Community Practitioners' and Health Visitors' Association

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New Approach to Health Visiting Documentation:
  The OMAHA Project - A brief Overview


There has been increasing pressure to demonstrate that nurses, and in particular health visitors, provide a service that is value for money. "Realising the Potential" (Welsh Assembly 2000) has stated that the value of nursing needs to be demonstrated.One of the ways this can be done is through the routine measurement of nursing outcomes. Practitioners are more concerned with clinical outcomes than service outcomes. A clinical outcome may be defined as a change in the clientís condition or health status that is related to an intervention.

The recently completed review of Health Visiting and School Nursing for Wales found that there wasnít a Trust in Wales that could demonstrate what health visitors are doing, how they are doing it, for what clients and with what problems. Trusts in Wales therefore have no idea about whether they are receiving value for money or whether they are achieving clinical effectiveness.

Documentation poses special difficulties for health visiting as it is a universalist, preventative service, which does not necessarily focus on problems. The range of topics is wide, covering not only health topics but also social issues. The timescale for dealing with issues can be very long, much more so than in the acute setting, with some issues taking many months or more commonly years, before they are resolved. Another issue that can be problematic is that health visitors deal not only with individuals but also with entire families or even communities.

Previous attempts to measure outcomes have centred on population profiles or broad aggregated goals such as activity levels. Research has demonstrated that the measurement of activity levels and the counting of contacts provides very little information about the quality of a service (Symonds 1997, King 1995), but to date there hasnít been another system to replace it.

A group of health visitors from Swansea and Bro Morgannwg Trusts got together under the leadership of Professor Dame June Clark to consider these problems. They decided that the solution lies in the retrospective analysis of client records. Before this could be done the records needed to be structured, use a standardised language and contain key elements (a minimum data set). As shown in the diagram these key elements needed to contain diagnoses, interventions and outcomes, which are interdependent.

As a standardised language is not in use in the UK at present, the team looked to what was going on in other parts of the world. The Omaha System, developed by the Visiting Nursing Association of Omaha, Nebraska in the USA was chosen because it was developed specifically for community nursing and provided a structured framework which utilised a standardised nursing language that described and measured nursing problems, nursing actions and client outcomes It has been well validated for use in the community since the 1970ís in a variety of settings.

The research programme has been conducted in two phases. In phase one, a pilot study was carried out over a period of three months from January to March 1999,
involving 17 health visitors collecting data on a specially designed encounter form, with all families who had babies born within that time frame. At the end of the study participating health visitors were asked to complete a questionnaire, which asked them to compare the Omaha System with their present documentation system. The results showed that health visitors overwhelmingly felt that the Omaha system was a better documentation system than their present system.

Following the success of phase one of the study the group made a successful bid for a CPHVA/ DOH Centenary award of eight thousand pounds which was used to finance the second stage of the project.

In phase two of the study, 30 health visitors were enlisted from Swansea and Bro Morgannwg Trusts to test the use of the Omaha System with a much broader variety of clients, and over a period of 9 months finishing at the end of July 2000. Health visitors were asked to record their contacts with families on an encounter record that is divided into three broad categories:

The first section covers service details. A code is entered for the type of visit the health visitor is doing followed by a code for the Patientís Charter.

The second section of the encounter record is about the nursing diagnosis or focus of intervention. The health visitor first writes in which client the problem is relating to, as every member of the family is recorded on the same sheet. So they write in F if they are talking about the whole family, or I if itís an individual within the family, but they also have to identify the family member. They then write a few key words that describe the health topic they are discussing, and then code it from the problem classification codebook that the team developed. In the next axis the health visitor qualifies the diagnosis by writing P (problem), R (risk of problem) or N (no problem at all i.e. health promotion). The KBSC scoring is then completed for each topic discussed. A score is given for knowledge, behaviour, status and coping on a Likert scale of 1- 5, where 1 is the least desirable outcome and 5 is the best. It is the repeated measurement of KBSC over a series of visits that results in a change in outcome. Another way of measuring outcomes is by seeing how many Pís and Rís become Nís.

The third section of the encounter record is about the interventions that the health visitor undertakes. She can record any number of the broad categories of Assessment, Teaching, Case Management and Procedure, followed by a short description.

If the Omaha System were used on all clients by all health visitors, then the list of most commonly used topics that would result, would enable the development of an epidemiology of health visiting.

Although data entry and analysis for phase two is not yet complete, results are indicating that the system appears to work and already itís spreading. Swansea and Bro Morgannwg Trusts have adopted the Omaha System to evaluate their Sure Start programmes, and health visitors in different parts of Britain have expressed interest in trying out the system.

Further research includes the development of a computerised prototype and a more detailed intervention classification scheme than is used at present. This will add greater clarity to the process of health visiting and make it possible to link specific interventions to improved outcomes.

King W. (1995) Counting what counts. Health Visitor 68, 1, 14- 15.

Symonds A. (1997) Medical Mantras: Why health visiting risks losing its way. Health Visitor 70,3,99-100

The National Assembly for Wales (1999) "Realising the Potential". A Strategic Framework for Nursing, Midwifery and Health Visiting in Wales into the 21st Century. Cardiff: The National Assembly for Wales.