Description of COVID-19 patients and mapping nursing data to ICNP 2021 reference set in SNOMED CT

INTRODUCTION

When the COVID-19 pandemic started, and the patients were admitted to hospitals, their problems and needs were unknown to nurses. Nurses faced seriously ill patients that needed nursing care, which was a challenge. Recommendations from the World Health Organization (WHO) on clinical management were published on 12 January 2020. The symptoms identified earlier were fever, cough, sore throat, nasal congestion, malaise, headache or muscle pain, and those with more severe symptoms developed dehydration, pneumonia, sepsis or shortness of breath (World Health Organization, 2020).

The first patient diagnosed with COVID-19 in Iceland was hospitalised on 28 February 2020. In the so-called first wave of the pandemic, which is defined as being from 28 February to 30 June, 1,810 confirmed COVID-19 infections were detected (Directorate of Health and The Department of Civil Protection and Emergency Management, 2020). Iceland was a nation with a population of close to 370,000 in the year 2020 (Statistic Iceland, 2022). It has universal healthcare, and 85% of financing comes through taxes. Health status is high as life expectancy was 83.07 years in 2021 (World Population Review, 2022). Nursing education is on a baccalaureate level and is in accordance with requirements made by the European Union (EU) and the European Federation of Nurses Association (EFN) Competency Framework. Icelandic nurses are responsible for diagnosing and planning nursing care based on evidence and clinical experience, using standardised nursing language (EFN, 2015; EU Council Directive, 2013). For years, NANDA–International and Nursing Interventions Classification (NIC) were used in education and clinical practice. They have not been updated for more than 15 years or since the Icelandic Directorate of Health decided that nurses in all health institutions in Iceland should use International Classification for Nursing Practice (ICNP®), which was developed by the International Council of Nurses (ICN) and is one of the WHO-related classifications, to document nursing care (Directorate of Health, 2021).

METHODS

RESULTS

The total number of patients admitted to the NUH in Iceland was 91, or 91% of all patients admitted to hospital during the first wave of COVID-19 (5.03% of those diagnosed with COVID-19 in Iceland). Admissions of men (n = 56) were more prevalent than of women (n = 35), just over 60%. The mean age of the patients was 62.6 years, standard deviation 13.24, median 64, mode 60 and range 21–88. The mean length of stay was 9.7 days (men 9.7 days and women 9.6), standard deviation 8.89, median 6, mode 1 and range 1–35 days. The biggest age group was patients between 60 and 69 years of age and mean length of stay increased with higher age. See Table 1.

To document nursing care of the COVID-19 patients, nurses used 62 different nursing diagnoses and 79 interventions. The ten most frequently used nursing diagnoses and interventions are reported in Table 2. Nursing diagnoses and interventions used by nurses in Iceland for COVID-19 patients were best represented by SCT (85.4%; 100%), then by ICNP 2019 version (79.2%; 85%) and least by ICNP 2021 reference set (70.8; 83.3%). Ten nursing diagnoses did not have a match in the ICNP 2021 reference set: Alteration in blood sugar, impaired consciousness, ineffective/risk for ineffective perfusion to heart and lungs, insomnia, risk for bleeding, risk for fluid deficit, risk for fluid imbalance, risk for increased blood sugar, and risk for irregular heartbeat. Five nursing diagnoses available in ICNP 2019 were not found in ICNP 2021: impaired consciousness, infection/risk for, insomnia and self-care deficit. All nursing interventions had a match.

The interrater reliability of translations from Icelandic to English for nursing diagnoses and interventions was 88.7% (k(Kappa) = 0.259) and 67.8% (k = not significant), respectively; for translated terms mapped to ICNP 2019 version 74.2% (k = 0.637) and 71.8% (k = 0.611), respectively; and for the ICNP 2021 reference set in SCT 74.2% (k = 0.615) and 69.2% (k = 0.520), respectively. Agreement between raters was one stage or less, for example, between complete and semantical fit, in 69% to 88% of instances. Disagreements were discussed between translators and raters until a 100% agreement was reached. See Table 3.

DISCUSSION

To our knowledge, this is the first study where real nursing data of COVID-19 patients are used with ICNP 2021 as a reference set in SCT. The study sample consisted of 91% of all hospitalised COVID-19 patients in Iceland during the first wave of the pandemic. None of the results of the trajectory of COVID-19 patients took us by surprise. Commonly described symptoms for COVID-19 in the literature were also reflected in recorded nursing diagnoses and interventions, e.g., breathing difficulties, fluid imbalance, hyperthermia, self-care deficit (Ardic & Turan, 2021; Asghariet al., 2021; WHO, 2020). At least one nursing diagnosis was recorded for all the patients as that is required in the EHR and nursing interventions for 83.5% of the patients. The latter may be due to lack of time for documentation (Kim & Park, 2005) or that it is not a required feature in the EHR as for the diagnoses. Moreover, 24.2% of the patients (n = 22) were admitted to ICU, which uses a different system from elsewhere in the hospital, and there is a lack of interoperability between the two systems. The diversity of nursing diagnoses and interventions used may be reflected in the number of units (n = 5) and staging of the disease. The situation with COVID-19 was new, all available hands were called on deck, and nurses with various work experience and background took care of COVID-19 patients. These nurses may not have had experience with standardised nursing terminologies.

In 13 instances, the discrepancy between raters was high. Medication complications and medication side effects were, for example, rated differently, as was risk for bed rest/immobility complications and risk for disuse or at risk for disuse syndrome. The latter, disuse syndrome, does not translate well into Icelandic, and the meaning may have been lost. When concepts are looked at in context, as here with real data from COVID-19 patients, the understanding of the meaning becomes different from without context. The intervention Ventilation Assistance was, for example, initially wrongly mapped into Ventilator Care but, because of poor interrater reliability on this item and on reading the free text, the meaning became clearer. One of the raters (ERR) cared for COVID-19 patients during the first wave. Her inside information shed light on the real use of many of the nursing diagnoses and interventions in clinical practice, and the nuances of nursing knowledge (Block et al., 2021). A lot of time of nurses went into giving information to families on patients’ status by telephone as no visits were allowed during the hospitalisation. For that, nurses used the intervention providing health status information which, by the translator and one rater, meant providing information between staff members. Another example was when she did not find a match for peripheral venous catheter management while the other rater found semantical fit to maintaining intravenous access. She meant that to maintain intravenous access was only a small part of managing a peripheral venous catheter and did not necessarily include activities such as changing dressings, observing the flow of fluids and the skin around the penetration site. Mapping requires conceptual congruity, and the conceptual understanding is important (Burkhart et al., 2005).

Some concepts that had been considered equivalent by the ICNP R&D centres to the 2019 version of ICNP were not transparent and received a low interrater reliability score. An example is the diagnosis Impaired Breathing in ICNP 2019, which was considered equivalent to Impaired Spontaneous Ventilation in ICNP 2021 and SCT, and the intervention Breathing Exercises in ICNP 2019 versus Physiotherapy of Chest in ICNP 2021 and SCT. Other examples were when management and maintenance, which may include surveillance, monitoring and overseeing, and decision-making on behalf of nurses, was considered equivalent by the ICNP R&D centres to a much simpler task, such as administration of something, and electrolyte management or electrolyte therapy in ICNP 2019 was said to be equivalent to administration of electrolyte. It became evident that monitoring in SCT seems to imply use of a device that was not the case for monitoring in ICNP 2019 and which explains lower interrater reliability scores. No equivalence was found for the concepts diagnostic testing or discharge preparation as diagnoses in ICNP 2019 or SCT because, in theory, they are not diagnoses. For practical purposes, these concepts are used by the nurses to gather information related to the respective activities. Complex physiological concepts, such as ineffective perfusion to the heart and lungs and invasive hemodynamic monitoring, did not have any match in either version of ICNP, which may indicate lack of coverage of ICU terms and concepts in ICNP. These results may indicate that the transition of ICNP into SCT is in its infancy. These two terminologies are different, and a compromise was needed in finding equivalent terms in the mapping process, but nursing practice and knowledge is now better represented in SCT than before the transition.

From an informatics perspective, few lessons were learned or confirmed. The first lesson from this study, although not new, was to see not only that the condition of patients was reflected in the nursing data, but rather that it emphasised the importance of structured data in the EHR to reveal the contribution of nursing and nursing knowledge (Hannah & Kennedy, 2011). The second lesson was the confirmation of the importance of having nursing data transported into a data warehouse with data models structured in the best way for nurses to retrieve and analyse the data; for example, that relationships between data elements are kept (Thoroddsen et al., 2014). In copying data from one source to another, many things can go wrong, and data cleaning is an integral part of transferring data from the EHR to a data warehouse (Strome, 2013). Only one example will be used here to describe the third lesson showing the importance of data use for quality assurance (Strome, 2013). The first delivery of retrieved data showed that 43% of the COVID-19 patients had sepsis, which we found to be quite high. In exploring this further, we found out that somewhere on the way to the data warehouse, infection and sepsis were considered synonyms in the nursing data, but only in the nursing data. Actually, none of the 91 patients had developed sepsis during the hospitalisation, but 87% of the patients had some kind of infection.

The results indicate that the ICNP reference set in SCT does not have terms/concepts that reflect nursing diagnoses and intervention for patients in all specialties in nursing, e.g., ICU. It is up to nurses to keep up with the development of ICNP and submit to ICN new terms and concepts deemed necessary for nursing practice for inclusion in ICNP and SCT. Use of structured, common nursing language, that can support representation of nursing knowledge, is a prerequisite for effective and accurate data capture and sharing. Through its use, nurses can articulate the unique contribution made by the profession and make visible the specific role of nursing worldwide (ICN, 2021).

AUTHOR CONTRIBUTIONS

Study design, ÁT, BÖ; data collection: ERR; data analysis: ÁT, ERR, BÖ; study supervision: ÁT; manuscript writing: ÁT, BÖ; critical revisions for important intellectual content: ÁT, ERR, BÖ.

CONFLICTS OF INTEREST

The authors have no competing interests to declare.