All in all, nearly 90% of the ICF categories which were identified as relevant aspects of functioning in the acute and early post-acute situation could also be linked with goals of nursing interventions. Therefore, the ICF categories and especially the ICF Core Sets are indeed highly relevant for nursing care.
Nursing interventions could be linked to a multitude of different aspects of functioning. However, some of these aspects were linked more frequently than others, particularly those related to respiration (Respiration functions, Additional respiratory functions and Respiratory muscle functions), consciousness and perception (categories from the ICF domain Mental functions), pain (Pain) and skin (Protective functions of the skin, Repair functions of the skin and Structures of areas of skin).
Functions related to respiration were linked with 15 out of the 48 nursing interventions, e.g. exercising effective coughing (included in "therapeutic intervention"), adequate positioning ("positioning"), early mobilisation ("mobilising"), chest tapping ("respiration support") or patient education, predominantly undertaken in post-acute settings ("patient-nurse communication/information giving"). These interventions prevent pulmonary complications or enhance patients' respiration performance. They are of prime importance since respiration functions are often impaired in the acute situation or at risk for being compromised by prolonged immobility. Therefore, interventions regarding respiration prevent severe sequels resulting from impaired breathing and related respiratory functions [27
Pain is linked with numerous interventions, ranging from "therapeutic intervention" to "mobilising", "positioning", "personal hygiene/dressing", "perception training" "compressions", "massage" and "elimination". The goal of these interventions is not only to treat and reduce pain, but also to prevent it, since pain is always a major concern for nurses in the acute care and therefore seen as a highly prevalent challenge [31
]. Furthermore, pain is also one of the most frequently addressed goals of physical therapists in the acute situation [33
Pressure ulcers and their prevention are the main challenges for nurses in hospital care and therefore must be treated by multimodal approaches [34
]. Consequently, one could expect that categories related to the skin were frequently linked with LEP nursing interventions in the acute situation.
Surprisingly, ICF categories related to consciousness and perception are also common goals of nursing interventions. This might be due to the increasing relevance of therapeutic concepts in rehabilitation nursing. Both specialized rehabilitation nurses in early post-acute facilities and nurses at intensive care units have adopted and are meanwhile familiar with treatment concepts used by other health professions, e.g. Bobath's approach to treat patients with hemiplegia [37
], Affolter's concept for people with brain injuries [40
] or the Kinaesthetics concept [41
]. All of those concepts assume that adequate perception is a precondition of human movement and more complex activities and should therefore be addressed prominently. Additionally, an impairment of consciousness, orientation and perception is common after an acute episode of illness or injury [42
] and will be addressed by most of the interventions, even by those ostensibly aimed at self care.
Although a total of 16 ICF Categories of the ICF Core Sets could not be linked to LEP nursing interventions (see Table ) these categories are nevertheless indispensable for nursing practice. ICF categories such as Seeing functions
, Hearing functions
or Immunological system functions
are important for nursing in the acute situation and have to be compensated or taken into account. They are, however, not directly addressed by nursing interventions with the intention to be regained or improved, nor can their loss be compensated by nursing interventions. For instance, seeing functions can be at risk due to impaired eyelid closure. Adequate nursing interventions in relation to the underlying condition are occlusive dressings or using artificial tears which directly aim to protect the conjunctives (covered by Structure of the eyeball
) and only indirectly seeing functions [43
The fact that Religion and spirituality was not linked to a nursing intervention needs a special annotation. Some might argue that religious and spiritual needs should be addressed by nursing interventions, because fulfilling these needs and beliefs is highly relevant for many patients, especially in critical situations after an acute episode. We agree with this, however, the ICF category Religion and spirituality does not describe spiritual and religious beliefs, which are Personal Factors that are not covered by the ICF yet, but a participation issue in terms of engaging in activities or ceremonies, what not seems to be a realistic goal in the early situation. Nevertheless, participation in religious activities may be very relevant for some acute patients and should therefore be enabled as soon as practicable.
"Therapeutic intervention", „patient-nurse communication/information giving" and "mobilising" were the most versatile nursing interventions linked with the highest number of different ICF categories (see additional file 1
). By definition of the LEP, "Therapeutic intervention" includes nursing interventions additionally performed besides the routine interventions with therapeutic intentions [44
]. These address the training of specific abilities, e.g. swallowing in patients with dysphagia, recapitulating lessons from speech or language therapy, or transferring from bed to the chair. „Patient-nurse communication/information giving" comprises each nursing intervention which seeks to inform or teach patients concerning their situation. Informing patients about their situation is essential at any time in hospital. Furthermore, teaching patients how to manage their new situation is of utmost importance for their recovery and rehabilitation, especially in the early post-acute situation and therefore might even influence a multitude of different aspects of functioning [45
]. Our finding, that "mobilising" is able to address several aspects of functioning is also in line with the literature [10
Even though 17 LEP nursing interventions (see Table ) could not be directly linked with patients functioning in terms of ICF categories, these are important for the caring process and therefore for patient outcomes. Some of these nursing interventions concern the field of team-communication ("Administration/Coordination", "Conference/Consultation with physician", and "Interdisciplinary Care Conference"), others are related to getting blood samples and conducting other kinds of tests. In our opinion, interventions concerning the administration of medication ("Inserting venous catheter", "Administering medication orally/rectally/vaginally or elsewhere", and "Injection") do not influence patients' functioning. This might seem counterintuitive. However, the effects of drugs and medical products – albeit influencing functioning – are quite distinct from the effects of drug application and ought not to be attributed to application.
Our findings confirm the results of a previous study insofar as nursing interventions could be linked to the ICF [15
]. However, in contrast to our study, the nursing interventions were derived from a different set of documentation terminology, and mainly focused on activities of daily living [46
]. Thus, the results are not comparable.
Our study has some limitations. The two experts carried out an integrated two-step linking process. The first step was to derive goals of interventions from their practical knowledge, the second step was to link these goals to the most appropriate ICF category. The linking process is straightforward and an established procedure. Goal definition, however, is subjective and depends on professional training and experience. Nevertheless, although our approach might be only an approximation, results are supported by the literature, indicating that there is general consensus on the goals of nursing interventions.
Another limitation pertains to the LEP nursing interventions catalogue. It is a comprehensive workload classification, but not scientifically evaluated regarding its comprehensiveness. Yet, it has been reported to be practical and feasible [7
], and it is used in a wide variety of settings by numerous institutions [8