Nursing diagnoses and interventions used in home care in Korea

Nursing diagnoses and interventions used in home care in Korea

Hur, Hea Kung

PURPOSE. To identify and classify nursing diagnoses and nursing interventions used in home care in Korea.

METHODS. Interventions for nursing diagnoses used with 123 home care clients were compared to the Nursing Interventions Classification (NIC) to determine the appropriateness of NIC for use in home care in Korea.

FINDINGS. Many of the interventions used with the diagnoses impaired skin integrity, risk for infection, altered nutrition: less than body requirements, pain, and knowledge deficit matched with NIC. Interventions that did not match included Positioning and Bathing used as Skin/Wound Management, Perineal Care, Urinary Tube Care, Tube Care and Cough Enhancement, all used as Risk Management, and IV Therapy used as Nutrition Support.

CONCLUSIONS. Most of the nursing interventions were in the physiological domain of NIC. Difficulties in identifying which intervention was intended were related to the inclusion of activities in more than one intervention in NIC, and the language used on the records. Korean customs also accounted for differences in the intended use of some interventions. With modifications to account for Korean culture, NIC has promise for use in nursing in Korea.

Key words: Home care, nursing diagnosis, nursing interventions

Diagnostics infirmiers et interventions de soins dans un service de soins a domicile en Coree

BUTS. Identifier et classifier les diagnostics infirmiers et les interventions utilisees a domicile en Core.

METHODES. Les interventions utilisees pour traiter les diagnostics infirmiers poses aupres de 123 patients a domicile furent comparees a celles de la Classification des Interventions de Soins (CIS) afin d’evaluer l’utilite de la CIS pour les soins a domicile Coreens.

RESULTATS. Plusieurs interventions utilisees pour traiter les diagnostics d’Atteinte a l’integrite de la peau, Risque d’infection, Deficit nutritionnel, Douleur et Manque de connaissances etaient assorties a la CIS. Les interventions divergentes incluaient: le positionnement et le bain dans la prise en charge des plaies / de la peau; les soins perineaux, les soins de sonde ou de drains et la stimulation de la toux dans la gestion des risques et la perfusion veineuse utilisee dans l’aide nutritionnelle.

CONCLUSIONS. La plupart des interventions de soins faisaient partie du domaine physiologique de la CIS. Certaines interventions furent difficiles a identifier et a classer pour deux raisons principales: les memes activates se retrouvent parfois sous plusieurs titres d’intervention dans la CIS ou la redaction du dossier de soin est ambigue. Les habitudes coreennes sont aussi une source de divergence dans l’utilisation de quelques interventions. La CIS pourrait etre utilisee avec succes par les infirmieres Coreennes a condition d’effectuer les modifications permettant de l’adapter a la culture du pays.

Diagnosticos e intervenuoes de enfermagem usadas em cuidado domiciliar na coria

OBJETIVO. Identificar e classificar diagnosticos de enfermagem e intervencoes de enfermagem usados em cuidado domiciliar na Coreia.

METODOS. Interven&es para diagnosticos de enfermagem usados com 123 clientes de cuidado domiciliar foram comparados com a Classificacao de Intervencoes de Enfermagem (NIC) para determinar a adequacao da NIC para utilizacao em cuidado domiciliar na Coreia.

ACHADOS. Muitas das intervencoesusadas para os diagnosticos Integridade da pele prejudicada, Risco para in fecio, Nutricao alterada: menos que o corpo necessita, dor e Deficit de conhecimento coincidem com a NIC. As intervencoes que nao coincidem incluem: Banhar e Posicionar usadas como Controle da pele/ferida, Cuidado perineal, Cuidado com o cateter urinario, Cuidado com o cateter e aumento da tosse, todas usadas como Controle de risco, e Terapia endovenosa usada como Suporte nutritional.

CONCLUSOES. A majoria das intervencoes de enfermagem estavam no dominio fisiologico da NIC. Dificuldades em identificar qual intervencao era pretendida foram relacionadas com a inclusao de atividades em mais de uma intervencao na NIC e a linguagem usada nos registros. Os costumes Coreanos tambem explicam as diferencas na intencao de uso de algumas intervenuoes. Com modificacoes que atendam a cultura Coreana, a NIC promete ser util no uso pela enfermagem na Coreia.

Palavras chave: Cuidado domiciliar, diagnosticos de enfermagem, intervencoes de enfermagem

Diagnosticos enfermeros e intervenciones utilizados en cuidados

PROPOSITO. Identificar y clasificar diagnosticos e intervenciones enfermeras utilizados en cuidados domiciliarios en Corea.

METODOS. Para determinar la adecuacion de la NIC para el uso en cuidados domiciliarios en Corea, se compararon las intervenciones realizadas para los diagnosticos enfermeros utilizados con 123 clientes de cuidados domiciliarios, con la Clasificacion de Intervenciones Enfermeras (NIC).

HALLAZGOS. Muchas de las intervenciones usadas con los diagnosticos: Deterioro de la integridad cutanea, Riesgo de infection, Alteration de la nutrition: por defecto, Dolor y Deficit de conocimientos, se emparejaron con la NIC. Intervenciones que no se emparejaron incluian: Posicionamiento y Banar, utilizados como gestion de cuidados de la Piel/Heridas. Cuidado Perineal, Cuidado de la Sonda Urinaria, Cuidado del Tubo y Mejora de la Tos, todos se utilizaron como Gesti6n del Riesgo. Terapia Intravenosa, se utilizo como Apoyo a la Nutrition.

CONCLUSIONES. La mayoria de las Intervenciones de Enfermeria eran del dominio fisiologico de la NIC. Dificultades en identificar que intervention fue pensada, estaban relacionadas con la inclusion de actividades en mds de una intervencion en la NIC y el lenguaje utilizado en los registros. Las diferencias en el uso intentional de algunas intervenciones, obedecian a las costumbres coreanas. Con modificaciones a considerar para la cultura coreana, la NIC tiene porvenir en la enfermeria Coreana.

Palabras clave: Cuidados domiciliarios, diagnostico enfermero, intervenciones enfermeras.

Hea Kung Hur, PhD, RN, is Assistant Professor, Department of Nursing, Wonju College of Medicine, Yonsei University, Wonju, Korea. So-Sun Kim, PhD, RN, is Assistant Professor, and Margaret Storey (Mi Hae Suh), PhD, RN, is Professor, College of Nursing, Yonsei University, Seoul, Korea.

As the Korean economic situation continues to improve, many people are beginning to take greater interest in their health. The Korean national health insurance system, introduced in the early 1980s, is being used extensively, and expenditures for medical care have risen dramatically as more people are admitted to the hospital. More efficient use of hospital beds through early discharge is one of the objectives of a home care nursing service. This frees beds for the acutely ill, an advantage to the hospital, and at the same time decreases costs to clients who receive care at home. Home care in Korea, however, is relatively new and is hospital based. Referral for home care is contingent on a decision by the hospital physician, and the quality of home care depends on the skill of individual home care nurses.

In September 1994, the Korean government passed a law allowing the national health insurance system to reimburse home care. Four hospitals were designated home care demonstration hospitals. There are now 45 hospitals providing home care, but there have been no attempts to standardize home care nursing. Wonju Christian Hospital Home Care (WCHHC), one of the original four demonstration projects, has used the nursing diagnoses developed by the North American Nursing Diagnosis Association (NANDA) as a framework for the delivery of nursing care and to improve the quality of care, but has not yet begun to use a systematized intervention system. At WCHHC a need is felt to identify and conceptualize nursing interventions in order to further improve the quality of home care nursing. Nursing interventions then could be considered when charging for home care. This would allow for the development of a home care intervention classification system, as well as a prospective payment system for nursing care to be validated through the nursing record.

Research was initiated to obtain basic data for the purpose of beginning standardization of home care nursing interventions. The research questions were:

Would nursing activities from the nursing records of home care clients of WCHHC match the nursing activities of the Iowa University research team’s Nursing Interventions Classification (NIC), for the purpose of using the intervention concepts?

Do the intended purposes of the home care nurses in using nursing activities match the indicated intervention’s class and domain in NIC?

What problems would be encountered in using this classification system for home care nursing in Korea?

Literature Review

Changes in healthcare delivery have compelled many healthcare facilities to reexamine their methods of care delivery and to develop creative approaches to improve the quality of care. The nursing profession has recognized that the development and use of a standardized language is a first priority in providing a framework that clearly outlines nurses’ activities and responsibilities in a variety of settings.

Nursing diagnoses, a standardized language for nursing, were first published in the United States in the 1970s, and since then have been used in care planning and as a part of nursing curricula (Thomas & Newsome, 1992). In Korea, nursing diagnoses were not used or studied until the 1980s. Most of the early studies focused on validation of the defining characteristics (Kim, 1995; M. Park, 1988; Y Park, 1987), status of clinical application of nursing diagnoses (Park et al., 1989), the effectiveness of using nursing diagnoses in the clinical settings (Park, 1990; Rhee et al., 1989), identification of factors hindering the use of nursing diagnoses (Choi, Rhee, Kim, Kim, & Park, 1996a), and Korean translations of nursing diagnoses (Choi et al., 1996b). Most of these studies were conducted in acute tertiary settings.

Categorization of direct and indirect nursing care activities is the first step in using the unique language of nursing to describe what nursing does. Through continued development and dissemination of this language, there will be increasing opportunities to show that nursing interventions make a difference in patient outcomes (Robbins, 1997). The identification of interventions also contributes to the development of nursing information systems, staff-related programs and evaluation, networks, examinations for certification and licensing, education, research, and theory construction (McCloskey, Bulechek. & Donahue. 1998).

The NIC, the Omaha System, and Saba’s Home Health Care Classification (HHCC) are intervention systems that have been published. HHCC, which was developed for community-based home care nurses, lists a 20-factor nursing intervention scheme, with each intervention being further refined as assessment, direct care, education, and management, resulting in a total of 80 interventions (Saba & Zuckerman, 1992). The Omaha system is similar, with each problem being modified to classify it as health promotion, potential impairment, actual impairment, and pertaining to family or individual. Interventions are categorized as health teaching, guidance and counseling, treatments and procedures, case management, or surveillance; they are used with targeted activities and client specific information. This allows the nursing interventions and nursing activities to be related in the intervention classification (Martin & Scheet, 1992). While both the HHCC and Omaha systems were developed for use in the community, neither can be used easily with the NANDA nursing diagnoses.

The Iowa University’s NIC is arranged in a three-level taxonomy consisting of 6 domains, 27 classes, and 433 nursing interventions. Each intervention is defined as a concept and includes a list of representative activities. NIC is linked with NANDA nursing diagnoses and is in the process of being linked with outcomes in the Nursing Outcomes Classification (Johnson & Maas, 1997). It is also appropriate for individual, family, or community care and describes interventions performed by nurses in all settings and specialties (McCloskey et al., 1998).

In Korea, Yom (1997) tested the face validity of a Korean translation of NIC by surveying nurses working in a variety of positions. The results, when compared to a similar group of American nurses, showed that American nurses working in the area of intensive care used more nursing interventions than their counterparts in Korea, but on other units Korean nurses used more nursing interventions. M. Kim (1997) studied the application of NIC to patient care in a cardiac intensive care unit (ICU), and S. Kim (1997) published a list of 105 interventions being used by nurses working in intensive care. Ryu and colleagues (1998) found that nurses in the medical ICUs recorded chest physiotherapy, airway suctioning, and cough enhancement as the most frequently used interventions, whereas nurses in surgical ICUs recorded airway suctioning as most frequent. On both medical and surgical ICUs, the most frequent interventions were from the physiological: complex domain. Kim and Lee (1997) identified 57 nursing diagnoses used in adult health nursing and found that, when linked to the NIC, the physiological: basic and physiological: complex domains were the most frequently used. Suh and Hur (1998) found that the NANDA diagnoses most frequently used in home care were from the exchanging pattern. None of these studies identified the nursing activities used to indicate the interventions.

These studies indicate that Korean nurses are beginning to identify nursing interventions necessary for the standardization of nursing practice. They are familiar with NANDA nursing diagnoses, which have been used in home care in Korea, but there has been no study of nursing activities and interventions linked to diagnoses used in home care. This study analyzed nursing diagnoses and nursing activities, the nursing activities being conceptualized as nursing interventions.

Methods

The subjects for the study were the nursing records of 123 clients (68 [55.3%] men, 55 [44.7%] women) seen between September 1994 and August 1998 at the WCHHC in the rural city of Wonju, Korea. The average age was 66.11 (range 32-91), with 93 clients (75.6%) over 60 years of age. Cancer (n = 50, 40.7%) and cerebral vascular accident or traumatic brain injury (n = 33, 26.8%) were the two most frequent medical diagnoses. The major reason for discharge from home care was death (n = 57, 46.3%), followed by problem resolution (n = 32, 26.0%). The average length of admission was 69.03 days (range 1-424), and the average number visits was 8.83 (range 1-62).

The instrument used in this study was a checklist developed by the researchers, which included the demographic characteristics of the subjects, nursing diagnoses and nursing interventions, and for each intervention a list of nursing activities. The Korean language for the diagnoses was that approved in 1996 by the Korean Nurses Association (Choi et al., 1996b). The intervention list was the NIC as translated by Yom, Kim, Park, and Park (1998).

Ten records were jointly examined and discussed by the researchers to increase interrater reliability. An attempt was made to match all the recorded nursing activities for each nursing diagnoses with an NIC intervention. Those that could not be matched were classified as “extra.”

One rule was applied to the data-collection process. An intervention was recorded if any of the activities for that intervention, as listed in NIC, were included in the “planning and intervention” part of the record. Two major problems were encountered: (a) where to place activities that were listed for more than one NIC intervention, and (b) the language used in describing the activities, which was broad and often open to several interpretations. Both these problems were solved by examining the recorded etiology of the diagnosis and other parts of the record for information that would enable the researchers to make a judgment as to which intervention was intended. Data were analyzed using frequencies and percentages.

Results

Types and Number of Nursing Diagnoses

Twenty diagnoses were chosen for analysis, based on previous work by Suh and Hur (1996). Of these, six were found on 20% or more of the records. These six diagnoses and their related interventions were used for analysis. The six diagnoses were:

Impaired skin integrity, found on 55 (44.7%) of the records

Risk for infection (n = 47,38.2%)

Altered nutrition: less than body requirements (n = 45, 36.6%)

Risk for impaired skin integrity (n = 31, 25.2%) Knowledge deficit (n = 27,22.0%)

Pain (n = 24,20.0%)

Interventions Linked to Nursing Diagnoses

In linking the interventions included in NIC to nursing diagnoses from NANDA, McCloskey and Bulechek (1996) have grouped interventions for each diagnosis into three groups: (a) suggested interventions considered essential for resolution of the diagnostic problem; (b) obvious interventions, the treatments of choice from the suggested interventions; and, (c) additional/optional interventions to ensure individualized patient care. Table I lists each of the six nursing diagnoses and the interventions according to these three groups (Suggested, Obvious, and Additional/Optional), plus one grouping for interventions that could not be matched to NIC, labeled “Extra.

For the diagnosis impaired skin integrity, there were a total of 18 interventions. Pressure Ulcer Care was the most frequently used intervention (n = 43, 28.4%), followed by Pressure Ulcer Prevention (n = 25, 16.6%), and Positioning (n = 24, 15.8%), all of which are suggested, but not obvious, interventions. Two obvious interventions (included in “Other”) were Skin Surveillance (n = 4, 2.6%), and Wound Care (n = 4, 2.6%). Incision Site Care, an obvious intervention, was not used at all. joint Mobility Exercise (n = 5, 3.2%) is an optional intervention. Activities that indicated pressure ulcer care included Apply Dressings as Appropriate (n = 34), Position to Avoid Prolonged Pressure on Other Sites (n = 28), and Apply Ointments as Appropriate (n = 10).

For the diagnosis risk for infection, there were a total of 18 interventions. The most frequently used were Infection Protection (n = 20, 15.7%) and Infection Control (n = 19, 14.9%), both of which are obvious interventions. Wound Care (n = 11, 8.8%) and Perineal Care (n = 10, 7.9%) are suggested interventions. Immunization/Vaccination Administration, an obvious intervention, was not used, but two optional interventions were used frequently–Urinary Tube Care (n = 18, 14.2%) and Tube Care (n = 15, 11.8%). The most frequent activity indicating infection protection was Encourage Fluid Intake as Appropriate (n = 9).

For the diagnosis altered nutrition: less than body requirements, 16 interventions were recorded. Suggested interventions included Nutritional Counseling (n = 29, 24.6%), Nutrition Management (n = 14, 11.9%), Nutrition Therapy (n = 13, 11.0%), Nutrition Monitoring (n = 9, 7.6%), and Fluid Management (n = 8,6.8%). Of these, the only obvious intervention is Nutritional Management. Eating Disorder Management and Weight Gain Assistance, which are obvious interventions, were not used. The second most frequent intervention was Intravenous Therapy (n = 26, 22.0%), an optional intervention. The most frequent activity indicating Nutritional Counseling was Discuss Patient’s Food Likes and Dislikes (n = 13).

Twenty interventions were used with risk for impaired skin integrity. Pressure Management was the most frequent (n = 17, 20.7%), followed by Positioning (n = 13, 15.9%), Skin Surveillance (n = 13,15.9%), Skin Care: Topical Treatment (n = 6, 7.3%), and Pressure Ulcer Prevention (n = 6, 7.3%), all of which are suggested interventions. Three–Pressure Management, Skin Surveillance, and Pressure Ulcer Prevention–are obvious interventions. The activity that most frequently indicated Pressure Management was Turn the Immobilized Patient at Least Every 2 Hours, According to a Specific Schedule (n = 9), followed by Administer Back Rub/Neck Rub as Appropriate (n = 7).

For the nursing diagnosis pain, 16 interventions were used. The most frequent were Analgesic Administration (n = 19, 32.2%), Pain Management (n = 5, 8.4%), and Medication Management (n = 5, 8.4%). All are suggested interventions. Analgesic Administration and Pain Management are both linked as obvious interventions, as is Conscious Sedation (n = 1, 1.7%). Patient-Controlled Analgesic Assistance, an obvious intervention, was not used. Positioning (n = 6, 10.2%) is an optional intervention. For Analgesic Administration, the most frequent activity was Determine Analgesic Selections, Based on Type and Severity of Pain (n = 9).

For knowledge deficit, 15 interventions were used. All were teaching interventions and linked as obvious for this diagnosis. Most frequent were Teaching: Procedure/Treatment (n = 11, 21.5%), and Teaching: Disease Process (n = 10, 19.6%). Interventions not used included Teaching: Individual; Teaching: Infant Care; Teaching: Preoperative; Teaching: Safe Sex; and Teaching: Sexuality. The activities most frequently indicating Teaching: Procedure/Treatment were Explain the Purpose of the Procedure/Treatment (n = 6) and Explain the Procedure/Treatment (n = 5).

Activities that could not be matched to the NIC were classified as “Extra.” These included Teaching Families to do Pressure Ulcer Care (n = 9, 6.0%), used with impaired skin integrity; Teaching: Care of Equipment (n = 13, 10.2%), used with risk for infection; Oral Health Maintenance (n = 5,4.2%), used with altered nutrition, but which in NIC is not linked as an intervention for this diagnosis; Teaching Family to Give Skin Care (n = 5, 6.1%), used with risk for impaired skin integrity; and four teaching interventions used with knowledge deficit-Teaching: Infection Control (n = 6, 11.8%); Teaching: Wound Care (n = 1, 2.0%); Teaching: Artificial Airway Management (n = 1, 2.0%); and Teaching: Tube Care (n = 1, 2.0%).

Linkage of Nursing Interventions to Nursing Diagnoses, NIC Class, and Domain

Ten nursing interventions that did not match the NIC class were reclassified according to Intended Intervention Class–that is, the most probable intention of each intervention according to the way in which the intervention was used by the home care nurses. These were then linked to nursing diagnoses and NIC class and domain (Table 2).

Positioning, intended to manage skin and wound care, is classified as Immobility Management in NIC, whereas Bathing, also intended to manage skin/wound problems, is in the class Self-Care Facilitation. Three interventions– Urinary Tube Care classified as Elimination Management in NIC; Tube Care, as Self-Care Facilitation; and Cough Enhancement, as Respiratory Management-were all used with risk for infection and intended as risk management interventions. In this study the frequently used IV Therapy, classified as Tissue Perfusion Management in NIC, was used with altered nutrition: less than body requirements as a Nutrition Support intervention.

Discussion

The records of 123 home care clients, most of whom had advanced cancer or severe brain lesions, showed that the most frequently used nursing diagnoses were physiological. Nursing diagnoses such as caregiver role strain, ineffective management of therapeutic regimen, and ineffective family coping, which are evolving as major problems in home health care, were not identified, indicating that care is limited to physiological care. The severity of the clients’ conditions and the limited financial support for home care in Korea explain the home care nurses’ primary concern with nursing care that is physiological and individual, rather than nursing care directed at family problems.

For some of the NIC interventions, it was difficult to match the class with intended use by the nurses. In the NIC taxonomy, positioning is classified as Immobility and bathing as Self-Care Facilitation, but in this study the nurses used these interventions as Skin/Wound Management.

The researchers experienced difficulties in deciding which intervention should be used because of similarity in language. For impaired skin integrity, NIC links the suggested interventions Skin Surveillance, Wound Care, and Incision Site Care as obvious interventions. But Pressure Ulcer Care was the most frequently used intervention for impaired skin integrity in this study, with Wound Care being used only four times and the other two not at all. The definitions for Pressure Ulcer Care and Incision Site Care clearly distinguish between pressure ulcers and surgical incisions, but the definition for Wound Care, while emphasizing prevention, could be applicable to either type of wound. This may contribute to confusion in the appropriate use of these three interventions. Further, the activities Apply Dressing as Appropriate and Apply Ointment as Appropriate are found, with slight differences in wording, as activities for three of the interventions, and Inspect Skin is an activity for all four. Although other activities more definitely indicate any single interventions, it is difficult to move from activity to conceptualized intervention without a dear distinction between them.

Within the Korean context, interventions for two diagnoses–risk for infection and altered nutrition–need attention and possible modification of NIC for use by Korean nurses. For risk for infection, Perineal Care and Tube Care were frequently used interventions, both of which are in the NIC class Self-Care Facilitation. The nurses may be assessing a risk for infection because neither the client nor the family caregiver is able to adequately perform self-care activities. The Urinary Tube Care intervention, also frequently used with this diagnosis, is in the NIC class Elimination Management. Risk for infection may be explained by noting that many Korean people do not use beds but sleep on a mat on a heated floor, so the urinary bag is only slightly lower than their bodies, as it is also on the floor. Extra care needs to be taken to prevent infection related to inadequate drainage and the temperature of the bag. If this intervention is used only in the class Elimination Management, the emphasis that needs to be placed on awareness of risk for infection may be lost. Thus, for Korean clients with urinary catheters, the nursing diagnosis risk for infection is appropriate, and this intervention should be considered a suggested intervention. For risk for infection, vital sign monitoring, while not contributing directly to resolution of the problem, should be included as a suggested intervention.

The other intervention needing consideration for use by Korean nurses is IV therapy, which is linked in NIC as a suggested intervention for the diagnosis fluid volume deficit and in the class Tissue Perfusion Management. Whereas in NIC it is only linked as an optional intervention for altered nutrition: less than body requirements, in this study it was used almost exclusively with the diagnosis altered nutrition. In the Korean context there are three possible explanations: First, there is no dietitian on the home care team; second, many doctors will write an order for fluids for any client who has trouble with oral feedings; and third, for many clients who are receiving care for terminal cancer, both the client and the family feel more comfortable if the client is receiving IV therapy, even when it is not for treatment. Further, since many of the clients in this study also had a nutrition deficit, it was easy for the nurse to use this intervention with the diagnosis of altered nutrition: less than body requirements, a common diagnosis, rather than the less familiar fluid volume deficit.

Within the NIC system of linked interventions, several obvious interventions were not used in this study. Some of these are related to the sample, which did not include teenagers, young adults, children, newborns, or new mothers, virtually ruling out the use of Immunization/Vaccination Adminstration; Teaching: Infant Care; Teaching: Safe Sex; and Teaching: Sexuality. Patient-controlled anesthesia (PCA) administration, used only once, is not widely used in Korea, but it is expected that this intervention will be used more frequently as soon as this mode of treatment becomes more widely available in home care. Considering that many of the clients had a nutrition deficit, it is noteworthy that Weight Gain Assistance was not used. This may be related to the general physical condition of the clients and expectations of a terminal outcome, which resulted in care to promote comfort, rather than vigorous care to overcome a deficit, which would be expected for clients with a prognosis of recovery.

In much of nursing, teaching as an intervention is a vital part of almost all interventions and should be linked as a suggested intervention to many of the nursing diagnoses. This is particularly true in home care in Korea, which is still very limited and must involve the family in many nursing activities so that not only client teaching, but also family teaching, of nursing care is a very important intervention. The relatively high number of interventions used in home care in Korea that could not be matched in the NIC system is related to the need for families to be able to do simple dressings, dean and sterilize equipment at home, and be aware of the risks for infection. Disposable supplies are not easily available in rural Korea, and when they are, it often is difficult for families to meet the cost.

As Korean nurses move to more adequately define their nursing practice, the concepts involved in the interventions need to be stressed. In trying to classify the nursing activities by interventions, it was frequently found that an activity would be part of more than one intervention and the etiology of the nursing diagnosis and other recordings had to be used to determine to which intervention the activity belonged. Further, many activities listed in NIC, while probably being done, were not recorded. Without additional information, it would be difficult for a nurse to determine the intervention from just the activity; but if the nurse held the concept embedded in the intervention, it would be easy to record that intervention, having included all the relevant activities when giving care.

Nursing implications from this study suggest that these results can promote the computerization of nursing records and standardization of nursing practice, and increase the inclusion of nursing care in the costing of home care in Korea. While this research only began to identify diagnosis intervention linkages, development of a system in which nursing interventions appropriate to the Korean culture are linked to nursing diagnoses would aid in the development of protocols for home care and in the development of nursing curricula and continuing education. Further, cross-cultural research on nursing practice would be facilitated by the development of this kind of system. Differences found in this study compared to the linkages developed by McCloskey and Bulechek (1996) emphasize the need to carefully consider cultural differences when doing cross-cultural research.

This study was an attempt to represent the current stages of development of nursing records in Korea and provide basic data to support the need for further refinement and definition of nursing interventions. A limitation of the study is that the data collection involved only one home care agency, and the type of client, while typical, was not comprehensive. Considering the results of this study, however, in which many of the activities could be assigned to an intervention, there is an indication of support for the use of the NIC format, with some adaptations to Korean culture, as a basis for nursing interventions in home care nursing.

Conclusion

This study identified nursing activities that can be matched to NIC interventions as linked to nursing diagnoses. This was difficult, however, because many of the activities were part of more than one intervention, and without the concept of the intervention it was difficult to determine what the nurse had in mind when using the activity. For example, in the intervention Pain Management, other pain-related interventions are included as nursing activities. Further development of the Obvious Interventions as major interventions that might include other suggested interventions as minor interventions would contribute to solving this problem.

In order to validate the interventions, further study is needed in which home care nurses actually use the nursing interventions with the nursing diagnoses.

Author contact: stoney@yumc.yonsei.ac.kr, with a copy to the Editor: rose_mary@earthlink.net

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