Thoughts on the Construction of Evidence-based Nursing Standard Plan for Dominant Diseases in Traditional Chinese Medicine

Li Xuejing (李學靖), Yan Lijiao (晏利姣), Ma Jingya (馬睛雅), Qv Chang (曲 暢),Wang Dou (王 斗), Wang Jinfang (王晉芳), 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 The evidence-based Traditional Chinese Medicine (TCM) nursing in standard plan is to be constructed by a combination of evidence-based thinking and expert consensus. ① The symptoms of diseases with better curative effect in TCM and the nursing techniques of TCM based on scientific evidence can be preliminarily presented through bibliometric analysis. ② Expert consultation letters can be developed based on bibliometric results, and symptoms of dominant diseases in TCM and TCM nursing techniques can be selected through those letters. ③ Based on the selected symptoms and TCM nursing techniques, the PICO can be determined, and then evidence search, evidence extraction,evidence analysis can be conducted and synthesized, and recommendations would be chosen. ④ The recommendation grade of each recommendation can be determined by applying the Delphi method and referring to GRADE. ⑤ The plan will be determined through discussions of experts. The construction of TCM nursing plan would make sure that TCM nursing is scientific, and internationalize TCM nursing.

Traditional Chinese medicine (TCM) nursing is the application of TCM therapy in nursing, which plays a great role in the relief of suffering and rehabilitation of patients[1]. There is consensus among health professionals and patients that TCM nursing has the distinguishing quality and good curative effect especially for dominant diseases in TCM[2]. However, a lot of obstacles emerge when the TCM nursing is applied in patients because the current guidance is not scientific.One of the most serious problems is the difficulty of the application of theories and techniques with TCM nursing characteristics for the practicability of current guidance is not satisfactory[3]. This paper is written for the solution of those problems and maintenance of the quality of TCM nursing. The importance and detailed procedure for the construction of Evidencebased Standard TCM Nursing Plan in the combination of evidence-based thinking and expert consensus was discussed in this paper. It provides references for the construction of scientific and practical Evidence-based Standard TCM Nursing Plan which would meet clinical standard.

INTRODUCTION OF DOMINANT DISEASES IN TCM

Diseases which should be focused on and improved in the application of TCM are called dominant diseases in TCM[4]. At present, 259 dominant diseases in TCM,such as stroke and diabetes, have received recognition of State Administration of Traditional Chinese Medicine of the People's Republic of China[5]. On the one hand,the proposition of dominant diseases in TCM effectively prevents blindly using TCM-related techniques, and on the other hand, it provides a clearer direction for the embodiment and exertion of the advantages of TCM.Therefore, the premise to give full play to TCM nursing's advantages is the application of scientific methods and standardization of TCM nursing from dominant diseases in TCM.

CONNOTATION AND DEVELOPMENT OF EVIDENCE-BASED TCM NURSING

Evidence-based nursing provides the reliable scientific evidence for clinical decisions, which asks for the best clinical evidence, the professional judgment of nursing staff, and the preference of patients[6]. TCM nursing, based on TCM theories, is a branch of nursing.It has the characteristic of Chinese Medicine and Western Medicine. On the one hand, the guidance of it is the TCM philosophy, and the theoretical basis is zang-fu organs theory, meridian and collateral theory, qi, blood, and body fluid theory. On the other hand, it also combines the theory and skills of modern nursing. Influenced by translational medicine and evidence-based practice,public recognition and popularization of TCM nursing cannot lack the explanation and support of strict research results. Therefore, the combination of TCM nursing and evidence-based thinking is of great significance to the development and promotion of the two, and the concept of evidence-based TCM nursing has been introduced.

NECESSITY OF CONSTRUCTING EVIDENCE-BASED NURSING STANDARD PLAN FOR DOMINANT DISEASES IN TCM

At present, State Administration of Traditional Chinese Medicine of the People's Republic of China and all-level administrations of Traditional Chinese Medicine, Chinese Medicine hospitals have adopted a series of methods, such as the research on the quality control of TCM nursing[8], development of quality care service demonstration project[9], personnel training of TCM nursing and scientific research development, and the establishment of TCM nursing plans, with the aim of maintaining and exerting the advantages of TCM nursing,and promoting the clinical work of it. However, there are still obstacles in the clinical application of TCM nursing.

First, many nurses of TCM do not have the ability to rightly put the TCM theories into practice[10], and they are not proficient in many TCM nursing techniques.Second, there is a lack of clinical practice guidelines for the application of TCM nursing techniques. The present methods for formulating TCM nursing plans[11]are lacking in rigor[12], which makes quite a lot potential errors in the program. With the promotion and application of clinical nursing programs in Chinese medicine, some problems have been exposed, which has made its authority and scientificity challenged.

Guan Fengguang[15,16]and other people pointed that the plan lacked qualitative and quantitative description of TCM nursing techniques, resulting in poor operability of the plan. The plan did not explain the evidence source and quality of the corresponding recommended content,etc[17]. Therefore, it can be seen that the main problem in the clinical application of TCM nursing is the poor standardization of operation, and the clinical shortage of high-quality TCM nursing operation guidance. However,as with evidence-based Chinese medicine, the low level of academic development and scientific research achievements is the current situation of evidence-based Chinese medicine nursing[18]. Hence, the construction of evidence-based Chinese medicine nursing plan should also refer to the construction method of TCM evidencebased practice guide, combining scientific research evidence with expert consensus, and using expert experience to make up for the defects of insufficient evidence and low quality.

PROCESS OF THE CONSTRUCTION OF EVIDENCE-BASED NURSING STANDARD PLAN FOR DOMINANT DISEASES IN TCM

Bibliometric analysis of TCM nursing related to dominant diseases in TCM

The common symptoms listed in the TCM nursing plan and the TCM nursing techniques are the core contents of the clinical application of the plan. First,comprehensively search and analyze the literature related to TCM nursing. Second, understand the general situation of TCM nursing related research of various diseases on the bibliometric analysis of the operative word such as symptoms and TCM nursing techniques. Finally, the symptoms of relevant TCM dominant diseases based on scientific evidence and TCM nursing techniques would be comprehensively and preliminarily presented.

Database ① Guideline related websites: National Guideline Clearinghouse (NGC), Scottish Intercollegiate Guidelines Network (SIGN), National Institute for Health and Clinical Excellence (NICE), New Zealand Guidelines Group (NZGG), The Registered Nurses' Association of Ontario (RNAO); ② Related professional institute websites: USA National Stroke Society, Taiwan Brain Stroke Society, World Stroke Organization (WSO),International Stroke Association (ISS), World Stroke Federation (WSF), Sino-American Stroke Group (SASG);③ Chinese databases: CNKI, CBM, VIP, WanFang; ④English databases: PubMed, Web of Science, Proquest,Springer, JBI, Cochrane.

在我們的傳統(tǒng)觀念中，允許女兒與母親一起上衛(wèi)生間，一起洗澡；男孩可以和父親一起上衛(wèi)生間，一起洗澡。但男孩與母親之間就不可以這樣，反之，女兒與父親之間也不可以這樣。在許多家庭里，父母認為讓孩子看見自己的裸體很尷尬，從不在孩子面前裸體，不與孩子一起洗澡、上洗手間，這都是不正確的。

Terms: dominant diseases and TCM nursing;retrieval time: the construction time of each database to retrieval time. Inclusion criteria: literature related to TCM nursing of dominant diseases; exclusion criteria: ①repeated literature; ② animal studies; ③ review studies(including systematic review, bibliometric analysis); ④traumatic brain injury; ⑤ subjects less than 18 years old;⑥ incomplete data in the literature (no author, author's affiliated organization, literature source, keywords or subject term); ⑦ unimportant contents of TCM nursing.

All the retrieved literature was exported to NoteExpress in the catalogue format for document management. After the literature was checked and screened, the extracted literature data was extracted into Excel. The extracted information included the publication year of the literature, the journals included,and the first author's affiliation, fund support, keywords,abstracts, etc. Then, the acquired data was processed by quantitative analysis. High-frequency word calculation formula: According to the high-frequency word and lowfrequency word boundary formula proposed by Donohue in 1973, where I1 is the number of keywords whose word frequency is 1, and the formula is as follows:

Organize expert questionnaires related to the symptoms of dominant diseases and TCM nursing techniques, and conduct expert consultation

First, the relevant symptoms of the dominant diseases and their corresponding high-frequency words of TCM nursing techniques were organized based on statistical result of the preliminary literature word frequency. Then the consultation form was developed.Next this table was used as a research tool for expert consultation. Finally, the symptoms and TCM care techniques to be included and removed can be identified through expert consultation.

Research methods: expert consultation. The number of experts selected and related standards are shown in Table 1.

Table 1. Standards for selecting the experts

Research tools

Tool type: This section can use the general information questionnaire (self-made), selection consultation form of symptoms and TCM nursing techniques. The consultation form is based on the previous symptoms and results of the bibliometric analysis of TCM nursing techniques. All TCM nursing techniques appearing in the consultation form are within the scope of the Nursing Handbook for TCM Nursing Techniques issued by the State Administration of Traditional Chinese Medicine.

The way of using the tool: First score the symptoms, and 1-10 points indicates the extent to which the symptoms remain in the program. TCM nursing techniques which are considered scientific and applicable to clinical practice can be ticked (2-3 items). The TCM nursing techniques not mentioned in the program would be supplemented according to the expert's own clinical experience.

Determine PICO and conduct evidence retrieval and inclusion, quality evaluation of evidence

The PICO (P: participants, I: Interventions, C:Comparisons, O: Outcomes) is recognized according to the symptoms of stroke and TCM nursing techniques selected by experts. Then it is used for evidence retrieval and evidence entry. The search database is the same as the bibliometric search database. The search criteria are:dominant diseases in TCM and symptoms, and TCM nursing techniques.

Firstly, systematic reviews or meta-analysis should be searched: if the relevant literature is retrieved and entered, the quality should be evaluated first. After the consultation, the systematic reviews or meta-analysis with lower quality will be excluded, and those with higher quality will be included.

Literature inclusion criteria: clear diagnostic criteria for relevant diseases, and the main symptoms are P-I corresponding symptoms; exclusion criteria: disease(symptoms) is used as a clinical study of comorbidities;review articles; animal experiments; intervention methods do not describe specific TCM nursing techniques operation;the content is repeated with late publishing year.

Principles of literature quality evaluation: using the JBI Evidence Practice Center of Australia to evaluate the quality of various documents (2014), select the highest quality evidence as the final reference for this study.

Integrate the relevant symptoms of the dominant diseases and the scientific evidence of TCM nursing techniques to form a Delphi expert consultation letter

According to the evidence 6S pyramid model:evidence-based practice guideline, systematic review or meta-analysis, RCT, cohort study, case-control study,medical record series, case report, expert opinion, animal experiment. For each TCM nursing technique, the material with the highest level of evidence is selected as the evidence for the study.

If the relevant guidelines are not retrieved, (1) the higher quality systematic review should be preferred. For the literature of systematic review, the relevant evidence related to the content is directly descriptively analyzed.(2) the RCT with higher quality: For the literature of RCT, the first step is to judge whether there is clinical heterogeneity and methodological heterogeneity among the research results of the retrieved literature. If no such heterogeneity exists, meta-analysis is performed by RevMan5.3 software provided by Cochrane Collaboration.It tests whether there is statistical heterogeneity. If P ＞ 0.1,I ＞ 0.1, fixed effect model is selected; if P ＜ 0.1, I ＜ 0.1,random effects model is selected. If P ＜ 0.1 and the source of heterogeneity cannot be judged, and only a descriptive analysis is performed. (3) for other types of documents of higher quality, only descriptive analysis is performed after content extraction.

Extraction of the literature: Researchers develop extraction table of literature. See table 2.

Table 2. Extraction form of references

Analysis of the literature: Descriptive analysis method is adopted for the analysis of the literature,covering the following basic information analysis of the literature; intervention measures/exposure factor analysis:measurement of specific acupoints; evaluation index analysis.

Based on the basic situation of the evidence, an expert consultation letter is formed, which includes:recommendations, specific operations, quality classification of evidence based on GRADE, reference excerpts and references, which are formed through preliminary research; and the balance of evidence quality and disadvantages, recommendations related values,resource allocation, recommendation grade and other suggestions, which need experts to fill in.

Use the Delphi method to give recommendations for different items

The consultation questionnaire is formed according to the evidence description of the TCM nursing techniques corresponding to each symptom of the dominant diseases in TCM. Give questionnaire to experts and collect the revision opinions of all experts, aggregate them, and distribute the results to the experts again, and make the second revision, and so on. When aggregating the expert opinions, only opinions are given, but the specific names of the experts who issued the opinions are not revealed. After three rounds of expert consultation,the recommendations for the specific implementation methods of TCM nursing techniques will be finalized.

Subjects and sample content: The number of experts and the selection criteria are shown in Table 3.

Table 3. The number of experts and inclusion criteria

This part of the study used Delphi method,theoretical approach. The first step: determine the number of participants, explain the purpose of the study to the experts and the requirements of the Delphi, and implement the Delphi with the consent. The second step: start the first round of expert consultation, and the purpose is to understand the extent to which the clinical care workers combine the clinical patient and the characteristics of the environment to the specific content of the program, the degree of implementation.This section selects only the items that workers wish to exclude for the clinical purpose and find out reasons. The third step: conduct a second round of expert consultation,give experts feedback on the results of the first round, and issue the questionnaire again. The purpose of this round is to analyze the retained items and give recommendations and reasons. The fourth step: conduct a third round of expert consultation, and give experts feedback on the results of second round. Ask the experts to analyze the retained items and give recommendations and reasons.Revised again and finalize the recommendations for each item.

The Delphi method reflects the representativeness of experts and the reliability of forecasts based on the experts' positive coefficient, dependability of expert, the concentration of opinions and the degree of coordination. Descriptive analysis, such as the general situation of the expert, is expressed in terms of frequency and percentage.

Draw up the draft plan, then discuss, revise and finalize the plan

The contents of evidence-based nursing standard plan for dominant diseases in TCM: background,scope and purpose of the study, summary sheet of recommendations, descriptions of the grade of the evidence and recommendations, the process of developing the plan (include data relating to Delphi method), details of recommendations, suggestions for the clinical application of the plan, statement on the conflict of interest, update on the plan, acknowledgements,references.

Authorities on TCM nursing, clinical medicine,public health, and rehabilitation science are invited to conference on the plan. Relevant materials, such as TCM nursing standard plan for dominant diseases and relevant evidence are presented to each expert. They are asked to give recommendations to draft plan according to the evidence evaluation form. After discussions and revisions about the draft, evidence-based nursing standard plan,which can be applied to clinical situation, is finalized.

The table of evidence evaluations converted from relevant items at the evidence level in the Evidence-Based Practice Preparation Metrics (Table 4).

Table 4. The evidence evaluation form

CONCLUSION

The construction of Evidence-based Nursing Standard Plan for Dominant Disease in TCM is a matter of urgency. The combination of evidence-based thinking and expert consensus standardizes TCM clinical nursing,and helps the TCM nursing guidelines be more scientific and practical. For the better development of Evidencebased TCM nursing, the construction of Evidencebased Nursing Standard Plan with TCM characteristics should fully learn from experience of the construction of evidence-based TCM. Not only dose the standardization of Evidence-based Nursing Plan internationalize the TCM nursing, but also it modernizes TCM nursing.