Jing ZHANG, Xue-Ling MA, Jian-Hua DENG,Jing LI, Zhi-Yun ZHANG, Ling TANGSchool of Nursing, Beijing University of Chinese Medicine,Beijing, China; Nephrology Department, Dongfang Hospital of Beijing University of Chinese Medicine, Beijing, China;Department of Nursing, Xiyuan Hospital CACMS, Beijing,China; Department of Nursing, Beijing Ditan Hospital of Capital Medical University, Beijing, China; Department of Nursing, Dongfang Hospital of Beijing University of Chinese Medicine, Beijing, China

ABSTRACT

Objective: The objective of this study is to establish a nursing standard of integrated traditional Chinese and Western medicine for patients with COVID-19 (mild and common) in Beijing, to provide reference for clinical nursing of patients with COVID-19 (mild and common).

Methods: Through online communication meeting with nurses who are in the frontline of anti-epidemic, clinical investigation, literature research, and expert demonstration meeting are carried out to prepare the draft of the standard, and the Delphi method is applied to determine the standard of integrated traditional Chinese and Western medicine care for patients with COVID-19 (mild and common) in Beijing.

Results: The nursing standard of integrated traditional Chinese and Western medicine for patients with COVID-19 (mild and common) was established, which included 5 first-level indicators, 14 second-level indicators and 60 third-level indicators. After two rounds of Delphi method,the positive coefficients of experts were 96% and 83%, the authoritative coefficients of experts were 0.89 and 0.91, and the Kendall’s coefficient of concordance (W) of experts were 0.12, 0.09, 0.10, 0.13 (P < 0.05) and 0.44, 0.43, 0.37, 0.39 (P < 0.05).

Conclusion: The standard of integrated traditional Chinese and Western medicine nursing for patients with COVID-19 (mild and common)in Beijing constructed by the Delphi method is scientific and practical, which provides a reference for clinical application of integrated traditional Chinese and Western medicine nursing to fight against COVID-19 infection.

Keywords: Common, COVID-19, Delphi method, integrated traditional Chinese and Western medicine nursing, mild,nursing standard

INTRODUCTION

Novel coronavirus infections are characterized by rapid and wide spread and are now prevalent worldwide.[1]It is named as “COVID-19” by the World Health Organization. Most of the patients with the mild and common type of COVID-19 have respiratory symptoms such as cough, expectoration,shortness of breath and gastrointestinal symptoms such as abdominal distension, diarrhea and constipation, and some patients suffer from insomnia and anxiety due to panic about the prognosis of the disease.[2,3]Traditional Chinese medicine (TCM) nursing has unique advantages in improving symptoms, alleviating bad mood and improving the quality of life.[4,5]Nondrug therapies have significant effects in alleviating adverse symptoms of patients with COVID-19,such as Taijiquan, Baduanjin, auricular acupoint sticking,acupoint massage, and acupoint sticking of TCM.[6,7]To further play the advantages of integrated traditional Chinese and Western medicine nursing, through a large number of literature analysis and the use of the Delphi method,this study constructed nursing standards of integrated traditional Chinese and Western medicine for patients with COVID-19 (mild and common), to provide a reference for clinical nursing work of COVID-19 infection.

METHODS

Draw up the first draft of nursing standard

First, the clinical investigation is carried out through online communication meetings with nurses who are in the frontline of anti-epidemic to understand the needs of current clinical nursing work and the problems to be solved. Second, the normative framework and implementation content are formulated on the basis of consulting expert consensus on COVID-19 and high-quality literature on COVID-19. Then,through expert demonstration meetings, the first draft of nursing standard is drawn up.

Work out the questionnaire

It includes three parts: (1) explanation of expert inquiry form; (2) expert information table, including basic information of experts, familiarity with the research questions and judgment basis; (3) questionnaire subject:including the first-level index decision table, the second-level index decision table, and the third-level index decision table. On the basis of the preliminary draft, the first round of the questionnaire was formed. It included 4 first-level indicators, 18 second-level indicators and 77 third-level indicators. The decision tables of the first-level and the second-level indicators contain the contents of indicators and their rationality assignment. The decision table of three-level indicators contains the contents of indicators and their rationality assignment and nurse competency. The Likert grade 5 scoring method is used, with very low to very high scores of 1 to 5, respectively, and an expert suggestion column is added to the questionnaire.

Selection of panelists

A convenient sampling method was used to select consultants. Selection criteria for experts: (1) Expert’s degree is undergraduate or above, the title is vice-senior or above; (2) Clinical nurses with the intermediate title or above, who are or have been in the frontline of anti-epidemic; (3) Experts who have certain knowledge and experience in the prevention and treatment of COVID-19; (4)Experts who voluntarily fill in questionnaires and participate in the study. Thirty consultant experts were finally selected.They worked in medical or nursing for 7–39 years, with an average working time (24.40 ± 8.04) years, 8 senior, 15 vice senior, and 7 intermediates. Their fields of study involve medical treatment, infectious disease nursing, nursing management, nutrition nursing, pharmacy, standardization of TCM characteristic technology, nursing scientific research,and other fields.

Ethic considerations

The inquiry form contains instructions for filling in,explaining the purpose and significance of the investigation to the experts for their support. The questionnaire was nonanonymous and we promised that all identifying information of experts were kept strictly confidential,and the collected data were used only for the scientific research.

Process of Delphi expert inquiry

Due to the geographical limitations caused by the epidemic,the questionnaire was sent online for two rounds of inquiry and retrieved as soon as possible. After the first round of inquiry, the rationality of indicators at all levels and the assignment mean and coefficient of variation (CV) of nurse competence were statistically analyzed, and some indicators were modified, deleted, or increased according to the Delphi method entries and combined with group discussion to form the second round of questionnaire. When the degree of coordination and scoring of expert opinions tend to be consistent, the inquiry ends.

Criteria for screening indicators

According to the requirements of the Delphi Expert Consultation Method, items were screened by three judgment criteria: rationality of indicators at all levels and nurse competence score, CV and expert-written opinion, and the indicators with rationality and nurse competence assignment mean >3.50 and CV <0.25 were retained.[8]

Statistical methods

Data were input and checked by EXCEL and analyzed using the SPSS 26.0 statistical software, (IBM, Armonk, New York,USA). The basic data of experts are described by frequency and composition ratio; the rationality of indicators and the score of competence of nurses are described by mean,standard deviation and CV, and the positive coefficient of experts is described by questionnaire recovery rate; the authoritative coefficient of experts is expressed by Cr, and the degree of coordination of expert opinions is expressed by Kendall’s coefficient of concordance (Kendall’s W).

RESULTS

Expert information Expert enthusiasm

Thirty questionnaires were sent in both rounds of this study,and the effective recovery rate was 97% (29/30) in the first round. A total of 18 (60%) experts put forward 37 constructive opinions. In the second round, the effective recovery rate was 83% (25/30), and a total of 3 (10%) experts put forward 4 constructive suggestions. In general, it is considered that the effective recovery rate of the questionnaire of >70.0% can represent the high enthusiasm of experts and the high positive coefficient of experts.[9,10]

Level of the authority of expert opinion

The degree of authority of experts is mainly determined by two factors: the basis on which experts judge the project (Ca)and the familiarity of experts with the problem (Cs). The Cr is the arithmetic mean of familiarity (Cs) and judgment basis (Ca), and the calculation formula is Cr = [Ca + Cs]/2.Expert familiarity is divided into five levels: very familiar,familiar, general, not familiar, unfamiliar, degree coefficient is 1.0, 0.8, 0.6, 0.4, 0.2, respectively. Judgment basis includes practical experience, theoretical analysis, reference to domestic and foreign literature, intuitive selection, and different quantitative values are assigned according to the degree of influence. The specific assignment is shown in Table 1. The Cr in the two rounds of inquiry was 0.89 and 0.91, respectively.

Table 1: Item judgment basis and its impact

Degree of concordance of expert opinions

Kendall’s W was used to reflect the consistency of experts’scores on the rationality of indicators at all levels and nurse’s competence at third-level indicators, with Kendall’s W ranging from 0 to 1. There was a significant difference in Kendall’s W between the two rounds of expert inquiries in this study (P< 0.05), as shown in Table 2.

Table 2: Kendall’s W at all levels

Inclusion of entries of nursing standards of care for patients with COVID-19 (mild and common)

After two rounds of inquiries, finally, the nursing standard of integrated traditional Chinese and Western medicine for patients with COVID-19 (mild and common) is determined that includes five first-level indicators, including an overview,clinical classification, etiology and pathogenesis, prevention and control measures, and nursing measures, 14 second-level indicators, and 60 third-level indicators. In this study, the average value of rationality assignment of the five first-level indicators was 4.04–4.84, and the CV was 0.08–0.09; the average value of rationality assignment of the second-level indicators was 3.92–5.00, the CV was 0.00–0.11; the average value of the rationality assignment of the third-level indicators were 3.76–5.00, the CV was 0.00-0.12; the average value of nurse competence assignment was 3.84–5.00, and the CV was 0.00–0.13. The first-level indicators are shown in Table 3, the second-level indicators in Table 4, and the third-level indicators in Table 5.

Table 3: Rationality score and coefficient of variation of the first-level items

Table 4: Rationality score and coefficient of variation of the second-level items

Table 5: Rationality score, nurse competence score and their coefficients of variation of the third-level items

Table 5: Contd...

DISCUSSION

RELIABILITY ANALYSIS OF INQUIRY RESULTS

In the first round of expert inquiry, Kendall’s W was 0.12, 0.09, 0.10, 0.13, and the W values were low, which indicated that the degree of expert coordination was low and the entries needed to be adjusted. According to the requirements of Delphi method, the items were screened and adjusted by three judgment criteria: rationality of indicators at all levels, nurse competence score, CV and expert-written opinion. The adjusted second round of letter inquiry form showed that Kendall’s W was 0.44, 0.43, 0.37, 0.39 and was significantly improved. It shows that the coordination of experts’ opinions is significantly improved due to the adjustment of inquiry items. Finally, this nursing standard isdetermined that includes five first-level indicators, including overview, clinical classification, etiology and pathogenesis,prevention and control measures, and nursing measures,14 second-level indicators, and 60 third-level indicators.The positive coefficient of experts represents the attitude of experts to care and cooperate in the research. It is expressed by the questionnaire recovery rate. The recovery rates of the two rounds of expert inquiry in this study are 96% and 83%, both of which are >70%. This shows that the positive coefficient of experts is good, and the experts are highly motivated to participate in this study. In addition, the Cr of the two rounds of expert inquiries in this study were 0.89 and 0.91. In general, it is considered that Cr >0.7 is acceptable,which indicates that this study has good authoritativeness.Cr shows that the results of this study are of high value and credible.

Necessity of establishing nursing standards of care for patients with COVID-19 (mild and common)

TCM has a long history of preventing and treating plague,and thus played a unique advantage of the prevention and treatment of COVID-19. Many TCM physicians believe that COVID-19 belongs to the category of “epidemic disease” in TCM, which is mostly caused by damp pathogens. According to the basic theory and the principle of three-factor adjustment, the implementation of dialectical treatment and care can provide individualized treatment and nursing programs for patients, effectively reducing fever symptoms,controlling the development of the disease, reducing the dosage of hormones, and the occurrence of complications.[11]Some clinical data published by Academician Zhang Boli’s team of Chinese Academy of Chinese Medical Sciences show that the overall efficacy of integrated traditional Chinese and Western medicine treatment is significantly better than that of Western medicine alone in the improvement of various examination indicators, and it has been confirmed from clinical studies that integrated traditional Chinese and Western medicine treatment has obvious advantages.[12,13]TCM plays an important role in combating COVID-19 with its holistic concept, treatment and nursing based on syndrome differentiation. However, TCM diagnosis lacks unified and objective indicators, mostly relies on the subjective sensation and treatment experience of the physician, and the treatment often depends on the symptoms and signs of the patients;there is a lack of understanding of the specific infectious sources, transmission routes, pathogenic factors, and internal pathological changes of the disease development, and hence, the combination of TCM and Western medicine is an inevitable trend to prevent and treat the disease.[14,15]TCM nursing varies from person to person and fully embodies the characteristics of “syndrome differentiation and treatment”.Yinget al.’s[16]study show that, on the basis of conventional integrated Chinese and Western medicine diagnosis and treatment, the additional implementation of comprehensive TCM nursing can significantly improve patients’ symptoms,alleviate patients’ bad moods, improve patients’ quality of life,and TCM nursing can highlight the advantages of simplicity,cheapness, and effectiveness. It is of great significance to construct a nursing standard of integrated traditional Chinese and Western medicine to popularize TCM characteristic nursing to the clinic and make up for the limitations of prevention and treatment of TCM.

Practicability of establishing nursing standards of care for patients with COVID-19 (mild and common)

The nursing norms constructed in this study provide a detailed introduction to the integrated traditional Chinese and Western medicine nursing for mild and common patients with COVID-19, from the five dimensions of disease overview, clinical classification, etiology and pathogenesis,prevention and control measures, and nursing measures. To solve the problem of differentiation of symptoms among clinical nurses, this standard enumerates TCM syndrome types according to the specific clinical symptoms easily understood by nurses in Western medicine hospitals in the formulation of differentiation of symptoms and nursing contents, which facilitates the reference and use of clinical nurses in integrated Chinese and Western medicine hospitals and TCM hospitals. The selection of the normative items is based on rigorous literature research and clinical expert experience. Sports nursing and emotional nursing have sufficient theoretical basis and literature support.[17-19]The selection of acupoints for appropriate techniques of TCM nursing is based on high-quality clinical research and expert clinical experience summary.[3,19-22]Therefore, the final nursing standard is practical and conforms to clinical practice.

Limitations of this study and recommendations for subsequent studies

This study constructed nursing standards of care for patients with COVID-19 (mild and common), due to the knowledge of infectious diseases and the complexity of disease etiology and pathogenesis evolution has not been explored in depth,which needs to be further improved. In addition, there is no standardized treatment and treatment plan for this epidemic in the world. In the study, it is found that the TCM syndrome types in different regions also differ, and the universality of this standard needs to be further verified.

CONCLUSION

The formulation of this standard combines the overall requirements of the state for the prevention and control of COVID-19 and the nursing characteristics of patients with mild and common COVID-19. Expert inquiries are conducted on the contents of the standard using the Delphi method,which makes the content scientific and practical. It is hoped to give full play to the advantages of integrated traditional Chinese and Western medicine nursing and provide a basis for clinical nurses to use TCM syndrome differentiation thinking to care for patients with mild and common COVID-19.

Financial support and sponsorship

Nil.

Con flicts of interest

There are no conflicts of interest.