=Paper=
{{Paper
|id=Vol-1574/paper3
|storemode=property
|title="IPLOS" - Countable Care?
Use of Care Mapping for Statistical Purposes in Norwegian Municipalities - What are the Challenges for Nurses?
|pdfUrl=https://ceur-ws.org/Vol-1574/paper3.pdf
|volume=Vol-1574
|authors=Jorunn Bjerkan,Hildfrid Brataas,Une Hallem
|dblpUrl=https://dblp.org/rec/conf/pahi/BjerkanBH15
}}
=="IPLOS" - Countable Care?
Use of Care Mapping for Statistical Purposes in Norwegian Municipalities - What are the Challenges for Nurses?
==
https://ceur-ws.org/Vol-1574/paper3.pdf
“IPLOS” - Countable Care?
Use of Care Mapping for Statistical Purposes in Norwegian
Municipalities – What are the Challenges for Nurses?
Jorunn Bjerkan1, Hildfrid Brataas1,2, Une Hallem3
1Nord University, dept. of Health Science, Levanger, Norway
2 Centre for Care Research Mid-Norway, Steinkjer, Norway
3 Municipality of Verdal, Norway
Abstract. Introduction: “IPLOS” is a central health register providing the basis
for mandatory national statistics on care in Norwegian municipalities. Data are
entered in IPLOS under 16 variables, for example “dressing” or “social
behavior”. A score reflecting the care level is assigned for each variable. The
aim of this study was to explore knowledge, skills and needs for increased
competence in IPLOS mapping among care providers and to pilot a
collaborative “World Café” training intervention. Methods: A three-step
sequential approach starting with a questionnaire, followed by field observation
of an intervention using the “World Café” method. The third step was a follow–
up questionnaire. Results: The first questionnaire showed that four IPLOS
variables were challenging to map and score. The World Café activated the
participants through discussions and reflections. The second questionnaire
showed no general improvement in mapping skills. Discussion and conclusion:
The nurses obtained an insight into their own IPLOS competence and lack of
competence, and their motivation for mapping. There seems to be a need for
more experience-based learning during everyday practice.
Keywords. Nursing assessment, municipal care, statistics, electronic patient
records, World Café method.
1 Introduction
In Norway, IPLOS is a tool for documenting and reporting care needs in
municipalities [1]. The system type and amount statistics of care required to meet all
individual patients' needs, and is used for organizing healthcare. Health care personnel
in Norwegian municipalities carry out the care mapping for planning and statistical
purposes. This study explored care providers’ perceptions on IPLOS mapping
challenges, and their experiences of learning additional mapping skills by attending a
World Café intervention.
Copyright © 2016 by the paper's authors. Copying permitted for private and academic purposes.
In: G. Cumming, T. French, H. Gilstad, M.G. Jaatun, E.A A. Jaatun (eds.):
Proceedings of the 3rd European Workshop on Practical Aspects of Health Informatics
(PAHI 2015), Elgin, Scotland, UK, 27-OCT-2015, published at http://ceur-ws.org
22
Individual-based statistics for nursing and care services (IPLOS) is a Norwegian
system of care mapping. The name “IPLOS” is an acronym for “Individbasert pleie-
og omsorgsstatistikk”, in English: “Statistics linked to individual needs for care”.
IPLOS was introduced in 2006 as a basis for mandatory national statistics for
municipal care. IPLOS information is collected about each individual patient or care
service recipient in care planning and care practice. (see Table 1 for an overview of
the variables and score levels). IPLOS mapping is carried out as soon as care needs
occur or change, unless the change is temporary. It is then followed up regularly.
National authorities collect municipal IPLOS statistics twice a year. The objectives
are to gain systematic knowledge of care in Norwegian municipalities, to develop
quality of care and to utilize resources optimally. IPLOS information is also used for
improving equality of care between municipalities, or even among care recipients
individually [1].
Table 1 IPLOS variable and score levels
Variables: Score levels:
Daily housework
Food and goods supply
Personal hygiene
Dressing/undressing
Toilet routines Score 1: No problems or challenges
Eating Score 2: No need for help/assistance
Walk around in house Score 3: Some need for help/assistance
Walk around outside Score 4: Great need for help/assistance
Take care of own health Score 5: Total need for help/assistance
Memory Score 9: Not applicable
Communication
Daily life decisions
Social activities
Control own behaviour
Score 1: Normal vision/hearing
Vision Score 2: Slight visual/hearing impairment
Hearing Score 3: Moderate visual/hearing impairment
Score 4: Severe visual/hearing impairment
Score 5: Blind or deaf
Score 9: Not applicable
Municipal care providers in Norway document healthcare in electronic health
records (EHRs) [2]. The three main EPR systems used in Norwegian municipalities
all include domains for IPLOS registration. System functionality varies from full
23
integration between daily care documentation and IPLOS registration to separate
domains for daily care documentation and IPLOS registration.
Implementing IPLOS, municipalities experienced discrepancies in IPLOS mapping
and documentation practices in different care districts. Therefore, one municipality in
mid-Norway conducted an internal survey on nurses’ practice and knowledge about
IPLOS mapping [3]. Nurses in the municipality expressed a need for more training in
IPLOS documentation. Our study was a follow-up. Were all the IPLOS variables and
criteria well understood? Could a collaborative learning intervention lead to more
knowledge and shared understanding of the IPLOS mapping among the care
providers?
Aim of the study:
• To gain insight into which variables were hard to map and score
correctly according to the criteria for the IPLOS variables.
• To find out whether care providers experienced any IPLOS variables
as challenging to understand.
• To explore whether the World Café method could stimulate
collaborative learning and increase competence in IPLOS mapping
and scoring among care providers.
2 Methods
In this study, we applied a multi-method, three-step sequential approach:
1: An initial questionnaire with questions on the 16 IPLOS variables as well as
some questions on the ICT system used.
2: Field observation of an intervention using the “World Café” method.
3: A follow-up questionnaire with identical questions to the initial questionnaire to
evaluate the result of the intervention.
This study was carried out in a medium-sized municipality in mid-Norway (14000-
15000 inhabitants in 2011).
2.1 Sample and sampling
The sample was information-rich and homogeneous [4] in that the respondents were
nurses and nursing assistants in health care services in the municipality who worked
with IPLOS mapping. Nurses and nurse assistants at one ward in a nursing home and
in one care district of the municipality were included. The 29 registered nurses
(bachelor’s degree level) and the 17 nursing assistants (technical college level)
working part-time or in fulltime positions at these two sites were asked to participate
in the study. An information note from the researchers requesting participation was
24
distributed in advance of the study. This study started in January 2011. The World
Café seminars took place during two weeks in April/May, and the last questionnaire
was distributed 20 weeks after the intervention period.
The objectives of the World Café meetings were 1) to learn from university college
teachers, 2) to engage in meaningful conversations about the four IPLOS variables
that were experienced as difficult to score, and 3) to promote future IPLOS scoring
competence experiences among the World Café participants. The World Café format
[5] created a dialog in order to explore questions in small group discussions and co-
create a learning culture aimed at raising the nurses’ competence in future scoring
practice. “The World Café is a simple yet powerful conversational process that helps
people engage in constructive dialogue, build personal relationships, foster
collaborative learning, and discover new possibilities for action”. The World Café
method is useful for creating dialogs and stimulating learning through reflection [6,
7]. The World Café method emphasizes an informal style and atmosphere, without a
focus on the performance of the participants [7]. The philosophy behind World Café
education is that each person has his or her interpretations and mental models of the
world, and individuals can broaden their understanding only by sharing viewpoints
and learning about alternative interpretations and understanding of various
alternatives for action [8].
2.2 The questionnaires
The questionnaires were developed especially for this study, because no
representative and validated questionnaire was found. We arranged a pilot test of the
initial questionnaire among 11 nurses who were using IPLOS mapping in a
neighboring municipality. After receiving their responses, we modified two questions
linguistically.
The questionnaires focused on two main areas:
• Understanding of IPLOS as a system for mapping nursing interventions and
care needs.
• Understanding of IPLOS registration challenges finding the correct level for
scoring care needs.
A third, minor area of the questionnaire focused on ICT system challenges in
mapping and scoring IPLOS variables.
The initial and follow-up questionnaires had identical questions about IPLOS
registration. There were four alternatives for answers in a Likert scale: Totally agree,
agree somewhat, disagree somewhat and totally disagree. Some parts of the
questionnaires included open areas for complementary comments. Questionnaires
were analyzed using SPSS 19, frequency analyses.
We used the results from questionnaire 1 for the following intervention, the World
Café. In a World Café process, each table has its own host. Groups of five to seven
participants circulate between the “café tables”, discussing the theme in focus at each
25
table. We arranged three café sessions each covering one or two of the four themes
identified in the responses to questionnaire one. To involve the participants working
shift hours, each café session was repeated once. Each session lasted for two hours.
Nurse education professors or assistant professors at the University College of
Nord-Trøndelag introduced each theme. After the introductions, the discussions at
each table started. For each group, the discussion at the table lasted for 15 minutes.
The groups then moved to the following two tables for 15 minutes each. At each
table, the host had prepared relevant questions to reflect upon within the theme,
served coffee and cakes, and stimulated discussion without interfering with the results
of the discussion. The participating groups documented their IPLOS challenges,
reflections, discussions and ideas for improvements. They sketched on paper at each
table in a way that was not focused on performance. The results from all participating
groups were collected and discussed in a plenary summary at the end of each seminar
[3].
The second questionnaire was distributed to participants 20 weeks after the
intervention. The period was chosen in order to allow time for IPLOS mapping
experiences and collaboration.
2.3 Ethics
The research project was approved by the Norwegian Social Science Data Services
(NSD). Participation in the study was voluntary. Department heads provided verbal
information to their employees before the questionnaires were distributed to
respondents. Written information and a consent form accompanied the distributed
questionnaires and the World Café intervention part of the study. All information was
kept confidential.
3 Results
3.1 The initial questionnaire
We received 19 answers for the first questionnaire, a response rate of 41.3 % of the
nurses and nurse assistants asked to participate in the study. The results showed that
four variables were more challenging than others to map correctly and document in a
proper nursing professional style; results are presented in the next paragraph, and in
Table 2. The results also showed that scoring “Some need for help/assistance” was
less challenging than other levels and that scoring “Great need for help/assistance”
was more challenging than other scoring levels.
26
3.2 The field study of the “World Café” intervention
In total, 46 health care personnel (29 nurses and 17 nursing assistants) participated in
the seminars. Based on the results from the initial questionnaire, three themes that
refer to the four ‘difficult’ variables were introduced, and thereafter discussed in the
seminars:
1. To control one’s own behavior.
2. To take care of one’s own health, AND to make daily life decisions
(two variables in one seminar).
3. To participate in social activities.
The results from these seminars showed that participants reflected upon each of the
challenging IPLOS variables in a professional way. They discussed which data and
which identification of patient needs by nurses would be relevant to include in IPLOS
mapping, and how to score variables at correct levels.
1. “To control one’s own behavior” was regarded as referring to both verbal and
physical behavior related to each individual health situation, illness and
emotional balance. The seminar participant’s interpretations of behavior and
causal connections then influenced criteria for score levels. Challenges in
understanding of the “behavior” variable were the staff’s acceptance level for
“uncontrolled” behavior, and variations for each patient during a day, e.g. in
connection with patients with dementia.
2. “To take care of one’s own health and to make daily life decisions”: The
participants showed little confidence in scoring these variables. They discussed
the patients’ scope and capability for decision-making and the difference between
scoring these variables in a home-care situation and in an institutional situation.
3. “To participate in social activities”: Motivation for and confidence in the
situation were elements highlighted in the discussion about the patient’s social
life. Challenges were factors such as scoring the possibility of active living and
needs for activity for the patients. Individual mapping including available
background information about individual patients was regarded as essential.
Summarizing comments from seminar participants were: “It is necessary to
implement IPLOS mapping routines”, and “All my colleagues should have
participated here”. Participants suggested changes in mapping practice, scoring more
frequently and pairs of two nurses mapping IPLOS.
27
3.3 The follow–up questionnaire
The second questionnaire was distributed to 15 nurses who had participated in two or
three seminars. Fourteen nurses answered (93.3 %). Comparing results from
questionnaire 1 and 2, we found minor, but no clear changes in understanding the
meaning of each IPLOS variables. See Table 2.
Table 2, "I know what these IPLOS variables mean", responses from questionnaires
before and after intervention.
IPLOS Survey number, Response alternatives
Variable and sample size
Totally Somewhat Somewhat or
agree agree totally disagree
Social 1st questionnaire, n 19 7 (36.8%) 8 (42.1% ) 4 (21.1%)
Activities 2nd questionnaire, n 14 4 (28.6%) 7 (50.0%) 3 (21.4%)
Take care of 1st questionnaire, n 19 8 (42.1%) 7 (36.8%) 4 (21.1%)
own health 2nd questionnaire, n 14 6 (42.9%) 6 (42.9%) 2 (14.3%)
Daily life 1st questionnaire, n 19 5 (26.3%) 9 (47.4%) 5 (26.3% )
decisions 2nd questionnaire, n 14 7 (50.0%) 4 (28.6%) 3 (21.4%)
Control own 1st questionnaire, n 19 6 (31.6%) 8 (42.1%) 5 (26.3%)
Behaviour 2nd questionnaire, n 14 5 (35.7%) 8 (57.1%) 1 (7.1%)
Was there a difference in knowledge about how to score each IPLOS variable from
the first to the second survey? Comparing the results, we found changes from
questionnaire 1 to questionnaire 2. The majority of answers showed increased
understanding for the “somewhat agree” statement. Fewer nurses totally disagreed
with the statement on knowing how to score all IPLOS variables after the
intervention. For those who totally agreed that they knew how to score some of the
variables in the first questionnaire, the results varied from no change to both higher
and lower agreement with the statement in the second questionnaire.
28
Table 3, "I know how to score each IPLOS variable", answers from questionnaires
before and after intervention.
Score levels: Survey number, ¨ Response alternatives
and sample size
Totally Somewhat Somewhat or
agree agree totally disagree
Score no 1: No 1st questionnaire, n 19 4 (21.1%) 5 (26.3% ) 9 (47.4%)
problems or challenges 2nd questionnaire, n 14 1 (7.1%) 10 (71.4%) 3 (21.4%)
Score no 2: 1st questionnaire, n 19 5 (26.3%) 4 (21.1% ) 7 (36.8%)
No need for assistance 2nd questionnaire, n 14 10 (71.4%) 3 (21.4%) 1 (7.1%)
Score no 3: Some need 1st questionnaire, n 19 3 (15.8%) 7 (36.8%) 6 (31.6%)
for assistance 2nd questionnaire, n 14 3 (21.4 %) 11 (78.6%) 0
Score no 4: Great need 1st questionnaire, n 19 6 (31.6%) 1 (5.3%) 9 (47.4%)
for assistance 2nd questionnaire, n 14 1 (7.1%) 9 (64.3%) 3 (21.4%)
Score no 5: Need for 1st questionnaire, n 19 4 (21.1%) 3 (15.8%) 9 (47.4%)
full assistance 2nd questionnaire, n 14 2 (14.3%) 8 (57.1%) 4 (28.6%)
Score no 9: 1st questionnaire, n 19 7 (36.8%) 1 (5.3%) 7 (36.8%)
Not applicable 2nd questionnaire, n 14 5 (35.7%) 3 (21.4%) 6 (42.9%)
The responses to the initial questionnaire did not highlight ICT as one of the major
challenges in mapping practice, thus this subject was not specifically addressed in the
World Café seminars. The answers in the second questionnaire nevertheless showed
that fewer nurses answered ‘totally agree’ when asked whether they had had suitable
ICT training after the intervention period than in questionnaire 1, before the
intervention.
Asked if they thought the EHR system was difficult to use for mapping and scoring
IPLOS variables, more nurses totally agreed with that statement after than before the
intervention, and vice versa: more nurses totally disagreed to the statement before
than after the intervention.
Table 4, ICT training and documenting challenges in the EPR system. Answers from
questionnaires before and after intervention.
Survey questions Survey number, Response alternatives
and sample size
Totally Somewhat Somewhat or
agree Agree totally disagree
Suitable ICT 1st questionnaire, n 19 13 (68.4%) 1 (5,3% ) 5 (26.4%)
system training for 2nd questionnaire, n 14 3 (21.4%) 8 (57.1%) 3 (21.4%)
IPLOS mapping
Difficult to use 1st questionnaire, n 19 1 (5.3%) 10 (52.6%) 7 (36.8%)
the EHR system 2nd questionnaire, n 14 5 (35.7%) 7 (50.0%) 2 (14.2%)
for IPLOS mapping
29
4 Discussion
The first survey identified challenging areas of IPLOS mapping. The World Café
activated the participants by discussions and reflections, but the second questionnaire
did not indicate an improvement in their understanding of the ‘difficult’ IPLOS
variables. There seems to be some change in their knowledge about how to score each
IPLOS variable.
• Understanding IPLOS as a system for mapping needs for nursing care seems to
be changing among the participants. Motivation for IPLOS mapping was
expressed during the intervention. The results from the second survey did not
reflect change in understanding and mapping practices.
• Understanding IPLOS registration challenges due to scoring the intervention
needs at a correct level still seemed problematic several weeks after the
intervention.
It is uncertain whether the World Café participants had any learning outcome from
lectures given by the teachers of the University College. On the other hand, the
findings showed that the participants in the World Café seminars discussed both
relevant professional matters and technical mapping problems. The occurrence of
open discussions is consistent with World Café method theory [7, 8]. We found that
participants showed interest in increasing their competence, but results from
questionnaire 2 showed no clear indication of increased mapping or scoring
competence.
The World Café method is considered to be a suitable methodology for educating
groups of people [6, 7]. In this project, the World Café method seem to be useful for
creating dialogs and to stimulate learning through reflection, in line with other
research findings [6, 7]. The participants were also motivated for collaborative
learning by suggesting mapping IPLOS variables together in pairs. This is also in
accordance with World Café method theory [5, 7]. In line with the philosophy of the
World Café method [8], participants expressed their own perspectives, collaborated,
and extended their knowledge.
The data from the questionnaires and the seminars showed a change in
understanding of the content of IPLOS variables. The results from the World Café
method may indicate learning as described in the theory of group-based experiential
learning through reflection on experience from practical professional work [9]. On the
other hand, the results of this study do not indicate that use of a World Café method
improved the care staff’s confidence in their own IPLOS mapping and scoring
competence, and therefore they were motivated for more collaborative learning and
mapping practice. This corresponds with results regarding needs for ICT training and
learning about how to overcome EHR documentation challenges regarding IPLOS
mapping.
The intervention in this study, and use of the World Café method, relied on the
nurse’s experience-based knowledge. During the World Café discussions, they could
support each other in learning about the four mapping variables they all seem to feel
uncertain about. By collaborating, they could gain knowledge from the “zone of
proximal development” [10]; the zone of what was difficult was about the same for all
30
participants. This could lead to a feeling of equality that supported the collaborative
discussions underlined as a philosophy of the World Café method [8]. This may have
led to an increase in collaborative learning confidence as well as a stronger focus on
participants’ own mapping and scoring challenges seen in the results of the second
questionnaire. We consider this to be relevant learning in the sense that nurses
obtained an insight in their own IPLOS competence and even more important;
insights into areas where they did not have enough knowledge.
During everyday nursing practice, IPLOS mapping should be learned gradually,
like learning other complex skills. Ways of working that include organizational
changes and ICT systems have been found to take 17 years to implement [11, 12].
People learn from remembering something and may then analyse and evaluate
knowledge, and in the end learn to use the knowledge in a situation-based way [13].
In the learning process during the World Café seminars, the participants stated that
they had increased their understanding of IPLOS mapping and scoring as such.
Understanding the challenge in utilizing this knowledge also seemed to increase. In
line with theory and research underlining that learning about new mapping systems
and change of practice may last several years, our results underline a need for more
time for learning activities [14]. The World Café created an opportunity for
reflections, although these were not necessarily followed up in daily mapping
practices. From the World Café experiences, we learned that nurses wanted to sit
down together in pairs to discuss, map and document the IPLOS variables and scores
before entering the results in the patient EHRs. This collaboration during mapping
practice may support learning in a situation-based way [13]. On the other hand, there
seemed to be a need for development of methods and tools to support nurses in their
learning and mapping of countable care. After completion of this study, the
Norwegian Directorate of Health has identified training needs [15, 16], and generated
an e-learning platform to support nurses in learning IPLOS mapping practice [17].
4.1 Study limitations
No validated questionnaires regarding content, criteria and knowledge about IPLOS
variable scoring were found. Another limitation was the low number of participants in
the study. To obtain statistically significant results, there is a need for larger samples
in future research. Respondents from only two care entities of one municipality also
represented a limitation that may make the results of the study less representative.
5 Conclusion
Charting experiences of challenging IPLOS variables and scoring levels, followed by
three World Café seminars, seemed to support the participants in obtaining an insight
into their own IPLOS competence and lack of competence, and to heighten their
motivation for mapping. The results indicate that collaborative learning and reflection
during World Café sessions may provide more insight into each participant’s
31
knowledge level. There seemed to be a need for more training to achieve relevant
competence and a need for more experience-based learning during daily practice.
Acknowledgments We want to thank the nurses who answered our questionnaires
and participated in the World Café seminars. We also want to thank Gunn Wolden,
Aud Moe and Bente Northug for being lectures in the World Café seminars. Finally,
thanks to Margaret Forbes for her contribution in improving the language of the
article.
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