Exploration of nurses’ experience in clinical application of stroke nursing scheme based on PARIHS framework

Xue-Jing Li,Hong Chen

1Nursing College of Beijing University of Traditional Chinese Medicine, Beijing 102488, China. 2Department of Surgery II Breast, Dongfang Hospital of Beijing University of Chinese Medicine,Beijing 100078,China.

Abstract Objective: Based on evidence-based thinking, a qualitative research method was used to analyze the clinical application status of the traditional Chinese medicine nursing program to provide scientific references for its optimization. Methods: Based on the three elements of the PARIHS framework, combined with clinical investigation, the interview outline was determined to interview the users and promoters of the program. After transcribing and coding the collected data with Nvivo software,referring to Colaizzi’s seven-step analysis and generic analysis, all codes are classified and integrated with the core elements and specific connotations of the PARIHS framework to form a theme. Results:The interviewees thought that although the program promoted the development of traditional Chinese medicine nursing to a certain extent, the content lacked scientific research evidence support, and some contents were inconsistent with clinical scenarios and past experience, and the implementation method was rigid, and the effect evaluation was unreasonable. There were 11 themes in three categories. Conclusion: Specific operation processes and scientific research evidence should be added to the scheme, and it should be improved according to clinical practice.

Keywords: traditional Chinese medicine nursing program; PARIHS framework;evidence-based nursing; qualitative research

Background

According to the survey results of the World Health Organization, the incidence of stroke in China ranks first in the world, among which ischemic stroke (also known as cerebral infarction) accounts for 85%,and stroke has become the first cause of death and disability in China[1, 2]. At present, the superiority of traditional Chinese medicine(TCM) nursing in stroke nursing is gradually being affirmed. The survey of basic status of traditional Chinese medicine shows that stroke is the first dominant disease in hospitals of different regions,levels and categories [3]. In order to standardize TCM nursing and give full play to the characteristics and advantages of TCM nursing,in 2013, the National Administration of Traditional Chinese Medicine promulgated the “TCM nursing plan for dominant diseases-acute stroke and recovery stroke”(referred to as the“program”), which was promoted in TCM hospitals all over the country [4]. It became the only guiding standard for TCM nursing for stroke in TCM hospitals in China. The application of the “program” has brought certain clinical effects,while its clinical applicability and the scientific and normative content have also been questioned by clinical workers [5]. At present,the clinical practice guidelines based on evidence-based thinking are internationally recognized as scientific and normative, which can effectively standardize clinical practice. The analysis of the plan with evidence-based review can show the deficiency of scientific and normative nature of the plan. PARIHS evidence-based conceptual framework emphasizes that the successful application of existing theories to clinical practice and the improvement of quality depend on three independent core elements:evidence element(E),organizational environment (C) and promotion factor (F) [6, 7]. Therefore, the current program analysis based on the PARIHS framework can show the gap between it and evidence-based practice guidelines. Clinical nurses in Chinese medicine hospitals are the direct users of the plan.Its experience can reflect the difficulties and needs in clinical application. Therefore, this study introduces evidence-based thinking to formulate an interview outline; through interviews, we learned about nurses’ experience in applying the plan in clinical practice,made clear the clinical needs of stroke TCM nursing in China, and presented the contents of the plan and its shortcomings in evidence-based scientificity and standardization according to PARIHS evidence-based conceptual framework, providing a reference for further optimization and improvement of the plan.

Research object and method

Subjects of study

In this study,objective sampling was adopted from September 2020 to November 2020. The clinical nurses with different working years (3 years or more), different professional titles and different positions were selected from the encephalopathy departments of 5 3A Chinese medicine hospitals. The number of interviewees was saturated with information and no new topics appeared. A total of 15 clinical nurses were interviewed, including 4 head nurses and 11 front-line nurses.See Table 1 for general information on interviewees.

Data collection methods

As a sub-project of a subject, this research has been approved by the school before it is carried out.Data were collected through one-to-one semi-structured in-depth interviews.Based on the application guide of PARIHS framework, the interview outline was formulated after consulting one TCM nursing clinical expert, one evidence-based nursing methodology expert and pre-interviewing two clinical nursing staff [8]. The outline includes the interview nursing staff’s views on the scientificity and timeliness of the contents of the program, the matching degree between the program and patients’ wishes, clinical experience and clinical situation, the experience of promoting and obstructing factors in the application of the program,the views on the advantages and disadvantages brought by the application of the program and the suggestions on the optimization and perfection of the program. The interview consists of a series of open-ended questions.Before the interview begins, the interviewee is given an informed consent statement and the interview starts after obtaining the consent.The interview begins with“please talk about your views on the plan in combination with the contents of the plan”, and the interviewee will use questioning, rhetorical questions, repetition, response and other ways to obtain the interviewee’s accurate and comprehensive views and experiences in due course. Each interviewee will interview once for 40–60 min, and the whole process will be recorded based on the interviewee’s consent; otherwise, the whole process will be recorded in writing.

Data analysis method

Data analysis can be started at the beginning of the interview,observation and recording are carried out during the interview, and notes and recordings are marked and classified. The collected materials are imported into the qualitative research and analysis software Nvivo, and all the verbal and non-verbal information of the interviewees is transcribed and encoded. The specific analysis process refers to Colaizzi’s seven-step analysis method and combines the generic analysis method, and classifies and integrates all the codes with the core elements and specific connotations of PARIHS framework to form a theme [8–10]. Finally, 107 codes are collected into three categories, namely, scheme content, scheme implementation, and scheme application, with a total of 11 topics.After describing the results in detail, the researchers returned to the interviewees for verification. All 15 interviewees read the text description and said that the information presented by the results was objective and accurate.

Results

Views on the content of the program

The contents of the plan include the dominant diseases targeted (i.e.,acute and convalescent stroke) and the specific six parts of the plan:“common symptom points”, “common symptom/syndrome nursing”,“traditional Chinese medicine characteristic treatment nursing”,“health guidance”, “nursing difficulties” and “effect evaluation table of traditional Chinese medicine nursing plan”. Clinical nursing staff’s views on the contents of the plan are summarized as follows.

Lack of source-based description of the part of theme 1“program” guiding clinical practice. Respondents all indicated that“nursing care of common symptoms/syndromes”, “special treatment and nursing care of traditional Chinese medicine” and “health guidance” in the contents of the plan all lacked descriptions of relevant sources. Eight interviewees emphasized the concept of evidence. It is considered that the scheme lacks the basis of relevant research evidence, Such as N12: “i think the Plan is equivalent to the standard of clinical work, but at present, it does not describe the evidence source and basis of related contents, which is imprecise and unscientific as a standard”. Another five respondents compared the plan with the current clinical infusion guidelines, and stressed that“the‘program’should have clear evidence to support the embodiment of the situation like the infusion guidelines we use now”.

Parts of theme 2 “program” are inconsistent with nursing experience. Respondents indicated that some contents in the plan were inconsistent with their clinical nursing experience. In the determination of dominant diseases, all seven interviewees have doubts about dividing stroke into acute stage and recovery stage,among which N2: “the nursing plan for stroke is divided into acute stage and recovery stage, and from my experience, most of the patients seen in TCM nursing clinic are in recovery stage and sequela stage”. In terms of determining common symptoms, respondents believe that the symptoms in the program basically cover the common symptoms directly caused by stroke, but there are still shortcomings such as N9:“we already know that 50%of patients who have just been admitted to hospital with cerebral infarction have dysphagia,so there is no such symptom in the acute stage of the program”. In terms of Chinese medicine nursing technology, most respondents are skeptical about the technology that has not been practiced. As N3 said: “in the past, clinical moxibustion was mostly aimed at urinary incontinence patients, and now it can be aimed at constipation, hemiplegia, etc.,but its real clinical effect is unknown, and we have no way to know”.Theme 3 “program” content does not consider patients’ wishes.Most interviewees believe that from the specific content,the plan does not consider the wishes of patients.For example, N15:“if the patient’s wishes are emphasized in the plan, the advantages and disadvantages of each operation will be explained. For example, moxibustion will taste,and some patients don’t like it.The plan can provide instructions or descriptions related to moxibustion, but it is not reflected at all”.Part of the content of theme 4“program”is inconsistent with the clinical work situation. Respondents indicated that the main structure provided in the “program” basically matched the clinical work. However, “key points of common syndromes”, “nursing of common symptoms” and “evaluation table of effect of traditional Chinese medicine nursing scheme” do not match the clinical work. In terms of “common symptoms”, the dialectical typing provided, does not match the dialectical classification of clinicians. All the interviewees mentioned this point.As described in N10:“the first step in the application of the scheme is dialectical classification, which needs doctors to do,but more than 80%of the dialectical classification given by doctors is inconsistent with that provided by the scheme”.Nursing for common symptoms does not reflect the essence of TCM nursing for dialectical nursing, such as N4: “only nursing for symptoms, dialectical nursing should be reflected according to syndrome types rather than symptoms”.

Table 1 Basic information of interviewees

Experience of the implementation mode of the program

The implementation process of theme 1 “program” is rigid without combining clinical practice, resulting in many negative emotions. Respondents believe that, hospitals and departments introduce the program without combining clinical practice. As a result, the understanding and implementation of the program are rigid, and the overall attitude of nursing staff is negative, without considering the original application conditions and conditions of TCM nursing technology in clinical departments. For example, N12: “the consciousness disorder in the program needs a medicine pillow, how to make the medicine pillow, and the department does not have these things, so it cannot be carried out at all”. The differences between the north and the south, including the differences in customs and habits,are not considered. N7: “the dietotherapy of the diet aftercare part,the south pays more attention to the familiarity of diet aftercare, and the ingredients in the north are incomplete and not necessarily applicable”. There is no risk assessment for clinical implementation.N2: “the plan requires hemiplegic patients to need acupoint massage,but there may be thrombosis in patients with cerebral infarction.I will be swollen after massage, and I will never press it directly in the future. It is too dangerous not to conduct this assessment”. Without considering the TCM level of nurses in the department, N9: “there are 10 nurses in our department, only two of whom are from Chinese medicine background. We can’t read the main points of syndromes in the plan, should we consider our actual level before implementation?‘The implementation is rigid without combining with the actual nursing work?’ We are nurses in encephalopathy department, and the mandatory requirements of the implementation of the program make us have more workload and more negative emotions, but we really don’t have so much time, so we should be more flexible”.

The implementation type of theme 2 “program” is task-based passive nursing work. Respondents believe that the implementation of the program has been task-based from the beginning to the present,and the implementation purpose is single and rigid without incentive measures, which makes the nursing work full of passivity. Set the amount of tasks. From taking patients as the center, Use scheme N3 just for the sake of using scheme: “to complete the workload in clinic,it is not what patients need at all, but what can be used. For example,auricular point sticking is the simplest, so on the basis of ensuring patient safety,we use auricular point sticking the most,not to say that the effect is good, but passively to complete the task”. The implementation method is rigid, Blindly instilling content leads to poor enthusiasm of nurses,such as N1:“when it was introduced,there was training, but there was no less training, but it only gave us books to tell us what to do and did not tell us what the basis was for every detail. We could not deeply understand the plan from our hearts, but only implemented it mechanically”.

Experience in the application and management of the Program

The application of theme 1 “program” promotes the improvement of TCM nursing work level and cultural atmosphere in departments.Respondents generally indicated that the application of the “program” really promoted the exertion of TCM characteristics in nursing in departments and hospitals, improved the knowledge level of TCM nursing among nursing staff, and enhanced the cultural atmosphere of TCM nursing work.For example,N14 means:“after the introduction of the program, the department immediately set up a TCM nursing program team”. In the study of the scheme, because the general content of the program promotes our survey of the relevant theoretical knowledge of Chinese medicine,the department purchased books related to acupoint map, massage, diet aftercare, health preservation, etc., to organize everyone to study, and everyone’s theoretical knowledge has improved. In addition, the application of the scheme has increased the practice of TCM nursing technology,and the water products of TCM nursing operation have also been improved,which makes our TCM hospital have its own characteristics.The application of theme 2 “program” stimulates the clinical enthusiasm for the application and research of TCM nursing.Respondents indicated that the emphasis on TCM nursing technology in the plan made them pay attention to the application of TCM nursing technology. For example, N11: “the application of the ‘Program’makes us begin to feel that Chinese medicine nursing also needs to be studied. For example, constipation applications in our department used to be done by doctors. Now our nurses are also consciously observing the effect and learning to do their own nursing research. I think this is brought about by the‘Program’”.

Application of theme 3 “program” to promote medical cooperation and exchange. Respondents all indicated that the plan involves professional operations such as dialectical typing and acupoint massage. Nurses will seek the doctor’s guidance when applying it,and the number of medical exchanges and cooperation has obviously increased. For example, N9: “in the past, we used to do what doctors prescribed (doctor’s advice). Now that we have a plan,we will take the initiative to go to the doctor to suggest whether we can do some Chinese medicine nursing techniques for patients”.

Discussion

The plan needs to reflect the formulation process and content basis and increase scientific research evidence

The formulation of the plan is mainly based on the consensus of experts’ experience. The essential goal of the “Program” is to standardize the practice level of clinical TCM nursing, improve the quality of TCM nursing, and give full play to the characteristics of TCM nursing. The core of evidence-based is to use the best clinical research evidence available at present to guide clinical medical decision-making. Therefore, clinical practice guidelines and programs must follow current research evidence [11]. The formulation of TCM nursing plan should not only rely on clinical experience, especially since the current research related to TCM nursing has accumulated to a certain extent, and the existing evidence should be sorted out in the formulation process to provide a more scientific basis for the plan. In addition, the specific process of program formulation should be reported in the program, and the transparent process of program formulation can provide nurses with clearer decision-making basis for clinical practice.

The contents of the program should be improved according to clinical practice

Determine the superiority of TCM nursing in each stage of stroke according to clinical information. In the interview, there are many controversies about the acute and recovery stages of stroke as two schemes, respectively. The determination of dominant diseases in the plan refers to the TCM clinical pathway and diagnosis and treatment plan of 304 diseases in the National Administration of Traditional Chinese Medicine in 2012, studies show that 422 guidelines for diagnosis and treatment of common illnesses formulated and published by the Chinese Medicine Association are consistent with the clinical pathways and diagnosis and treatment plans of the above 304 diseases [5, 12]. Only 183 diseases are found to be consistent. It can be seen that whether the dominant diseases in TCM guidelines or clinical pathways can directly represent the dominant diseases in the clinic needs to be certified, and whether the actual dominant diseases in TCM nursing are consistent with TCM treatment is uncertain.Therefore,the choice of stages in stroke TCM nursing plan needs to be determined by combining clinical information, such as using medical record information, selecting diseases with the number of patients in the forefront of various internal medicine departments, and comparing and analyzing their average hospitalization days; only in this way can we truly determine the stages of stroke TCM nursing.

Improve the nursing content of common symptoms according to the needs of clinical work. Respondents all indicated that symptom care in the plan did not reflect TCM syndrome differentiation care.The main purpose of taking common syndrome points as the first part of the“program”is to realize dialectical nursing,that is,to guide TCM nursing operations with the help of doctors’ dialectical classification results. However, the follow-up part of the program is the nursing of symptoms, which has little guiding value for the characteristic dialectical nursing of TCM nursing. In addition, the nursing part of common symptoms focuses on TCM nursing technology, which has a certain guiding role for clinical nurses. However, the implementation details of these technologies and taboos in different situations are not explained, which will bring many potential risks to clinical nursing work. Therefore, first of all, it is necessary to focus on the content of dialectical classification and add the nursing content that should be paid attention to under different syndrome points based on common symptoms. In addition, it is necessary to explain the source and basis of TCM nursing content, and clearly mark the applicable conditions,related taboos and risk assessment.

Provide reference materials involved in the application of the scheme considering the convenience of clinical operation.

Through the interview results, it can be seen that the “program”involves professional skills related to Chinese medicine, while nurses in Chinese medicine hospitals have a limited level of Chinese medicine, and they often need to purchase additional relevant materials. Therefore, some relevant materials such as acupoint maps can be provided in the“program”,which is more conducive to guiding nurses’ work and increasing the convenience of application of the program. In addition, in the evaluation, only the overall evaluation of the program, if the evaluation scale related to each symptom can be provided, the nursing effect in the application of the program can be recorded more objectively, related studies have also confirmed this point.Hong-Feng Zhang and others found that there was no difference in the content and results of the evaluation table in the TCM nursing program in the clinical research on the evaluation effect of syndrome differentiation [13]. Still, the two groups showed differences after using the National Institutes of Health stroke scale score, self-care ability score and comfort score. It can be seen that quantitative evaluation tools can better reflect the effect of TCM nursing to a certain extent.

Before the “program” is introduced into the department, it should be evaluated and adjusted based on the current clinical situation

Respondents emphasized the rigid behavior in the current implementation of the Program. The root cause problem is that the program’s applicability has not been adjusted based on the clinical status before it is introduced into the department.The current solution to this problem is to adjust the program to the content that conforms to the situation of our hospital through expert meetings before it is promoted in different hospitals so as to make the connection between medical care and nursing closer in clinical application. Similarly, in other parts of the program, such as common symptoms and nursing techniques. For example, according to the analysis of economic benefits and the solicitation of patients’wishes,the doctors and nurses in the department can evaluate the applicability of the contents of the scheme according to the actual situation of the department through a meeting before introducing the scheme, and finally adjust it to a scheme suitable for the department.

Establish process management mechanism and reward mechanism related to the application of the program

The interview results showed that the current clinical nursing staff had a negative attitude towards the “program”, mainly because the related obstacles in the application process could not be solved in time, and the task-based implementation mode made nurses in a passive state of implementation. The core of process management is that scientific planning management can get a higher level of effect output after in-depth operation situation [14]. Therefore, establishing process management for the application of the plan, that is, adjusting the implementation and application method of the plan at any time according to the actual situation in clinical practice, can better promote the application effect of the plan.In addition, by establishing a reward mechanism, the efforts of nursing staff in the application of the program will be rewarded, and nursing staff will be promoted to improve their passive role orientation in the application of the program and participate in the application of the Program more objectively [15].

Conclusion

Based on the PARIHS framework,the above results are sorted out and analyzed . The contents of the “program” lack the description of scientific research evidence support, do not consider the patient’s wishes and are different from clinical experience and clinical work information.It can be concluded that the core elements of evidence in the “program” are low. According to the plan, it is task-based, and Nurses’ passive execution and rigid implementation mode show that the promotion factors in the PARIHS framework are at a low level.According to the clinical benefits brought by the application of the program, it can be seen that the organizational environment of the program is gradually more suitable for the application of the program.The unreasonable evaluation of the application effect and the lack of flexible management and control in the clinic indicate that the current clinical application environment is still insufficient. Hence, the organizational environment elements are at a medium level. Based on this, it is necessary to improve the content, implementation and application environment of the plan in a targeted manner.