Ana Belem López-Morales,1 Antonio Barrera-Cruz,1 Claudia Alarcón-Morales,2 Rebeca Martínez-Ravelo2
1Instituto Mexicano del Seguro Social, Coordinación de Unidades Médicas de Alta Especialidad, Coordinación Técnica de Excelencia Clínica; 2Instituto Mexicano del Seguro Social, Hospital de Infectología Centro Médico Nacional La Raza. Ciudad de México, México
Correspondence: Ana Belem López-Morales
Received: May 13rd2016
Judged: June 13rd 2016
Accepted: July 29th 2016
Introduction: Infection with human immunodeficiency virus (HIV) remains a major public health problem worldwide. The most advanced stage of infection is acquired immunodeficiency syndrome (AIDS). Treatment whit antiretroviral drugs can control the virus and help prevent transmission, so that people with HIV or at high risk of contracting it can enjoy a healthy and productive life. In that sense, the nursing staff should provide comprehensive care with a holistic view to people affected by HIV/AIDS, their families and friends.
Development: The preparation of care plan included the creation of nominal groups of experts, meetings, selection of the problem to be addressed, prioritization of diagnostic labels, search of systematic information, critical analysis of scientific evidence, use of nursing taxonomy and prioritization model of reasoning network, adopting and adapting national and international recommendations of Clinical Practice Guidelines (CPG) and internal validation by peers to the final document.
Conclusions: The care provided by the nurse should be based on a care plan that supports nursing staff in decision-making through an organized and efficient methodology, leading to the solution of the patient´s health problem.
Keywords: Health programs and plans; Evidence-based practice; Evidence-based nursing; AIDS serodiagnosis
In 2012, an estimated 35.3 (32.2 to 38.8) million people worldwide were living with human immunodeficiency virus (HIV), a figure that has increased considering that more people now have access to antiretroviral therapy and therefore survive longer. The number of new HIV infections is estimated at 2.3 million (1.9 to 2.7), 33% lower than estimated in 2001, which was 3.4 (3.1 to 3.7). In the same vein, the number of deaths from AIDS has decreased, with 1.6 (1.4 to 1.9) million deaths in 2012, a figure below 2.3 (2.1 to 2.6) million in 2005.1
In 2013, the estimated prevalence of HIV in the population between 15 and 49 years old was 0.23%. An estimated 180 thousand people of all ages were living with the virus (from 140 to 230 thousand), and the mortality rate was 4.2 for every 100,000 inhabitants (2012).2
For more than 25 years, people have taken action in response to HIV and AIDS. Undeniable progress has been made in prevention and attention, diminishing stigma and discrimination through public policies adopted by strategic individuals and public institutions. Social movements and participation of civil society and people with HIV from the Mexican republic have also taken such actions.2
Health promotion and disease prevention are the cornerstones of public health, essential components of the model of health attention in Mexico. A substantive element of health promotion is its anticipatory nature, which seeks to address not the disease directly, but instead the social determinants of health. It’s about creating and strengthening the positive determinants and narrowing or eliminating the negative ones.
People affected by HIV / AIDS and their families and friends need care, information, education and support in all stages of the disease. In that sense, the nursing staff provides comprehensive attention through a holistic lens that considers each person a unique being. The model used in the Instituto Mexicano del Seguro Social addresses human pathophysiological responses to promote the person’s welfare and reintegration into their sociocultural environment in the best conditions possible.3
Nurses possess two tools for providing warm quality care that respects peoples’ dignity. These tools are standardized language and the nursing process, in which the diagnosis is central. Identified problems are the basis of the care plan; they define the determinants of the most effective interventions and achieve results. Obtaining these results is the nurse’s profession and responsibility.4
This responsibility means being capable of taking accurate and continuous action with patients through the nursing care plan, based on scientific evidence to help guide the care.
The creation of the care plan included forming groups of experts, meetings, and the selection of the issue to be addressed. Diagnostic label prioritization was based on the main reason for consultation, hospital admittance or discharge. The plan used systematized information, definition of scope and objectives, adoption of taxonomies (NYA, NOC and NIC), critical analysis of scientific evidence, adoption and adaptation of recommendations to meet national and international guidelines, and an internal peer validation phase of the final document.
The working group included nurses from secondary and tertiary care, who have experience with HIV / AIDS patients and with developing Clinical Practice Guidelines (GPC) and nursing care plans. The following criteria were considered in the selection: experts’ careers, academic formation, knowledge of management care, training in theoretical and methodological aspects of nursing and NYA, NOC and NIC classification. Given the importance of integrating a multi- and interdisciplinary work group, in addition to registered nurses, medical personnel helped structure the attention plan and improve overall patient care.
Phase 1: Planning
Three previous meetings with the work group and its leader were held in February 2016 to define the topics and diagnostic labels to address, and to select the documents which would be used as sources for the nursing care plan in the institutional format. In these meetings, there was a training in CPG evaluation.
The diagnostic labels to be used, after the prioritization exercise, were: infection risk, ineffective protection, non-compliance, ineffective breathing pattern, and mourning.
Results were co-selected by a NYA-NOC with the Current Status Outcome Analysis Model (AREA, Modelo de análisis de resultado del estado actual in Spanish).5,6 The selection of indicators (Measurable units derived from human response) was based on the diagnostic conditions or related factors. Also, intervention selection (treatments based on clinical knowledge and judgment by a professional) was performed by collaboration of NOC-NIC and NYA-NIC.6
Phase 2: Research
The CPG was consulted in the adoption of recommendations, as well as compiling entities such as processors of CPG, national and international publications, or those available online that had been updated (from the period 2013-2016). Sites consulted were: National Guideline Clearinghouse (NGC), National Institute for Clinical Excellence (NICE), Scottish Intercollegiate Guidelines Network (SIGN), NZGG (New Zealand Guidelines Group), GIN (Guidelines International Network) and Guíasalud.
The research included related care plans from national and international sources.
Further research included systematic reviews, controlled trials, and analytic observational studies in the Cochrane and Medline database. Finally, the Internet was utilized for research, specifically nursing sites (CUIDEN, CUIDATGE, ENFERPRO, ENFERSALUD, BIREME). Searches were made during February 2016. The searches were done generically, for “HIV” (Human Immunodeficiency Virus). All group members shared information electronically during their readings.
Phase 3: Evaluation of Clinical Practice Guidelines
Once adopted and adapted, when the CPG showed sufficient methodological quality, it was recommended for evaluation according to the AGREE II7 instrument.8
As far as general recommendations, national and international CPG were adopted and adapted to standardize nursing care. This would ensure effective management and a risk-free nursing practice, and would improve the quality of health services and meet organizational commitment to institutionalize nursing care plans.
Phase 4: Taxonomy
NYA, NOC and NIC taxonomy allow nursing professional to plan care using standardized language.
Nursing taxonomy has three classifications:
North American Nursing Diagnosis Association. The NYA is a diagnostic classification. The nursing diagnosis is a methodological reference fundamental to identifying the problem, and choosing the nursing intervention that elicits the expected result.9
Nursing Outcomes Classification (NOC) is used for nursing results. NOC taxonomy is used to conceptualize, denominate, validate, and classify results obtained from nursing interventions. The results represent the most concrete level of classification and express modified or sustained changes desired in individuals, family, or community.10
Nursing Interventions Classification (NIC) taxonomy is a global, standardized classification that nurses use to bring about the desired result for the individuals, family, or community. They include direct and indirect care as well as treatments used by nurses, medical professional, and other care providers.11
To prioritize diagnostics, results, or intervention, the Current Status Outcome Analysis Model (AREA)5,6 a reasoning and prioritization network method, was used. Given that AREA seeks a structure for clinical reasoning with emphasis on pattern detection and recognizing relationships established with high numbers of diagnoses, it served as a framework for analysis and reflection on decision making during the diagnoses, outcomes, and the intervention selection process.5
To select the expected results, the NYA-NOC interrelation was used, while NOC-NIC collaborated for the interventions, which determine the relationship between the problem and the intervention’s expected outcomes.6
Phase 5: Development of care plans
In three working days, the groups of experts drafted and agreed on diagnostic labels, classification of nursing interventions, expected results, and solutions based on the best evidence available.
The scales and classification systems used for original source evidence showed the progression of the recommendations’ strength. Recommendations based on original studies were described with the NICEClassification system8 (Table I). In the absence of conclusive evidence or clinical issues of particular relevance, they were identified as examples of good practice and considered of best practice or opinion based on clinical experience by consensus.
|Table I. Evidence levels for NICE therapy studies|
|1++||High quality meta-analyses, systematic reviews of RCTs, or RCTs with a very low risk of bias|
|1+||Well-conducted meta-analyses, systematic reviews, or RCTs with a low risk of bias|
|1-||Meta-analyses, systematic reviews, or RCTs with a high risk of bias|
|2++||High quality systematic reviews of case control or cohort or studies
High quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal
|2+||Well-conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal|
|2-||Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal|
|3||Non-analytical studies, such as case reports and case series|
|** Studies with a level of evidence "-" should not be used as a basis for a recommendation. Adapted from Scottish Intercollegiate Guidelines Network|
|Recommendation levels for NICE therapy studies|
|A||At least one meta-analysis, systematic review, or RCT rated as 1++, and directly applicable to the target population; or a body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results|
|B||A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or extrapolated evidence from studies rated as 1++ or 1+|
|C||A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or extrapolated evidence from studies rated as 2++|
|D||Evidence level 3 or 4; or extrapolated evidence from studies rated as 2+; or formal consensus|
Phase 6: Validation
The draft document was submitted to a process of internal validation by peers. Serving on the validating group were nurses with experience in HIV / AIDS patient care, at management and operational levels. Before amendments and suggestions were issued by the validator group, they were discussed with the working group. The final document includes a set of graduated explicit recommendations by the quality of scientific evidence that they support.
The central purpose caring for people living with HIV is to provide comprehensive care from a diverse group of professionals with equally valuable contributions and with different types of information and interventions to provide. This care considers physical, psychological, social and ethical aspects.Therefore, the care plan is a support tool for professional health personnel’s decision making, with the aim of delivering quality, efficient results which impact the physical, and psychological well-being of people living with HIV / AIDS.