| BACKGROUNDHome visiting aims to meet the health needs of the individual and family, and to offer regular professional health care that can improve their health status and the ability to using the community resources and self-care. Home visiting in Western countries has developed for a long time and has constructed a health protect system which consists of Community medical and hospital medical. It has become an important health service pattern. Also, all sorts of nursing assessment tools and the standardized nursing language have been developed to reduce the risk of home care services, and ensured the home care services to achieve a good economic and social benefits. But, home visiting is just beginning in our country. In fact, the current practice of visiting procedure is based on nurse personal empirical principles and experiences. The used assessment tables were designed by themselves, the descriptive record mode and the outcome of medical practice used in the documentation and the evaluation have not been scientifically organized. The situation of no a unified, standardized, nor quantifiable record mode, nor the system of outcome evaluation, has resulted in a lack of relative data to expound the benefit of home visiting and contributions to patients by nursing, while the value of nursing will be undervalued by the whole society, which, consequently, will influence the development of the home visiting. In addition, with the development of electronic information, the complex, unintuitive of descriptive records will prevent the possibility of the visiting nursing information from the community residents electronic health records. And with National hygiene regulations improving and National legal consciousness strengthen constantly, medical disputes caused by non-standard nursing records are increasing. So, according to the present situation of China's community, we urgently need a uniform, standardized model to improve and promote the development of visiting nursing.The Omaha System is one of the standardized language classification system in the United States, including problem classification scheme, intervention scheme and problem rating scale for outcomes. It is mainly used for community nursing, and provide a guidance and a method of effective evaluation for the community nurses and other community health workers to comprehensive assess and make intervention plan for patients. It is a communication platform of practice guidance, practice documentation, outcome evaluation and information management. It has been translated into various languages and has been developed many software to be used in many service agencies, such as public health departments, home health system, school health institutions and community clinics and so on. we can assess the patient's problems comprehensively, make the intervention plan pertinently, and assess the patients status at before and after the intervention by use the system. In addition, the application of the standardized language ensure the accuracy of the information recorded and also provide a possibility of information communication for different countries. In order to regulate and promote the development of China's community home visiting, it is necessary introduce the concept of Omaha System and the frame to make a record mode that suitable for China's community. But there are differences of culture and medical system between Chinese and western. In order to avoid the possibility of difficulties for application because of copying the abroad mode, the application feasibility study must be done before introduction, so that partial modification combining with reality status in the community can be achieved. So, to explore feasibility of the system used in our community, the research plan is to retrospectively analyze the nursing records by use the method of content analysis, and use cross mapping to examine the concept coincide degrees between Omaha System and nursing record. Then make a visiting procedure and a record mode and a method of effectiveness evaluation for our community application by using the results of retrospective analysis, the concept and the framework of Omaha System, and in the light of the guidance of the relevant theories as well. Lastly, we adopted the procedure and the record mode and the method of effectiveness evaluation to evaluate the effective of home visiting.OBJECTIVESTo develop a home visiting procedure and a record mode and a method of effectiveness evaluation that fit for community application based on the Omaha System. So as to provide a visiting guidelines and record platform for community nurses and other staff members of the community.METHODSPartⅠExploring the possibility of carrying out the Omaha System in Chinese communityThis study is a secondary analysis of data from records written by the visiting nurse to document the care provided to the patients in 2009. It used convenience sampling method to choose a community health service center and randomly selected 44 case records, which excluded those cases of people after parturition. Use content analysis method to extract sentences described symptoms/signs and interventions of visiting case records as a analysis unit. And then apply the cross-mapping method to examine the degree of match between the Omaha System item and every analysis unit. Use percentage to describe the degree of match between them.PartⅡApplication of the Omaha System to secondary analyze the visiting case recordsThis study is a secondary analysis of data from records written by the visiting nurses to document the care provided to the patients in 2005-2009. It used convenience sampling method to choose one community health service center, and randomly selected 178 case records, which excluded those cases of people after parturition, applying content analysis method to extract sentences describing symptoms/signs and interventions of visiting case records as an analysis unit used the framework and items of the Omaha System to classify the visiting records. All data were analyzed by SPSS 13.0 with using frequencies and percentage to describe patients' problems and interventions adopted by visiting nurse during the home visiting.PartⅢFormulating the home visiting procedure and recording mode and method of effectiveness evaluation based on the Omaha SystemThis part aims to formulate the home visiting procedure and recording mode and method of effectiveness evaluation according to the results of the secondary analysis data, and the concept and framework of the Omaha system, and some other relevant theories.PartⅣApplication of the home visiting procedure and recording mode and method of effectiveness evaluationI chose some patients who moved from a hospital in Guangdong province to the community center of medical service during the period from January to April 2010. With the serving numbers of random select by computer,60 patients with Stroke, Hypertension, Diabetes were engaged in the study,20 for each category, and 58 of them were utility (a case of Stroke patient died and a case of Diabets patient lost). According to the home visiting procedure and the nursing schemes, we visited these patients, and used the assessment form and the record chart to evaluate the patients' status and document the care provided to the patients during the home visiting, and applying the evaluation criteria of home visits to assess the patients' problems before and after the intervention. Every patient will be visited three times and the knowledge, behavior and status of the patients' problems through this period will be evaluated and scored. All data were analyzed by SPSS 13.0. Descriptive statistical analysis was used to analyze baseline data, the problems and the intervention targets between the three chronic patients above.χ2 test was used to evaluate baseline condition. Kruskal Wallis H test was used to evaluate the difference of the intervention targets provided to the three groups during the home visiting. Friedman M test was used to evaluate variance effect of the different time.RESULTSPartⅠExploring the possibility of carrying out the Omaha System in Chinese community1.80% of the retrospective data describe symptoms and signs of patients, they perfectly match with the Omaha problem classification system in terms of concepts, 19.3% partly match, and 0.7% not.2. In the retrospective data,85.8% of interventions were perfect match with the interventions targets of Omaha System in concepts.13.4% partly match,0.8% not.PartⅡApplication of the Omaha System to secondary analyze the visiting case records 1. In the retrospective data,61.6% of patients were diagnosed as chronic disease. Among these. the percentage of patient problems in the environmental domain were 37%; The percentage of patient problems in the psychological domain were 28.7%; The percentage of patient problems in the physiological domain were 99.4%; The percentage of patient problems in the health related behaviors domain were 68.1%.2. In the retrospective data, The most frequent intervention categories was teaching, guidance, and counseling(94.3%), followed by surveillance(70.70%), treatments and procedures(66.80%), and case management(13.40%). The most frequent intervention targets were dietary management(80.9)%, symptoms/signs-physical (67.9), exercises (65.2%)3. In the retrospective data, the Omaha System could cover all the patients' problems and interventions adopted by the nurses. four problems of environmental and psychological domain which were not described in the records, and thirty-one intervention targets that were not applied in the records.PartⅢFormulating the home visiting procedure and recording mode and method of effectiveness evaluation based on the Omaha System1. Established a home visiting evaluation sheet, including problem assessment and problem evaluation.2. Established a home visiting nursing record sheet, which records from four domains that consists of environmental, social psychology, physiology, medicine and treatment.3. Established an evaluation sheet of home visiting effectiveness, which adopt 5-point Likert score for 37 problems from Knowledge, Behavior, Status, and scores based on a simple example.4. Established a home visiting flowchart and an implementation plan.PartⅣApplication of the home visiting procedure and recording mode and method of effectiveness evaluation1. In this part, the most common problems of the patients are related with the physical, followed by the health-related behaviors. The most frequent problems were' nutrition (84.5%), circulation (77.6%), medication regimen(75.9%).Nutrition, circulation, vision, oral health, communication with community resources, medication regimen, health care supervision were the common problems of patients with chronic diseases.2. In this part, there were no significant differences in the interventions categories among the three groups.The intervention targets provided to the different group were generally same. In the different visiting time, the most frequent intervention targets provided to the patients with Stroke were medication administration, symptoms/signs- physical, dietary management and so on, the most frequent intervention targets provided to the patients with Hypertension or Diabetes were symptoms/signs- physical, medication administration, medication effects/side effects and so on.3. The effectiveness of home visiting in the environmental domain:The patients showed significant differences in Knowledge and Behavior score related to Residence (P<0.001), Scores of status increased after visiting intervention but had no significant differences (p>0.05). The patients exhibited significant differences in Knowledge score related to Income(P=0.001), no significant differences in Behavior and Status score(P>0.05), but the scores of income Status decreased with the extension of duration of disease. The K-B-S scores related to Sanitation and neighborhood/workplace safety gradually increased after home visiting, but no significant differences except the Knowledge related to Sanitation.4. The effectiveness of home visiting in the psychological domain:The patients exhibited significant differences in K-B-S score related to communication with community resources (P<0.001).The K-B-S score related to Social contact, Interpersonal relationship, Mental health changed with the increase of home visiting time, but on significant differences.5. The effectiveness of home visiting in the physiological domain:The K-B-S score related to the patients'problems changed with the increase of home visiting time. The patients exhibited significant differences in K-B-S score related to Pain,Neuro-musculo-skeletal, Circulation, Bowel function (P<0.05); The patients exhibited significant differences in K-B score related to Vision, Oral health, Digestive-hydration, Urinary function (P<0.05), but no significant differences in the changes of the Status scores (P>0.05);The patients exhibited significant differences in Knowledge score related to Speech and language, Respiration (P< 0.05), but no significant differences in the change of the Behavior and Status score (P>0.05). The patients exhibited significant differences in B-S score related to Skin (P<0.05), but no significant differences in the change of the Knowledge score (P>0.05)6. The effectiveness of home visiting in the health related behaviors domain:The K-B-S score related to the patients' problems changed with the increase of home visiting time. The patients exhibited significant differences in K-B-S score related to Nutrition, Physical activity, Personal care, Health care supervision, Medication regimen (P<0.05), and exhibited significant differences in K-B score related to Sleep and rest patterns, Substance use (P<0.05),but no significant difference in the change of the Behavior score (P>0.05)CONCLUTIONS1. The study confirms that the Omaha System has items and entries matching with the nursing records with a high degree, and we can employ it as standardized language of community visiting nursing in China's mainland. 2. This study demonstrates that the Omaha System can cover common problems of patients and interventions adopted by nurses. But the system should make some changes according to our community status.3. The application of the home visiting procedure and recording mode can standardize the visiting nursing and quantify the visiting effectiveness. |
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