125). See Figure 1. ILSI
and BPRS data were examined for 36  people from
the total sample. Correlations with ILSI were not
found for positive symptoms (r.098, p.571) or
negative symptoms (r.-.087, p.617), although
Type II error cannot be excluded due to the small
sample size. Thus, the ability of symptoms to
predict living skills was not supported, and with
no significant correlations, divergent validity
could not be assessed.

Figure 1 Correlations at month 3 (Z-scores)
LOH, NOSIE ILSI