Korean hospice nursing interventions using the Nursing Interventions Classification system: A comparison with the USA

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<ul><li><p>Research Article</p><p>Korean hospice nursing interventions using the NursingInterventions Classification system: A comparisonwith the USA</p><p>Sung-Jung Hong, PhD, RN1 and Eunjoo Lee, PhD, RN21Department of Nursing, Semyung University, Jecheon and 2College of Nursing, Research Institute of Nursing Science,Kyungpook National University, Daegu, Korea</p><p>Abstract In this study, nursing interventions used by hospice nurses in Korea were identified and compared with coreinterventions selected by US end-of-life care nurses in order to determine similarities and differences betweenthe two nations regarding such care. Data were collected from the electronic medical records of 353 hospicepatients admitted to a tertiary hospital in Korea over a period of two years. First, extracted narrativeinterventions were mapped onto the Nursing Interventions Classification for comparison with interventionsselected by nurses in the USA. A total of 56,712 intervention statements were mapped onto 147 NursingInterventions Classification interventions. Hospice nurses in Korea performed more nursing interventions inthe physiological basic domain, compared to nurses in the USA. The most frequently-used interventions inKorea were related to patient pain management. Among 47 core Nursing Interventions Classification inter-ventions used in the USA, only 18 were used by Korean nurses in this study. This study highlights culturaldifferences in hospice care nursing interventions between the two countries.</p><p>Key words end of life care, hospice nurse, hospice nursing practice, Nursing Interventions Classification.</p><p>INTRODUCTION</p><p>Although nurses have always been an integral part of thehealthcare system, and often provide important direct care,their contributions have largely been invisible, becausenursing notes are narrative with an understructured format;therefore, aggregation and analysis are difficult (Bulecheket al., 2008). In addition, important information regardingnursing care has been underrepresented in communicatinghealthcare data, research, and education. Therefore, there isa pressing need to identify core, essential data and to thenperform systematic collection of that data in an easily-retrievable and comparable format that can be incorporatedinto national databases in the nursing profession (Delaney &amp;Huber, 1996).</p><p>Standardized nursing languages (SNL) were launched inorder to meet this need, and currently, the American NursingAssociation recognizes terminologies for a nursing practiceinformation infrastructure (ANA, 2008). One of the SNL, theNursing Interventions Classification (NIC), is a comprehen-sive standardized classification of interventions performed</p><p>by nurses; its purpose is to assist in efforts to describe theuniqueness of nurses compared with other healthcare pro-viders, and to articulate their contributions to the health ofpatients (Bulechek et al., 2008). To date, the NIC has beenimplemented in nursing information systems at national, aswell as international levels in order to describe and capturethe interventions performed by nurses (Haugsdal &amp; Scherb,2003). Recent studies using the NIC in Korea were conductedin diverse nursing practice care settings (Oh et al., 2001; Yonget al., 2001; Kwon &amp; Park, 2002; Lee &amp; Park, 2002; Oh &amp;Park, 2002; Choi et al., 2003; Park &amp; Jung, 2005; Cho &amp; Kim,2008; Hong et al., 2011). All of these studies reportedthat the NIC is applicable for use in describing nursingpractice in Korea. However, the NIC has not been used byhospice nurses.</p><p>Cancer, the number one cause of adult death in Korea,imposes an enormous emotional and financial burden onKorean society, and the number of cancer patients is rapidlyincreasing. Because of this trend, a special law to finance andprovide reimbursement for cancer treatments was passed bythe Korean legislature in 2006 (Yong et al., 2006). In addition,in response to social pressure to improve the quality ofnursing care for hospice patients, a specialized program wasdeveloped for hospice nurses at the master level in 2004 (Ohet al., 2007). Thus, hospice and end-of-life care are receivingsignificant interest and attention in Korea (Kyung et al.,2010).</p><p>Correspondence address: Eunjoo Lee, College of Nursing, Research Institute ofNursing Science, Kyungpook National University, 101 Dongin-dong, Jung-gu, Daegu700-422, Korea. Email: jewelee@knu.ac.krReceived 12 March 2013; revision received 13 November 2013; accepted 24November 2013</p><p>bs_bs_banner</p><p>Nursing and Health Sciences (2014), , </p><p> 2014 Wiley Publishing Asia Pty Ltd. doi: 10.1111/nhs.12120</p><p>mailto:jewelee@knu.ac.kr</p></li><li><p>Given these developments, the identification of NIC inter-ventions for hospice nursing will be valuable. These data willprovide empirical evidence to guide practice decisions thatwill promote high-quality hospice nursing care outcomes andeffectiveness (Lunney, 2006). The data will also be helpful tohospice nurses in describing the work they perform, so thatthe contribution of nursing care can be measured and valued.In addition, the identification of NIC interventions forhospice nursing in Korea to compare with those of othercountries, will be helpful in the effort to understand patternsof nursing interventions. This is a step toward the identifica-tion of culturally-sensitive care in hospice nursing in Korea.</p><p>The purposes of the study were: (i) to identify interven-tions performed by hospice nurses in Korea and then to mapthem onto NIC interventions; (ii) to compare NIC interven-tions performed by Korean nurses with NIC interventionsselected by members of the American End of Life CareNursing (AELCN) organization. Through this process, wewill be able to identify similarities and differences in nursinginterventions between Korean hospice nurses and AELCNnurses.</p><p>Background</p><p>NIC</p><p>The current healthcare system demands data and informa-tion on how effectively and economically healthcare profes-sionals contribute to health and quality-of-life of patients.Nurses must demonstrate which interventions in their prac-tice provide the most cost-effective and efficient health carecompared to interventions by other healthcare professionals(Simpson, 2003). However, without describing what nursesdo and studying ways to make nursing more cost-effectiveand efficient, that is not possible (Johnson et al., 2005). Beingable to describe these nursing interventions in a standardizedlanguage is a first step.</p><p>Prior to the development of the NIC, there was no stand-ardized classification and coding system for describing treat-ments administered by nurses. The project was initiated in1987, with the aim to assist in efforts to describe the unique-ness of nurses compared with other healthcare providers(Bulechek et al., 2008). It has been continuously updated andrevised with ongoing feedback and review from clinicalnurses and researchers in all settings. The sixth edition, pub-lished in 2013, includes more than 12,000 activities, which aregrouped into a three-level taxonomy for ease of use: sevendomains, 30 classes, and 554 interventions.The seven domainsare physiological basic, physiological complex, behavior,safety, family, health system, and community (Bulechek et al.,2013).</p><p>The NIC has been linked with nursing diagnoses and out-comes developed by the North American Nursing DiagnosisAssociation and Nursing Outcomes Classification, respec-tively (Moorhead et al., 2008). As a multidisciplinary view,the NIC is mapped onto SNOMED CT, a comprehensivehealthcare reference terminology that provides a frameworkfor the integration of concepts and languages from otherhealthcare disciplines (Campbell et al., 1997; SNOMED CT,</p><p>2002). These linkages facilitate the understanding and usageof nursing languages by diverse health professionals, and theyenhance interoperability among healthcare professions(Zollo &amp; Huff, 2000; Zeng et al., 2002).</p><p>The NIC has been adopted by hundreds of healthcareorganizations, and used in care plans, competency evalua-tions, and nursing-education programs. It has been translatedinto 12 different languages, including Korean, and has beenused in many countries, including Brazil, Canada, Denmark,England, France, Germany, Iceland, Japan, Korea, Spain,Switzerland, and the Netherlands (Bulechek et al., 2013).Although using standardized language to identify andcompare nursing interventions and their effects on patientoutcomes is at an early stage at the international level, it willbe studied more actively in the near future.</p><p>Nursing care quality and SNL</p><p>Electronic health record (EHR) systems are being imple-mented worldwide, with the goal being that their use will leadto improved quality and reduced medical costs (Park &amp;Hardiker, 2009). EHR enable nurses to provide virtual docu-mentation of the core nursing elements in the nursing infor-mation system and store them in databases. To achieve thesegoals, standardized classifications with coding systems withinthe EHR are a key and fundamental factor, because they canfacilitate the capture, storage, and retrieval of clinical infor-mation in documentation systems and databases (Haugsdal&amp; Scherb, 2003).</p><p>By collecting data and using databases in informationsystems, nurses can systemically analyze the treatments theyperform and the resulting patient outcomes, and can identifywhich interventions work best for a given population ofpatients or set of problems.This will improve nursing care forspecific populations, and the nursing profession will gain rec-ognition for its contribution to patient outcomes.</p><p>Nurses need to use databases for the systemic collectionand analysis of patient diagnoses, nursing interventions, andthe resulting patient outcomes. Based on this information,they can determine which nursing interventions work best fora given group of diagnoses or a population. By doing this,nursing research will be energized, and can effectively influ-ence the decision-making about nursing-related healthcarepolicies (Plowfield et al., 2005).</p><p>The Hospice model in Korea</p><p>Hospice nursing in Korea was started in 1965 by Catholicnuns, and the first hospice educational program for nurseswas started in 1979 (Kang, 2010). Most hospitals in Koreaprovide hospice care to terminally-ill patients in an effort tohelp control their pain and symptoms, or for those whosefamily members are exhausted or in crisis and in need ofrespite. In the main in Korea, hospice care is delivered usingone of the following four models: (i) the hospice unit withina hospital model; (ii) the inpatient scattered-bed consultativemodel; (iii) the free-standing model; or (iv) the hospicehome-care model (Lee et al., 2008).</p><p>2 S-J. Hong and E. Lee</p><p> 2014 Wiley Publishing Asia Pty Ltd.</p></li><li><p>Of the hospice care provided for inpatients (iiii), thehospice unit within a hospital and the inpatient scattered-bedconsultative models (i and ii) are used for patients who havealready been admitted to a hospital and are dying. In hospiceunits within a hospital, care is usually provided by certifiedhospice nurses, or nurses who have advanced training inhospice care. Inpatient scattered-bed consultative care is pro-vided by a team of nurses who specialize in hospice care.Admission to one of these units is dependent on bed avail-ability in the hospital. The free-standing hospice model (iii)provides hospice care through an independently-ownedhospice center, and might include both home hospice servicesand an inpatient care facility. The inpatient facility provideshospice care for patients who require medical services notsuitable for a home setting. In the hospice home care model(iv), care is provided in a patients home. The type of hospicecare services provided depends on the patients needs andpreferences. Most home care agencies and independently-owned hospice programs offer home hospice services.Although a nurse provides specialized nursing care for aterminally-ill patient in a home hospice program, the maincaregiver is usually a family member of the patient. Somefamily members are trained by the nurse to provide much ofthe hands-on care to the patients (Lee et al., 2008).</p><p>METHODS</p><p>Research design and participants</p><p>This study used a descriptive design to identify the natureand types of nursing interventions performed by nurses in ahospital hospice unit. Data were collected from the electronicnursing records of 353 hospice patients who were admitted toa tertiary hospital, and were either discharged or died follow-ing end-of-life care between January 2009 and December2010.</p><p>Instrument</p><p>NIC</p><p>The instrument used in this study was based on the fifthedition of the NIC (Bulechek et al., 2008), which is catego-rized according to seven domains, 30 classes, and 542 inter-ventions; each intervention has its own definition and uniquenumeric code.</p><p>Core intervention list of the AELCN</p><p>The development of the AELCN core interventions listwas performed by the Iowa Interventions Project Team(Bulechek et al., 2008). The AELCN core intervention listwas developed and finalized based on input, discussion, andfeedback from members of the AELCN, and then carefullyreviewed by the project investigators and staff of the IowaInterventions Project. Members of the AELCN identified 46interventions as core interventions.</p><p>Human participants</p><p>Kyungpook University Hospital institutional review boardapproval was obtained prior to the collection of the studydata. In addition, the purposes and procedures of thestudy were reviewed by the administrative office, andapproved by the hospital where the data were collected.The purpose of the study was also explained to the directorof the nursing department of the hospital. The patientshad already given their consent, because all patients admit-ted to the hospital provide informed consent for use oftheir de-identified demographic, diagnostic, and treatmentinformation recorded in electronic medical records inresearch. This consent process has been required by medicallaw for every inpatient throughout Korea since September2011.</p><p>Data collection</p><p>Data were downloaded from the electronic nursing docu-mentation system of the hospice care unit of KyungpookUniversity Hospital, with encryption of patients personalinformation, and compiled in an Excel file. Kyungpook Uni-versity Hospital, a tertiary hospital located in Daegu, SouthKorea, contains more than 850 beds. This hospice unit, whichwas established as a hospital-based hospice service in April2009 as a way to provide the best possible quality of life forterminally-ill patients, serves as a model for tertiary and otherhospitals, due to governmental efforts to develop a nationalhospice system in Korea.</p><p>All documented nursing statements were extracted andcategorized according to nursing assessments, nursing diag-noses, nursing outcomes, and nursing evaluations, and thenaccording to the meaning of each statement within each ofthese categories. A total of 140,369 nursing statements wereextracted, 56,712 of which were related to interventions oractivities only. These statements were used in this study. Theselection of statements on nursing in...</p></li></ul>

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