Introduction

The primary therapeutic approach for end-stage organ failure is transplantation [1]. With the advancement of transplant technology and the increasing elderly population, advanced age is no longer considered a contraindication for liver transplantation. In the 2013 Guidelines for the Evaluation of adult liver transplant recipients, both the American Liver Association and Transplantation Society stated that individuals aged ≥ 70 years are suitable candidates for liver transplantation [2]. However, as the number of procedures and survival rates among elderly liver transplant patients continue to rise, there are also an array of nursing challenges.

It has been reported that elderly patients have very high demands for nursing issues such as drugs, diet and self-monitoring during the home recovery period after surgery, reaching 97.4%, 94.7% and 81.6% respectively [3]. Nursing issues are expressed through a series of specific assessment indicators, enabling the most comprehensive assessment of patient outcomes. However, current sensitivity indicators for liver transplantation in China primarily focus on evaluating the quality of hospitalization, inclined structure and process control. Lacking patient outcome-oriented nursing sensitivity outcome indicators, especially in elderly patients, has not been addressed [4]. The Omaha Problem Classification System encompasses 42 nursing problems and thousands of evaluation indicators across four domains: physiological, psychosocial, health-related behavior, and environment. This system has been extensively utilized to evaluate nursing sensitivity outcomes in various conditions such as diabetes [5], inflammatory bowel disease [6], and bladder cancer after surgery [7], achieving positive results. Therefore, this study adopts the Omaha Question Classification System [8] as its framework and applies the Delphi method [9] to establish a nursing sensitivity outcome index system tailored for elderly patients undergoing home recovery after liver transplantation—providing nurses with a theoretical foundation for implementing an accurate group continuous nursing model.

Method

Set up a research group

The research team was established, comprising specialist nurses, head nurses, department directors, outpatient nurses, and researchers. Their primary responsibility involved determining the selection of topics, formulating indicators, selecting experts, collating data, and conducting analysis.

Develop a sensitivity outcome index system for home nursing of elderly liver transplant patients

In this paper, “Omaha problem classification system”, “elderly liver transplantation”, “home care”, “extended care”, “system construction”, “nursing sensitivity outcome indicators”, “quality evaluation/quality improvement/quality management” were used as the search terms. The search was conducted in Chinese databases (such as CNKI, Wanfang, Weipu) and English databases (such as Pubmed, Sciencedirect, Springer). The search time limit: from the establishment of the database to November 1, 2023.

After sorting and screening literature and discussion by the research group, a draft outcome index system for elderly liver transplant patients’ home care sensitivity based on the Omaha problem classification system was formed. Five experts were invited to participate in a pre-letter consultation. The selection criteria for the inclusion of these experts were as follows: an age range of 47.75 ± 3.34 years old, possessing a professional title of intermediate or above, and being actively involved in liver transplantation nursing more than ten years. After consolidating the expert opinions, a formal letter questionnaire was developed. This questionnaire comprised three sections: (1) An expert letter questionnaire that utilized the Likert 5-level scoring method to assess the importance of indicators. (2) General information about the experts, including their professional titles, ages, education levels, and years of experience. (3) The basis for expert judgment and familiarity with the index questionnaire. (The expert letter questionnaire is detailed in Annex I.)

Determine the expert for correspondence consultation

A total of 20 experts in China from tertiary hospitals and universities were selected. The pre-set inclusion criteria were as follows: (1) medical or nursing education experts from universities who willingly accepted letter inquiries and committed to continuous participation in the project. (2) possessing intermediate or higher professional and technical titles. (3) having more than 10 years of experience in liver transplantation nursing or being specialist nurses in liver transplantation. (4) holding a Bachelor’s degree or higher.

Implement expert letter consultation

Our study carried out two rounds of expert consultation from February to April 2023. The paper or electronic questionnaires were distributed by the same researcher to experts, and the interval between each round of survey was two weeks. Likert 5-point scoring method was also used to evaluate the importance of each item. The questionnaire was equipped with a modification column for experts to propose modification, addition and deletion. After two rounds of letter consultation, the expert opinions were basically reached. According to the expert opinions, the indicators were included to meet the criteria of the mean value of importance assignment ≥ 3.50 and the coefficient of variation < 0.25 [10]. After the collective review of the research team, the sensitivity outcome index system of home care for elderly patients with liver transplantation was confirmed.

Data processing

Using SPSS 22.0 statistical software, data entry, analysis, and finalization were conducted. Count data were presented as frequency and percentage. Measurement data were expressed as mean ± standard deviation and coefficient of variation. The recovery rate of questionnaires and the submission rate of opinions served as indicators for expert positivity coefficient determination. The authority coefficient (Cr) of experts was calculated using the judgment coefficient (Ca) and familiarity coefficient (Cs). The degree of agreement among expert opinions was assessed through the coefficient of variation and Kendall coordination coefficient W.

Results

Expert situation

A total of 20 experts from 9 cities, including Qingdao, Shanghai, Guangzhou, Tianjin, Beijing, Guiyang, Xi’an, Wuhan and Hangzhou successfully completed two rounds of effective letter consultation. Among them were 9 liver transplant specialist nurses or professional committee members (45.0%), 5 liver transplant nursing managers (25.0%), 3 liver transplant surgeon experts (15.0%) and 3 liver transplant nursing education experts (15.0%). The average age of the experts was (43.25 ± 2.20) years old. Among them, the working years of liver transplantation were (13.3 ± 2.20) years, 15 experts (75.0%) had associate senior title or above, and 5 experts (25.0%) had intermediate title. There were 9 bachelor degree holders (45.0%), 6 master degree holders (30.0%) and 5 doctor degree holders (25.0%).

Degree of expert activeness

The effective recovery rate of the two rounds of correspondence questionnaires was 100%, and constructive suggestions were put forward by experts in each round, indicating that experts were highly motivated, as shown in Table 1.

Table 1 The degree of expert activeness
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Degree of expert authority

As shown in Table 2, two rounds of correspondence of expert authority coefficient (Cr) > 0.80. This suggests that the study possesses a significant level of expert authority and yields credible research findings.

Table 2 Expert authority degree
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Expert opinion coordination degree

The Kendall coordination coefficient W ranges from 0 to 1, and the greater the W, the better the degree of expert coordination [11]. As shown in Table 3, the significance test of the coordination coefficient of the two rounds of letter consultation in our study showed statistical significance, indicating that the expert opinions were coordinated and reliable (Table 4).

Table 3 Expert opinion coordination degree and significance test
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Expert letter inquiry results

Table 4 The first and second round of expert letter consultation revised the indicators
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After two rounds of expert consultation and group discussion, 4 first-level indicators, 20 s-level indicators and 72 third-level indicators were finally established. The analytic hierarchy process was used to determine the weight and combined weight of each index, as shown in Table 5.

Table 5 Results of expert letter inquiry on evaluation index system of nursing problems of liver transplant patients at home
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Discussion

Scientific and reliability analysis of index construction

Through literature review and clinical research, this study use of Omaha question classification system, through the enquiry for two rounds of the Delphi method, build the index system of nursing sensitivity in elderly patients with liver transplantation outcome. This study provides a solid theoretical basis for extending nursing services to patients and has a strong scientific basis. The effective recovery rate of the two rounds of questionnaires was 100%, and the experts in each round could put forward constructive opinions, indicating that the experts had good participation and attention. The authority coefficients of the two rounds of consultation were 0.904 and 0.905, respectively, indicating that the experts were familiar with the content of the field and the judgment basis was strong. The Kendall coordination coefficients of the first-level, second-level and third-level indicators obtained by expert consultation were 0.419, 0.418 and 0.394, respectively. The mean of each index was ≥ 3.50, and the coefficient of variation was < 0.25, which indicated that the expert opinions tended to be unified and the reliability was good.

Index construction can be comprehensive and targeted

Environment field

Environment field is the most neglected but extremely important. Zhao QF et al. [12] point out that income and hygiene are the key factors affecting the prognosis and quality of life of elderly patients. The same argument was made in our study, the income and hygiene also ranks the top two in the environment field. “Internet + Extended nursing service” can enable medical staff to guide elderly patients’ postoperative self-management remotely and effectively [13]. “Internet + Extended nursing service” can improve the ideological consciousness of elderly patients through popular science education and other forms, and fundamentally eliminate unclean practices and dirty environments. However, at present in China, many remote and rural areas [14] still lack network signals and terminal equipment. Health education resources for elderly patients after transplantation are very limited, and the source of income is also uncertain. Therefore, the national government also needs to improve medical insurance [15], remote service [16] and other aspects, so as to reduce the economic pressure of elderly patients. To improve health conditions, the weight value of the third-level indicator “lack of network/device " in this study is 0.030, which is much higher important than other indicators, which also indicates that experts believe that the construction of telemedicine services is very important, which is also in line with the development trend of “Internet + Extended nursing services”.

Psychological field

In the psychology field, the average scores of “connection with community resources” and “family care/emotional support” both reached 5.00 ± 0.00, ranking the top two in this field, indicating that experts attach great importance to these two indicators. At present, the construction of advanced nursing practice model of liver transplantation is still being explored in China. The community medical service resources available to postoperative patients are very limited [17], resulting in heavy burden of family care, especially for elderly patients due to lack of knowledge, low self-management behavior and other reasons, which aggravate the burden of family care. In contrast to developed countries, they have formed a hospital-community-family integrated nursing pattern. The problem of home care for liver transplant patients can be systematically solved [18].

The weight of the outcome indicator “mental health” was 0.040, ranking the third. Gu Yanmei et al. have shown [19] that the mental health of elderly liver transplant patients is at a low level. Moreover, the degree of mental health is closely related to family care [20] and social support [21]. State-owned literature also pointed out that the mental health problems of elderly liver transplant patients after surgery may be closely related to the lack of community medical resources [22] and family care [23]. Therefore, in order to truly solve the social and psychological problems of patients, it is necessary for the state to increase the construction of primary medical units and build the construction of hospital-community-family medical union, to meet the social and psychological needs of elderly liver transplant patients.

Physiological field

In the physiology field, the three most prominent indicators are “oral hygiene,” “infection,” and “skin numbness,” with respective values of 0.067, 0.063, and 0.045. Notably, “oral hygiene” holds the highest weight ratio among them It is well known that the oral cavity serves as a primary site for bacterial colonization. Prolonged usage of immunosuppressive drugs like rapamycin may result in oral ulcers and compromise the integrity of oral mucosa [24]. Only by maintaining proper oral hygiene can infections be prevented effectively. Furthermore, the weight values of the three-level indexes “oral ulcer” and “oral mucosal integrity” also ranked first and second, indicating that the experts’ views were consistent with those of the literature.

The reason for the analysis of “infection” index may be that the T lymphocyte immune response of liver transplant patients after long-term immunosuppressants is suppressed, and the immune function of elderly patients is lower than that of the general population. Moreover, under the influence of the novel coronavirus epidemic for three years, elderly patients are more likely to be infected, which is also consistent with the research results of Cui Heng et al. [25].

“Skin numbness” may be related to peripheral nerve injury and ischemia in the operative area [26]. The weight and combined weight of the subordinate tertiary index “skin scar numbness at surgical incision” rank first in this field, which also indicates that experts attach great importance to the problem of postoperative local skin numbness and unconsciousness of patients.

The “abnormal blood sugar " and “diarrhea” are indicators with high weight value in this field, indicating that experts attach great importance to these two indicators. Yujian Z et al. [27] also point out that hyperglycemia and diarrhea are also the most common complications of elderly liver transplant patients at home after surgery. Therefore, the government of China need to increase the intelligent construction of primary medical units, so that medical staff can use the network to achieve linkage management. In order to better self-monitoring of elderly liver transplant patients at home.

Health behavior related fields

The only health behavior field with an average score of 5.00 ± 0.00 was “drug treatment compliance”, highlighting the significant emphasis experts place on postoperative medication for elderly liver transplant patients. It also indicates that poor drug compliance is relatively common in the substantive organ transplantation field [28]. Domestic studies [29] show that 39.40-78.38% of liver transplant recipients have poor medication compliance, which may be attributed to elderly liver transplant patients’ old age, memory loss, and the variety, quantity and duration of medication taken at home after surgery. In the absence of supervision by medical staff, there is a sense of burnout, and occasionally in the case of missing medication, there is no significant change in physical function. In the long run, the patient will let his guard down in his mind, leading to low adherence to medication.

In addition, in this field, the average scores of “nutrition” and “substance abuse” are also greater than 4.50 ± 0.00, indicating that experts attach great importance to these issues, which is also consistent with Fuchi Yang et al. [30]. It indicate that patients’ overall self-management behavior at home needs to be improved. It is more necessary for the state to increase the intelligent construction of grass-roots medical units, so that medical staff can use the network to achieve linkage management, and build the construction of hospital-community-family medical union, so as to meet the needs of patients’ health behaviors.

Indicators have clinical applicability

When implementing the evaluation of the sensitivity outcome index system of home care for elderly liver transplant patients established in this study, medical staff should also receive standardized training and convert the indicators into plain language to ask patients, so as to integrate the core nursing problems faced by patients at home. In addition, the standardized expression of nursing problems in our study was mostly adopted in the Omaha problem classification system, which laid the foundation for the establishment of a unified language for electronic nursing information system, the unification of the expression of nursing information between different institutions and different staff, and the creation of high-quality “Internet + nursing” service.

Conclusion

Based on the Omaha problem classification combined with Delphi method, our study constructed a sensitivity outcome index system for home nursing of elderly liver transplant patients, providing a theoretical basis for nursing staff to build an accurate individualized continued nursing model. However, due to the lack of knowledge and time of researchers, the effectiveness and effectiveness of indicators need to be continuously adjusted in clinical application, and the combination of Internet technology in extended care to further improve patients’ self-management ability is also a future development trend.