Exploring the nexus between the standardized nursing terminologies and the unfinished nursing care phenomenon: An empty systematic review.

PURPOSE: To identify and synthesize evidence regarding the documented relationship between the standardized nursing terminologies and the unfinished nursing care phenomenon. DATA SOURCES: A systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed, Scopus, and Cumulative Index to Nursing and Allied Health Literature Complete databases were last consulted on November 27, 2023. The review included primary quantitative studies that reported an association between recognized standardized nursing terminologies and unfinished nursing care. Two researchers completedtitle and abstract and full-text screening. DATA SYNTHESIS: Our search identified 149 citations. A full-text review of one paper was undertaken. No studies met our inclusion criteria. We report an empty review. CONCLUSIONS: Standardized nursing terminologies and Unfinished Care are two sides of the same coin: despite their potential commonalities, no studies have documented their potential links. Digital systems, such as electronic health records and decision support systems, could foster this linkage. IMPLICATIONS FOR NURSING PRACTICE: This review suggests that linking the conceptual frameworks can promote the diffusion of standardized nursing terminologies in clinical practice and increase accuracy in the measurement of Unfinished Care. This synergy could promote the contribution of nursing knowledge to patient care, nursing visibility, and be beneficial to clinical nurses, managers, and healthcare systems to international level.

Using interoperable nursing care data to improve outcomes for multiple traumas patients with Impaired Physical Mobility.

AIM(S): To demonstrate how interoperable nursing care data can be used by nurses to create a more holistic understanding of the healthcare needs of multiple traumas patients with Impaired Physical Mobility. By proposing and validating linkages for the nursing diagnosis of Impaired Physical Mobility in multiple trauma patients by mapping to the Nursing Outcomes Classification (NOC) and Nursing Interventions Classification (NIC) equivalent terms using free-text nursing documentation. DESIGN: A descriptive cross-sectional design, combining quantitative analysis of interoperable data sets and the Kappa's coefficient score with qualitative insights from cross-mapping methodology and nursing professionals' consensus. METHODS: Cross-mapping methodology was conducted in a Brazilian Level 1 Trauma Center using de-identified records of adult patients with a confirmed medical diagnosis of multiple traumas and Impaired Physical Mobility (a nursing diagnosis). The hospital nursing free-text records were mapped to NANDA-I, NIC, NOC and NNN linkages were identified. The data records were retrieved for admissions from September to October 2020 and involved medical and nursing records. Three expert nurses evaluated the cross-mapping and linkage results using a 4-point Likert-type scale and Kappa's coefficient. RESULTS: The de-identified records of 44 patients were evaluated and then were mapped to three NOCs related to nurses care planning: (0001) Endurance; (0204) Immobility Consequences: Physiological, and (0208) Mobility and 13 interventions and 32 interrelated activities: (6486) Environmental Management: Safety; (0840) Positioning; (3200) Aspiration Precautions; (1400) Pain Management; (0940) Traction/Immobilization Care; (3540) Pressure Ulcer Prevention; (3584) Skincare: Topical Treatment; (1100) Nutrition Management; (3660) Wound Care; (1804) Self-Care Assistance: Toileting; (1801) Self-Care Assistance: Bathing/Hygiene; (4130) Fluid Monitoring; and (4200) Intravenous Therapy. The final version of the constructed NNN Linkages identified 37 NOCs and 41 NICs. CONCLUSION: These valid NNN linkages for patients with multiple traumas can serve as a valuable resource that enables nurses, who face multiple time constraints, to make informed decisions efficiently. This approach of using evidence-based linkages like the one developed in this research holds high potential for improving patient's safety and outcomes. NO PATIENT OR PUBLIC CONTRIBUTION: In this study, there was no direct involvement of patients, service users, caregivers or public members in the design, conduct, analysis and interpretation of data or preparation of the manuscript. The study focused solely on analysing existing de-identified medical and nursing records to propose and validate linkages for nursing diagnoses.

Commonly used diagnostic label, classes, domain, and formulation among nursing students in Ibadan, Oyo State Nigeria.

BACKGROUND: In order to select nursing actions that will produce the desired results, a nursing diagnosis is crucial. Despite this, it can be challenging for nursing students to recognize and create precise nursing diagnostic labels that are particular to a patient's situation. The study's objectives are to identify the diagnostic labels, classes, and domains that are frequently formulated by nursing students. MATERIALS AND METHODS: A descriptive cross-sectional methodology and a self-developed questionnaire were utilized to gather information from 120 nursing students who were chosen using a simple random sampling technique. Descriptive and inferential (Chi-square) statistics were used to analyze the data. The 0.05 P- value was chosen. RESULTS: The respondent's average age is 23 ± 21.4 years. The majority of respondents (94.2%) concurred that greater exposure to clinical settings, case discussion methods (92.5%), as well as group case studies (90.8%) strategy, can all improve the creation of precise diagnostic labels. Additionally, the deficient fluid volume diagnostic label is the one that is most usually utilized (78.3%). Overall results show that the diagnostic labels that are used the most frequently are those for domains 4 (Activity/Rest) and 11 (Safety/Protection). There was no relationship (P = 0.061) between the commonly used diagnostic label and the chosen schools. CONCLUSION: The study offered empirical data on the most used diagnostic labels and domains. Therefore, it will be important that nursing students involve critical reasoning skills as well as familiarize themselves with other significant domains and classes that are useful in the patient's care.

The effect of the clinical supervision model on nursing internship students' nursing process-based performance: an experimental study.

BACKGROUND: The nursing process is a systematic method for identifying the patient's problems and planning to resolve them. It is also a crucial pillar of high-quality nursing care. Nursing internship students may lack the necessary skills to implement the nursing process due to the increased independence, the absence of constant professorial supervision, and limited experience. The clinical supervision model is a method of clinical education that bridges the gap between theory and practice. OBJECTIVE: This study was conducted to investigate the impact of the clinical supervision model on the performance of nursing internship students in each of the five stages of the nursing process, as well as overall. METHOD: This experimental study was conducted in 2022. The 70 eligible internship students were conveniently selected and randomly assigned to either an intervention or a control group. In the present study, the clinical supervision model was implemented for the intervention group, while the control group received routine supervision. This was carried out over six sessions in three months. The data collection was conducted using a researcher-developed checklist of nursing process-based performance in both groups. Moreover, the Manchester questionnaire was used to evaluate the model in the intervention group. The variables considered as confounding factors included age, gender, marital status, number of monthly shifts, and grades of the nursing process credit completed in the third semester. SPSS version 16 software, descriptive statistics (frequency distribution, percentage, mean, and standard deviation), and analytical statistics (independent t-test, chi square, repeated measures Anova and LSD) were used to analyze the data. RESULTS: Intergroup analysis revealed that there was no significant difference between the scores of nursing process steps and the total score before the intervention in the control and intervention groups, as well as in baseline characteristics (P > 0.05). According to the intragroup analysis, the intervention group showed a significant increase in both the total scores and scores of nursing process steps over time (P < 0.001), whereas the control group exhibited contradictory results (P > 0.05). Finally, the "P-Value Intervention" demonstrated the effectiveness of this training model in improving the performance of the intervention group based on the nursing process compared to the control group. The mean score of the Manchester questionnaire in the intervention group was 136.74, indicating the high impact of implementing the clinical supervision model in the intervention group. CONCLUSION: The results indicated that the implementation of the clinical supervision model led to improved utilization of the nursing process by nursing internship students at all stages. Therefore, it is recommended that nurse educators utilize the clinical supervision model by providing feedback on errors in action during supervision sessions to enhance the quality of nursing care provided by nursing internship students and improve patient safety in clinical environment.

Mapeamento das ações do enfermeiro de prática avançada em uma instituição de ensino superior / Mapping the actions of advanced practice nurses in a higher education institution

Mapear as ações do Enfermeiro de Prática Avançada nos campos de ensino clínico e estágio curricular supervisionado de um curso de graduação em enfermagem. Métodos: estudo transversal, descritivo, incluindo 21 enfermeiros. A coleta de dados deu-se por questionário sócio-profissiográfico, alinhado às competências do Conselho Internacional de Enfermeiros no tocante à Prática Avançada de Enfermagem. Resultados: Os enfermeiros demonstraram médio conhecimento em Prática Avançada de Enfermagem, e ações de prática avançada mapeadas como prescrição de agentes terapêuticos para lesões, procedimento de catéter central de inserção periférica, solicitação de exames de imagem e swab peri-anal, pareceres em lesão, manejo e consulta de enfermagem no pré-parto, assistência no parto. Competências no domínio do cuidado e no domínio da gestão/educação foram evidenciadas. Conclusão: evidenciou-se potenciais de ação de Prática Avançada na Instituição de Ensino.(AU)

To map the actions of Advanced Practice Nurses in the clinical teaching and supervised curricular internship fields of an undergraduate nursing course. Methods: A cross-sectional, descriptive study including 21 nurses. Data was collected using a socio-professional questionnaire, aligned with the International Council of Nurses' competencies regarding Advanced Nursing Practice. Results: The nurses demonstrated medium knowledge of Advanced Nursing Practice, and mapped advanced practice actions such as prescribing therapeutic agents for injuries, peripherally inserted central catheter procedures, requesting imaging tests and peri-anal swabs, injury opinions, management and nursing consultation in the prepartum period, and assistance in childbirth. Skills in the care domain and the management/education domain were highlighted. Conclusion: There was potential for action in Advanced Practice at the Teaching Institution.(AU)

Mapear las acciones de las Enfermeras de Práctica Avanzada en los campos de la enseñanza clínica y de las prácticas curriculares supervisadas de un curso de enfermería de pregrado. Métodos: Se trató de un estudio transversal, descriptivo, en el que participaron 21 enfermeras. Los datos fueron recogidos a través de un cuestionario socio-profesional, alineado con las competencias del Consejo Internacional de Enfermería en relación a la Práctica Avanzada de Enfermería. Resultados: Las enfermeras demostraron conocimiento medio de la Práctica Avanzada de Enfermería, y mapearon acciones de práctica avanzada como prescripción de agentes terapéuticos para lesiones, procedimientos de catéter central de inserción periférica, solicitud de pruebas de imagen e hisopos perianales, emisión de dictámenes sobre lesiones, manejo y consulta de enfermería en el período preparto, asistencia al parto. Se destacaron las competencias en el ámbito de los cuidados y en el de la gestión/educación. Conclusión: Hubo potencial de actuación en la Práctica Avanzada en la Institución de Enseñanza.(AU)

Care Plan Templates in Adult Community Mental Health Teams in England and Wales: An Evaluation.

Adults accessing community mental health services are required to have a care plan, developed in collaboration with the person accessing the service. The variation in care plan templates in use in England and Wales, and their impact on care planning, is unknown. This study evaluates the community mental health care plan templates in use across England and Wales. Data were obtained from a Freedom of Information request to 50 NHS Mental Health Trusts. An evaluation tool was designed and used to extract data. Data were rated red, amber, or green against clinical and design standards. Forty-seven care plan templates were obtained. The clinical aspect of the care plan template had 60% adherence to the national standards, and the design aspects had 87% adherence. A 'high/low' typology is proposed against the design/clinical standards. The study identifies priority areas for improvement in the care plan templates as space to record the actions that service users and carers will take to contribute to their care plan, space to record the name and contact details for their care coordinator or lead professional, plus others involved in the person's care. This study was not registered.

Developing and validating a 2D digital version of the Brazilian Children's anxiety questionnaire.

PURPOSE: This study aims to transpose the printed Brazilian Children's Anxiety Questionnaire (CAQ BR) into a 2D digital format, validate it with nurses and hospitalized children, and analyze the association between the printed and 2D digital format versions. DESIGN AND METHOD: This is a descriptive and multicentric study, conducted from 2021 to 2022 on working in pediatric care at two hospitals in Brazil. The nurses analyzed the printed and digital instruments and subsequently applied them to a child and proposed suggestions. A cutoff score of 0.80 on the content validity index was used; items that scored an average lower than the CVI in the study were adequate. Eighty children responded to the questionnaires sequentially according to the randomization table. A 90% agreement rate was used. RESULTS: The digital instrument was validated in content by 51 experts, with a CVI of 0.95. Face validation data for 80 children (mean age = 7.9 years) shows a 90% agreement rate. The intraclass correlation index for the general score was 0.87 and 95% CI (0.79-0.91), which shows good stability of the children's responses in both questionnaires. In addition, 59% (n = 47) of the children reported a preference for the digital questionnaire. CONCLUSIONS: The digital CAQ BR can be used as an audiovisual instrument by nurses when implementing the systematization of nursing care in pediatrics. PRACTICAL IMPLICATIONS: The digital 2D version was successfully applied and can be used in hospitals to measure children's self-reported anxiety.

Acciones del enfermero en la consulta de enfermería de puericultura en la atención primaria / Nurses' actions in childcare Nursing consultations in Primary Care

Introducción: En la Consulta de Enfermería de Puericultura, el enfermero realiza el seguimiento delcrecimiento y desarrollo del niño, práctica fundamental para la promoción y prevención de la salud. Sin embargo, hay fragilidades en la implementación, como vacíos en los registros y fallas en la evaluación preventiva de resultados importantes en la infancia, como obesidad y desnutrición. Objetivo: Identificar las acciones del enfermero en la consulta de enfermería de puericultura en la red de Atención Primaria de un municipio de la región semiárida del Nordeste de Brasil. Método: Estudio cualitativo descriptivo-exploratorio realizado con 9 enfermeros que trabajan en las Estrategias Salud de la Familia de la Atención Primaria de un municipio del estado de Río Grande del Norte, en la región semiárida del nordeste de Brasil. Los datos fueron recolectados a través de entrevistas semiestructuradas entre enero y marzo de 2021 y analizados mediante Análisis de Contenido Temático. Resultados: Surgieron 5 categorías de análisis y discusión: acogida para el vínculo; antropometría y examen físico; seguimiento del desarrollo infantil; educación para la salud: comportamiento para el cuidado; Dificultades para completar la libreta de salud del niño. Conclusión: Se observó que el enfermero es capaz de realizar una evaluación integral de la salud del niño, el vínculo y la acogida y la educación para la salud forman parte de la atención. Se verificó que hay deficiencias en la cumplimentación de la cartilla y que el proceso de enfermería no sigue la estructura esperada, lo que puede comprometer la calidad de la atención (AU)

Introdução: Na Consulta de Enfermagem em puericultura, o enfermeiro realiza a vigilância do crescimento e desenvolvimento da criança, prática essencial para promoção e prevenção da saúde. Entretanto, evidencia-se fragilidades na sua implementação como lacunas de registros e debilidades na avaliação preventiva de desfechos importantes na infância, como obesidade e desnutrição. Objetivo: Identificar as ações do enfermeiro na consulta de enfermagem em puericultura na rede de Atenção Básica de um município do Semiárido Nordestino brasileiro.Métodos: Estudo qualitativo descritivo-exploratório realizado com 9 enfermeiros atuantes nas Estratégias de Saúde da Família da Atenção Básica de um município do Estado do Rio Grande do Norte, interior do semiárido nordestino brasileiro. Os dados foram coletados por entrevista semiestruturada entre janeiro e março de 2021 e analisados por Análise de Conteúdo do tipo Temática. Resultados: Emergiram 5 categorias de análise e discussão: acolhimento para o vínculo; antropometria e exame físico; vigilância do desenvolvimento infantil; educação em saúde: atitude de cuidado; dificuldades no preenchimento da caderneta de saúde da criança. Conclusão: Percebeu-se queos enfermeiros conseguem realizar ampla avaliação de saúde das crianças, perpassando o cuidado pelo vínculo e acolhimento e pela educação em saúde. Evidencia-se que as deficiências no preenchimento da caderneta existem e que o processo de enfermagem não obedece a estrutura prevista, podendo comprometer com a qualidade da assistência (AU)

Introduction: In Childcare Nursing Consultations, nurses monitor children's growth and development, an essential practice for health promotion and prevention. However, there are weaknesses in their implementation, such as gaps in records and deficits in the preventive assessment of important outcomes in childhood, such as obesity and malnutrition. Objective: To identify nurses' actions in childcare Nursing consultations in the Primary Care network of a municipality in the semi-arid region of northeastern Brazil. Methods: A qualitative and descriptive-exploratory study carried out with 9 nurses working in the Family Health Strategies of Primary Care in a municipality from the state of Rio Grande do Norte, in the inland of the semi-arid region of northeastern Brazil. The data were collected through semi-structured interviews between January and March 2021 and analyzed using Thematic Content Analysis. Results: A total of 5 analysis and discussion categories emerged: welcoming for the bond; anthropometry and physical examination; child development surveillance; health education: caring attitude; and difficulties completing the children's health booklets. Conclusion: It was noticed that nurses are able to carry out a comprehensive assessment of children's health, permeating care through bonding, welcoming and health education. It is evidenced that there are deficiencies in completing the booklets and that the Nursing Process does not follow the expected structure, which may compromise care quality (AU)

Desenvolvimento da Intervenção de Enfermagem "Ultrassonografia: bexiga" segundo a Nursing Interventions Classification / Desarrollo de la intervención de enfermería "ecografía de vejiga" de acuerdo con la Nursing Interventions Classification / Development of the "Ultrasound: bladder" nursing intervention according to the Nursing Interventions Classification

Resumo Objetivo Desenvolver uma intervenção de enfermagem com o uso de ultrassonografia de bexiga segundo a Nursing Interventions Classification. Métodos Estudo metodológico em duas etapas: revisão integrativa de literatura e desenvolvimento da intervenção. Para etapa da revisão integrativa de literatura foram investigadas quatro bases de dados (PubMed, CINAHL, LILACS e SCOPUS), incluindo estudos de acesso gratuito e disponíveis na íntegra, nos idiomas inglês, português e espanhol, sem delimitação temporal. Na etapa de desenvolvimento da intervenção, foram seguidas as Diretrizes para Submissão de uma Intervenção à Nursing Interventions Classification Nova ou Revisada. Resultados Na revisão integrativa de literatura foram encontrados 328 estudos primários nas bases de dados, sendo incluídos 17 na análise final. Destacaram-se estudos com delineamento descritivo, sendo prevalente o nível de evidência VI. Os achados possibilitaram desenvolver cada um dos componentes da intervenção de enfermagem (Título, Definição, 17 atividades, Nível de Formação e o Tempo Estimado para realização). Conclusão A Intervenção de Enfermagem intitulada "Ultrassonografia: bexiga" foi desenvolvida, submetida ao Comitê Editorial da Nursing Interventions Classification e aceita para publicação na oitava edição da Classificação.

Resumen Objetivo Desarrollar una intervención de enfermería con el uso de ecografía de vejiga de acuerdo con la Nursing Interventions Classification. Métodos Estudio metodológico en dos etapas: revisión integradora de la literatura y desarrollo de la intervención. Para la etapa de revisión integradora de la literatura se investigó en cuatro bases de datos (PubMed, CINAHL, LILACS y SCOPUS), con la inclusión de estudios de acceso gratuito y disponibles con texto completo, en idioma inglés, portugués y español, sin límite temporal. En la etapa de desarrollo de la intervención, se siguieron las directrices para el envío de una intervención a Nursing Interventions Classification Nueva o Revisada. Resultados En la revisión integradora de la literatura, se encontraron 328 estudios primarios en las bases de datos, de los cuales se incluyeron 17 en el análisis final. Se destacaron los estudios con diseño descriptivo, con prevalencia de nivel de evidencia VI. Los resultados permitieron desarrollar cada uno de los componentes de la intervención de enfermería (título, definición, 17 actividades, nivel de formación y tiempo estimado para la realización). Conclusión La intervención de enfermería titulada "Ecografía: vejiga" fue desarrollada, enviada al Comité Editorial de la Nursing Interventions Classification y aprobada para publicar en la octava edición de la Clasificación.

Abstract Objective To develop a nursing intervention using bladder ultrasound according to the Nursing Interventions Classification. Methods This is a methodological study in two steps: integrative literature review and intervention development. For the integrative literature review step, four databases were investigated (PubMed, CINAHL, LILACS and Scopus), including free access studies available in full, in English, Portuguese and Spanish, without time limits. In the intervention development step, the Guidelines for Submission of a New or Revised Nursing Interventions Classification Intervention were followed. Results In the integrative literature review, 328 primary studies were found in the databases, 17 of which were included in the final analysis. Studies with a descriptive design stood out, with level of evidence VI being prevalent. The findings made it possible to develop each component of the nursing intervention (title, definition, 17 activities, level of training and estimated time for completion). Conclusion The nursing intervention entitled "Ultrasound: bladder" was developed, submitted the Nursing Interventions Classification Editorial Committee and accepted for publication in the 8th edition of the Classification.

Validação de conteúdo dos elementos do diagnóstico de enfermagem "amamentação ineficaz" / Content validation of the elements of the nursing diagnosis "ineffective breastfeeding" / Validación de contenido de los elementos del diagnóstico de enfermería "lactancia materna ineficaz"

Objetivo: revisar e validar os elementos do Diagnóstico de Enfermagem "Amamentação ineficaz" (00104) a partir da literatura e consenso de especialistas e construir definições operacionais para suas características definidoras. Método: trata-se de uma pesquisa metodológica desenvolvida em duas fases : revisão de escopo, baseada no proposto pelo Joanna Briggs Institute, e validação de conteúdo. Foram considerados validados os itens com Índice de Validade de Conteúdo ≥ 0,80 quanto a relevância, clareza e precisão. Resultados: elementos do Diagnósticos de Enfermagem foram mantidos como estão na atual edição da Classificação de Diagnósticos de Enfermagem da NANDA International (NANDA-I), enquanto outros sofreram modificações. Além disso, foi proposta a inclusão de fatores relacionados, populações de risco e condições associadas. Conclusão: este estudo possibilitou revisão e validação de conteúdo do Diagnóstico de Enfermagem "Amamentação ineficaz", presente na Classificação dos Diagnósticos de Enfermagem da NANDA-I

Objective: to review and validate the elements of the Nursing Diagnosis "Ineffective Breastfeeding" (00104) based on the literature and expert consensus, and to construct operational definitions for its defining characteristics. Method: this is a methodological study carried out in two phases: a scoping review, based on that proposed by the Joanna Briggs Institute, and content validation. Items with a Content Validity Index ≥ 0.80 in terms of relevance, clarity and precision were considered validated. Results: elements of the Nursing Diagnoses were kept as they are in the current edition of the NANDA International Classification of Nursing Diagnoses (NANDA-I), while others were modified. In addition, the inclusion of related factors, risk populations and associated conditions was proposed. Conclusion: this study enabled a review and validation of the content of the Nursing Diagnosis "Ineffective breastfeeding", present in the NANDA-I Classification of Nursing Diagnoses

Objetivos: revisar y validar los elementos del Diagnóstico de Enfermería "Lactancia Ineficaz" (00104) a partir de la literatura y el consenso de expertos, y construir definiciones operativas para sus características definitorias. Método: se trata de un estudio metodológico realizado en dos fases: una revisión de alcance, basada en la propuesta por el Joanna Briggs Institute, y una validación de contenido. Se consideraron validados los ítems con un Índice de Validez de Contenido ≥ 0,80 en términos de relevancia, claridad y precisión. Resultados: se mantuvieron elementos de los Diagnósticos de Enfermería tal y como están en la edición actual de la Clasificación Internacional de Diagnósticos de Enfermería NANDA (NANDA-I), mientras que otros fueron modificados. Además, se propuso la inclusión de factores relacionados, poblaciones de riesgo y condiciones asociadas. Conclusión: este estudio permitió la revisión y validación del contenido del Diagnóstico de Enfermería "Lactancia materna ineficaz", presente en la Clasificación de Diagnósticos de Enfermería NANDA-I

Psychometric evaluation of the Functional Health Pattern Assessment Screening Tool - Modified Brazilian Version / Evaluación psicométrica del instrumento Functional Health Pattern Assessment Screening Tool - Versión modificada para Brasil / Avaliação psicométrica do Functional Health Pattern Assessment Screening Tool - Versão Brasileira Modificada

Objective: to test the factorial structure, reliability and convergent validity of the Functional Health Pattern Assessment Screening Tool - Modified Brazilian Version. Method: this was a psychometric evaluation of the Functional Health Pattern Assessment Screening Tool - Modified Brazilian Version. Seven hundred and seventeen participants answered the data collection instrument consisting of two parts. Part I included a structured questionnaire to collect sociodemographic data and the participants' perceptions and satisfaction with their current health status. Part II consisted of the tool being tested. The internal structure was assessed using Confirmatory Factor Analysis. Convergent validity was evaluated by the correlation of the tool scores with the rates corresponding to self-perception and satisfaction with current health status. Reliability was assessed using Cronbach's alpha. Results: the Confirmatory Factor Analysis confirmed a three-factor solution. The factor loadings were significant and varied from 0.16 to 0.75; the fit indices suggested moderate fit of the model. Internal consistency for all three components varied between 0.779 and 0.919. Conclusion: the findings suggest that the tool is valid and reliable to be used in the Brazilian population, although caution is recommended when interpreting the results due to the moderate fit of the model.

Objetivo: someter a prueba la estructura factorial, confiabilidad y validez convergente del instrumento Functional Health Pattern Assessment Screening Tool - Versión modificada para Brasil. Método: evaluación psicométrica del instrumento Functional Health Pattern Assessment Screening Tool - Versión modificada para Brasil. Setecientos diecisiete participantes respondieron el instrumento de recolección de datos, compuesto por dos partes. La Parte I incluyó un cuestionario estructurado para recopilar datos sociodemográficos y las percepciones y el nivel de satisfacción de los participantes con respecto a su estado de salud actual. La Parte II consistió en la herramienta sometida a prueba. La estructura interna se evaluó empleando Análisis Factorial Confirmatorio. La validez interna se evaluó por medio de la correlación entre las puntuaciones obtenidas en la herramienta y los índices correspondientes a los niveles de autopercepción y satisfacción con respecto al estado de salud actual. La confiabilidad se evaluó utilizando el coeficiente alfa de Cronbach. Resultados: el Análisis Factorial Confirmatorio confirmó una solución con tres factores. Las cargas factoriales fueron significativas y variaron entre 0,16 y 0.75; los índices de ajuste sugirieron ajuste moderado del modelo. La consistencia interna correspondiente a los tres componentes varió entre 0,779 y 0,919. Conclusión: los hallazgos sugieren que la herramienta es válida y confiable para ser usada en la población de Brasil, aunque se recomienda interpretar los resultados con precaución debido al moderado ajuste del modelo.

Objetivo: testar a estrutura fatorial, a confiabilidade e a validade convergente do Functional Health Pattern Assessment Screening Tool - Versão Brasileira Modificada. Método: avaliação psicométrica do Functional Health Pattern Assessment Screening Tool - Versão Brasileira Modificada. Setecentos e dezessete participantes responderam os itens do instrumento de coleta de dados composto por duas partes. A Parte I incluiu um questionário estruturado contendo dados sociodemográficos e a percepção e satisfação dos participantes com seu estado de saúde atual. A Parte II consistiu no instrumento testado. A estrutura interna foi avaliada por meio de Análise Fatorial Confirmatória. A validade convergente foi avaliada pela correlação dos escores do instrumento com os índices correspondentes à autopercepção e à satisfação com o estado de saúde atual. A confiabilidade foi avaliada pelo alfa de Cronbach. Resultados: a Análise Fatorial Confirmatória confirmou uma solução de três fatores. As cargas fatoriais foram significativas e variaram de 0,16 a 0,75; os índices de ajuste sugeriram ajuste moderado do modelo. A consistência interna dos três componentes variou entre 0,779 e 0,919. Conclusión: os achados sugerem que o instrumento é válido e confiável para ser utilizado na população brasileira, embora seja recomendada cautela na interpretação dos resultados devido ao ajuste moderado do modelo.

Oral hygiene self-care: Concept analysis for the development of a new nursing diagnosis.

OBJECTIVE: This study aims to analyze the concept of oral hygiene self-care and develop a new problem-focused nursing diagnosis (ND) based on the NANDA-I terminology. METHOD: A concept analysis was performed based on the Walker and Avant framework, including a scoping review phase according to the Joanna Briggs Institute guidelines. Searches were performed in PubMed, Cumulative Index to Nursing and Allied Health Literature, Scopus, Web of Science, Virtual Health Library, and specific gray literature databases. The development of the diagnostic structure followed the NANDA-I guidelines with a focus on Orem's self-care theory. RESULTS: Including 51 studies, the analysis facilitated the formulation of attributes, antecedents, and consequences of oral hygiene self-care. The ND "Oral hygiene self-care deficit" was created and included 17 defining characteristics, 9 related factors, 5 associated conditions, and 5 high-risk populations. Two cases were constructed to illustrate the use of key terms. CONCLUSIONS: The conceptual analysis provided insight into the concept of oral hygiene self-care and supported the structure of a new ND. IMPLICATIONS FOR NURSING PRACTICE: This study contributes to the implementation of the nursing process by focusing on the identification of individuals with oral hygiene self-care deficit. It will facilitate the promotion of oral health, thereby impacting the individual's quality of life. In addition, it will aid in the development of public policy for the prevention of oral diseases.

Ressignificando o aprendizado acerca do processo de enfermagem para desenvolver raciocínio clínico

Introdução: A aplicação das etapas do processo de enfermagem na prática clínica requer aperfeiçoamento constante. Objetivo: Analisar as ressignificações do aprendizado que enfermeiros, professores e estudantes obtiveram durante oficinas de aperfeiçoamento do processo de enfermagem. Metodologia: Pesquisa Convergente Assistencial realizada por meio de cinco oficinas, na qual totalizou 12 participantes. Na análise dos dados, elaborou-se síntese, teorização e transferência para a prática das ressignificações do aprendizado. Resultados: Destacou-se que informações insuficientes no instrumento de coleta de dados gera inconsistências na identificação diagnóstica. Enfatizou-se a relevância das taxonomias na etapa do planejamento e incompreensões no manejo da Escala Likert dos indicadores. Conclusões: Discutiram-se as etapas do processo a partir da sua aplicabilidade, por se entender ser deste lugar que se devem disparar as discussões desta temática. Conclui-se a necessidade do aperfeiçoamento, por estratégias inovadoras que permitam a participação ativa dos profissionais e valorização dos serviços de saúde, assim como as oficinas produzidas no estudo que se embasaram em um modelo local, potencializando o aprendizado significativo de estudantes e professores.

Introduction: The application of the steps of the Nursing Process in clinical practice requires constant improvement. Objective: To analyze the new meanings of learning that nurses, professors, and students obtained during workshops to improve the Nursing Process. Methodology: Convergent Care Research was carried out through five workshops, in which a total of 12 participants. In the data analysis, a synthesis, theorization, and transference to the practice of the learning resignifications were elaborated. Results: It was highlighted that insufficient information in the data collection instrument generates inconsistencies in diagnostic identification. The relevance of taxonomies in the planning stage and misunderstandings in the management of the Likert Scale of indicators was emphasized. Conclusions: The stages of the process were discussed based on their applicability, as it is understood from this place that discussions on this theme should be launched. It concludes the need for improvement, through innovative strategies that allow the active participation of professionals and enhancement of health services, as well as the workshops produced in the study that were based on a local model, enhancing meaningful learning of students and teachers.

Diagnósticos e Intervenções de Enfermagem em Pacientes Com Ferida Crônica na Atenção Primária e Secundária / Nursing Diagnoses and Interventions in Patients With Chronic Wound in Primary and Secondary Care / Diagnósticos e Intervenciones de Enfermería en Pacientes con Heridas Crónicas en Atención Primaria y Secundaria

Objetivo:Identificar os diagnósticos e as intervenções de enfermagem relacionados a pacientes com ferida crônica produzidos por um sistema específico na atenção primária e secundária. Método: Estudo descritivo, quantitativo, realizado entre julho e outubro de 2022. Utilizaram-se os dados do sistema Sistematização da Assistência de Enfermagem em Feridas ­ gerencial (SAEFg). O estudo foi aprovado pelo Comitê de Ética em Pesquisa sob Parecer nº 4.329.008/2020. Resultados: No total, foram 314 registros de diagnósticos e 1.300 de intervenções de enfermagem. Os principais diagnósticos de enfermagem foram: úlcera venosa (17,6%), cicatrização da ferida prejudicada e ansiedade (7,6%), risco de queda (7,1%), risco de infecção (6,7%) e prurido (6,4%). As intervenções foram: prescrever/orientar a elevação das pernas (9,3%), orientar não coçar ou usar produtos abrasivos (8,3%), examinar condições da pele (7%), descrever/documentar as características da ferida (5,5%). Conclusão: Os principais diagnósticos e intervenções de enfermagem versaram sobre os aspectos tegumentares, emocionais e de riscos como queda e infecção. A maior ocorrência de registros foi na atenção secundária.

Objective:To identify nursing diagnoses and interventions related to patients with chronic wound produced by a specific system in primary and secondary care. Method: Descriptive study conducted between July and October 2022. We used data from the Systematization of Nursing Care in Wounds­anagerial (SAEFg) system. The study was approved by the Ethics and Research Committee, under Opinion no. 4.329.008/2020. Results: There were 314 records of diagnoses and 1,300 of nursing interventions. The main nursing diagnoses were: venous ulcer (17.6%), impaired wound healing and anxiety (7.6%), risk of falling (7.1%), risk of infection (6.7%), and pruritus (6.4%). The interventions were: prescribe/guide leg elevation (9.3%), guide not to scratch or use abrasive products (8.3%), examine skin conditions (7%), and describe/document wound characteristics (5.5%). Conclusion: The main nursing diagnoses and interventions were about tegumentary, emotional and risk aspects such as fall and infection. The highest occurrence of records was in secondary care.

Objetivo:Identificar los diagnósticos de enfermería y las intervenciones relacionadas con los pacientes con herida crónica producidas por un sistema específico en Atención Primaria y Secundaria. Método: Estudo descritivo, realizado entre julho e outubro de 2022. Se utilizaron los datos del Sistema "Sistematización de la Asistencia de Enfermería en Ferias - gerencial (SAEFg)". El estudio fue aprobado por el Comité de Ética e Investigación con el Dictamen nº 4.329.008/2020. Resultados: Hubo un total de 314 registros de diagnósticos y 1.300 de intervenciones de enfermería. Los principales diagnósticos de enfermería fueron: úlcera venosa (17,6%), deterioro de la cicatrización y ansiedad (7,6%), riesgo de caídas (7,1%), riesgo de infección (6,7%) y prurito (6,4%). Las intervenciones fueron: prescribir/guiar la elevación de las piernas (9,3%), guiar para no rascarse ni utilizar productos abrasivos (8,3%), examinar las condiciones de la piel (7%), describir/documentar las características de la herida (5,5%). Conclusión: Los principales diagnósticos e intervenciones de enfermería fueron sobre aspectos tegumentarios, emocionales y de riesgo como caídas e infecciones. El mayor número de registros se produjo en la atención secundaria.

[Development and implementation of primary nursing in the intensive care unit: evaluation in mixed-methods design.] / Entwicklung und Implementierung von Prozessverantwortlicher Pflege auf der Intensivstation.

Development and implementation of primary nursing in the intensive care unit: evaluation in mixed-methods design. Abstract:Background: In a university hospital, the development and implementation of Primary Nursing (Prozessverantwortliche Pflege, PP) in a pilot intensive care unit was initiated. To develop the roles of nurses with and without process responsibility a working group PP was founded while taking into account the skill-grade mix. Aim: The working group aimed to develop the roles of process-responsible nurses (PP) and nurses (P), as well as to plan and implement the implementation process. Methods: Development and piloting steps were taken based on the recommendations of the Medical Research Council. At three measurement points, the instrument for recording nursing systems (IzEP©) was used quantitatively and a focus group interview, as well as a ward process analysis, were used qualitatively in t0 (as-is analysis before development and piloting), t1 (6 months after implementation) and t2 (12 months after implementation). Results: PP mainly take over the care process's design and control. The IzEP© analysis showed that room care was practiced in t0 with 50.0%. The values increased towards PP from 74.0% in t1 to 83.5% in t2. Qualitatively obtained data supported these results and showed further optimization potential for practice. Conclusions: The results prove the successful implementation of PP in practice. For the development and implementation of new nursing roles, the involvement of the affected nurses is mandatory.

Effectiveness of a Standardized Nursing Process Using NANDA International, Nursing Interventions Classification and Nursing Outcome Classification Terminologies: A Systematic Review.

The decision-making in clinical nursing, regarding diagnoses, interventions and outcomes, can be assessed using standardized language systems such as NANDA International, the Nursing Interventions Classification and the Nursing Outcome Classification; these taxonomies are the most commonly used by nurses in informatized clinical records. The purpose of this review is to synthesize the evidence on the effectiveness of the nursing process with standardized terminology using the NANDA International, the Nursing Interventions Classification and the Nursing Outcome Classification in care practice to assess the association between the presence of the related/risk factors and the clinical decision-making about nursing diagnosis, assessing the effectiveness of nursing interventions and health outcomes, and increasing people's satisfaction. A systematic review was carried out in Medline and PreMedline (OvidSP), Embase (Embase-Elsevier), The Cochrane Library (Wiley), CINAHL (EbscoHOST), SCI-EXPANDED, SSCI and Scielo (WOS), LILACS (Health Virtual Library) and SCOPUS (SCOPUS-Elsevier) and included randomized clinical trials as well as quasi-experimental, cohort and case-control studies. Selection and critical appraisal were conducted by two independent reviewers. The certainty of the evidence was assessed with the Grading of Recommendations Assessment, Development and Evaluation Methodology. A total of 17 studies were included with variability in the level and certainty of evidence. According to the outcomes, 6 studies assessed diagnostic decision-making and 11 assessed improvements in individual health outcomes. No studies assessed improvements in intervention effectiveness or population satisfaction. There is a need to increase studies with rigorous methodologies that address clinical decision-making about nursing diagnoses using NANDA International and individuals' health outcomes using the Nursing Interventions Classification and the Nursing Outcome Classification as well as implementing studies that assess the use of these terminologies for improvements in the effectiveness of nurses' interventions and population satisfaction with the nursing process.

The quality of nursing diagnoses, interventions, and outcomes in Romanian nursing documentation measured with the Q-DIO: A cross-sectional study.

PURPOSE: To assess the quality of the nursing process in Romania by evaluating nursing documentations with the quality of diagnoses, interventions and outcomes (Q-DIO) measurement instrument. METHODS: A quantitative cross-sectional research design was employed using probabilistic sampling to select nursing documentations from a Romanian university hospital. The data were analyzed using the Q-DIO measurement instrument. FINDINGS: Low quality levels of nursing process documentation were found. The Q-DIO subscale "Nursing diagnoses as process" (assessment) revealed a mean = 1.36 (SD 0.52) of maximum 2. Nurses collected lots of data but did not use these to state nursing diagnoses. "Nursing diagnoses as product" showed inaccurate diagnoses; mean = 1.24 (SD 0.48) of maximum 4. Nursing interventions were planned and documented, but their impact on the etiology of nursing diagnoses was low; mean = 0.76 (SD 0.18). The quality of nursing outcomes mean was 0.57 (SD 0.29). Nurses failed making connections between nursing assessment, diagnoses, interventions, and outcomes, and standardized nursing languages (SNLs) were not used. Statistically significant differences were found among all Q-DIO sub-concepts except for "Nursing diagnoses as process." CONCLUSIONS: The documentation was structured but did not support the nursing process and its documentation, and SNLs were not implemented. There was an underutilization of data to state nursing diagnoses, and nursing interventions were mostly ineffective, leading to low nursing outcomes. IMPLICATIONS FOR NURSING PRACTICE: This study provides new insights on the nursing process and its documentation in Romania and a baseline for future research. Policymakers, administrators, and educators should consider educating nurses to use standardized nursing languages and apply the Advanced Nursing Process.

Evaluation of nursing process competencies, nursing quality, and patient safety using virtual simulation with debriefing: A quasi-experimental study.

Background: Investing in clinical education is important for adult urgent and emergency surgery and traumatology as it promotes registered nurses' competencies by providing professional development training to respond to urgent or emergency surgeries. Objective: To examine registered nurses' self-assessment of the effects of virtual video simulation with an immediate debriefing approach on nursing process competencies, nursing care quality, incomplete care, and patient safety in surgical units. Methods: This study used a quasi-experimental two-group pre- and post-test design. The study was conducted at two provincial hospitals in Cambodia. Participants included registered nurses employed in surgical units. The experimental group (n = 46) completed a virtual video simulation and immediate debriefing. The control group (n = 35) completed virtual training on the nursing process. Data were collected two months after a successful second-week follow-up using Competency of Nursing Process, Cambodian Nursing Care Quality, Care Left Undone, and Patient Safety scales. Wilcoxon signed-rank test and Mann-Whitney U test were used to evaluate the differences before and after the sessions. Generalized linear model was used to compare the differences between the two groups. Results: The results showed statistically significant improvements in the experimental group on competency, nursing care quality, patient safety, and reducing care left undone after the intervention. However, the control group revealed statistically insignificant differences. In addition, the experimental group provided positive feedback, such as experiencing a real patient scenario, developing critical-thinking, improving communication skills, and having an opportunity to ask questions. Conclusion: Our study showed that VVS and immediate debriefing have the potential to support in-service training of RNs from diverse backgrounds. Particularly, integrating virtual video simulation and immediate debriefing may to promote competency in the nursing process and improve care outcomes.

The nursing process: A supportive model for nursing students' learning during clinical education - A qualitative study.

AIM: The aim of this study was to increase understanding of nursing students' learning during clinical education in relation to the nursing process. BACKGROUND: Nursing students' learning during clinical education is of great importance in creating meaning for theory and development of core competencies. As a theoretical model, the nursing process is challenging to apply in practice for both students and registered nurses, although use of the model has benefits for patient care. DESIGN: This is a descriptive qualitative study with an abductive approach. METHODS: Twelve semi-structured interviews with nursing students in education from six universities in Sweden were conducted in 2021-2022. Data were examined using qualitative content analysis. RESULTS: The results revealed that the nursing process supported learning when theory and practice 'spoke the same language'. This allows for the opportunity to perform in a consistent way with the theory, while obtaining awareness of an invisible process. Furthermore, the nursing process supported learning by incorporating a thought structure for the student´s professional role through developing independence to conduct a holistic assessment and increasing an understanding of the nurse´s area of responsibility. CONCLUSION: The results revealed that when theory and practice were aligned, the nursing process became a meaningful structure to develop a sustainable, safe way of thinking for one's future professional role. It is important to use supportive pedagogical models for students and supervisors that facilitate the integration of concepts of the nursing process in practice.

Nursing assistance systematization: understanding the care implementation process

Introduction: the Systematization of Nursing Care is one of the main tools for the development and organization of services for nursing professionals, its application guides the planning of individualized care and focuses on the specific needs of each individual. Objective: the study's general purpose is to analyze primary health nursing care in light of the basic human needs theory. Methods: this is a descriptive study with a qualitative approach, developed in the city of Rio Branco, Acre, Brazil, with nurses from the Basic Family Health Units. As a method for organization and interpretation, we opted for the content analysis proposed by Bardin. Results: the Systematization of Nursing Care is perceived by nurses as an instrument for organizing care, but in practice, they think it is focused on assistance directed to the use of ministerial protocols. In this context, it was also evidenced that they focus on aid for health problems and complaints, indicating the anamnesis as a phase of the implemented nursing process with the other stages focused on the diagnosis of the disease and specific interventions. Conclusion: our findings showed that professionals in primary health care end up directing their care only to momentary complaints, failing to broaden their look as a whole. In this way, assistance occurs in a fragmented way, failing to meet the real needs of the population.

Introdução: a Sistematização da Assistência de Enfermagem é uma das principais ferramentas para o desenvolvimento e organização dos serviços dos profissionais da enfermagem, a aplicação da mesma orienta quanto ao planejamento de uma assistência individualizada e com foco nas necessidades específicas de cada indivíduo. Objetivo: analisar a assistência de enfermagem na atenção primaria à saúde à luz da teoria das necessidades humanas básicas. Método: trata-se de um estudo descritivo de abordagem qualitativa. A pesquisa foi desenvolvida no município de Rio Branco, com profissionais enfermeiros das Unidades Básicas de Saúde da Família. Como método para a organização e interpretação optou-se pela análise de conteúdo proposta por Bardin. Resultados: a Sistematização da Assistência de Enfermagem (SAE) é percebida pelos profissionais enfermeiros como um instrumento de organização do cuidado, porém estes na prática acabam achando que a SAE está voltada para a assistência direcionada ao uso de protocolos ministeriais. Nesse contexto, evidenciou-se ainda que estes focam a assistência em problemas de saúde e as queixas, indicando a anamnese como fase do processo de enfermagem implementado, sendo as demais etapas voltadas para diagnóstico da doença e intervenções pontuais. Conclusão: evidenciou que os profissionais na atenção primária à saúde acabam direcionando seus cuidados apenas para as queixas momentâneas, deixando de ampliar o olhar para o mesmo como um todo. Desse modo, a assistência ocorre de modo fragmentado, deixando de atender as necessidades reais da população