Nurses' Observation Scale for Inpatient Evaluation (NOSIE): Psychometric Properties

The Nurses' Observation Scale for Inpatient Evaluation (NOSIE) is a highly sensitive ward behaviour rating scale. The NOSIE, developed by G.Honifeld and CJ Klett, is a 30-item scale designed to assess the behaviour of patients on an inpatient unit [1,2].. The scale was developed in 1965 and still used with a moderate degree of frequency. The advantage of the NOSIE is that it is quick, simple to administer, and may be used to assess patients that may be too ill to participate in more interactive rating scales including nonverbal individuals [3].

  • The scale is frequently used to assess behaviours from baseline, and can be utilized to with most severely ill patients.
  • The scale is frequently utilized to assess change in behaviours from baseline. The rating is based on continuous observation.
  • The scale is rated according to the frequency of occurrence of the 30 designated behaviours during the previous three days.
  • Interrater reliability has been generally demonstrated by interclass correlations for pairs of ratingof 0.73 to 0.74 for manifest and depressive psychosis [3].
  • Nurses play an important part both in pursuing the goals of treatment and in assessing the change in individual patients.The NOSIE is a particularly well- developed rating scale whose content has been tailored to the task of assessing change in long stay patients and has been successfully used for this purpose in the US[4].
  • The NOSIE was developed to involve nurse in the assessment of people with psychosis in hospital care. This and similar instruments recognized the crucial role played by nurses in the planning of health care. Since they spent all day with the people- in- care, they were in the best position to comment on the presence or absence of specific patterns of behaviour associated with mental disorder.
  1. In studies conducted in UK and America the scale has been found to be a reliable, brief and unambiguous tool for the assessment of people with enduring mental disorder, requiring mental disorder, requiring longer term care. The rating is quick and simple to use and, despite requiring little training of staff, the scale is reliable. [5]
  2. In a methodological study, validation of two rating scales, Modified Overt Aggression Scale (MOAS) and the Nurses' Observation Scale for In-patient Evaluation (NOSIE), which cover different aspects of psychopathology, were done by a group of Italian researchers. The scales were first translated into Italian and tested their validity and reliability in terms of inter-rater and internal consistency. For validity, both cases and controls were included: for the MOAS comparison was made between patients who were aggressive (cases) to those who were presumably non-aggressive (controls). For the NOSIE, cases were acute inpatients and controls were subjects with expected stable behaviour. The Brief Psychiatric Rating Scale (BPRS) was also administered to cases in order to test convergent validity. Either the NOSIE and/or MOAS scales were administered to 358 psychiatric inpatients. A subset of these patients (131 for the MOAS and 226 for the NOSIE) was also used to test the inter-rater reliability. Both scales showed good psychometric properties. The correlation coefficients between raters were much higher than 0.75 (for the NOSIE) or 0.90 (for the MOAS), while the discriminant power between cases and controls was confirmed for both scales and good concordance with BPRS was observed. The NOSIE showed good internal consistency for all domains except neatness. In general the MOAS showed better results than the NOSIE for all psychometric properties, although both scales are suitable for monitoring the behaviour and aggression of acute ward inpatients.[6]
  3. A re-evaluation of the Nurses' Observation Scale for Inpatient Evaluation carried out to confirm that it remains reliable in a modern United Kingdom (UK) setting. The scale was tested for the degree of agreement between two individual raters and not, as in previous studies, between two pairs of raters. A total of 100 patients were each rated by two nurses, and a least-squares simple regression model was used to describe the average level of agreement between the pairs of ratings. The result showed that correlation in total scale scores was 0.76 (F = 136, P < 0.0001). The correlations for Negative and Positive Factors were 0.68 (P < 0.001) and 0.75 (P < 0.001), respectively. This study has shown that the Nurses' Observation Scale for Inpatient Evaluation retains satisfactory inter-rater reliability with current clinical populations.  The researchers suggested that NOSIE remained as a useful tool for everyday clinical practice and a basis for meaningful communication between staff about patient status. [7]
  4. A study evaluated the Nurses' Observational Scale for Inpatient Evaluation (NOSIE), the Brief Psychiatric Rating Scale (BPRS), the Mini Mental State Examination (MMSE), and other measures as predictors of assaults that occurred during psychiatric hospitalization. On admission, the MMSE was administered to 335 acutely ill psychiatric patients, and diagnostic and demographic data were recorded. Immediately after admission, patients were rated by nurses using the NOSIE and by psychologists using the BPRS. Patients who committed assaults during hospitalization (N = 47) and those who did not were compared, and relationships between several variables and assaults were evaluated by t tests, Mann-Whitney U tests, chi square tests, and analyses of variance. Results showed a high score on the irritability factor of the NOSIE and failure to complete the MMSE correctly predicted the occurrence or non occurrence of assault 81 percent of the time. None of the other variables examined were significantly related to assaults, including total scores on the BPRS and MMSE, psychiatric diagnosis, and several demographic variables. Scores on a test of distress level shortly after admission and failure to complete the MMSE on admission can help the clinician predict who will later engage in an assault.[8]
  5. The interrater reliability, temporal stability and factorial, convergent, discriminant and predictive validity of the Nurses Observation Scale for Inpatient Evaluation (NOSIE-30) were investigated in a heterogeneous group of psychiatric inpatients in the Netherlands (n = 179). Data in support of the scale's dimensional structure, discriminatory power and convergent validity are presented. Interrater reliability was satisfactory at global scale level. However, 3 subscales (irritability, psychosis and depression) were found to lack interrater reliability. Although temporal stability coefficients were high, large score changes are presupposed to show that pre- versus post therapy differences are attributable to real change rather than error. NOSIE-30 had limited predictive value [9].
  6. In a methodological study positive and negative a priori symptom scales were operationalized with the BPRS and the NOSIE. Acutely and consecutively admitted psychiatric patients (N = 247) were rated with these scales. Research questions dealt with the psychometric properties of the scales. It was found that the positive symptom scales had sufficient internal consistency; the negative scales did not. Diagnostic groups could be distinguished better with the positive symptom (PS) than with the negative symptom (NS) scales. The outcome of this research suggests that the positive and negative symptoms distinction is less meaningful in cross-sectional research, in which acute patients are rated, than in longitudinal research.[10]
  7. The predictive value of the NOSIE, a ward behaviour rating scale, was investigated in a group of long-stay patients. After a follow-up period of 3 1/2 years, it was found that all NOSIE scales differentiated continuing in-patients from those discharged. Regression analysis showed that age and florid psychoticism carried most predictive weight.11
  8. The relation between the NOSIE (Nurses' Observation Scale for Inpatient Evaluation) and the BOP (Dutch version of the Stockton Geriatric Rating Scale) was studied in a psycho-geriatric sample. The results supported the hypothesis of a trans-cultural difference in the use of the NOSIE. Dutch nurses subsume personal neatness under social competence. Anglo-Saxons do not. The factor solution of the NOSIE, with the exception of the depression factor, was comparable with earlier Dutch research, and was interpreted as support for the notion, that the NOSIE is a reliable observation scale. The correlation between factor scales of the NOSIE and the BOP were significant, but of moderate range. This was taken to mean that there is limited convergent validity between the NOSIE and the BOP. A high correlation was found between the infirmity scale and other subscales of the BOP. The BOP as well as the NOSIE were able to purposefully distinguish diagnostic groups when an external criterion or mixed criteria were used. It was concluded that both the BOP and the NOSIE may supplement each other in psycho-geriatric research practice.[12]
  9. Twelve Token Economy patients rated by nine staff members were followed for 1 year. Patients discharged within a year after the NOSIE-30 was administered had higher scores on Social Competence, Personal Neatness, Total Positive Factors, Total Patient Assets and a lower score on Total Negative Factors than patients who remained hospitalized. There were higher interrater reliabilities on subscales such as social competence, neatness, and irritability, and less agreement on subscales such as manifest psychosis and social interest. Sex differences found in the raters' perception of a patient behaviour indicated that male raters tend to be more tolerant of a patient's negative behaviours. Results suggest that the NOSIE-30 may have predictive utility. The NOSIE-30 can be a useful tool in staff training and in patient evaluation with a multidisciplinary approach[13].
  • Nurses' observation scale for inpatient evaluation is a reliable, easy-to-use tool for measuring patient's progress in hospital and in-patient facilities.
  • NOSIE has undergone extensive psychometric testing in various setting and is found to be reasonably valid and reliable.
  1. Honigfeld G, Gillis RD, Klett CJ. Nurses' observation scale for inpatient evaluation: a new scale for measuring improvement in chronic schizophrenia. J Clin Psychol.1965;21, 65-71.
  2. Honigfeld G, Gillis RD, Klett CJ. NOSIE-30: A treatment-sensitive ward behavior scale. Psychol Rep. 1966; 19, 180-182.
  3. Sajotovic M, Ramirez L. Rating scales in mental health. Lexi-Comp, Hudson, 2003.
  4. Philip A E. A note on the nurses’ observation scale for inpatient evaluation. Brit. J. Psychiat. 1973; 122, 593-6
  5. Reynalds W, Cormack D & Hall. Assessment in psychiatric and mental health nursing,1990).
  6. Margari F, Matarazzo R, Casacchia M, Roncone R, Dieci M, Safran S, Fiori G, Simoni L; The EPICA Study Group.Italian validation of MOAS and NOSIE: a useful package for psychiatric assessment and monitoring of aggressive behaviours. Int J Methods Psychiatr Res. 2005;14(2):109-18
  7. Lyall D, Hawley C, Scott K.Nurses' Observation Scale for Inpatient Evaluation: reliability update. J Adv Nurs. 2004 May;46(4):390-4
  8. Swett C, Mills T.Use of the NOSIE to predict assaults among acute psychiatric patients. Nurses' Observational Scale for Inpatient Evaluation. Psychiatr Serv. 1997 Sep;48(9):1177-80.
  9. Hafkenscheid A.Psychometric evaluation of the Nurses Observation Scale for Inpatient Evaluation in The Netherlands. Acta Psychiatr Scand. 1991 Jan;83(1):46-52
  10. Dingemans PM.The Brief Psychiatric Rating Scale (BPRS) and the Nurses' Observation Scale for Inpatient Evaluation (NOSIE) in the evaluation of positive and negative symptoms. J Clin Psychol. 1990 Mar;46(2):168-74.
  11. Philip AE.Prediction of successful rehabilitation by nurse rating scale. Br J Psychiatry. 1979 Apr;134:422-6.
  12. Dingemans PM, Bleeker JA, Bakker-Winnubst M, Frohn-de Winter ML.[Comparison between 2 behavior observation scales in psychogeriatrics. A closer look at the NOSIE and the BOP]  Gerontol Geriatr. 1983 Dec;14(6):223-30.
  13. McMordie WR, Swint EB. Predictive utility, sex of rater differences, and interrater reliabilities of the NOSIE-30. J Clin Psychol. 1979 Oct; 35(4):773-5.
Nurses’ Observation Scale for Inpatient Evaluation (NOSIE=30)
Name _____________________________ Age/Sex __________  
Hosp. No:____ Date________ Time_____ AM/PM   
Current Medical illness: ______________Duration of illness: _____
No. of Hospitalization: _______________Date of Discharge: _____
Final Diagnosis: ____________________Occupation: ___________
Education (in years)________________ Family History: ________
1.      Is sloppy.                                                                                 0__ 1__ 2__ 3__ 4
2.      Is impatient.                                                                             0__ 1__ 2__ 3__ 4
3.      Cries.                                                                                      0__ 1__ 2__ 3__ 4
4.      Shows curiosity and interest in activities around him/her.   0__ 1__ 2__ 3__ 4
5.      Sits, unless directed into activity.                                          0__ 1__ 2__ 3__ 4
6.      Gets angry or annoyed easily.                                                0__ 1__ 2__ 3__ 4
7.      Hears things that are not there                                               0__ 1__ 2__ 3__ 4
8.      Keeps his/her clothes neat.                                                    0__ 1__ 2__ 3__ 4
9.      Tries to be friendly with others                                               0__ 1__ 2__ 3__ 4
10.  Becomes upset easily if something doesn’t suit him/her.      0__ 1__ 2__ 3__ 4
11.  Refuses to do the ordinary things expected of him/her.         0__ 1__ 2__ 3__ 4
12.  Is irritable and grouchy.                                                          0__ 1__ 2__ 3__ 4
13.  Has trouble remembering.                                                      0__ 1__ 2__ 3__ 4
14.  Refuses to speak.                                                                    0__ 1__ 2__ 3__ 4
15.  Laughs or smiles at funny comments or events.                    0__ 1__ 2__ 3__ 4
16.  Is messy in his/her eating habits.                                           0__ 1__ 2__ 3__ 4
17.  Starts up a conversation with others                                      0__ 1__ 2__ 3__ 4
18.  Says he/she feels blue or depressed                                     0__ 1__ 2__ 3__ 4
19.  Talks about his/her interests.                                                   0__ 1__ 2__ 3__ 4
20.  Sees things that are not there.                                                  0__ 1__ 2__ 3__ 4
21.  Has to be reminded what to do.                                                0__ 1__ 2__ 3__ 4
22.  Sleeps, unless directed into activity.                                       0__ 1__ 2__ 3__ 4
23.  Says that he/she is no good.                                                    0__ 1__ 2__ 3__ 4
24.  Has to be told to follow hospital routine.                                 0__ 1__ 2__ 3__ 4
25.  Has difficulty completing even simple tasks on his/her own 0__ 1__ 2__ 3__ 4
26.  Talks, mutters, or mumbles to him/her.                                    0__ 1__ 2__ 3__ 4
27.  Is slow moving or sluggish.                                                     0__ 1__ 2__ 3__ 4
28.  Giggles or smiles to him/herself for no apparent reason.         0__ 1__ 2__ 3__ 4
29.  Is quick to fly off the handle.                                                      0__ 1__ 2__ 3__ 4
30. Keeps him/herself clean.                                                            0__ 1__ 2__ 3__ 4
Rater’s Signature________________


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