ARTICLE IN PRESS. i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s x x x ( ) xxx xxx

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jo u r n al h o m e p a g e :w w w . i j m i j o u r n a l . c o m

A

comparison

between

the

VIPS

model

and

the

ICF

for

expressing

nursing

content

in

the

health

care

record

Jan

Florin

a,∗

_,

_Anna

_Ehrenberg

a

_,

_Margareta

_Ehnfors

b

_,

_Catrin

_Björvell

c,d

a_School_of_Health_and_Social_Studies,_Dalarna_University,₇₉₁₈₈_Falun,_Sweden b_School_of_Health_and_Medical_Sciences,_Örebro_University,₇₁₀₈₂_Örebro,_Sweden c_Manager_of_Nursing_Quality,_Karolinska_University_Hospital,₁₇₁₇₆_Stockholm,_Sweden d_Department_of_Neurobiology_Care_Sciences_and_Society,_Karolinska_Institutet,_Stockholm,_Sweden

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received16February2012

Receivedinrevisedform

22May2012 Accepted28May2012 Availableonlinexxx Keywords: Documentation Classiﬁcation ICF Mapping Nursing VIPS

a

b

s

t

r

a

c

t

Background:Multi-professionalstandardizedterminologiesareneededthatcovercommon

aswellasprofession-speciﬁccarecontentinordertoobtainafullcoverageanddescription

ofthecontributionsfromdifferenthealthprofessionals’perspectivesinhealthcare.

Imple-mentationofterminologiesinclinicalpracticethatdonotcoverprofessionals’needsfor

communicationmightjeopardizethequalityofcare.

Purpose:TheaimofthestudywastocomparethestructureandcontentoftheSwedishVIPS

modelfornursingdocumentationandtheinternationalclassiﬁcationoffunction,disability

andhealth(ICF).

Method:Mappingwasperformedbetweenkeywordsandprototypicalexamplesforpatient

status in the VIPS modeland terms in the ICFand its framework of domains,

chap-tersandspeciﬁc terms.Thestudyhadtwophases.Intheﬁrstphase13keywordsfor

patient statusintheVIPS modeland the289terms(prototypicalexamples) describing

related contentweremappedtocomparabletermsintheICF.Inphasetwo,1424terms

on levels2–4 inthe ICFweremappedto thekey wordsforpatient statusin theVIPS

model.

Results:Differencesinclassiﬁcationstructuresandcontentwerefound,withamore

elab-orated levelofdetaildisplayed intheICFthanintheVIPSmodel.Amajorityofterms

couldbemapped,butseveralessentialnursingcareconceptsandperspectivesidentiﬁed

in theVIPSmodelweremissinginthe ICF.Two-thirdsofthe contentinthe ICFcould

bemapped totheVIPS’keywordsforpatient status;however, theremainingtermsin

the ICF, describingbodystructure andenvironmental factors,are not partofthe VIPS

model.

Conclusion: Despitethata majority ofthe nursing contentin the VIPSmodelcould be

expressedbytermsintheICF,theICFneedstobedevelopedandexpandedtobefunctional

fornursingpractice.Theresultshaveinternationalrelevanceforglobaleffortsto

imple-mentunifyingmulti-professionalterminologies.Inaddition,ourresultsunderlinetheneed

forsufﬁcientcoverageandlevelofdetailtosupportdifferentprofessionalperspectivesin

healthcareterminologies.

∗ _{Corresponding}_author_at_:_School_of_Health_and_Social_Studies,_Dalarna_University,₇₉₁₈₈_Falun,_Sweden._Tel.:₊₄₆₂₃_778446.

E-mailaddress:jﬂ@du.se(J.Florin).

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Pleasecitethisarticleinpressas:J.Florin,etal.,AcomparisonbetweentheVIPSmodelandtheICFforexpressingnursingcontentinthehealth

ARTICLE IN PRESS

IJB-2881; No.ofPages10

2

international journal of medical informatics xxx (2012)xxx–xxx

1. Introduction

Communication betweenhealth professionals, both within

aprofession andbetweenprofessionalgroups,isimportant

for the delivery of high quality care with respect to

con-tinuity of care, patient safety and patient participation in

healthcare.Professionalcontributionstopatientcareneed

to berepresented inthe patient’s electronic health record

(EHR)inordertosupportplanning,deliveryand evaluation

of comprehensive and safe patient care. The need to use

standardized terminologies in health care and to develop

multi-professionalEHR systems haslong been recognized.

Standardizedterminologies are not onlyneeded to reduce

theriskforcommunicationbreakdownbutarealsonecessary

toenablethe extractionofrelevant informationfrom

elec-tronicinformationsystemsthatcouldbeusedforknowledge

development,benchmarking,qualityimprovement,resource

allocation and research. In general, the use of

standard-izednursingterminologieshasbeenratherscarceinhealth

care. Traditionally,registered nurses (RNs) have used local

documentation methods, often in the form of narrative

descriptions.Thereis,however,arangeofstandardized

nurs-ingterminologiesavailablethatdescribenursingdiagnoses,

interventions and outcomes (either separate or in various

combinations). One example is the NANDA International

NursingDiagnosesandClassiﬁcations[1].Anotherexample

istheInternationalClassiﬁcationforNursingPractice(ICNP),

whichwasestablishedbytheInternationalCouncilofNurses

(ICN)[2].TheICNP,whichcomprisestermsfornursing

phe-nomena and activities, is a comprehensive summation of

severalterminologies.

Currently, no multi-professional terminology for health

careinpracticaluseexiststoday,butamajorefforthasbeen

directedtowardthistarget.Suchaterminologyisneededto

capturealltypesanddimensionsofhealthcaredatatoensure

better health care practiceand more appropriateresource

allocation. The work of multiple professional groups (e.g.,

nurses,physiotherapistsandoccupationaltherapists)needs

representationsinEHRsinawaythatmakestheinformation

retrievable for multiple purposes. Standardized

Nomencla-tureofMedicine–Clinicalterms(SNOMED-CT)[3]hasbeen

translated into several languages and its development for

practical use has been initiated. Medicine has a long

tra-ditionof using standardizedterminologies (e.g., the World

Health Organization (WHO) approved International

Classi-ﬁcation of Diseases (ICD)) [4]. Further, part of the current

WHOfamilyofclassiﬁcationsistheinternational

classiﬁca-tionoffunction,disabilityandhealth(ICF)[5],whichprovides

a complementary functional perspective to ICD based on

theknowledgeareasofother healthdomains.TheICFwas

developedprimarilybyphysio-andoccupationaltherapists.

Currently, the VIPSmodel hasbeen widelyused sincethe

early 1990s by RNs in Sweden [6] and other Nordic

coun-triesfornursingdocumentation. TheICFhasrecentlybeen

introducedformulti-professionaluseinsomeﬁeldsofhealth

care in Sweden. However, there has not been any critical

analysis of the coherence of the two. This study

there-forefocuses onmapping termsin theVIPSmodeland the

ICF.

1.1. TheVIPSmodel

In Sweden, RNs’ recording in the health record has been

mandatorybylawsince1986andnowadaysaddressedinthe

revisedSwedishpatientrecordact[7].TheVIPSmodelisthe

SwedishacronymforWell-being,Integrity,PreventionandSafety,

which reﬂectsfour basicvaluesunderpinningnursingcare

[6,8].Themodelwasﬁrstpublishedin1991[6]withtheaimof

providingaconceptualizationofessentialelementsin

nurs-ingandastructureofkeywordstoorganizenursingcontentin

thepatientrecordinaccordancewiththenursingprocess.To

facilitateapatient-centeredapproach,theVIPSmodelfocuses

ontheindividualpatient’sfunctioningindailylifeactivities

ratherthanonpathophysiologicalproblemsororgansystems.

Themodel wasthe resultofa structuredresearch process

thatincludedanextensiveliteraturereview,reviewofrecords,

empiricaltestinginclinicalpracticeandvalidationwith

exist-ingtheoreticalmodelsinnursing[6].TheVIPSmodelprovides

aframeworkfornursingdocumentationtosupportnursesto

acknowledgeandverbalizeessentialdatathatreﬂects

nurs-ingpractice.InthiswaytheVIPSmodelhelpstofacilitatethe

structuringofinformationandknowledgereﬂectingnursing

practice,aswellassupportteachingandresearchactivitiesin

nursing.

TheVIPSmodelpresentskeywordsontwolevels[6,8,9].

Level oneconcerns thenursingprocess model:assessment

(nursinghistory, nursingstatus),nursingdiagnosis,nursing

goal,nursinginterventionandnursingoutcome(Fig.1).Level

twoconsistsofasubdivisionofkeywordsundernursing

his-tory,nursing statusand nursinginterventions. Prototypical

examplesareprovidedforeverykeywordonleveltwo.

Nursingstatuscomprisesdescriptionsofsignsand

symp-toms regardinga patient’s healthsituation and conditions

inﬂuencing nursing care, as assessed from different

per-spectives (e.g.,nurseand patient).Thedocumentationofa

patient’shealthstatusshouldaddressthefollowing

dimen-sions: function, including alterations, risks and resources;

comfort, both from a physical and psychosocial point of

view; inﬂuencing factors/circumstances (e.g., environment,

resources–demands,internal–external,positive–negativeand

expectations–values);aids/devicesused bythe patient(e.g.,

pharmacological,technicalorpsychosocial)[6,8,9].

TheVIPSmodelhasshowngoodcontentvalidityinmany

areas of nursing care, including acute surgical and

medi-cal,stroke,dementia,geriatric,pediatric,peri-operativeand

psychiatric care[8,10]. The VIPSmodel is usedfor

record-ingnursingandindividualcareplanningthroughoutSweden,

aswellasinDenmark,Norway,Estonia andLatvia.Several

softwareapplicationsfortheEHRhaveincludedthemodel.

Moreover, it is taughtin mostnursing undergraduate

pro-gramsinSwedenandSwedishtextbooksinnursinghavebeen

organizedaccordingtotheVIPSmodel.

1.2. Theinternationalclassiﬁcationoffunctioning, disabilityandhealth

WHOhasdevelopedseveralclassiﬁcationssupportinghealth

care practice,including the ICF [5]. It was ﬁrst releasedin

2001and laterpresented(in 2007)inaversion forchildren

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Fig.1–OverviewoftheVIPSmodel.

Fig.2–Theinternationalclassiﬁcationoffunctioning,disabilityandhealth[5].

describebodystructure,functioninganddisabilitybutalsoto

captureconceptionsofadynamicinteractionbetweenhealth

conditionsandcontextualfactors[5].TheICFisbasedona

bio-psycho-socialmodel, which combinesprevious models

forfunctioninganddisability[12],andconsistsoftwo

sepa-ratepartswithtwocomponentseach:functioninganddisability

withthecomponentsbody structuresandbody functionsand

activitiesandparticipationandcontextualfactorswiththe

compo-nentsenvironmentalfactorsandapersonalfactor,whichhasbeen

identiﬁedbutnotyetdeveloped.Thestructureispresentedin

Fig.2withthecomponentbodystructuresandbodyfunctions

presentedastwoseparateentitiesforclariﬁcationofthe

num-berofterms.

Eachcomponentismadeupofdifferentchapters

contain-ingterms(levels2–4)thataretheunitsoftheclassiﬁcation.

Intotal,thereare30chaptersand1424terms.Themaximum

numberoftermsavailabletodescribeaperson’shealthand

ahealth-relatedconditionis30ontheﬁrstlevel,362onthe

secondlevel,926onthethirdleveland136onthefourthlevel.

A hierarchicalcodingsystem isused inwhichthe

compo-nents are designated byletters:b forbody functions,sfor

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Table1–ExamplesoftermsandcodesonfourlevelsintheICFconceptualframe.

Component Level1 Level2 Level3 Level4

bBodyfunctions b2Sensoryfunctionsandpain b280Sensationofpain b2801Paininbodypart b28013Paininback

environmentalfactors.The letter isfollowed byanumeric codedisplayingthelevelandpositionoftheterminthe hier-archy(Table1).Further,twoﬁgurescanbeaddedtothecode

thatdisplayqualiﬁersrepresentingtheperspectivesof

capac-ityandperformance.

The ICF has gained increased attention internationally

asaunifyingclassiﬁcationsystemapplicabletothe

knowl-edgeareasandresponsibilitiesforvarioushealthprofessions,

includingnursing.Ithasbeensuggestedasameanstoexpand

nurses’thinkingandclinicalpracticebyaddinganincreased

awarenessofsocial,culturalandpoliticaldimensionsof

dis-ability[13].Further,itisregardedasausefulframeworkand

foundationinsettinggoalsfornursinginterventions

regard-ingacute and earlypost-acuterehabilitation[14]. However,

theICFisnotsuitableforformulatingnursingdiagnosesto

thesameextentastheNANDA[1]andtheICNP[2]that

con-tainstandardizeddiagnosisexpressions,orconsideringthe

InternationalStandardreferenceterminologymodel(RTM)for

nursingdiagnosis[15]ortheuseofcurrentlyestablished

cri-teriafordiagnosesaccordingtothePES(problem-etiology–

signsandsymptoms)format[16].However,elementsin

nurs-ingdiagnosesretrievedfromapatient’sEHRcouldbeclassiﬁed

usingtheICF,butwithratherlowinterrateragreementfrom

61to75%onahigherleveland42to60%onamoredetailed

levelintheclassiﬁcationhierarchy[17].Theapplicationofcore

setsfromtheICFfornursinghasbeentestedwithacceptable

results[18].SeveralauthorshaveconcludedthattheICFhas

relevancetonursingcare,butthatnursesoughttotakeamore

activepartinthefurtherdevelopmentoftheICF[13,14,17,19].

The ICF is currently implemented in some areas in

Sweden(primarily withinresidentialcarefacilities)to

sup-port multi-professionaldocumentation practice concerning

patient status and communication between health

profes-sionsand theirrespective knowledgedomains. InSweden,

theICFisintroducedasaninterfaceterminologyreplacing,

orimplementedincombinationwith,previousstructuresof

standardizedterms,oftenbasedonthe VIPSmodel,which

presentsanewstructuretotheEHR.Comprehensivecoverage

isaqualityfactorofterminologycontentthatneedsexternal

referencestandardstobeestablished(e.g.,userrequirements

anddomain-speciﬁcneedsofcontent)[20]. Thetwo

termi-nologies have different purposes. The ICF was developed

primarilyfromaparamedicalandrehabilitationperspective.

Thus,studies investigatingthe coherence betweennursing

knowledgeand theICF onagenerallevel are lacking. Itis

thereforeimportanttoascertainthattheICFprovidesa

com-prehensivecontentcoverageinwhichtermsareonasufﬁcient

levelofdetail tosupportand representspeciﬁc knowledge

domainsand professionalclinicalpracticeswithinnursing.

ItisimportantthattheICFprovidecomprehensivecoverage

inordertoacquiresensitivedataonallaspectsofapatient’s

problemsandneedsunderpinningcaredecisions.Becausethe

VIPSmodelwasdevelopedspeciﬁcallyfor(andiscurrently

usedsuccessfullywithin)nursingpractice,oneapproachto

evaluatethenursingsensitivityoftheICFistomapthecontent

oftheICFandVIPSmodel.

2. Aim

Theaimofthestudywastocomparethestructureand

con-tentoftheSwedishVIPSmodelfornursingdocumentation

withtheICF.Thiscanbedonebymappingthekeywordsand

prototypicalexamplesofsuggestedcontentforpatientstatus

intheVIPSmodeltotheframeworkofdomains,chaptersand

termsintheICF.

Threeresearchquestionsguidedthestudy:

1. Towhatextentcanthekeywordsinthe VIPSmodelon

levels1and2forpatientstatusbemappedtotheICF?

2. Towhatextentcannursingdatadescribedasprototypical

examplesforpatientstatusintheVIPSmodelbemapped

tothetermsonlevels1–4intheICF?

3. Towhatextentcanthetermsonlevels1–4intheICFbe

mappedtopatientstatusintheVIPSmodel?

3. Methods

Thestudyusedadescriptivedesignbyperformingmapping

ofcontentintwoclassiﬁcations.

3.1. Material

The Swedish versions ofthe VIPSmodel [6,8] and the ICF

[21] were used in this study. Thirteen of 14 key words in

the VIPS model for patient status were used for

compari-son, alongwiththe prototypicalexamplesprovided(thisis

because theICFcategorizesterms limitedtopatient status).

Subsequently, thekey wordsin theVIPS fornursinghistory

and nursing interventions were not used formapping. The

selectedkeywordsintheVIPSforpatientstatuswere

com-munication,cognition/development,breathing/circulation,nutrition,

elimination,skin/integument,activity,sleep,pain/perception, sexu-ality/reproduction,psychosocial,spiritual/culturalandwell-being. Thekeywordcompositeassessmentwasexcludedbecausethe

content reﬂectspatientstatusbasedonassessment

instru-mentsorscalesnotnaturallylinkedtoothersinglekeywords.

Additionally, 289 terms were identiﬁedfrom the

prototypi-calexamplesprovidedforthe13keywords.Forexample,the

keywordcognition/developmentconsistedofeightprototypical

examples ofcontent thatcouldbedividedinto 15separate

termstobemapped(Table2).Intotal,1424termsonlevels

2–4oftheICFwereusedinthemappingprocess,aswellas30

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Table2–Examplesofextractedmappingtermsfromlevel2keywordsandprototypicalexamplesintheVIPSmodel

(Englishversion2002).

Keywordonlevel2inVIPS Prototypicalexamplesofcontent Termstobemapped

Cognitionand development

Cognitiveabilityand development Cognitiveability Cognitivedevelopment Needofinformationor education Needofinformation Needofeducation Understandingofhealth andillness Understandingofhealth Understandingofillness Short-termmemory Short-termmemory Motivation,ambitionand

abilitytoparticipate

Motivationtoparticipateambitiontoparticipate Abilitytoparticipate

Willingnessandabilityfor co-operationandparticipation

Willingnessforco-operation Abilityforco-operation Willingnessforparticipation Abilityforparticipation Physicalandpsychological

maturityanddevelopment

Physicalmaturity Psychologicalmaturity Physicaldevelopment Psychologicaldevelopment Certainneedsregardingattitude,

treatmentorintellectualstimulus

Certainneedsregardingattitude Certainneedsregardingtreatment

Certainneedsregardingintellectualstimulus

3.2. Mappingprocedure

Themappingprocedureconsistedoftwoparts.Intheﬁrstpart thetermsweremappedtograspthecomprehensivenessand completenessofterms[22]inthe ICFrepresentingnursing

sensitiveinformationdescribedintheVIPS.Atotalof13key

wordsand289termsderivedfromprototypicalexamplesin

patientstatusintheVIPSmodelweremappedtotermsonlevels

1–4intheICFbytwooftheauthors(JFandCB).

Inthe second part, terms on levels 2–4 inthe ICF were

mappedaccordingtothekeywordsforpatientstatus inthe

VIPSmodelbytwootherauthors(MEandAE).Themapping

procedureswereperformedpartlyindependentlywithinthe

pairofauthors,withﬁnalagreementreachedafterdiscussion.

Excelspreadsheetswereusedtoorganizethedatafor

com-parisonanddescriptivestatisticswereappliedtopresentthe

data.

4. Results

4.1. ComparisonbetweentheVIPSmodelandtheICF

Thekey wordsonlevel 1intheVIPSmodel,whichdisplay

thestepsofthenursingprocess,wereabsentintheICF.The

ICFisaclassiﬁcationtodescribevarioushealthconditionsfor

functionandactivity,whichwouldcorrespondtopatient

sta-tusbutdoesnotsupportprocesses,andsubsequently,notthe

nursingprocessasawhole.

Inall,12keywordsonlevel2intheVIPSmodelforpatient

statuscouldbestatedusingtermsonlevel1(chapters)inthe

ICF,mostoftenfoundaspartofabroadertermorasasimilar,

butdifferentlyworded,term(Table3).However,theVIPSkey

wordwell-being,asenseofone’sownperceivedhealthanda

summaryofanindividual’slifesituationcouldnotbemapped

totheICF.Well-beingoccursintheICFaspartoflookingafter

one’shealth(d570)orassistingothers(d660).Further,asanaim

descriptionforhealthservices(e5800),healthsystems(e5801)and

health policies(e5802),butnotasadescription ofthehealth

conditionofthepatient.

A semantically perfect match tothe ICF could oftenbe

foundforthekeywordsintheVIPSmodel.However,the

hierar-chicalplacementandscopeofthetermswereoftensomewhat

different, which meant that several terms in the ICFwere

neededtocoverthesuggestedcontentforaspeciﬁedkeyword

intheVIPSmodel.Forexample,therewasaperfectmatch

inwordingbetweenchapterd3intheICFandthekeyword

communicationintheVIPSmodel,butthedescribed content

withintheICFwasnarrower,leadingtotheneedtouse

sev-eralchaptersintheICFtocoverthecontentforcommunication

intheVIPSmodel.Therelevantcontentwasrepresentedin

theICFchaptersb1,b2,d3ande1,reﬂectingthreedomainsat

thesametime.Onereasonforthatisthedivisioninfunction

andactivity(i.e.,apatient’sactivityoractivities,notnursing

activities)(chapterbandd)intheICFthathasnoparallelin

theVIPSmodel,whereahigherlevelofabstractionisused.

Ontheotherhand,termsforproductsandtechnologywere

presentundereightofthekeywordsintheVIPSmodelbut

gatheredunderonechapter(e1)intheICF.

Content described asprototypical examples for the key

wordnutritioncouldbemappedtotheareasofﬁvechaptersin theICF:functionsofthedigestivemetabolicandendocrinesystems

(b5),mentalfunctions(b1),self-care(d5),productsandtechnology

(e1)andstructuresinvolvedinvoiceandspeech(s3)(Table3).The keywordsleepintheVIPSmodelcouldbemappedtotheICF

aspartofthebroadertermmentalfunctions(b1),whichwasalso

thecasewithseveralofthekeywordsintheVIPSmodel.

4.2. ContentoftheVIPSmodelmappedtotheICF

Ofthe289termsdescribingprototypicalexamplesintheVIPS

model,179(62%)couldbemappedtothe ICF.However,the

termsintheVIPSmodelaredescribedonamoreaggregated

andlessdetailedlevelthantheICFterms.Someofthe

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Table3–Mappingofkeywordsonlevel2intheVIPSmodeltochaptersintheICF.

VIPS Code ICFchapters

Communication b1 Mentalfunctions

b2 Sensoryfunctionsandpain

d3 Communication

e1 Productsandtechnology Cognition/development b1 Mentalfunctions

d1 Learningandapplyingknowledge

d7 Interpersonalinteractionsandrelationships

Breathing/circulation b4 Functionsofthecardiovascular,hematological,immunologicalandrespiratorysystems b5 Functionsofthedigestive,metabolicandendocrinesystems

e1 Productsandtechnology Nutrition b1 Mentalfunctions

b5 Functionsofthedigestive,metabolicandendocrinesystems

d5 Self-care

e1 Productsandtechnology

s3 Structuresinvolvedinvoiceandspeech

Elimination b5 Functionsofthedigestive,metabolicandendocrinesystems b6 Genitourinaryandreproductivefunctions

d5 Self-care

e1 Productsandtechnology Skin/integument b2 Sensoryfunctionsandpain

b8 Functionsoftheskinandrelatedstructures e1 Productsandtechnology

s8 Skinandrelatedstructures

Activity b5 Functionsofthedigestive,metabolicandendocrinesystems b7 Neuromusculoskeletalandmovement-relatedfunctions. d Activitiesandparticipation

d2 Generaltasksanddemands

d4 Mobility

d5 Self-care

d6 Domesticlife

d9 Community,socialandciviclife e1 Productsandtechnology

Sleep b1 Mentalfunctions

e1 Productsandtechnology Pain/Perception b2 Sensoryfunctionsandpain

e1 Productsandtechnology

Sexuality/reproduction b6 Genitourinaryandreproductivefunctions

s6 Structuresrelatedtothegenitourinaryandreproductivesystems Psychosocial b1 Mentalfunctions

d2 Generaltasksanddemands

d7 Interpersonalinteractionsandrelationships d9 Community,socialandciviclife

e3 Supportandrelationships

e4 Attitudes

Spiritual/cultural b1 Mentalfunctions

d9 Community,socialandciviclife e1 Productsandtechnology

e4 Attitudes

e5 Services,systemsandpolicies

whichwasmostcommonintheareasofthepatient’sown per-spectiveandperceptionsrelatedtopsychosocialorexistential matters(e.g.,termsrelatedtofeelings,experiences, percep-tions,habits, skills,intentions, meaningsor preferencesof thepatientorfamily).Further,somephysicalmattersanda senseofwell-beingasaglobalestimationofapatient’shealth conditionandtermsdescribingpersonalfactorsintheVIPS modelcouldnotbeexpressedbytheICF.Thereisalackof

termsinexpressinggender,ethnicity,ageandother health-relatedfactors(e.g.,ﬁtnesslevel,lifestyle,habits,upbringing, socialbackground,education,professionandcommon behav-iorpatternsandcharacteristics).

Theconceptofqualityoflifecouldnotbemappedtothe ICFthoughtherearetermsintheICFreﬂectingqualityrelated tospeciﬁcareas,suchasconsciousness(b1102),sleep(b1343), psychomotor functions(b1471),vision(b2102),voice (b3101)

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94 59 51 53

_{24 32}

299

8

92

29

187

6

0 50 100 150 200 250 300 350

Number of ICF terms

Key words in

VIPS

Fig.3–NumberofICFtermsthatcouldbemappedtokeywordsforpatientstatusintheVIPSmodel(n=934).

andqualityofenvironmentalfactors.TermsintheICFcould

beusedtodescribecurrenthealthconditionsbutdidnot

per-mitthedescriptionofrisksorpotentialproblemsofpatients.

Forinstance,sensationoffalling(b2402)couldbedescribedbut

notincreasedriskoffalling.Alackofsomethingoraneedof

somethingaspartofthedescriptionofapatient’sstatus(e.g.,

knowledgedeﬁcitregardingtreatmentandself-care

manage-mentasdescribedintheVIPSmodel)couldnotbeexpressed

bytheICF.Apatient’slackofknowledgeandneedsof

infor-mationweremissingintheICF,whereastherewereICFterms

todescribelearningneeds(mostlybasicskillssuchaswriting

andreading)andapatient’sabilitytoapplyknowledge.

Suchfeelingsasanxiety,fear,anger,hate,tension,sadness,

sorrow,emotionalinstabilityorjoy,happinessandlovethat

arepresentintheVIPSmodelcouldnotbeexplicitlymapped

tothe ICF.However, these feelingscould bemapped on a

moregenerallevelasemotionalfunctions(b152)orfromthe

per-spectiveofchildren:functionsofappropriatenessofemotion

(b1520),regulationofemotion(b1521)andrangeofemotion

(b1522).Termstodescribecopingstrategies,lossofcontrol,

dependenceand helplessnessin theVIPSmodel could not

bemappedtotheICF,althoughsomefeaturesof

psycholog-icalcharacteristicsweredescribedundergeneralinterpersonal

interactions(d710–d729)intheICF.Thewillingnessofapatient

tocooperateorparticipate,asdescribedintheVIPSmodel,

could notbemappedto theICF.Further,psychosocial

fac-tors(such asfeelingsofsecurityor insecurityand trustor

mistrust)couldnotbemappedtotheICF.Itispossible,

how-ever,todescribeaperson’scharacterintheICF:forexample,

trustworthiness(b1267)isdeﬁnedas“amentalfunctionthat

producesapersonaldispositionthatisdependableand

prin-cipled,ascontrastedtobeingdeceitfulandanti-social”.Hence,

anassessmentbyanobservercouldbedescribed,whereasa

patient’sownfeelingoftrust,aspresentintheVIPSmodel,

couldnotbemappedtoICFterms.Spiritualandcultural

fac-tors(e.g.,meaningoflifeandperspectiveondeath,sickness

experiences,senseofbelongingandsenseofcoherence),as

presentintheVIPSmodel,couldnotbemappedtotheICF.

CoherenceispresentintheICFinrelationtoorganizinga

log-icalthinkingprocess,butdescriptionofamoreholisticsense

ofapatient’ssenseofcoherencecouldnotbemappedtothe

ICF.

ThereweretermsintheICFforsleepfunctions(b134)

regard-ing amount, onset, maintenanceand quality of sleep, but

termscoveringfeelingsoftiredness,exhaustionorfatigue,as

presentintheVIPSmodel,couldnotbemappedtotheICF.

TheICFfocusesonfunctionsthatshouldleadtopersonal

feel-ingsandexperiences,buttheactualresult(e.g.,thefeelingof

beingrestedorrelaxed)couldnotbeexpressed.Restis

men-tionedinthe ICFasanendgoalinrelationtothefunction

qualityofsleep(b1343),whichisdescribedas“mentalfunctions

thatproducethenaturalsleepleadingtooptimalphysicaland

mentalrestandrelaxation”.Thereisatermforexpressing

fati-gability(b4552),afunctionrelatedtosusceptibilitytofatigue

atanylevelofexertion.Thistermisconsideredamore

pre-cisedescriptionofexercisetolerancefunctions(b455).However,

fatigueinitself,asdescribedintheVIPSmodel,couldnotbe

mappedtotheICF.

Atermforsensationofpain(b280)doesexistintheICF,with

someexamplesofdifferentfeaturesofpain,butanelaborated

descriptionofthecharacterofpain(e.g.,terms forpattern,

durabilityandintensity)thatisdescribedintheVIPSmodel

couldnotbemappedtotheICF.TermsintheVIPSmodelfor

givingbirth,orrelatedtoaperson’sowndeath,couldnotbe

mappedtotheICF.

4.3. ICFtermsmappedintotheVIPSmodel

In all, 934 terms (66%) on levels 2–4 in the ICF could be

mappedtothekeywordsforpatientstatusintheVIPSmodel

(Fig. 3). Thekey wordactivity in the VIPSmodel was

suit-able for the largest amount of mapped terms in the ICF

(n=299),followedbythekeywordpsychosocial(n=187).The

keywordsspiritual/culturalandsleepwereleastfrequentlyused

formappedtermsfrom theICF,coveringonlysixandeight

ICFterms,respectively.TherewerenotermsintheICFthat

mappedintothekeywordwell-beingintheVIPSmodel.

Alto-gether,490ICFterms(34%)couldnotbemappedintotheVIPS

model,including280termsrelatedtobodystructuresand210

termsrelatedtootherissuesthatarenotintendedtobepart

oftheVIPSpatientstatuskeywords.Someanatomicalterms

intheICFfortheskincouldbemappedtotheVIPSkeyword

skin/integument,whereas therest ofthe anatomicalterms

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ARTICLE IN PRESS

8

coversarangeofareasnotrelevantfornursingandtherefore

notpossibletomaptotheVIPSmodel(e.g.,thelevel2category

intheICFforservices,systemsandpolicies)(e5).

5. Discussion

Themainﬁndingsinthisstudywerethatthetwomodels

stud-ieddevelopedfordifferencepurposes,haddifferentstructures

andcontent;thecontentforeachofthekeywords

represent-ingpatientstatusintheVIPSmodelcouldnotbemappedto

onesinglecategoryintheICFandthusseveralcategoriesinthe

ICFhadtobeusedtocoverthecontent;amajorityofpatient

statustermsintheVIPSmodelcouldbemappedtotheICF

(andoftenonamorespeciﬁclevel).Further,important

con-tentofrelevancefornursing,accordingtotheVIPSmodel,was

missingintheICF;whilethemajorityoftheICFtermscouldbe

mappedtothekeywordsforpatientstatusintheVIPSmodel.

IntheICF,66%ofthelevels2–4termscouldbemappedtothe

12patientstatuskeywordsintheVIPSmodel,indicatingthat

thosetermsarerelevantfordescribingnursingcare.

ThecategoriesintheVIPSmodelandtheICFdidnot

cor-respond fully,revealing structural differences between the

two,presumablyduetodifferencesinpurposeandtheoretical

frameworkunderpinningtheclassiﬁcations.TheVIPSmodel

isprocess-oriented,focusingonprovidingadocumentation

structureand content to reﬂectthe complete nursing

pro-cess.TheICF,incontrast,focusessolelyondescriptionsofthe

healthconditionsofpatientsanddoesnotclaimtocoverthe

entirecareprocess.TheﬁndingsindicatethattheICFcould

onlycorrespond to parts of a patient’s health status from

anursingperspective.Inthisstudy 62%oftheprototypical

examplesprovidedintheVIPSmodelcouldbemappedtothe

ICFand66%oftheICFtermscouldbemappedtothekeyword

structureintheVIPSmodel.Despitedifferencesinmapping

procedures,thereareresemblanceswithpreviousreportsin

which46%ofthetermsintheICFcouldbemappedtotheICNP

withanexactor partialmatch[23].Ourﬁndingsshowthat

asubstantial portionofrelevantnursingcontent described

intheVIPSmodelisnotcoveredbythecurrentlyavailable

termsintheICF.Otherstudiesregardingcomprehensiveness

intheICFinrelatedknowledgedomainshavereporteda

bet-ter matchbetween thecontent inassessmentinstruments

forspeciﬁchealthareaswiththeICFterms.Thus,reported

lowerﬁgures formissingtermsintheICFwerefound,e.g.,

for5%ofthecontentinhealthrelatedqualityoflife

instru-ments[24],20%inoutcomemeasuresforburninjuries[25],

and 23%forpatient reportedoutcome measuresrelated to

hemophilia,ofwhich10%wereconceptsonamoregeneral

andunspeciﬁclevel [26]. Comparisonmadebetweenterms

inthehomecareassessmentinstrumentInterRAI(Resident

AssessmentInstrument)homecareandtheICFclassiﬁcation

showedthat25%oftheassessmenttermscouldnotbecoded

withICFcodes,ofwhich15%wereonagenerallevelandnot

preciselydeﬁned[27].

Further,thecontentforpatientstatusintheVIPSmodel

covers moreareas than solely descriptions of health

con-ditionsinthat self-careactivities andassistingdevices are

alsoincorporated.Ontheotherhand,environmentalfactors

andbodystructuresareincludedintheframeworkoftheICF

togetherwithfunctionsandactivities.Thedifferencebetween

functionandactivityisemphasizedintheICF,whereasthe

VIPSmodelfocusesonactivitiesindailylifeandthus

sub-sumessomedegreeoffunctioning.Forexample,thedegree

andqualityofmusclepowercanbecategorizedintheICFas

musclepowerfunction(b730).Incontrast,intheVIPSmodel

it iscategorized aspartofthekeywordactivityand

there-forefocusesmoreonuseandconsequencesofimpairment

inactivitiesindailylifewherethefunctionisneeded.Inthis

casetheICFprovidesacleardistinctionbetweenfunctionand

activity,whichcouldbeusefulinnursing.

Onebasicpresumptionunderpinningthenursingprocess

istheindividualizationofnursingcareandpatients’active

engagementintheirowncare.Innursingitisimportantto

acknowledgethepatientsintheirlifecontext,whichincludes

thefamily,buttheICFhasastrongfocusontheindividualand

doesnotincludeafamilyperspective.Thisﬁndinglimitsthe

use-fulnessofICFforrepresentingfamily,orgroup-baseddescriptionsof healthstatus,and,asaconsequence,hindersthecomparisonand crossreference offamily-based conceptsfromnursing, e.g. Nurs-ingMinimumDataSets[28].Surprisingly,patientparticipation

isdifﬁculttoexpressusingspeciﬁctermsintheICF.Patient

participationismerelyusedasanoverarchingconceptinthe

ICFandthusmoreprecisetermsdescribingactual

participa-tionarelackingintheICF.ThetermsintheICFreﬂectmore

ofanassumingly objectiveassessmentofaperson’shealth

asdescribedbyhealthprofessionalsandnotbythepatients

themselves asactiveparticipantsincare.Asubjective

per-spective(e.g.,regardingfeelingsemanatingfromapatient’s

perceptionsandpreferences)isnotpossibletodescribeusing

theICF.Further,aperson’ssenseofqualityoflifeand

well-beingassubjectivedescriptions,presentintheVIPSmodel,is

notpossibletostateusingtheICF,butthedescriptions

pro-videdbytheICFtermscanbeseenasoperationalizationsof

amoreobjectivewell-being[12].TheICFneedstoexpandin

theseareastoincludeconceptsofqualityoflife,andthismight

alsoinvolveexpandingtheconceptualmodelofICFwith

qual-ity oflifeandhumandevelopment,as hasbeensuggested

intheliterature[29].Suggestionshavepreviouslybeenmade

regardingtheneedtoexpandtheICFclassiﬁcation,toconduct

amultidisciplinaryclinicalmodiﬁcationtograsptheneedsof

allprofessionalsgroups[30],andtheﬁndingsfromthisstudy

supportthissuggestion.IntheICFthereisaneedformore

speciﬁcterms(e.g.,skincondition,self-careandnutrition)in

severalareasofcentralimportancefornursing.Informationof

apatient’sskinconditionisanimportantpartofnurse

assess-ment, regardlessof clinical specialty. In the ICFprotective

functionsoftheskin(b810)coverarangeofhealthconditions

(e.g.,callusformation,hardeningandimpairments,suchas

skinlesions,ulcers,bedsoresandthinningofskin).More

spe-ciﬁctermsareneededintheICFtodescribeskinconditions

regardingcolor,cleanness, injuries,dryness,rashandstate

ofhealingthatcannotbeexpressedinthecurrentversionof

theICF.Anotherareaofvitalconcernfornursingisself-care.

Inthisrespect,theICFistoogeneral,i.e.,itdoesnotprovide

termsatasufﬁcientlevelofdetail.ByusingtheICF,a

descrip-tioncanbemadeofapatienthavingproblemswithself-care

(d5),e.g.,withwashingoneself(d510)(moreprecisely,washing

wholebody,d5101).Inadditiontothis,nursesneedtoconvey

(9)

assistapatient(e.g.,ifthereisaproblemforthepatientin

reachingvariouspartsofhisorherbody,usingtheshoweror

thesoap,orknowingtheproperorderinperformingpersonal

hygiene).

TheICFisusefulindescribingapatient’shealthstatuson

adetailedlevel. However,previous reportshaveshownthe

limitedusefulnessoftheICFindocumentingnursing

diag-noses[17]ortocrossreferencenursingdiagnosticconcepts

[28].ThislimitationisbecausetheICFdoesnotmeetcurrently

establishedqualitycriteriafornursingdiagnosis[16].

To reach a domain-speciﬁc (e.g., nursing) analysis of a

patient’s situation,asuitable theoretical framework

under-pinningtheprofessionalperspectiveinquestionisrequired.

Suchaframeworkwould alsohelpintheguidanceofwhat

dataandinformationareimportantinassessingthecurrent

situationand formaking interpretationsofthe assessment

ﬁndings.

5.1. Methodologicalconsiderations

TheuseoftheVIPSmodeltodepictcorenursingcontentfor

mappingwiththeICFstrengthenedthestudysinceitisawell

researchedand validated modeltodocument nursing

con-tentinpatienthealthrecordswhichiswidelyusedinvarious

clinicalareasofnursingcare,bothnationallyand

internation-allyinEurope.Inthisstudywechoosetoperformamapping

procedurebetweentheICFtermsandhealthstatuscontent

describedintheVIPSmodel.Nursingdiagnosesconceptswere

notincludedinthemappingastheICFtermsarenotcoherent

withthecurrentwayofstructuringandstatingnursing

diag-noses[1,2,16,17].Themappingprocedurehasbeenconducted

byresearcherswellacquaintedwithboththeVIPSmodeland

theICF,andrepeateddiscussionsamongtheauthorsyielded

consensusregardingthemappingofspeciﬁcterms.Initially

anattemptwasdonetoutilizemoreexplicitjudgment

cat-egoriesinthemapping:perfectmatch,broaderornarrower

concept.However,thatstrategywasabandonedsincethetwo

conceptualmodelscomprisetermsonquitedifferentlevels,

anditwasanticipatedthatthetermsintheICFweregenerally

describedonamoredetailedlevel.Atthesametimeabroader

conceptcouldalsobefoundhighupintheclassiﬁcation

hier-archyoftheICF.Adecisionwasmadetoidentifyconceptual

comprehensivenessandcompletenessbetweenthetwo

mod-els.TheoriginalICFclassiﬁcationwasusedinthisstudyand

possiblysomeoftheareasthatweremissing(e.g.,relatedto

termsforchildren)mighthavebeenidentiﬁediftheICF-CY

classiﬁcationhadalsobeenused.

6. Conclusion

and

clinical

implication

Thisstudy addressedthe content coverage ofthe ICFas a

standardizedclassiﬁcationfromanursingpointofview.The

ﬁndings indicated some problems in using a classiﬁcation

developedfromacertainprofessionalperspectivethataimsto

coverthatﬁeldofknowledgeandhealthcareactivityasa

uni-fyingclassiﬁcationforanotherprofessionalgroupinhealth

care– in this case nursing. The VIPS and the ICF operate

ondifferentlevels:hence,withsomedegreeofoverlapping

ofthe twoclassiﬁcationsystems, theycouldco-exist inan

EHR.TheICFclassiﬁcationprovidesdetailsonfourlevelsthat

willbenecessary forcomprehensivedocumentation inthe

healthrecord.However,theICFdoesnotprovideenough

cov-erageanddetailinsomeareasandaspectsofvitalimportance

innursingcare.Further,thetheoretical frameworks

under-pinningthe VIPSmodelandthe ICF,aswell asdifferences

in structure, level of detail and degree of process

orienta-tionneedtobeacknowledged.IftheICFistobeusedinits

currentformandcontent,withouttheuseofadditional

sup-plementingnursing-speciﬁccontent,thereisahighriskof

missingimportantdataandperspectivesonapatients

situ-ation,whichultimatelymayaffectthequalityandsafetyof

nursingcare.TheICFhasthepotentialformulti-professional

use,anddespiteitselaborateddetails,itneedstobedeveloped

andexpandedtoprovideacomprehensiveaccountfor

nurs-ingknowledgeinhealthcare.Furtherstudiesareneededto

addressthecontentoftheICFinrelationtonursingand

espe-ciallytheeffectofusingtheICFonpatientcareandnurses’

abilitytorecordandcommunicatenursing-speciﬁc

informa-tion.

Authors’

contribution

JF,AE,MEandCBdesignedandplannedthestudy,andwere

all activeinthemappingprocessandanalysesofthedata.

JFwasresponsiblefordraftingthemanuscriptwhileAE,ME

andCBmadecriticalrevisionsofthemanuscriptforimportant

intellectualcontent.

Conﬂict

of

interest

statement

Twooftheauthors(AEandME)aredevelopersandcopyright

holdersoftheVIPSmodel.

Summarytable

“Whatwasalreadyknownonthetopic?”

• TheVIPSmodelhasbeenwidelyusedandtestedin variousnursingcontexts.

• A multi-professional standardized terminology is neededinhealthcare.

• The ICF is suggested to provide a common frame-workandlanguageforallhealthprofessions,including nurses.

“Whatthisstudyaddedtoourknowledge?”

• ThisstudyinvestigatedthecontentvalidityoftheICF fromanursingperspective.

• TheICFcoversamostofthenursingcontentinthe VIPSmodelandoftenwithasufﬁcientlevelofdetails.

• Corenursingtermsandnursingperspectivesare miss-ingintheICF.

• TheICFtermscanlargelybemappedtothekeywords forpatientstatusintheVIPSmodel.

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