Quality Evaluation on Traditional Chinese Medicine Nursing Plan for Stroke in Acute and Recovery Phases

Li Xuejing (李学靖), Zhang Xiaoyan (张小艳), Ma Jingya (马睛雅), Yan Lijiao (晏利姣),Wang Dou (王 斗), Wang Jinfang (王晋芳), Hao Yufang (郝玉芳)

School of Nursing, Beijing University of Chinese Medicine, Beijing 102488, China; Canadian Ontario Nurses Association BPSO Branch; JBI Excellence Cooperation Center

ABSTRACT OBJECTIVE: To formulate the quality evaluation questionnaire of Traditional Chinese Medicine (TCM) nursing plan for stroke in acute and recovery phases, and to evaluate the quality of TCM nursing plan for stroke by clinical nurses. METHODS: The questionnaire was designed by referring to the Applicability Questionnaire of TCM Clinical Diagnosis and Treatment Guideline, and the expert consultation was used to assess the content validity. In addition, the results of the questionnaire were processed and analyzed with SPSS20.0 software. RESULTS: The content validity of the self-designed questionnaire was 0.94 for the S-CVI/Ave score. The results of the questionnaire demonstrated that the overall content of the plan was "better than the original routine nursing plan" (59.18%); the recognition degree of"common symptoms" (36.70%) and "syndrome classification" (36.70%) of the plan was the lowest. CONCLUSION:The plan is supposed to be further improved in the future in order to be coincident with clinical reality.

KEYWORDS: Stroke; Traditional Chinese medicine nursing plan; Questionnaire; Quality evaluation; Clinical application status

A survey conducted by World Health Organization(WHO) has demonstrated that the incidence of stroke in China ranks first in the world[1], and ischemic stroke(also known as cerebral infarction) accounts for 85%. In China, stroke has become a leading cause of death and disability[2]. With the promotion of Traditional Chinese Medicine (TCM) nursing technique, the characteristics and effects of TCM nursing are gradually affirmed[3], as TCM having the advantage of treating stroke. At present,TCM care for patients with stroke in a nation-wide TCM hospital generally follows two TCM clinical care plans(hereinafter referred to as the plans) for stroke (cerebral infarction) during the acute and recovery phases[4]. These two plans are similar to the clinical practice guidelines.In clinical application of the plans, it was found that there was a lack of qualitative and quantitative descriptions of TCM nursing techniques in the plans[5-6], leading to poor operability. The plans failed to report the source of evidence and quality of the recommendations[7].Furthermore, it was the quality of the plans that directly poses impacts on the clinical application and development

of the theory with TCM characteristics and technique of TCM nursing[8]. The evaluation of the plans' qualities is able to comprehensively and timely find problems of plans so as to adjust it as soon as possible, which promotes the successful clinical practice of existing theory and technique of TCM nursing. As direct users of the plans, the quality of the plans and the gap between the plans' quality and clinical practice are directly reflected from clinical front-line nurses in TCM hospitals[9].Therefore, this study proposes to formulate a quality assessment questionnaire related to the TCM care plans of stroke, and also to evaluate nurses.

DEVELOPMENT OF INVESTIGATION TOOLS

Basis for the development of investigation tools

At present, there are no investigation tools about the quality evaluation of TCM nursing plans. Two basic reference books for the formulation process have been founded during collecting and organizing the background information of the plan's development. One is TCM Clinical Diagnosis and Treatment Plan (abbreviated as the treatment plan) issued by the State Administration of Traditional Chinese Medicine in terms of content and format, and a matched book named Clinical Route of TCM(abbreviated as the clinical route). In terms of content, the above-mentioned treatment plan is referred with another one that is Regulations on TCM Nursing Operations issued by China Association of Chinese Medicine in 2006.

The Questionnaire for the Applicability of the Guidelines for Clinical Practice of Traditional Chinese Medicine is included in the guideline for diagnosis and treatment. The format of the questionnaire is consistent with the format of the guidelines for diagnosis and treatment.The investigation content is the quality assessment of guidelines for the diagnosis and treatment. Therefore, a survey tool for this study was developed on the basis of The Questionnaire for the Applicability of the Guidelines for Clinical Practice of Traditional Chinese Medicine. Besides,the questionnaire was adjusted according to the actual content of the plan. The self-designated questionnaire was named as Quality Assessment Questionnaire of TCM Nursing Plan. The questionnaire was divided into two parts: the basic information and the investigation part. The investigation part was further divided into four dimensions,28 items in total, which were familiarity of the nursing staff with the plan (1), content evaluation of the plan(2-11), evaluation of clinical application of the plan(12-25) and suggestions (26-28). Among them, 2-25 items were score questions, which were rated on a 7-point scale(1- extremely poor to 7- excellent). Other questions were for multiple choice questions. Descriptive analysis was performed on the scores of each item when analyzing the results. The total scores in each domain and the total score of the scale were not analyzed in this study.

CONTENT VALIDITY OF THE QUESTIONNAIRE

The evaluation method of content validity in this study was the expert consultation method. The relevant experts are invited to make judgments on the degree of coincidence (correlation) between the scale items and the scope of the original content following by the calculation of the content validity index from the collected data in order to judge the content validity of the questionnaire.According to Davis's requirement for content validity of more than 5 experts[10], a total of 7 experts were included(see Table 1 for the basic information of experts).Besides, 7 questionnaires from experts were returned.Therefore, the positive coefficient of experts was 100%.Except for one expert, the personal authority coefficient of other experts was greater than 0.70, and the overall authority coefficient of experts was 0.74 (see Table 2 for the expert authority coefficient). Thus, the result of the expert consultation was credible. The scores of content validity of each item (I-CVI) were all above 0.86.Additionally, the content validity of the calculation level of questionnaires S-CVI/Ave scored 0.94. It can be seen that the self-designed questionnaires were of good content validity (see Table 3 for the expert content validity of each expert (I-CVI)).

Table 2. Expert authority coefficient

INVESTIGATION METHODS

Survey targets: 49 clinical nurses working in encephalopathy department from 9 Class A tertiary hospitals in Beijing.

Table 1. Basic information of experts

Table 3. Plan's quality and application questionnaire expert content validity I-CVI

Inclusion criteria: ① with practice experience of using TCM nursing plan for stroke in the acute and recovery period; ② clinical front-line registered nurses;③ over 3 years' working experience or obtained a bachelor degree or above; ④ informed consent; ⑤ be voluntary and has ability to cooperate in this study.

Exclusion criteria: nurses who are not working in surveyed hospitals.

Questionnaire process

This study was a subproject of a subject that has received ethical approval from university. Investigators were members of the research team and were familiar with the way that questionnaires were filled out. Questionnaires were sent by researcher 1 to 1 after the informed consent was obtained. The respondents were required to fill in the questionnaires independently. In order to ensure the quality of the questionnaire, investigators were allowed to interpret the filling method when respondents were confused about that. The completed questionnaires were immediately numbered and put into the file for uniformly processed.

Questionnaire data processing

Two researchers except investigators independently organized and put data into Excel. After data were input and checked, it was imported into SPSS 20.0 for data processing. All data were processed by using descriptive statistics method.

RESULTS

Basic information of respondents

In this study, 49 questionnaires were distributed and 49 questionnaires were returned. The questionnaire returning rate was 100%. The basic information of the respondents was shown in Table 4.

Content evaluation of TCM nursing plan for stroke in acute and recovery phases

Score 6 and 7 were regarded as high recognition to the content of the plan when analyzing the survey data.The high recognition rates (high recognition rate=number of questionnaires with 6-7 scores each item/total number of questionnaire) of questionnaire's each item was performed. Table 5 demonstrated the results about the content evaluation of each part of TCM nursing plan for stroke in acute and recovery phases from clinic nurses.The evaluation of total content of plan was (sorted by high recognition rate): the overall TCM nursing plan for stroke in acute and recovery phases "was better than the original nursing routine of the unit" (59.18%) ＞ "was better than guidelines for specialist nursing" (48.98%) ＞ "was better than experience of nursing specialists" (48.98%) ＞ "was better than the latest clinic research achievements (46.94%).

Clinical implementation evaluation of TCM nursing plan for stroke in acute and recovery phases

Score 5-7 means that the implementation is applicable of TCM nursing plan for stroke in acute and recovery phases. Table 6 indicated the applicable rate(applicable rate of each item= number of questionnaires with 5-7 score/ total number of questionnaires).

Suggestions on TCM nursing plan for stroke in acute and recovery phases

The results of the survey have showed perspectives about the aspects that need to be improved in the plan.83.67% nurses thought that it was necessary to "improve the applicability of the plan". 30.61% nurses agreed to"improve the total level of the plan". The number of people who claimed to "improve the plan's quality" also accounted for 30.61%. As for suggestions, 55.10% people gave advice to "extend publicity", following with 48.98%people who suggest to "offer the development process of the plan and increase the nurses' credibility with the plan". 36.73% individuals voted to "increase evidences to improve the credibility of the plan".

Table 4. Basic information of respondents

Table 5. Evaluation of the contents of each part of the TCM nursing plan for stroke in acute and recovery phases

Table 6. Clinic applicable situation of TCM nursing plan for stroke in acute and recovery phases

DISCUSSIONS

The questionnaire did not set a definite value of score for each domain. It is impossible to judge the quality of the plan through scores.

As for research results, the quality evaluation was conducted by analyzing the proportion of people giving different scores for an item in Quality Assessment Questionnaire of TCM Nursing Plan. The quality assessment questionnaire was supposed to identify the merits and limitations of guidelines, comparing the quality of two plans and selecting a high-quality plan. However, there was no experimental data linking specific quality scores with specific implementation results or specific clinical outcomes until now.Therefore, it was challengeable to distinguish boundary values of high, medium and low quality. The following methods were proposed to set the boundary value of quality evaluation, consequently, identify the quality of the plan according to the updated domains' scores from AGREE II team in 2017.

(1) Priority domain: Determined by expert decisions or consensus, identify one domain that is prior to others.Thus, the boundary value can be established based on the priority domain's score. (For example, domain 3 is regarded as a priority area, and when its score is higher than 70%, then considering the plan is high quality).

(2) Staged evaluation: If a domain is considered more important than other domains, it is firstly used to assess the plan. Only after the evaluated plan achieved the boundary value (for example, higher than 70%), other domains are sequentially evaluated.

(3) Consider all domains' scores: Establish a unified boundary value for all domains through expert consensus or decision (for example, a plan with all domains' scores higher than 70% is regarded as high-quality plan), or set different boundary value for each domain.

Moreover, before starting to use the quality evaluation questionnaire of TCM nursing plan, any decision about quality boundary should be made by all stakeholders. The decision should be guided by contexts and the importance of different domains and items in this context.

The limited number of nurses in TCM hospital and the weak foundation of TCM theory

A total of 9 TCM hospitals in Beijing, which were representative and currently implementing TCM nursing plan were investigated. Each TCM hospital had only one department for stroke TCM nursing plan. Each department met the inclusion criteria for no more than 6 nurses. To a certain extent, it reflected the status of lacking high-level clinical nurses in TCM hospitals, which was consistent with WANG Yanmei's research result on senior nursing practice[12]. Therefore, this study has included a total of 49 nurses who were able to complete the quality assessment and put forward suggestions for improvement, providing reference value for the quality evaluation scores of stroke nursing plan. In addition, the general data of target population indicated that 73.47% nurses did not graduate from TCM universities, failing to study the knowledge and operation of TCM care, though young and highly educated were characteristics of high-level nursing staff in TCM hospitals. A research[13]has demonstrated that lack of understanding of TCM nursing techniques was a major problem in the clinical implementation of TCM nursing implementation. Therefore, it is possible to carry out training on TCM related knowledge based on the situation of the department while implementing the TCM nursing plan for stroke in acute and recovery phases.

There is low recognition of the plan from clinical nurses

According to the results of the quality evaluation of TCM nursing plan for stroke in acute and recovery phases, the recognition of the overall quality of the plan in perspective of clinical nurses was in the mid-to-lower level.The recognition of "common symptoms" and "classification of syndromes" was the lowest. As for the nursing plan,the classification of syndromes part did not belong to the category of nursing. Thus, it may not be listed as a part of the independent content of the plan. As for common symptoms, it should be combined with the symptoms what TCM was good at to count as common symptoms.

Clinical nurses believe that the plan is not consistent with existing work

According to the analysis of the clinical application situation of the TCM nursing plan for stroke in the acute and recovery phases of stroke, nurses thought that the plan has higher guiding value than the previous one. However,the recognition of matching the current clinical situation and the existing working mode is low. For example, a research[14]showed that the application of TCM nursing plan was likely to increase the actual workload of clinical nurses and thus limit the application of the plan. In addition, the survey also demonstrated that that the TCM nursing plan for stroke in acute and recovery phases had a low degree of recognition in terms of economy and convenience of clinical application. Some studies[5]suggested that the same problem. Because currently 50%of the TCM nursing techniques provided were free of charge, which decreased the nurses' motivations. On the other hand, another part of the fee cannot or partially be reimbursed because of medical insurance, which make patient reluctant to accept resulting in failure of popularize. All in all, TCM nursing plan for stroke in the acute and recovery phases needs to be implemented in a way that can be integrated with clinical work patterns and clinical practice situations, considering the economy and simplicity of clinical applications.

Nursing staff recommend optimizing the plan based on clinical practice and supplementing research results

From the perspective of nurses, it was the evaluation method of plan's application that mostly needed to be improved. Relevant quantitative evaluation indicators or supplementary evaluation tools were recommended to add. Most investigators believed that the most valuable result was "hospital-specific treatment plan" which was based on clinical practice, emphasizing the "feedback of first-line nurses". Therefore, clinical practice is the prerequisite for plan optimization. Besides, the highest advocacy of "increase of plan propaganda" reflected the fact that nurses do not understand the theoretical knowledge of TCM involved in the content of the plan and were not familiar with the process of formulating the plan. Meanwhile, more than one-third people believe that it is necessary to absorb and supplement existing scientific research results and high-quality experience to improve the quality of the plan. Thus, nurses recommended supplementing scientific research results to improve the quality and optimize it based on clinical practice.