Self-Management of Medication Regimen in Chronic Disease: Analysis of the Portuguese Nursing Information System (NIS)

Actually, the world is confronted with a high proportion of diseases and premature deaths caused mainly by chronic diseases. Chronic illness represents indeed the principal cause of death and morbidity in Portugal and in the world, with an estimated increase in prevalence in next years. We even see a reality in which people are simultaneously affected by more than one chronic illness which makes the treatment regimen more complex. To control and live with this diseases, patients should integrate several self-care behaviors into their daily lives . These behaviours include taking regular medication, making exercise, reduce fat intake, etc. Since nurses are the professionals who help clients experiencing these illness transitions, the training for self-management is a key area in nursing.

In Portugal, nurses use nursing information systems to document their decision-making process. They document nursing diagnoses and nursing interventions, using the terminology of international council of nurses’ classification. Therefore, it is important to analyze how they document the care needs in information systems related to one aspect that is common in the treatment of all chronic disease: taking medication.

Purpose: The aim of this study is to analyse the documentation (nursing diagnoses and nursing interventions) customized in Portuguese nursing information system (SAPE®) about self-management of medication regimen.

Methods: Content analysis of all nursing documentation customized in the Portuguese nursing information system (SAPE® – Nursing Practice Support System) was made, using an a priori model – ISO 18104: 2003 standard. The International Classification for Nursing Practice (ICNP®) language was used as ontology. A total of 31583 nursing diagnoses and 27380 nursing interventions were analyzed.

Results: A total of 598 nursing diagnoses and 509 nursing interventions were identified, related with self-management of the medication regimen. The comparative analysis of different statements revealed multiple redundancies, i.e. different syntaxes for the same semantics. As a result of the content analysis 29 nursing diagnoses and 67 nursing interventions were considered by a panel of experts as being clinically useful, thus they will be included in the clinical data model being developed.

Conclusion: Nurses use different terms and concepts to represent the same care needs and the same nursing intervention. The proliferation of different statements of diagnosis reflecting the same reality makes information management and production of indicators more difficult. The extended variety in the form of documentation does not add clinical utility and hampers the visibility of nursing contributions to people‘s health.

This is a first contribution to the development of a clinical data model on self-management of the medication regimen, which will facilitate semantic interoperability between different nursing information systems and help nurses‘ decision making.