Implementation of Improvements in an Electronic Documentation Nursing Process System Structured on NANDA-I, NOC and NIC (NNN) Classification.

The aim of this study was to present the experience of a teaching hospital with the implementation of improvements to an electronic documentation system of the nursing process (PROCEnf-USP®). The improvements were based on functional performance and technical quality of the system. It was adopted Scrum™ method for version control PROCEnf-USP® by enabling agility, flexibility and possibility of integration between development and users. The PROCEnf-USP® has been used since 2009 and has professional and academic environments. The current version lets you generate reports and supports decisions about diagnoses, outcomes and interventions. It is provided the use of indicators to monitor results and registration at the point of care. The establishment of important.

Caregiver role strain: bi-national study of content validation / Cansancio del rol de cuidador: estudio binacional de validación de contenido / Tensão do papel de cuidador: estudo binacional de validação de conteúdo

Objective.To estimate content validity of the diagnosis Caregiver Role Strain. Methods. Content validation of the defining characteristics according to Fehring's model was undertaken by 6 Colombian nurses and 9 Brazilian counterparts. The relevance of each defining characteristic for the diagnosis was assessed using 5-point Likert type scale. The Mann-Whitney test was used to estimate differences in assessing the relevance of defining characteristics between Brazilian and Colombian nurses. Results. From 36 defining characteristics, 22 were identified as major, 13 as secondary and one as irrelevant (rash). The content validity index(sum of weighted averages divided by the total number of defining characteristics) was 0.79, considered adequate. Conclusion. Most of the defining characteristics were considered relevant to the nursing diagnosis Caregiver Role Strain. These findings reflect consensus among specialists from two different countries in relation to the relevance of the defining characteristics for this diagnosis.

Objetivo.Estimar la validez de contenido del diagnóstico Cansancio del rol de cuidador. Métodos. Validación de contenido de las características definitorias por seis enfermeras colombianas y nueve enfermeras brasileñas, de acuerdo con el modelo de Fehring's. La relevancia de cada característica definitoria para el diagnóstico se evaluó utilizando una escala Likert de cinco puntos. Resultados. De las 36 características definitorias, 22 se identificaron como principales; 13, secundarias y una como irrelevante. No hubo diferencia entre las puntuaciones atribuidas por las enfermeras brasileñas y colombianas. El puntaje total de validez de contenido del diagnóstico (sumatoria de los promedios ponderados, medias ponderadas divididas por el número total de características definitorias) fue adecuado (0.79). Conclusión. La mayoría de las características definitorias fueron consideradas relevantes para el diagnóstico Cansancio del rol de cuidador. Estos hallazgos reflejan un consenso entre expertos de dos países diferentes con relación a la relevancia de las características definitorias para el diagnóstico.

Objetivo.Estimar a validade de conteúdo do diagnóstico de enfermagem Tensão do papel de cuidador. Métodos. Validação de conteúdo das caraterísticas definidoras por 9 enfermeiros brasileiros e 6 enfermeiros colombianos, segundo o modelo proposto por Fehring. A pertinência de cada caraterística definidora ao diagnóstico foi avaliada por meio de escala tipo Likert de 5 pontos. Resultados. Das 36 caraterísticas definidoras 22 foram identificadas como principais, 13 como secundárias e uma como irrelevante. A pontuação total de validez de conteúdo do diagnóstico (somatória das médias ponderados dividida pelo número total de características definitivas) foi adequado (0.79). Não houve diferenças entre as pontuações atribuídas pelos enfermeiros brasileiros e colombianos. Conclusão. A maioria das características definidoras foram consideradas pertinentes para Tensão do papel de cuidador. Os detectados refletem consenso entre expertos de dois países em relação à pertinência das características definidoras ao diagnóstico.

Caregiver role strain: bi-national study of content validation.

OBJECTIVE: To estimate content validity of the diagnosis Caregiver Role Strain. METHODS: Content validation of the defining characteristics according to Fehring's model was undertaken by 6 Colombian nurses and 9 Brazilian counterparts. The relevance of each defining characteristic for the diagnosis was assessed using 5-point Likert type scale. The Mann-Whitney test was used to estimate differences in assessing the relevance of defining characteristics between Brazilian and Colombian nurses. RESULTS: From 36 defining characteristics, 22 were identified as major, 13 as secondary and one as irrelevant (rash). The content validity index(sum of weighted averages divided by the total number of defining characteristics) was 0.79, considered adequate. CONCLUSION: Most of the defining characteristics were considered relevant to the nursing diagnosis Caregiver Role Strain. These findings reflect consensus among specialists from two different countries in relation to the relevance of the defining characteristics for this diagnosis.

Usability Testing of PROCEnf-USP: A Clinical Decision Support System.

Decision support systems (DSSs) are recognized as important tools, capable of processing high volumes of data and increasing productivity. The usability of these tools affects their effectiveness. By evaluating the interactions between registered nurses (RNs) and the DSSs, this study explores how they impact RN decision-making. This study analyzed 24 months (2011-2012) of data collected in Brazil in two units of a large, public, urban hospital in São Paulo that uses a nurse documentation system with an embedded DSS based on NANDA-I. Using mixed effects logistic regression, this study analyzed the agreement between RNs and a DSS when selecting nursing diagnoses. Results suggest that the agreement is mediated by characteristics of the RNs (education and experience) as well as units and year of encounter. Surprisingly, disagreement between RN and DSS when selecting defining characteristics (DC) had positive effects on the odds of agreement on diagnoses. Our results suggest that DSSs support nurses' clinical decision making, but the nurse's clinical judgment is the mediating factor. More research is necessary.

Nursing Clinical Documentation System Structured on NANDA-I, NOC, and NIC Classification Systems.

Information is a key feature that health professionals need to exercise their profession with efficiency and quality. This study aims to present the experience of the usage of an electronic system for clinical documentation in nursing in a university hospital. It is a methodological research of technology production. The system was developed in four phases: Conception, Elaboration, Construction, and Transition, and was named Electronic Documentation System of the University of São Paulo Nursing Process (PROCEnf-USP™). The knowledge base of PROCEnf-USP™ was organized in hierarchy of domains and classes, according to NNN linkages.