Using ACHIS to Analyze Nursing Health Promotion Interventions for Vulnerable Populations in a Community Nursing Center: A Pilot Study

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1 ORIGINAL ARTICLE Using ACHIS to Analyze Nursing Health Promotion Interventions for Vulnerable Populations in a Community Nursing Center: A Pilot Study Woi-Hyun S. Hong 1 *, Sally Peck Lundeen 2 1 Department of Nursing, Kyungnam University, Korea 2 College of Nursing, University of Wisconsin-Milwaukee, Wisconsin, USA Objectives The purpose of the study was to describe the health promotion interventions of nurses serving a low-income urban population in an academic community nursing center (CNC) in Wisconsin. Methods The Omaha System (OS) was used to code client problems and nursing interventions for 9,839 visits at the CNC. A dataset created by the Automated Community Health Information System (ACHIS), a computerized clinical information system, was used. A pilot testing was performed with the ACHIS data repository. Each intervention was linked to a nursing diagnosis coded with modifiers as either actual or potential problems or health promotion issues. The Lundeen s Comprehensive Community-based Primary Health Care Model (CCPHCM) which emphasizes primary prevention and health promotion activities served as the conceptual framework for this study. Results A total of 58,747 modifiers were documented for 58,747 nursing diagnoses where a total of 9,836 nursing interventions were provided to 9,839 community center visits at the CNC. Although a majority of the nursing diagnoses (61.8%) were coded as actual problems as might be expected for this vulnerable population, 38% of the client problems were documented as potential problems (20.6%) and health promotion issues (17.7%.) Health Teaching, Guidance and Counseling (38.9%) and Case Management (25.8%) were the most frequently coded interventions. Conclusion This research adds to the understanding of the importance of nurses interventions toward health promotion with the vulnerable population. This preliminary analysis suggests that the ACHIS provide a clinical information system for collecting, storing, processing, retrieving, and managing clinical data in a data repository. [Asian Nursing Research 2009;3(3): ] Key Words classification, community health nursing, health promotion, nursing model, vulnerable populations *Correspondence to: Woi-Hyun Hong, 449 Wolyoung-dong, Masan, Nursing Department, Kyungnam University, Masan, , South Korea. wshong@kyungnam.ac.kr; w.shong@hotmail.com Received: July 7, 2009 Revised: July 9, 2009 Accepted: September 9, Asian Nursing Research September 2009 Vol 3 No 3

2 ACHIS to Analyze Nursing Health Promotion INTRODUCTION Health promotion interventions for vulnerable population are complex and may require a non-traditional health care delivery model. Health promotion is a process of enabling people to increase control over the determinants of health and thus improving their health (WHO, 1986). By tackling the multiple health determinants and reducing obstacles, nurses can make a difference in the health and well-being of people (International Council for Nurses (ICN), 2000). Health promotion is a critical phenomenon of nursing science and one of the main roles of nurses. Nursing s Social Policy Statement (American Nurses Association (ANA), 2003) describes nursing as the protection, promotion, and optimization of health. Consistent with advocacy of the health promotion, the main goal of Healthy People 2010 (United States Department of Health and Human Services, 2000) focuses on eliminating health disparities and promoting quality of health for all individuals. Health promotion is a global issue that has drawn much attention from health professionals and public health settings and is broadly emphasized in the wide range of other disciplines. The need for analysis of community data has been greatly encouraged to redirect health professionals to provide the most appropriate level of nursing intervention based on community need (Hilderbrandt, Baisch, Lundeen, Bell-Calvin & Kelber, 2003). Nursing practice in community based settings provide health promotion services, in addition to the diagnosis and treatment of selected acute care problems. Health care data provide the foundation for health care information. Health care information results from processed health care data. Research requires data reliability that refers to the accuracy and completeness of computer-processed data, given the intended purposes for use (Morgan & Waring, 2004). The uses of clinical data for research purposes require some investigation to determine its quality and suitability for research. Nursing documentation for the use of healthcare data provides evidence of the nursing process which is broadly accepted as a conceptual framework for the science of nursing practice. There is a strong movement in nursing to represent nursing practice activities with standardized terminological system (Bakken, Cashen, Mendonca, O Brien, & Zieniewicz, 2000). The Omaha System (OS) is a research-based, comprehensive nursing terminology formulated to provide a useful guide for practice, a method for documentation of client care, and a framework for information management. The OS consists of three relational, reliable, and valid components: the Problem Classification Scheme, the Intervention Scheme, and Problem Rating Scale for Outcomes (Martin, 2005; Martin & Norris, 1996). The components provide a structure to document client needs and strengths related to nursing diagnosis, interventions, and outcomes. The Omaha System is a research-based classification and is being used in many settings including community nursing centers, home care, colleges of nursing, school health programs, and acute settings (Martin). Recent studies continue to support the usefulness of the OS in nursing practice, education, administration and research of community settings (Barton et al., 2003; Erdogan & Esin, 2006; Plowfield, Hayes, & Hall- Long, 2005; Sloan & Delahoussaye, 2003). The OS is useful for describing, and quantifying the practice of nurses and other health care professionals and as a framework for information management (Martin). The Lundeen s Comprehensive Community- Based Primary Health Care (CCPHC) Model (Figure 1) serves as the conceptual framework for this study. The Lundeen s CCPHCM proposes a comprehensive approach to health care of vulnerable populations in community settings that integrates medical and nursing care with social services. (Hong, 2007; Lundeen, 1993). In consistent with the vision of Healthy People 2010 of the United States, community-based nursing has been an important practice area in nursing historically and is a key in changing the health care system. The purpose of the study is (a) to describe the health promotion issues identified by nurses serving a vulnerable population in a community-based primary care setting; (b) to describe the interventions used by nurses to address health promotion issues presented by a vulnerable population in a communitybased primary care setting; and (c) to test the ability Asian Nursing Research September 2009 Vol 3 No 3 131

3 W.H.S. Hong, S.P. Lundeen Principle services Primary prevention Secondary prevention Tertiary prevention Epidemiological assessment Planning Public education Case finding Screening Assurance Surveillance Health data management Coalition building Public health agencies Services are population focused and occur in community settings (health departments & in the field ) Health promotion Community mobilization/ empowerment activities Community assessment Community outreach Case finding Health teaching (individual and group) Counseling Lifestyle modification Family Support Nrg Case management Dx/Tx of select acute conditions Surveillance Community nursing centers Services focus on both personal care and populations and are delivered where users live, work, learn & play schools, day care centers, worksites, neighborhood centers, homes, churches, senior centers, recreation centers, youth clubs Dx/Tx of acute health conditions Tx & surveillance of chronic health conditions Anticipatory guidance Health teaching (individual) Medical case management Sally P. Lundeen RN, PhD, FAAN UW-Milwaukee College of Nursing, 1993, 2005 Medical care facilities Services focus on personal care and are provided where medical providers come together (physicians offices, clinics, hospitals, emergency rooms) Figure 1. Lundeen s comprehensive community-based primary health care model. of nurses to use an electronic health record to capture nursing diagnosis and interventions related to health promotion practice for a vulnerable population in a community-based primary care setting. METHODS The Automated Community Health Information System (ACHIS), an electronic health record (EHR) system was developed and tested by Lundeen and her research team at the University of Wisconsin- Milwaukee (Hong & Lundeen, 2005; Lundeen, 2006; Lundeen & Friedbacher, 1994). The ACHIS was designed to capture clinical nursing data at the point of care using the Omaha System, a standardized nursing taxonomy. Each nursing diagnosis was coded with modifiers: actual problem, potential problem or health promotion issues. Each diagnosis was linked to one or more nursing interventions as coded by the OS. The ACHIS was used to collect data that include the minimum nursing data set elements. The ACHIS serves as an integrated clinical information system that captures and stores client and nursing data so as to facilitate easy retrieval for analysis of process and outcomes. This retrospective descriptive study used secondary data analysis of selected data elements from an aggregated client database from the ACHIS. A total of 30,121 encounters for 3,963 clients served at an urban community nursing center (CNC) in Wisconsin between January 1988 and December Of 30,121, 9,839 encounters where the modifiers were coded as health promotion potential problem or actual problem were selected to identify health promoting interventions provided by nurses at the CNC. A total of 9,836 interventions were analyzed. Each intervention was linked to a nursing diagnosis coded with modifiers as either actual or potential problems or health promotion issues with the standardized nursing taxonomy. ETHICAL CONSIDERATIONS The data were previously coded, documented and computerized in the OS and deidentified in data 132 Asian Nursing Research September 2009 Vol 3 No 3

4 ACHIS to Analyze Nursing Health Promotion set. The sample was the computerized client records data set in the CNC. The Institutional Review Board approval for the secondary data analysis was obtained before initiation of this study. RESULTS Clients characteristics A total of 3,963 clients in Wisconsin were included in this study. The ages of the subjects ranged from 3 to 103 with a mean age of years (SD = 19.25). About 2/3 of the clients were female 64.4% (n = 2,476) in this study. With respect to ethnic heritage, 69.9% of subjects (n = 2,773) were African Americans (Table 1). Table 2 provides the frequency distribution of the eight types of visits to the community nursing center. The walk-in clinic visit type was the most frequent 28.5% (n = 2,789). Table 3 provides a list of the most frequent problems reported during the period of 11 years. Income problem was the most frequent diagnosis (7.7%). The definition of income refers to monies from wages, interest, dividends, or other sources available to family for living and health care expenses (Martin, 2005, p. 76). The three most frequent problems diagnosed from the psychosocial domain were caretaking/parenting (11.4%), communication with community resources (9.8%), and emotional stability (6.7%). Frequent problems in the physiological domain were Table 1 Distribution of Heritage (n = 3,963 Clients) Heritage Frequency (%) Asian 20 (0.5) Black 2,773 (69.9) Caucasian 727 (18.4) Hispanic or Latino 89 (2.4) Hmong 2 (0.1) Native American 61 (1.6) Other 94 (2.4) Unknown 197 (4.9) Table 2 Frequency of Types of Visit for Health Promotion & Potential Problems (n = 9,839) Type of visit Frequency (%) Clinic appointment 1,917 (19.5) Clinic walk-in 2,789 (28.5) Non-clinic appointment 123 (1.3) Non-clinic walk-in 504 (5.1) Home visit 1,530 (15.6) Telephone call 2,017 (20.5) Group 181 (1.8) Other 778 (7.7) Table 3 High Frequency Problems from the Problem Classification Scheme Domain Problems Frequency (%) Environmental Income 2,319 (7.70) Residence 860 (2.85) Neighborhood/workplace safety 172 (0.58) Psychosocial Caretaking/parenting 3,433 (11.40) Communication with community resources 2,969 (9.86) Emotional stability 2,023 (6.72) Physiological Circulation 7,061 (23.44) Pain 3,388 (11.25) Integument 2,871 (9.53) Health-related behaviors Health care supervision 4,246 (14.09) Nutrition 2,817 (9.35) Prescribed medication regimen 2,017 (6.70) Asian Nursing Research September 2009 Vol 3 No 3 133

5 W.H.S. Hong, S.P. Lundeen circulation (23.4%), pain (11.2%), and integument (9.5%). In the domain of the health-related behaviors, health care supervision (14.1%) was the most frequent problem diagnosed which was defined as management of the treatment plan by a health care professional (Martin, 2005, p. 246), followed by nutrition (9.3%) and prescribed medication regimens (6.7%). For each of the 43 problems in the problem classification scheme, nurses select two modifiers: one that is individual, family or community and one that is health promotion, potential, or actual problem. So the nurses are expected to select one from each category. According to the Omaha System, nursing diagnosis (problems) can be modified based on the beneficiary of the nursing service and the type of diagnoses: health promotion, potential problem, actual problem. The actual problem is defined as the client status characterized by one or more existing signs and symptoms that may preclude optimal health whereas a health promotion nursing diagnosis defines a positive state of client need and the absence of risk factors or signs and symptoms (Martin, 2005, p. 46). In Figure 2, a total of 58,747 modifiers were documented. The actual problem of nursing diagnosis was highlighted at 61.8% (n = 36,280) along with potential problem (20.6%, n = 12,098), where only 17.7% of health promotion of nursing diagnosis (n = 10,369) was reported. A total of 9,839 interventions were documented for 11 years in the community nursing center. As illustrated in Figure 3, the most frequently provided intervention was in the categories of Health Teaching, Guidance, and Counseling (38.9%). These interventions were carried out through community nursing practice. The most frequent targets of the nursing focus area for health promotion were communication with community resources (n = 1,583, 15.7%), health care supervision (n = 1,364, 13.6%) and circulation (n = 1,054, 10.5%) in Table 4. The most frequent targets for potential and actual problems were communication with community resources (2,600, 23.1%) and circulation (n = 3,446, 10.1%). In summary, a majority of the nursing diagnoses (61.8%) were coded as actual problems for this 40,000 35,000 30,000 25,000 20,000 15,000 (n = 10, %) 10,000 5,000 0 Health promotion (n = 12, %) Potential problem (n = 36, %) Actual problem Figure 2. Frequency of nursing diagnosis (n = 58,747). 4,500 4,000 3,500 3,000 2,500 2,000 1,500 1, (n = 3, %) Health teaching guidance & counseling (n = %) Treatment & procedure (n = 2, %) (n = 2, %) Case Surveillance management Figure 3. Frequency of nursing interventions (n = 9,839). vulnerable population, whereas 38% of all client problems were documented as either potential problems (20.6%) or health promotion issues (17.6%). Most frequent nursing interventions for encounters where health promotion or potential problems are coded are Health Teaching, Guidance and Counseling (38.9%), Surveillance (25.5%), and Case Management (25.8%). Most frequently coded Actual Problems diagnosed are consistent with traditional medical diagnoses including Circulation (n = 7,061, 23.5%), Pain (n = 3,388, 11.25%), and Integument (n = 2,871, 9.53%). Most frequently coded focus 134 Asian Nursing Research September 2009 Vol 3 No 3

6 ACHIS to Analyze Nursing Health Promotion Table 4 Health Promotion Nursing Focus Areas for Severe Problems (n = 18,064) Modifiers Areas of focus Frequency (%) Health promotion (n = 4,001) Communication with community resources 1,583 (15.7) Health care supervision 1,364 (13.6) Circulation 1,054 (10.5) Potential (n = 4,276) Communication with community resources 2,600 (23.1) Health care supervision 975 (8.7) Ante-partum/postpartum 701 (6.2) Actual (n = 9,787) Circulation 3,446 (10.1) Pain 3,343 (9.8) Integument 2,998 (8.8) areas with Health Promotion or Potential Problem Modifiers are Communication with Community Resources, Health Care Supervision, Circulation, Care taking/parenting, and Growth & Development. DISCUSSION This was a secondary data analysis of selected data elements from an aggregated client database for 11 years to describe nurses role in a community setting and to identify nurses work in the areas of health promotion, potential problem and actual problem as coded by the OS. Nurses who practice in the CNC addressed health promotion and potential problems in clients as well as more traditionally diagnosed medical problems. While treatments and procedures were routinely provided by nurses in CNCs, teaching, counseling, case management and health surveillance were often the interventions of choice among nurses in these comprehensive communitybased primary health care delivery settings to promote the health of the population being served. Therefore, health promotion could be diagnosed as the clients interest in increasing knowledge, behavior, and expectations and in developing more assets and resources that maintain or toward well-being. Consistent with the definition of health by WHO (1998), nurses in this CNC setting practiced assessment of the clients health status in the four areas of domains: Environmental, Psychosocial, Physiological and Health-related Behavioral domains. In regard to the types of visits, the CNC offered eight different types of encounters (e.g., walk-in clinic, clinic appointment, telephone call, home visit, non-clinic walk-in, non-clinic appointment, group visit and other) in order that the vulnerable population could easily access primary health care services including health promoting services. A retrospective longitudinal analysis of data collected using ACHIS demonstrated the usefulness of the OS as a research tool. Computerization of the OS was essential for systematic collection and analysis of clinical data. The clinical nursing data coded in the OS contributed to this study, as a preferred standardized language for community health settings for several reasons. First, the OS is a communitybased taxonomy, developed by nurses documenting patient care. Second, this taxonomy was supported by 15 years of federal funding and developed using an empirical approach with practicing clinicians. Third, the OS included the Nursing Minimum Data Set (NMDS) elements of nursing diagnosis, intervention and outcomes. Finally, the simplicity of the characteristics in this nomenclature facilitates communication among nursing researcher. Since its initial development, the use of the OS has expanded to community-based nursing clinics, acute care, transitional care, school nursing, parish nursing program, ambulatory care centers, homeless clinics, residential Asian Nursing Research September 2009 Vol 3 No 3 135

7 W.H.S. Hong, S.P. Lundeen centers, and correctional centers (Bednardz, 1998; Bowles, 2000; Coenen, Masrek & Lundeen, 1996; Martin & Scheet, 1992; Naylor, Bowles, & Brooten, 2000). The use of such a standardized taxonomy contributed to expanding nursing knowledge by exchanging comparable patient information, and decision support. Using the ACHIS accelerated research activities based on the clinical data collected in community settings (Anderko & Kinion, 2001; Coenen et al., 1996; Frenn, Lundeen, Martin, Reisch & Wilson, 1996; Hilderbraudt et al., 2003; Hong, 2007; Hong & Lundeen, 2005; Lundeen, 1993; Lundeen, 1997; Lundeen & Friedbacher, 1994; Schoneman, 2002; Zachariah & Lundeen, 1997). The ACHIS allowed the researchers to obtain nursing process component data related to health promotion from the longitudinal data repository in the CNC. One of the great advantages of using the ACHIS was that these data were readily available in a format that converted easily and accurately to a statistical software program such as SPSS for analysis. Thus obtaining research data from a computerized data collection system such as the ACHIS provided advantages in terms of speed and economy. Nurses at the CNC worked with the individual population by assessing health problems in the four domains such as environmental, psychosocial, physiological, and health-related behaviors to implementing primary health care services based on health promotion services. The CNC nurses serve the clients in place where the individuals live, work, learn and play with understanding of the individuals demographic characteristics and risk factors that must be managed to meet client s health care need (Hong & Lundeen, 2005). CONCLUSION The collection and analysis of nursing clinical data can inform practice and redirect health professionals to provide the most comprehensive assessments and interventions and, to promote health as well as treat illness in vulnerable populations. The principle services of community nursing centers focus largely on primary and secondary prevention services in the four domains including environmental, psychosocial, physiological and health related behaviors to provide early detection. These primary and secondary prevention activities are delivered where individuals live, work, learn and play. Such sites include schools, day care centers, worksites, neighborhood centers, homes, churches, senior centers, recreation centers, youth clubs, and so on. Health promotion programs can be developed in community settings to reduce health disparities for vulnerable individuals. The Lundeen model reflects a broader continuum of services based on both individual and aggregate of population focus that recognizes group characteristics and risks, and recognizes the community as a location in space and time, and as a social system. (Swanson & Albrecht, 1993). CNCs provide delivery models that are suited to the WHO definition of primary care, and they play a key role in achieving the goals of Healthy People 2010 in the United States. The Lundeen Model has potential to facilitate the provision of complex health promotion interventions by nurses to vulnerable populations and, to reduce health disparities by providing a broader continuum of services that include health teaching, counseling, case management and surveillance in accessible community-based locations. In conclusion, nurses serve as primary care givers and advocate for the vulnerable populations served by the CNC and promote health for all clients regardless of socioeconomic status and ethnic backgrounds by providing comprehensive health promoting services. Recommendations were made for future research that is to examine the relationship and effectiveness between Nursing Problems Scheme and Interventions, and Nursing Interventions and Outcomes. ACKNOWLEDGMENTS This work was supported by Harriet H. Werley Doctoral Student Research Grant at the University of Wisconsin-Milwaukee. 136 Asian Nursing Research September 2009 Vol 3 No 3

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